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Temsirolimus	Temsirolimus, sold under the brand name Torisel, is an intravenous drug for the treatment of renal cell carcinoma (RCC), developed by Wyeth Pharmaceuticals and approved by the U.S. Food and Drug Administration (FDA) in May 2007, and was also approved by the European Medicines Agency (EMA) in November 2007. It is a derivative and prodrug of sirolimus. Mechanism of action Temsirolimus is a specific inhibitor of mTOR and interferes with the synthesis of proteins that regulate proliferation, growth, and survival of tumor cells. Though temsirolimus shows activity on its own, it is also known to be converted to sirolimus (rapamycin) in vivo; therefore, its activity may be more attributed to its metabolite rather than the prodrug itself (despite claims to the contrary by the manufacturer). Treatment with temsirolimus leads to cell cycle arrest in the G1 phase, and also inhibits tumor angiogenesis by reducing synthesis of VEGF.mTOR (mammalian target of rapamycin) is a kinase enzyme inside the cell that collects and interprets the numerous and varied growth and survival signals received by tumor cells. When the kinase activity of mTOR is activated, its downstream effectors, the synthesis of cell cycle proteins such as cyclin D and hypoxia-inducible factor-1a (HIF-1a) are increased. HIF-1a then stimulates VEGF. Whether or not mTOR kinase is activated, determines whether the tumor cell produces key proteins needed for proliferation, growth, survival, and angiogenesis.mTOR is activated in tumor cells by various mechanisms including growth factor surface receptor tyrosine kinases, oncogenes, and loss of tumor suppressor genes. These activating factors are known to be important for malignant transformation and progression. mTOR is particularly important in the biology of renal cancer (RCC) owing to its function in regulating HIF-1a levels. Mutation or loss of the von Hippel Lindau tumor-suppressor gene is common in RCC and is manifested by reduced degradation of HIF-1a. In RCC tumors, activated mTOR further exacerbates accumulation of HIF-1a by increasing synthesis of this transcription factor and its angiogenic target gene products. Efficacy In an international three-arm phase III study with 626 previously untreated, poor-prognosis patients, temsirolimus, interferon-α and the combination of both agents was compared. Median overall survival improved significantly in the temsirolimus group (10.9 months) compared with interferon-α group (7.3 months) and the combination group (8.4 months). Further studies are needed to determine the role of temsirolimus in the first-line treatment of patients with a more favorable prognosis, how it can be combined with other targeted agents and as sequential therapy with sunitinib or sorafenib. Adverse reactions The toxicity profile is based on what was found in the phase III trial. adverse reaction fatigue skin rash mucositis hematologic abnormalities hemoglobin decreased lymphocytes decreased laboratory abnormalities triglycerides increased glucose increased phosphorus decreasedTemsirolimus has been generally well tolerated in clinical settings by patients with advanced RCC. In patients with RCC, the adverse effect profile of temsirolimus is primarily metabolic in nature, with minimal impact on QoL compared with the commonly seen side-effects with oral multikinase inhibitors. Temsirolimus high level of specificity for mTOR likely contributes to the tolerability of temsirolimus. However, temsirolimus increases mortality in cancer patients. Lung toxicity Temsirolimus is associated with lung toxicity, and the risk of developing this complication may be increased among subjects with abnormal pre-treatment pulmonary functions or history of lung disease. The risk of interstitial lung disease is increased with temsirolimus doses greater than 25 mg, symptoms of which may include dry cough, fever, eosinophilia, chest pain, and dyspnea on exertion. Toxicity usually occurred early (within days to weeks) or late (months to years) after treatment. Dosing Although infusion reactions can occur while temsirolimus is being administered, most hypersensitivity reactions occurring on the same day as temsirolimus administration were not severe. Antihistamine pretreatment (e.g. 25–50 mg diphenhydramine, 30 minutes prior to administration) is recommended to minimize the risk of an allergic reaction. See also Discovery and development of mTOR inhibitors References External links "Temsirolimus". Drug Information Portal. U.S. National Library of Medicine.
Calcifediol	Calcifediol, also known as calcidiol, 25-hydroxycholecalciferol, or 25-hydroxyvitamin D3 (abbreviated 25(OH)D3), is a form of vitamin D produced in the liver by hydroxylation of vitamin D3 (cholecalciferol) by the enzyme vitamin D 25-hydroxylase. Calcifediol can be further hydroxylated by the enzyme 25(OH)D-1α-hydroxylase, primarily in the kidney, to form calcitriol (1,25-(OH)2D3), which is the active hormonal form of vitamin D.Calcifediol is strongly bound in blood by the vitamin D-binding protein. Measurement of serum calcifediol is the usual test performed to determine a persons vitamin D status, to show vitamin D deficiency or sufficiency. Calcifediol is available as an oral medication in some countries to supplement vitamin D status. Biology Calcifediol is the precursor for calcitriol, the active form of vitamin D. It is synthesized in the liver, by hydroxylation of cholecalciferol (vitamin D3) at the 25-position. This enzymatic 25-hydroxylase reaction is mostly due to the actions of CYP2R1, present in microsomes, although other enzymes such as mitochondrial CYP27A1 can contribute. Variations in the expression and activity of CYP2R1, such as low levels in obesity, affect circulating calcifediol. Similarly, vitamin D2, ergocalciferol, can also be 25-hydroxylated to form 25-hydroxyergocalciferol, (ercalcidiol, 25(OH)D2); both forms are measured together in blood as 25(OH)D.At a typical intake of cholecalciferol (up to 2000 IU/day), conversion to calcifediol is rapid. When large doses are given (100,000 IU), it takes 7 days to reach peak calcifediol concentrations. Calcifediol binds in the blood to vitamin D-binding protein (also known as gc-globulin) and is the main circulating vitamin D metabolite. Calcifediol has an elimination half-life of around 15 to 30 days.Calcifediol is further hydroxylated at the 1-alpha-position in the kidneys to form 1,25-(OH)2D3, calcitriol. This enzymatic 25(OH)D-1α-hydroxylase reaction is performed exclusively by CYP27B1, which is highly expressed in the kidneys where it is principally regulated by parathyroid hormone, but also by FGF23 and calcitriol itself. CYP27B1 is also expressed in a number of other tissues, including macrophages, monocytes, keratinocytes, placenta and parathyroid gland and extra-renal synthesis of calcitriol from calcifediol has been shown to have biological effects in these tissues.Calcifediol is also converted into 24,25-dihydroxycholecalciferol by 24-hydroxylation. This enzymatic reaction is performed by CYP24A1 which is expressed in many vitamin D target tissues including kidney, and is induced by calcitriol. This will inactivate calcitriol to calcitroic acid, but 24,25-(OH)2D3 may have some biological actions itself. Blood test for vitamin D deficiency In medical practice, a blood test for 25-hydroxy-vitamin D, 25(OH)D, is used to determine an individuals vitamin D status. The name 25(OH)D refers to any combination of calcifediol (25-hydroxy-cholecalciferol), derived from vitamin D3, and ercalcidiol (25-hydroxy-ergocalciferol), derived from vitamin D2. The first of these (also known as 25-hydroxy vitamin D3) is made by the body, or is sourced from certain animal foods or cholecalciferol supplements. The second (25-hydroxy vitamin D2) is from certain vegetable foods or ergocalciferol supplements. Clinical tests for 25(OH)D often measure the total level of both of these two compounds together, generally without differentiating.This measurement is considered the best indicator of overall vitamin D status. US labs generally report 25(OH)D levels as ng/mL. Other countries use nmol/L. Multiply ng/mL by 2.5 to convert to nmol/L.This test can be used to diagnose vitamin D deficiency, and is performed in people with high risk for vitamin D deficiency, when the results of the test can be used to support beginning replacement therapy with vitamin D supplements. Patients with osteoporosis, chronic kidney disease, malabsorption, obesity, and some other infections may be at greater risk for being vitamin D-deficient and so are more likely to have this test. Although vitamin D deficiency is common in some populations including those living at higher latitudes or with limited sun exposure, the 25(OH)D test is not usually requested for the entire population. Physicians may advise low risk patients to take over-the-counter vitamin D supplements in place of having screening.It is the most sensitive measure, though experts have called for improved standardization and reproducibility across different laboratories. According to MedlinePlus, the recommended range of 25(OH)D is 20 to 40 ng/mL (50 to 100 nmol/L) though they recognize many experts recommend 30 to 50 ng/mL (75 to 125 nmol/L). The normal range varies widely depending on several factors, including age and geographic location. A broad reference range of 20 to 150 nmol/L (8-60 ng/mL) has also been suggested, while other studies have defined levels below 80 nmol/L (32 ng/mL) as indicative of vitamin D deficiency.Increasing calcifediol levels up to levels of 80 nmol/L (32 ng/mL) are associated with increasing the fraction of calcium that is absorbed from the gut. Urinary calcium excretion balances intestinal calcium absorption and does not increase with calcifediol levels up to ~400 nmol/L (160 ng/mL). Supplementation Calcifediol supplements have been used in some studies to improve vitamin D status. Indications for their use include vitamin D deficiency or insufficiency, refractory rickets (vitamin D resistant rickets), familial hypophosphatemia, hypoparathyroidism, hypocalcemia and renal osteodystrophy and, with calcium, in primary or corticosteroid-induced osteoporosis.Calcifediol may have advantages over cholecalciferol for the correction of vitamin D deficiency states. A review of the results of nine randomized control trials which compared oral doses of both, found that calcifediol was 3.2-fold more potent than cholecalciferol. Calcifediol is better absorbed from the intestine and has greater affinity for the vitamin-D-binding protein, both of which increase its bioavailability. Orally administered calcifediol has a much shorter half-life with faster elimination. These properties may be beneficial in people with intestinal malabsorption, obesity, or treated with certain other medications.In 2016, the FDA approved a formulation of calcifediol (Rayaldee) 60 microgram daily as a prescription medication to treat secondary hyperparathyroidism in patients with chronic kidney disease. Interactive pathway map History Research in the laboratory of Hector DeLuca identified 25(OH)D in 1968 and showed that the liver was necessary for its formation. The enzyme responsible for this synthesis, cholecalciferol 25-hydroxylase, was isolated in the same laboratory by Michael F. Holick in 1972. Research Studies are ongoing comparing the effects of calcifediol with other forms of vitamin D including cholecalciferol in prevention and treatment of osteoporosis. See also Hypervitaminosis D Hypovitaminosis D Vitamin D References External links "Calcifediol". Drug Information Portal. U.S. National Library of Medicine.
Noritate	Noritate is a topical cream usually prescribed for rosacea, a disease of the skin commonly associated with adult acne and most notably frequent to constant flushing of the face around the cheeks and chin area.Noritate contains 1% anti-inflammatory drug metronidazole designed to reduce redness in inflamed areas. While noritate may get rid of some pustules and reduce redness, it has been shown to result in acne in an exceptionally small number of users. The drug information pamphlet claims only 1% of users see ill effects. In many cases, users see no reduction in general redness associated with rosacea and sometimes even a worsening effect. Similar results are reported for Metrogel, which contains the same 1% metronidazole. == References ==
Molindone	Molindone, sold under the brand name Moban, is an antipsychotic which is used in the United States in the treatment of schizophrenia. It works by blocking the effects of dopamine in the brain, leading to diminished symptoms of psychosis. It is rapidly absorbed when taken orally. It is sometimes described as a typical antipsychotic, and sometimes described as an atypical antipsychotic.Molindone was discontinued by its original supplier, Endo Pharmaceuticals, on January 13, 2010. Availability and Marketing in the USA After having been produced and subsequently discontinued by Core Pharma in 2015-2017, Molindone is available again from Epic Pharma effective December, 2018. Adverse effects The side effect profile of molindone is similar to that of other typical antipsychotics. Unlike most antipsychotics, however, molindone use is associated with weight loss. Chemistry Synthesis Condensation of oximinoketone 2 (from nitrosation of 3-pentanone), with cyclohexane-1,3-dione (1) in the presence of zinc and acetic acid leads directly to the partly reduced indole derivative 6. The transformation may be rationalized by assuming as the first step, reduction of 2 to the corresponding α-aminoketone. Conjugate addition of the amine to 1 followed by elimination of hydroxide (as water) would give ene-aminoketone 3. This enamine may be assumed to be in tautomeric equilibrium with imine 4. Aldol condensation of the side chain carbonyl group with the doubly activated ring methylene group would then result in cyclization to pyrrole 5; simple tautomeric transformation would then give the observed product. Mannich reaction of 6 with formaldehyde and morpholine gives the tranquilizer molindone (7). See also L-741,626 Losindole Piquindone == References ==
Lansoprazole	Lansoprazole, sold under the brand name Prevacid among others, is a medication which reduces stomach acid. It is used to treat peptic ulcer disease, gastroesophageal reflux disease, and Zollinger–Ellison syndrome. Effectiveness is similar to other proton pump inhibitors (PPIs). It is taken by mouth. Onset is over a few hours and effects last up to a couple of days.Common side effects include constipation, abdominal pain, and nausea. Serious side effects may include osteoporosis, low blood magnesium, Clostridium difficile infection, and pneumonia. Use in pregnancy and breastfeeding is of unclear safety. It works by blocking H+/K+-ATPase in the parietal cells of the stomach.Lansoprazole was patented in 1984 and came into medical use in 1992. It is available as a generic medication. In 2017, it was the 188th most commonly prescribed medication in the United States, with more than three million prescriptions. Medical uses Lansoprazole is used for treatment of: Ulcers of the stomach and duodenum, and NSAID-induced ulcers Helicobacter pylori infection, alongside antibiotics (adjunctive treatment), treatment to kill H. pylori causing ulcers or other problems involves using two other drugs besides lansoprazole known as "triple therapy", and involves taking twice daily for 10 or 14 days lansoprazole, amoxicillin, and clarithromycin Gastroesophageal reflux disease Zollinger–Ellison syndromeThere is no good evidence that it works better than other PPIs. Side effects Side effects of PPIs in general and lansoprazole in particular may include: Common: diarrhea, abdominal pain Infrequent: dry mouth, insomnia, drowsiness, blurred vision, rash, pruritus Rarely and very rarely: taste disturbance, liver dysfunction, peripheral oedema, hypersensitivity reactions (including bronchospasm, urinary, angioedema, anaphylaxis), photosensitivity, fever, sweating, depression, interstitial nephritis, blood disorders (including leukopenia, leukocytosis, pancytopenia, thrombocytopenia), arthralgia, myalgia, skin reactions including (erythroderma, Stevens–Johnson syndrome, toxic epidermal necrolysis, bullous eruption)PPIs may be associated with a greater risk of hip fractures and Clostridium difficile-associated diarrhea.: 22 Interactions Lansoprazole interacts with several other drugs, either due to its own nature or as a PPI. PPIs reduce absorption of antifungals (itraconazole and ketoconazole) and possibly increase digoxin in plasma Increases plasma concentrations of cilostazol (risk of toxicity)Lansoprazole possibly interacts with, among other drugs: sucralfate ampicillin bisacodyl clopidogrel delavirdine fluvoxamine iron salts voriconazole aminophylline and theophylline astemizole Chemistry It is a racemic 1:1 mixture of the enantiomers dexlansoprazole and levolansoprazole. Dexlansoprazole is an enantiomerically pure active ingredient of a commercial drug as a result of the enantiomeric shift. Lansoprazoles plasma elimination half-life (1.5 h) is not proportional to the duration of the drugs effects to the person (i.e. gastric acid suppression). History Lansoprazole was originally synthesized at Takeda and was given the development name AG 1749. Takeda patented it in 1984 and the drug launched in 1991. In the United States, it was approved for medical use in 1995. Society and culture Patents The lansoprazole molecule is off-patent and so generic drugs are available under many brand names in many countries; there are patents covering some formulations in effect as of 2015. Patent protection expired on 10 November 2009. Availability Since 2009, lansoprazole has been available over the counter (OTC) in the U.S. as Prevacid 24HR and as Lansoprazole 24HR. In Australia, it is marketed by Pfizer as Zoton. Research In vitro experiments have shown that lansoprazole binds to the pathogenic form of tau protein. As of 2015 laboratory studies were underway on analogs of lansoprazole to explore their use as potential PET imaging agents for diagnosing tauopathies including Alzheimers disease. References External links "Lansoprazole". Drug Information Portal. U.S. National Library of Medicine.
Avanafil	Avanafil is a PDE5 inhibitor approved for erectile dysfunction by the FDA on April 27, 2012 and by EMA on June 21, 2013. Avanafil is sold under the brand names Stendra and Spedra. It was invented at Mitsubishi Tanabe Pharma, formerly known as Tanabe Seiyaku Co., and licensed to Vivus Inc., which partnered with Menarini Group to commercialise Spedra in over forty European countries, Australia, and New Zealand. Metuchen Pharmaceuticals obtained exclusive rights within the United States.Avanafil acts by inhibiting a specific phosphodiesterase type 5 enzyme found in various body tissues, primarily in the corpus cavernosum penis. Other similar drugs are sildenafil, tadalafil and vardenafil. The advantage of avanafil is that it has very fast onset of action compared with other PDE5 inhibitors. It is absorbed quickly, reaching a maximum serum concentration in about thirty to forty-five minutes. About two-thirds of the participants were able to engage in sexual activity within fifteen minutes. Medical use Avanafil is used to treat erectile dysfunction (ED). Adverse effects Although avanafil is generally well tolerated, dose dependent adverse effects can occur. The most common adverse effects include headache, flushing, nasopharynigitis, nasal congestion, and back pain. While it is also uncommon, there is a potential for visual disturbances to occur in patients. Mechanism of action Avanafil inhibits phosphodiesterase-5, preventing the degradation of cGMP. The increased levels of cGMP causes vasodilation, resulting in an increased blood flow in the penis. Avanafils mechanism of action takes places once nitric oxide is released, in association with sexual stimulation. Synthesis Avanafil can be synthesized from a benzylamine derivative and a pyrimidine derivative: References External links "Avanafil". Drug Information Portal. U.S. National Library of Medicine.
Bisoprolol	Bisoprolol, sold under the brand name Zebeta among others, is a beta blocker medication used for heart diseases. This includes high blood pressure, chest pain from not enough blood flow to the heart, and heart failure. It is taken by mouth.Common side effects include headache, feeling tired, diarrhea, and swelling in the legs. More severe side effects include worsening asthma, blocking the ability to recognize low blood sugar, and worsening heart failure. There are concerns that use during pregnancy may be harmful to the baby. Bisoprolol is in the beta blocker family of medications and is of the β1 selective type.Bisoprolol is on the World Health Organizations List of Essential Medicines. Bisoprolol is available as a generic medication. In 2019, it was the 249th most commonly prescribed medication in the United States, with more than 1 million prescriptions. Medical uses Bisoprolol is currently used for prevention of cardiovascular events following a heart attack in patients with risk factors for disease progression, in the management of congestive heart failure with reduced ejection fraction, and as a second-line agent for hypertension.Bisoprolol may be beneficial in the treatment of high blood pressure, but it is not recommended as a first-line anti-hypertensive agent without an accompanying comorbid condition, for example, congestive heart failure.In cardiac ischemia, the drug is used to reduce the activity of the heart muscle, so reduced oxygen and nutrient demand, and reduced blood supply can still transport sufficient amounts of oxygen and nutrients. Side effects An overdose of bisoprolol can lead to fatigue, hypotension, hypoglycemia, bronchospasms, and bradycardia. Bronchospasms and hypoglycemia occur because at high doses, the drug can be an antagonist for β2 adrenergic receptors located in the lungs and liver. Bronchospasm occurs due to the blockage of β2 receptors in the lungs. Hypoglycemia occurs due to decreased stimulation of glycogenolysis and gluconeogenesis in the liver via β2 receptors. Cautions Non-selective beta-blockers should be avoided in people with asthma or bronchospasm as they may cause exacerbations and worsening of symptoms. A β1 selective beta-blocker like bisoprolol may be cautiously tried in those with controlled, mild-to-moderate asthma with cardiac comorbidities. A 2014 meta-analysis found that cardioselective beta-blockers may cause detrimental changes in lung function and partially blunts β2-agonist response. However, a 2017 control study found no significant association with asthma exacerbations by dose and exposure duration while a 2020 clinical trial found bisoprolol being non-inferior to placebo in bronchodilator response to salbutamol. Pharmacology Mechanism of action Bisoprolol is cardioprotective because it selectively and competitively blocks catecholamine (adrenaline) stimulation of β1 adrenergic receptors (adrenoreceptors), which are mainly found in the heart muscle cells and heart conduction tissue (cardiospecific), but also found in juxtaglomerular cells in the kidney. Normally, adrenaline and noradrenaline stimulation of the β1 adrenoreceptor activates a signalling cascade (Gs protein and cAMP) which ultimately leads to increased myocardial contractility and increased heart rate of the heart muscle and heart pacemaker, respectively. Bisoprolol competitively blocks the activation of this cascade, so decreases the adrenergic tone/stimulation of the heart muscle and pacemaker cells. Decreased adrenergic tone shows less contractility of heart muscle and lowered heart rate of pacemakers. β1-selectivity Bisoprolol β1-selectivity is especially important in comparison to other nonselective beta blockers. The effects of the drug are limited to areas containing β1 adrenoreceptors, which is mainly the heart and part of the kidney. Bisoprolol, whilst β1 adrenoceptor selective can help patients to avoid certain side-effects associated with non-selective beta-blocker activity at additional adrenoceptors (α1 and β2), it does not signify its superiority in treating beta-blocker indicated cardiac conditions such as heart failure but could prove beneficial to patients with specific comorbidities.Bisoprolol has a higher degree of β1-selectivity compared to atenolol, metoprolol and betaxolol. With a selectivity ranging from being 11-15 times more selective for β1over β2 However nebivolol is approximately 3.5 times more β1-selective. Renin-angiotensin system Bisoprolol inhibits renin secretion by about 65% and tachycardia by about 30%. Pharmacokinetics After ingestion, bisoprolol is absorbed and has a high bioavailability of approximately 90% with plasma half-life of 10-12 hours. When being eliminated, the body evenly distributes it (50–50) between kidney excretion and liver biotransformation (then excreted).Bisoprolol has both lipid- and water-soluble properties.The plasma protein binding of bisoprolol is approximately 35%, the volume of distribution is 3.5 L/kg and the total clearance is approximately 15 L/h. Bisoprolol is eliminated from the body in two ways - 50% of the substance is converted in the liver to inactive metabolites, which are then excreted in the kidneys. The remaining 50% is eliminated unchanged via the kidneys. Since elimination is equal in liver and kidney, no dose adjustment is required in patients with hepatic or renal impairment. The pharmacokinetics of bisoprolol are linear and independent of age.In patients with chronic heart failure (NYHA stage III), the plasma level of bisoprolol is higher and the half-life is longer than in healthy subjects. At a daily dose of 10 mg, the steady-state peak plasma concentration is 64±21 ng/mL and the half-life is 17±5 hours. History Bisoprolol was patented in 1976 and approved for medical use in 1986. It was approved for medical use in the United States in 1992. Brand names In India, it is sold under trade name Bisotab and is available in 2 strengths of 2.5 mg and 5 mg.In Italy, it is sold under trade name Congescor and is available in 6 strengths of 1.25 mg, 2.5 mg, 3.75 mg, 5 mg, 7.5 mg and 10 mg. In Germany and Eastern Europe bisoprolol is marketed as Bisoprolol-ratiopharm by Ratiopharm (Teva). References External links "Bisoprolol". Drug Information Portal. U.S. National Library of Medicine.
Tabloid	Tabloid may refer to: Tabloid journalism, a type of journalism Tabloid (newspaper format), a newspaper with compact page size Chinese tabloid Tabloid (paper size), a North American paper size Sopwith Tabloid, a biplane aircraft Tabloid (film), a 2010 documentary by Errol Morris Tabloid (TV series), a Canadian television series See also The Tabloid (Matlock episode), 1994 episode of the television show Matlock Tabloid Magazine (disambiguation)
Contraceptive patch	A contraceptive patch, also known as "the patch", is a transdermal patch applied to the skin that releases synthetic oestrogen and progestogen hormones to prevent pregnancy. They have been shown to be as effective as the combined oral contraceptive pill with perfect use, and the patch may be more effective in typical use.Xulane and Twirla are approved for use in the United States. Evra is approved for use in Canada and marketed by Janssen Inc., and it is approved for use in the United Kingdom and in Europe and marketed by Janssen-Cilag. The patches are packaged in boxes of three and are only available by prescription. Medical uses Because the patch works similar to that of birth control pills, many of the benefits are the same. For example, the patch may make a womans period lighter and more regular. It may also help to clear acne, decrease cramps, and reduce PMS symptoms. Additionally, the patch is associated with an increased protection against iron deficiency anemia, ovarian cysts, pelvic inflammatory disease, and endometrial and ovarian cancer.The patch is a simple and convenient form of birth control that requires weekly attention. When a woman stops using the patch, her ability to become pregnant returns quickly. Side effects In three large clinical trials involving a total of 3,330 women using the Ortho Evra / Evra patch for up to one year, 12% of users discontinued the patch because of adverse events. The most frequent adverse events leading to patch discontinuation were: nausea and/or vomiting (2.4%), application site reaction (1.9%), breast discomfort, engorgement or pain (1.9%), headache (1.1%), and emotional lability (1.0%).The most frequent adverse events reported while using the Ortho Evra / Evra patch were: breast discomfort, engorgement or pain (22%), headache (21%), application site reaction (17%), nausea (17%), upper respiratory tract infection (10%), menstrual cramps (10%), and abdominal pain (9%).Breakthrough bleeding and/or spotting while using the Ortho Evra / Evra patch was reported by: 18% in cycle 1, 12% in cycle 3, 8% in cycle 6 and cycle 13. Breakthrough bleeding (requiring more than one pad or tampon per day) was reported by: 4% in cycle 1, 3% in cycle 3 and cycle 6, and 1% in cycle 13.Overall, side effects that tend to go away after two or three months include bleeding between periods, breast tenderness, and nausea and vomiting. Symptoms that may last longer include skin irritation around the area where the patch is placed and a change in the womans sexual desires.Additional side effect information is provided in the Ortho Evra label information and the Evra Summary of Product Characteristics (SPC) and PIL. Interactions and contraindications Contraceptive effectiveness of the patch or any other hormonal contraceptive may be reduced significantly if administered alongside various antibiotics, antifungals, anticonvulsants, or other drugs that increase metabolism of contraceptive steroids.However, despite the interactions with many other antibiotics, a clinical pharmacokinetic drug interaction study showed that oral administration of tetracycline HCl 500 mg for three days prior to and seven days during use of Ortho Evra "did not reduce effectiveness of Ortho Evra." This is a significant factor in the common decision to administer tetracycline-derived antibiotics following an abortion (preventatively to fight potential infection) when synthetic hormone contraceptives are to be used afterwards.Drugs containing St. Johns wort are also known to affect the effectiveness of hormonal contraceptives.It has also been found that the patch is less effective in women who weigh more than 198 pounds (90 kg). The contraceptive patch and other combination hormonal contraceptives are contraindicated in women older than 35 years who smoke cigarettes.The contraceptive patch is contraindicated for use in women with a BMI ≥ 30 kg/m2. Thromboembolism All combined hormonal birth control products have a very small increased risk of serious or fatal thromboembolic events. There is ongoing research into the thromboembolic risks of Ortho Evra as compared to combined oral contraceptive pills. A recent study found that users of the contraceptive patch may have a twofold increased risk for non-fatal venous thromboembolic events compared with women who took a norgestimate-containing oral contraceptive with 35 µg of estrogen. However, a different study concluded that the risk of nonfatal venous thromboembolism for the contraceptive patch is similar to the risk for oral contraceptives containing 35 µg of ethinylestradiol and norgestimate. The contradiction in findings between the two studies is not easily resolved, because the confidence intervals for the studies are overlapping. In studies with oral contraceptives, the risk for cardiovascular disease (such as thromboembolism) is significantly increased in women over the age of 35 years who also smoke tobacco. Hence, Ortho Evras package insert states: "Women who use hormonal contraceptives, including Ortho Evra, should be strongly advised not to smoke." According to the manufacturer, the patches introduce a 60% higher level of estrogen into the bloodstream as compared to oral contraceptives; however, the clinical significance of this difference is unknown.On November 10, 2005, Ortho McNeil, in conjunction with the FDA, revised the label for Ortho Evra, including a new bolded warning about higher exposure to estrogen for women using the weekly patch compared to taking a daily birth control pill containing 35 µg of estrogen, noting that higher levels of estrogen may put some women at increased risk for getting blood clots. The label was again revised in September 2006, and on January 18, 2008, the FDA again updated the label to reflect study results: "The FDA believes that Ortho Evra is a safe and effective method of contraception when used according to the labeling, which recommends that women with concerns or risk factors for serious blood clots talk with their health care provider about using Ortho Evra versus other contraceptive options." Method of use The patch is first applied onto the upper outer arm, buttocks, abdomen or thigh on either the first day of the menstrual cycle (day 1) or on the first Sunday following that day, whichever is preferred. The day of application is known from that point as patch change day. Seven days later, when patch change day comes again, the user removes the patch and applies another to one of the approved locations on the body. This process is repeated again on the next patch change day. On the following patch change day, the patch is removed and not replaced. The user waits seven days without a patch in place, and on the next patch change day they apply a new patch. Extended use regimens, where patches are used for several weeks before a patch-free week, have been studied.The patch should be applied to skin that is clean, dry, and intact. This means if skin is red, irritated, or cut, the patch should not be placed in that area. Additionally, avoid using lotions, powder, or makeup around the area where the patch is or will be placed. Backup contraception If someone chooses to begin with their patch change day as day one of their menstrual cycle, the patch is able to take effect in time to prevent ovulation (see Mechanism of Action below) and no form of backup contraception is needed at all. In the case that one wishes to begin using the contraceptive patch following a first trimester abortion or miscarriage, patch application can be done immediately afterwards. This can be considered the same as a day one start above, and no backup contraception is required. If a user chooses to begin with their patch change day as the first Sunday following day 1, it is necessary to use a backup form of contraception such as spermicide or condoms for the first week of patch wear. If the user is late placing her patch in the first week, or more than two days late placing the patch in the second and third weeks, they should apply the patch immediately, and then use a backup form of barrier protection for a week. Mechanism of action Like all combined hormonal contraceptives, Ortho Evra / Evra works primarily by preventing ovulation. A secondary mechanism of action is inhibition of sperm penetration by changes in the cervical mucus. Hormonal contraceptives also have effects on the endometrium that theoretically could affect implantation; however, no scientific evidence indicates that prevention of implantation actually results from their use.The 20 cm2 Ortho Evra contraceptive patch contains 750 µg ethinylestradiol (an estrogen) and 6000 µg norelgestromin (a progestin). The 20 cm2 Evra contraceptive patch contains 600 µg ethinylestradiol and 6000 µg norelgestromin. The Ortho Evra contraceptive patch and the Evra contraceptive patch are both intended to gradually release into the systemic circulation approximately 20 µg/day of ethinylestradiol and 150 µg/day of norelgestromin. Lawsuits The patch has been associated with strokes and thrombosis and the mechanism for hormone absorption and dissipation from the bodys tissues is different from "the pill". Several lawsuits have been instigated over these issues.A lawsuit filed in Federal Court in New Jersey on September 2, 2005, by a Georgia woman who had a pulmonary embolism alleges the company promoted the patch despite knowledge of its health risks, for financial gain, while failing to warn of the risks of blood clots and other injuries.The parents of a 14-year-old girl from Wisconsin have filed a lawsuit against Johnson & Johnson because they claim that she died from a blood clot that arose from her use of the patch. References External links "Ethinyl Estradiol mixture with norelgestromin". Drug Information Portal. U.S. National Library of Medicine. Feminist Womens Health Center Planned Parenthood: The Patch
Recombinant factor VIIa	Recombinant factor VIIa also known as eptacog alfa (INN), and sold under the brand name NovoSeven among others, is a form of blood factor VII that has been manufactured via recombinant technology. It is administered intravenously (IV). Medical uses NovoSeven is approved for use in the United States and is indicated for the treatment of bleeding episodes and for the prevention of bleeding in surgical interventions or invasive procedures in patients with acquired hemophilia.NovoSeven RT is approved in the United States and is indicated for the treatment of bleeding episodes and peri-operative management in adults and children with hemophilia A or B with inhibitors, congenital Factor VII (FVII) deficiency, and Glanzmanns thrombasthenia with refractoriness to platelet transfusions, with or without antibodies to platelets and for the treatment of bleeding episodes and peri-operative management in adults with acquired hemophilia.Sevenfact [coagulation factor VIIa (recombinant)-jncw] is approved for use in the United States and is indicated for the treatment and control of bleeding episodes occurring in adults and adolescents twelve years of age and older with hemophilia A or B with inhibitors (neutralizing antibodies).As of 2012, recombinant factor VIIa is not supported by the evidence for treating most cases of major bleeding. There is a significant risk of arterial thrombosis with its use and thus, other than in those with factor VII deficiency, it should only be given in clinical trials. Recombinant human factor VII, while initially looking promising in intracerebral hemorrhage, failed to show benefit following further study and is no longer recommended.In people with hemophilia type A and B who have a deficiency of factors VIII and IX, these two factors are administered for controlling bleeding or as prophylaxis medication before starting surgeries. However, in some cases they subsequently develop neutralizing antibodies, called inhibitors, against the drug. These inhibitors often increase over time and inhibit the action of coagulation in the body. Recombinant factor VIIa, which is an activated form of factor VII, bypasses factors VIII and IX and causes coagulation without the need for factors VIII and IX. It cant be given without inhibitor. It is important for some patients to shift to proper blood factors according to their inhibitor titer. Other indications include use for patients with acquired hemophilia, people born with a deficiency of factor VII, and people with Glanzmanns thrombasthenia. Pharmacology Mechanism of action This treatment results in activation of the extrinsic pathway of blood coagulation. Coagulation factor VIIa (recombinant)-jncw Coagulation factor VIIa (recombinant)-jncw (Sevenfact) is expressed in the mammary gland of genetically engineered rabbits and secreted into the rabbits milk. During purification and processing of the milk, FVII is converted into activated FVII (FVIIa). The recombinant DNA (rDNA) construct in the genetically engineered rabbits used for the production of Sevenfact was approved by the FDAs Center for Veterinary Medicine.The safety and efficacy of coagulation factor VIIa (recombinant)-jncw were determined using data from a clinical study that evaluated 27 patients with hemophilia A or B with inhibitors, which included treatment of 465 mild or moderate, and three severe bleeding episodes. The study assessed the efficacy of treatment twelve hours after the initial dose was given. The proportion of mild or moderate bleeding episodes treated successfully both with the lower dose of 75mcg/kg and higher dose of 225 mcg/kg (requiring no further treatment for the bleeding episode, no administration of blood products and no increase in pain beyond 12 hours from initial dose) was approximately 86%. The study also included three severe bleeding episodes that were treated successfully with the higher dose.Another study evaluated the safety and pharmacokinetics of three escalating doses of coagulation factor VIIa (recombinant)-jncw in 15 subjects with severe hemophilia A or B with or without inhibitors. Results from this study were used to select the two doses, 75mcg/kg and 225 mcg/kg, that were evaluated in the study described above.The most common side effects of coagulation factor VIIa (recombinant)-jncw are headache, dizziness, infusion site discomfort, infusion related reaction, infusion site hematoma and fever.Coagulation factor VIIa (recombinant)-jncw is contraindicated in those with known allergy or hypersensitivity to rabbits or rabbit proteins. Society and culture Legal status NovoSeven was approved for use in the United States in March 1999, and indicated for the treatment of bleeding episodes in hemophilia A or B patients with inhibitors to Factor VIII or Factor IX. It was approved in October 2006, and indicated for the treatment of bleeding episodes and for the prevention of bleeding in surgical interventions or invasive procedures in patients with acquired hemophilia.NovoSevenRT was approved for use in the United States in May 2008, as a room temperature stable formulation. In January 2010, the label was updated to include a black box warning on serious thrombotic adverse events associated with the use of NovoSeven RT outside labeled indications.In April 2020, coagulation factor VIIa (recombinant)-jncw (Sevenfact) was approved for use in the United States.On 19 May 2022, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) adopted a positive opinion, recommending the granting of a marketing authorization for the medicinal product Cevenfacta, intended for the treatment of bleeding episodes. The applicant for this medicinal product is Laboratoire français du Fractionnement et des Biotechnologies (LFB). The active substance of Cevenfacta is eptacog beta (activated), a blood coagulation factor (ATC code: B02BD08). Eptacog beta is almost identical to, and functions like, coagulation factor VII. It activates factor X, which starts the clotting process and thereby provides control of the bleeding. Because factor VII acts directly on factor X, independently from factors VIII and IX, Cevenfacta can be used to restore haemostasis in their absence or in the presence of inhibitors. Military use rFVIIa was used routinely in severely wounded American troops during the Iraq War, credited with saving many lives but also resulting in a high number of deep venous thromboses and pulmonary emboli, as well as unexpected strokes, heart attacks, and deaths. References Further reading Croom KF, McCormack PL (2008). "Recombinant factor VIIa (eptacog alfa): a review of its use in congenital hemophilia with inhibitors, acquired hemophilia, and other congenital bleeding disorders". BioDrugs. 22 (2): 121–36. doi:10.2165/00063030-200822020-00005. PMID 18345709. S2CID 25678733. Ng HJ, Lee LH (2006). "Recombinant activated clotting factor VII (rFVIIa) in the treatment of surgical and spontaneous bleeding episodes in hemophilic patients". Vasc Health Risk Manag. 2 (4): 433–40. doi:10.2147/vhrm.2006.2.4.433. PMC 1994012. PMID 17323597. External links "Recombinant FVIIa". Drug Information Portal. U.S. National Library of Medicine. "Eptacog alfa". Drug Information Portal. U.S. National Library of Medicine.
Polio vaccine	Polio vaccines are vaccines used to prevent poliomyelitis (polio). Two types are used: an inactivated poliovirus given by injection (IPV) and a weakened poliovirus given by mouth (OPV). The World Health Organization (WHO) recommends all children be fully vaccinated against polio. The two vaccines have eliminated polio from most of the world, and reduced the number of cases reported each year from an estimated 350,000 in 1988 to 33 in 2018.The inactivated polio vaccines are very safe. Mild redness or pain may occur at the site of injection. Oral polio vaccines cause about three cases of vaccine-associated paralytic poliomyelitis per million doses given. This compares with 5,000 cases per million who are paralysed following a polio infection. Both types of vaccine are generally safe to give during pregnancy and in those who have HIV/AIDS but are otherwise well. However, the emergence of circulating vaccine-derived poliovirus (cVDPV), a form of the vaccine virus that has reverted to causing poliomyelitis, has led to the development of novel oral polio vaccine type 2 (nOPV2) which aims to make the vaccine safer and thus stop further outbreaks of cVDPV2.The first successful demonstration of a polio vaccine was by Hilary Koprowski in 1950, with a live attenuated virus which people drank. The vaccine was not approved for use in the United States, but was used successfully elsewhere. The success of an inactivated (killed) polio vaccine, developed by Jonas Salk, was announced in 1955. Another attenuated live oral polio vaccine was developed by Albert Sabin and came into commercial use in 1961.Polio vaccine is on the World Health Organizations List of Essential Medicines. Medical uses Interruption of person-to-person transmission of the virus by vaccination is important in global polio eradication, since no long-term carrier state exists for poliovirus in individuals with normal immune function, polio viruses have no non-primate reservoir in nature, and survival of the virus in the environment for an extended period of time appears to be remote. There are two types of vaccine: inactivated polio vaccine (IPV) and oral polio vaccine (OPV). Inactivated When the IPV (injection) is used, 90% or more of individuals develop protective antibodies to all three serotypes of polio virus after two doses of inactivated polio vaccine (IPV), and at least 99% are immune to polio virus following three doses. The duration of immunity induced by IPV is not known with certainty, although a complete series is thought to provide protection for many years. IPV replaced the oral vaccine in many developed countries in the 1990s mainly due to the (small) risk of vaccine-derived polio in the oral vaccine. Attenuated Oral polio vaccines were easier to administer than IPV, as it eliminated the need for sterile syringes and therefore was more suitable for mass vaccination campaigns. OPV also provided longer-lasting immunity than the Salk vaccine, as it provides both humoral immunity and cell-mediated immunity.One dose of OPV produces immunity to all three poliovirus serotypes in roughly 50% of recipients. Three doses of live-attenuated OPV produce protective antibodies to all three poliovirus types in more than 95% of recipients. OPV produces excellent immunity in the intestine, the primary site of wild poliovirus entry, which helps prevent infection with wild virus in areas where the virus is endemic. The live virus used in the vaccine can rarely shed in the stool and can rarely spread to others within a community. The live virus also has stringent requirements for transport and storage, which are a problem in some hot or remote areas. As with other live-virus vaccines, immunity initiated by OPV is probably lifelong.The trivalent (against wild types 1, 2, and 3) OPV has been used to nearly eradicate polio infection worldwide. Led by the Global Polio Eradication Initiative, 155 countries switched to use the bivalent (against wild types 1 and 3) between 17 April and 1 May 2016. The bivalent OPV is more effective against types 1 and 3, but does not cover type 2. The United States as of 2017 continues to recommend the use of a trivalent version, but a fully inactivated version. The switch to the bivalent vaccine and associated missing immunity against type 2 strains, among other factors, led to outbreaks of circulating vaccine-derived poliovirus type 2(cVDPV2), which increased from 2 cases in 2016 to 1037 cases in 2020. As a response, a novel oral polio vaccine type 2 (nOPV2) was developed with the aim to provide a safer form of vaccination against type 2 strains with less risk of reverting to infectious polio. Schedule In countries with endemic polio or where the risk of imported cases is high, the WHO recommends OPV vaccine at birth followed by a primary series of three OPV doses and at least one IPV dose starting at 6 weeks of age, with a minimum of 4 weeks between OPV doses. In countries with >90% immunization coverage and low risk of importation, the WHO recommends one or two IPV doses starting at 2 months of age followed by at least two OPV doses, with the doses separated by 4–8 weeks depending on the risk of exposure. In countries with the highest levels of coverage and the lowest risks of importation and transmission, the WHO recommends a primary series of three IPV injections, with a booster dose after an interval of six months or more if the first dose was administered before 2 months of age. Side effects The inactivated polio vaccines are very safe. Mild redness or pain may occur at the site of injection. Oral polio vaccine results in vaccine-associated paralytic poliomyelitis in about three per million doses. They are generally safe to give to those who are pregnant, and those who have HIV/AIDS, but who are otherwise well. Allergic reaction to the vaccine Inactivated polio vaccine can cause an allergic reaction in a few people since the vaccine contains trace amounts of antibiotics, streptomycin, polymyxin B, and neomycin. It should not be given to anyone who has an allergic reaction to these medicines. Signs and symptoms of an allergic reaction, which usually appear within minutes or a few hours after receiving the injected vaccine, include breathing difficulties, weakness, hoarseness or wheezing, heart rate fluctuations, skin rash and dizziness. Vaccine-induced polio A potential, adverse effect of the OPV is its known ability to recombine to a form that causes neurological infection and paralysis. This genetic reversal of the pathogen to a virulent form takes a considerable time (at least 12 months) and does not affect the person who was originally vaccinated. The vaccine-derived attenuated virus is normally excreted from vaccinated people for a limited period. Thus, in areas with poor sanitation and low vaccination coverage, the spontaneous reversal of the vaccine-derived virus to a virulent form and its spreading in the environment can lead to unvaccinated people becoming infected. Clinical disease, including paralysis, caused by vaccine-derived poliovirus (VDPV) is indistinguishable from that caused by wild polioviruses. Outbreaks of vaccine-associated paralytic poliomyelitis (VAPP), caused by a circulating vaccine-derived poliovirus (cVDPV), have been reported, and tend to occur in areas of low coverage by OPV, presumably because the OPV is itself protective against the related outbreak strain. With wild polio cases at record lows, 2017 was the first year where more cases of cVDPV were recorded than the wild poliovirus, a trend that is expected to continue.To combat this, the WHO in 2016, decided to switch from the trivalent polio vaccine to the bivalent polio vaccine. This vaccine no longer contains the type 2 polio virus because it was eradicated in 1999. Contamination concerns In 1960, the rhesus monkey kidney cells used to prepare the poliovirus vaccines were determined to be infected with the simian virus-40 (SV40), which was also discovered in 1960 and is a naturally occurring virus that infects monkeys. In 1961, SV40 was found to cause tumors in rodents. More recently, the virus was found in certain forms of cancer in humans, for instance brain and bone tumors, pleural and peritoneal mesothelioma, and some types of non-Hodgkin lymphoma. However, SV40 has not been determined to cause these cancers.SV40 was found to be present in stocks of the injected form of the IPV in use between 1955 and 1963. It is not found in the OPV form. Over 98 million Americans received one or more doses of polio vaccine between 1955 and 1963 when a proportion of vaccine was contaminated with SV40; an estimated 10–30 million Americans may have received a dose of vaccine contaminated with SV40. Later analysis suggested that vaccines produced by the former Soviet bloc countries until 1980, and used in the USSR, China, Japan, and several African countries, may have been contaminated, meaning hundreds of millions more may have been exposed to SV40.In 1998, the National Cancer Institute undertook a large study, using cancer case information from the institutes SEER database. The published findings from the study revealed no increased incidence of cancer in persons who may have received vaccine containing SV40. Another large study in Sweden examined cancer rates of 700,000 individuals who had received potentially contaminated polio vaccine as late as 1957; the study again revealed no increased cancer incidence between persons who received polio vaccines containing SV40 and those who did not. The question of whether SV40 causes cancer in humans remains controversial, however, and the development of improved assays for detection of SV40 in human tissues will be needed to resolve the controversy. During the race to develop an oral polio vaccine, several large-scale human trials were undertaken. By 1958, the National Institutes of Health had determined that OPV produced using the Sabin strains were the safest. Between 1957 and 1960, however, Hilary Koprowski continued to administer his vaccine around the world. In Africa, the vaccines were administered to roughly one million people in the Belgian territories (now the Democratic Republic of the Congo, Rwanda, and Burundi). The results of these human trials have been controversial, and unfounded accusations in the 1990s arose that the vaccine had created the conditions necessary for transmission of simian immunodeficiency virus from chimpanzees to humans, causing HIV/AIDS. These hypotheses, however, have been conclusively refuted. By 2004, cases of poliomyelitis in Africa had been reduced to just a small number of isolated regions in the western portion of the continent, with sporadic cases elsewhere. Recent local opposition to vaccination campaigns have evolved due to lack of adequate information, often relating to fears that the vaccine might induce sterility. The disease has since resurged in Nigeria and in several other African nations without necessary information, which epidemiologists believe is due to refusals by certain local populations to allow their children to receive the polio vaccine. Manufacture Inactivated The Salk vaccine, IPV, is based on three wild, virulent reference strains, Mahoney (type 1 poliovirus), MEF-1 (type 2 poliovirus), and Saukett (type 3 poliovirus), grown in a type of monkey kidney tissue culture (Vero cell line), which are then inactivated with formalin. The injected Salk vaccine confers IgG-mediated immunity in the bloodstream, which prevents polio infection from progressing to viremia and protects the motor neurons, thus eliminating the risk of bulbar polio and post-polio syndrome. In the United States, vaccine is administered along with the tetanus, diphtheria, and acellular pertussis vaccines (DTaP) and a pediatric dose of hepatitis B vaccine. In the UK, IPV is combined with tetanus, diphtheria, pertussis, and Haemophilus influenzae type b vaccines. Attenuated OPV is an attenuated vaccine, produced by the passage of the virus through nonhuman cells at a subphysiological temperature, which produces spontaneous mutations in the viral genome. Oral polio vaccines were developed by several groups, one of which was led by Albert Sabin. Other groups, led by Hilary Koprowski and H.R. Cox, developed their own attenuated vaccine strains. In 1958, the National Institutes of Health created a special committee on live polio vaccines. The various vaccines were carefully evaluated for their ability to induce immunity to polio, while retaining a low incidence of neuropathogenicity in monkeys. Large-scale clinical trials performed in the Soviet Union in late 1950s to early 1960s by Mikhail Chumakov and his colleagues demonstrated safety and high efficacy of the vaccine. Based on these results, the Sabin strains were chosen for worldwide distribution. Fifty-seven nucleotide substitutions distinguish the attenuated Sabin 1 strain from its virulent parent (the Mahoney serotype), two nucleotide substitutions attenuate the Sabin 2 strain, and 10 substitutions are involved in attenuating the Sabin 3 strain. The primary attenuating factor common to all three Sabin vaccines is a mutation located in the viruss internal ribosome entry site, which alters stem-loop structures and reduces the ability of poliovirus to translate its RNA template within the host cell. The attenuated poliovirus in the Sabin vaccine replicates very efficiently in the gut, the primary site of infection and replication, but is unable to replicate efficiently within nervous system tissue. In 1961, type 1 and 2 monovalent oral poliovirus vaccine (MOPV) was licensed, and in 1962, type 3 MOPV was licensed. In 1963, trivalent OPV (TOPV) was licensed, and became the vaccine of choice in the United States and most other countries of the world, largely replacing the inactivated polio vaccine. A second wave of mass immunizations led to a further dramatic decline in the number of polio cases. Between 1962 and 1965, about 100 million Americans (roughly 56% of the population at that time) received the Sabin vaccine. The result was a substantial reduction in the number of poliomyelitis cases, even from the much-reduced levels following the introduction of the Salk vaccine.OPV is usually provided in vials containing 10–20 doses of vaccine. A single dose of oral polio vaccine (usually two drops) contains 1,000,000 infectious units of Sabin 1 (effective against PV1), 100,000 infectious units of the Sabin 2 strain, and 600,000 infectious units of Sabin 3. The vaccine contains small traces of antibiotics—neomycin and streptomycin—but does not contain preservatives. History In a generic sense, vaccination works by priming the immune system with an immunogen. Stimulating immune response, by use of an infectious agent, is known as immunization. The development of immunity to polio efficiently blocks person-to-person transmission of wild poliovirus, thereby protecting both individual vaccine recipients and the wider community.The development of two polio vaccines led to the first modern mass inoculations. The last cases of paralytic poliomyelitis caused by endemic transmission of wild virus in the United States occurred in 1979, with an outbreak among the Amish in several Midwest states. 1930s In the 1930s, poliovirus was perceived as especially terrifying, as little was known of how the disease was transmitted or how it could be prevented. This virus was also notable for primarily impacting affluent children, making it a prime target for vaccine development, despite its relatively low mortality and morbidity. Despite this, the community of researchers in the field thus far had largely observed an informal moratorium on any vaccine development as it was perceived to present too high a risk for too little likelihood of successThis shifted in the early 1930s when American groups took up the challenge: Maurice Brodie led a team from the public health laboratory of the city of New York and Dr. John A. Kolmer collaborated with the Research Institute of Cutaneous Medicine in Philadelphia. The rivalry between these two researchers lent itself to a race-like mentality which, combined with a lack of oversight of medical studies, was reflected in the methodology and outcomes of each of these early vaccine development ventures. Kolmers live vaccine Kolmer began his vaccine development project in 1932 and ultimately focused on producing an attenuated or live virus vaccine. Inspired by the success of vaccines for rabies and yellow fever, he hoped to use a similar process to denature the polio virus. In order to go about attenuating his polio vaccine, he repeatedly passed the virus through monkeys. Using methods of production that were later described as "hair-raisingly amateurish, the therapeutic equivalent of bath-tub gin," Kolmer ground the spinal cords of his infected monkeys and soaked them in a salt solution. He then filtered the solution through mesh, treated it with ricinolate, and refrigerated the product for 14 days to ultimately create what would later be prominently critiqued as a "veritable witches brew".In keeping with the norms of the time, Kolmer completed a relatively small animal trial with 42 monkeys before proceeding to self experimentation in 1934. He tested his vaccine upon himself, his two children, and his assistant. He gave his vaccine to just 23 more children before declaring it safe and sending it out to doctors and health departments for a larger test of efficacy. By April 1935, he was able to report having tested the vaccine on 100 children without ill effect. Kolmers first formal presentation of results would not come about until November 1935 where he presented the results of 446 children and adults he had vaccinated with his attenuated vaccine. He also reported that together the Research Institute of Cutaneous Medicine and the Merrell Company of Cincinnati (the manufacturer who held the patent for his ricinoleating process) had distributed 12,000 doses of vaccine to some 700 physicians across the United States and Canada. Kolmer did not describe any monitoring of this experimental vaccination program nor did he provide these physicians with instructions in how to administer the vaccine or how to report side effects. Kolmer dedicated the bulk of his publications thereafter to explaining what he believed to be the cause of the 10+ reported cases of paralytic polio following vaccination, in many cases in towns where no polio outbreak had occurred. Six of these cases had been fatal. Kolmer had no control group but asserted that many more children would have gotten sick. Brodies inactivated vaccine At nearly the same time as Kolmers project, Maurice Brodie had joined immunologist Dr. William H. Park at the New York City Health Department where they worked together on poliovirus. With the aid of grant funding from the Presidents Birthday Ball Commission (a predecessor to what would become the March of Dimes), Brodie was able to pursue development of an inactivated or "killed virus" vaccine. Brodies process also began by grinding the spinal cords of infectious monkeys and then treating the cords with various germicides, ultimately finding a solution of formaldehyde to be the most effective. By the June 1, 1934, Brodie was able to publish his first scholarly article describing his successful induction of immunity in three monkeys with inactivated polio virus. Through continued study on an additional 26 monkeys, Brodie ultimately concluded that administration of live virus vaccine tended to result in humoral immunity while administration of killed virus vaccine tended to result in tissue immunity.Soon after, following a similar protocol to Kolmer, Brodie proceeded with self experimentation upon himself and his co-workers at the NYC Health Department laboratory. Brodies progress was eagerly covered by popular press as the public hoped for a successful vaccine to become available. Such reporting did not make mention of the 12 children in a New York City Asylum who were subjected to early safety trials. As none of the subjects experienced ill effects, Dr. Park, described by contemporaries as "never one to let grass grow under his feet," declared the vaccine safe. When a severe polio outbreak overwhelmed Kern County, California it became the first trial site for the new vaccine on very short notice. Between November 1934 - May 1935, over 1,500 doses of the vaccine were administered in Kern County. While initial results were very promising, insufficient staffing and poor protocol design left Brodie open to criticism when he published the California results in August 1935. Through private physicians, Brodie also conducted a broader field study, including 9,000 children who received the vaccine and 4,500 age- and location-matched controls who did not receive a vaccine. Again, results were promising. Of those who received the vaccine, only a few went on to develop polio. Most had been exposed prior to vaccination and none had received the full series of vaccine doses being studied. Additionally, a polio epidemic in Raleigh, North Carolina provided an opportunity for the U.S. Public Health Service to conduct a highly structured trial of the Brodie vaccine using funding from the Birthday Ball Commission. Academic reception While their work was ongoing, the larger community of bacteriologists began to raise concerns regarding the safety and efficacy of the new poliovirus vaccines. At this time there was very little oversight of medical studies, and ethical treatment of study participants largely relied upon moral pressure from peer academic scientists. Brodies inactivated vaccines faced scrutiny from many who felt killed virus vaccines could not be efficacious. While researchers were able to replicate the tissue immunity he had produced in his animal trials, prevailing wisdom was that humoral immunity was essential for an efficacious vaccine. Kolmer directly questioned the killed virus approach in scholarly journals. Kolmers studies however had raised even more concern with increasing reports of children becoming paralysed following vaccination with his live virus vaccine and notably, with paralysis beginning at the arm rather than the foot in many cases. Both Kolmer and Brodie were called to present their research at the Annual Meeting of the American Public Health Association in Milwaukee WI in October 1935. Additionally, Dr. Thomas M. Rivers was asked to discuss each of the presented papers as a prominent critic of the vaccine development effort. This resulted in the APHA arranging a Symposium on Poliomyelitis to be delivered at the Annual Meeting of their Southern Branch the following month. It was during the discussion at this meeting that Dr. James Leake of the U.S. Public Health Service stood to immediately present clinical evidence that the Kolmer vaccine had caused several deaths and then allegedly accused Kolmer of being a murderer. As Rivers recalled in his oral history, "All hell broke loose, and it seemed as if everybody was trying to talk at the same time....Jimmy Leake used the strongest language that I have ever heard used at a scientific meeting." In response to the attacks from all sides, Brodie was reported to have stood up and stated, "It looks as though, according to Dr. Rivers, my vaccine is no good, and, according to Dr. Leake, Dr Kolmers is dangerous." Kolmer simply responded by stating, "Gentlemen, this is one time I wish the floor would open up and swallow me." Ultimately, Kolmers live vaccine was undoubtedly shown to be dangerous and had already been withdrawn in September 1935 prior to the Milwaukee meeting. While the consensus of the symposium was largely sceptical of the efficacy of Brodies vaccine, its safety was not in question and the recommendation was for a much larger well-controlled trial. However, when three children became ill with paralytic polio following a dose of the vaccine, the directors of the Warm Springs Foundation in Georgia (acting as the primary funders for the project) requested it be withdrawn in December 1935. Following its withdrawal, the previously observed moratorium on human poliomyelitis vaccine development resumed and there would not be another attempt for nearly 20 years.While Brodie had arguably made the most progress in the pursuit of a poliovirus vaccine, he suffered the most significant career repercussions due to his status as a less widely known researcher. Modern researchers recognize that Brodie may well have developed an effective polio vaccine, however the basic science and technology of the time was insufficient to understand and utilize this breakthrough. Brodies work using formalin-inactivated virus would later become the basis for the Salk vaccine, but he would not live to see this success. Brodie was fired from his position within three months of the symposiums publication. While he was able to find another laboratory position, he died of a heart attack only three years later at age 36. By contrast, Park, who was believed in the community to be reaching senility at this point in his older age, was able to retire from his position with honors prior to his death in 1939. Kolmer, already an established and well respected researcher, returned to Temple University as a professor of medicine. Kolmer had a very productive career, receiving multiple awards, and publishing countless papers, articles, and textbooks up until his retirement in 1957. 1948 A breakthrough came in 1948 when a research group headed by John Enders at the Childrens Hospital Boston successfully cultivated the poliovirus in human tissue in the laboratory. This group had recently successfully grown mumps in cell culture. In March 1948, Thomas H. Weller was attempting to grow varicella virus in embryonic lung tissue. He had inoculated the planned number of tubes when he noticed that there were a few unused tubes. He retrieved a sample of mouse brain infected with poliovirus and added it to the remaining test tubes, on the off chance that the virus might grow. The varicella cultures failed to grow, but the polio cultures were successful. This development greatly facilitated vaccine research and ultimately allowed for the development of vaccines against polio. Enders and his colleagues, Thomas H. Weller and Frederick C. Robbins, were recognized in 1954 for their efforts with a Nobel Prize in Physiology or Medicine. Other important advances that led to the development of polio vaccines were: the identification of three poliovirus serotypes (Poliovirus type 1 – PV1, or Mahoney; PV2, Lansing; and PV3, Leon); the finding that prior to paralysis, the virus must be present in the blood; and the demonstration that administration of antibodies in the form of gamma globulin protects against paralytic polio. 1950–1955 During the early 1950s, polio rates in the U.S. were above 25,000 annually; in 1952 and 1953, the U.S. experienced an outbreak of 58,000 and 35,000 polio cases, respectively, up from a typical number of some 20,000 a year, with deaths in those years numbering 3,200 and 1,400. Amid this U.S. polio epidemic, millions of dollars were invested in finding and marketing a polio vaccine by commercial interests, including Lederle Laboratories in New York under the direction of H. R. Cox. Also working at Lederle was Polish-born virologist and immunologist Hilary Koprowski of the Wistar Institute in Philadelphia, who tested the first successful polio vaccine, in 1950. His vaccine, however, being a live attenuated virus taken orally, was still in the research stage and would not be ready for use until five years after Jonas Salks polio vaccine (a dead-virus injectable vaccine) had reached the market. Koprowskis attenuated vaccine was prepared by successive passages through the brains of Swiss albino mice. By the seventh passage, the vaccine strains could no longer infect nervous tissue or cause paralysis. After one to three further passages on rats, the vaccine was deemed safe for human use. On 27 February 1950, Koprowskis live, attenuated vaccine was tested for the first time on an 8-year-old boy living at Letchworth Village, an institution for physically and mentally disabled people located in New York. After the child had no side effects, Koprowski enlarged his experiment to include 19 other children. Jonas Salk The first effective polio vaccine was developed in 1952 by Jonas Salk and a team at the University of Pittsburgh that included Julius Youngner, Byron Bennett, L. James Lewis, and
Polio vaccine	Lorraine Friedman, which required years of subsequent testing. Salk went on CBS radio to report a successful test on a small group of adults and children on 26 March 1953; two days later, the results were published in JAMA. Leone N. Farrell invented a key laboratory technique that enabled the mass production of the vaccine by a team she led in Toronto. Beginning 23 February 1954, the vaccine was tested at Arsenal Elementary School and the Watson Home for Children in Pittsburgh, Pennsylvania.Salks vaccine was then used in a test called the Francis Field Trial, led by Thomas Francis, the largest medical experiment in history at that time. The test began with about 4,000 children at Franklin Sherman Elementary School in McLean, Virginia, and eventually involved 1.8 million children, in 44 states from Maine to California. By the conclusion of the study, roughly 440,000 received one or more injections of the vaccine, about 210,000 children received a placebo, consisting of harmless culture media, and 1.2 million children received no vaccination and served as a control group, who would then be observed to see if any contracted polio.The results of the field trial were announced 12 April 1955 (the tenth anniversary of the death of President Franklin D. Roosevelt, whose paralytic illness was generally believed to have been caused by polio). The Salk vaccine had been 60–70% effective against PV1 (poliovirus type 1), over 90% effective against PV2 and PV3, and 94% effective against the development of bulbar polio. Soon after Salks vaccine was licensed in 1955, childrens vaccination campaigns were launched. In the U.S, following a mass immunization campaign promoted by the March of Dimes, the annual number of polio cases fell from 35,000 in 1953 to 5,600 by 1957. By 1961 only 161 cases were recorded in the United States.A week before the announcement of the Francis Field Trial results in April 1955, Pierre Lépine at the Pasteur Institute in Paris had also announced an effective polio vaccine. Safety incidents In April 1955, soon after mass polio vaccination began in the US, the Surgeon General began to receive reports of patients who contracted paralytic polio about a week after being vaccinated with Salk polio vaccine from the Cutter pharmaceutical company, with the paralysis limited to the limb the vaccine was injected into. The Cutter vaccine had been used in vaccinating 200,000 children in the western and midwestern United States. Later investigations showed that the Cutter vaccine had caused 40,000 cases of polio, killing 10. In response the Surgeon General pulled all polio vaccines made by Cutter Laboratories from the market, but not before 250 cases of paralytic illness had occurred. Wyeth polio vaccine was also reported to have paralyzed and killed several children. It was soon discovered that some lots of Salk polio vaccine made by Cutter and Wyeth had not been properly inactivated, allowing live poliovirus into more than 100,000 doses of vaccine. In May 1955, the National Institutes of Health and Public Health Services established a Technical Committee on Poliomyelitis Vaccine to test and review all polio vaccine lots and advise the Public Health Service as to which lots should be released for public use. These incidents reduced public confidence in polio vaccine, leading to a drop in vaccination rates. 1961 At the same time that Salk was testing his vaccine, both Albert Sabin and Hilary Koprowski continued working on developing a vaccine using live virus. During a meeting in Stockholm to discuss polio vaccines in November 1955, Sabin presented results obtained on a group of 80 volunteers, while Koprowski read a paper detailing the findings of a trial enrolling 150 people. Sabin and Koprowski both eventually succeeded in developing vaccines. Because of the commitment to the Salk vaccine in America, Sabin and Koprowski both did their testing outside the United States, Sabin in Mexico and the Soviet Union, Koprowski in the Congo and Poland. In 1957, Sabin developed a trivalent vaccine containing attenuated strains of all three types of poliovirus. In 1959, ten million children in the Soviet Union received the Sabin oral vaccine. For this work, Sabin was given the medal of the Order of Friendship of Peoples, described as the Soviet Unions highest civilian honor. Sabins oral vaccine using live virus came into commercial use in 1961.Once Sabins oral vaccine became widely available, it supplanted Salks injected vaccine, which had been tarnished in the publics opinion by the Cutter incident of 1955, in which Salk vaccines improperly prepared by one company resulted in several children dying or becoming paralyzed. 1987 An enhanced-potency IPV was licensed in the United States in November 1987, and is currently the vaccine of choice there. The first dose of polio vaccine is given shortly after birth, usually between 1 and 2 months of age, and a second dose is given at 4 months of age. The timing of the third dose depends on the vaccine formulation, but should be given between 6 and 18 months of age. A booster vaccination is given at 4 to 6 years of age, for a total of four doses at or before school entry. In some countries, a fifth vaccination is given during adolescence. Routine vaccination of adults (18 years of age and older) in developed countries is neither necessary nor recommended because most adults are already immune and have a very small risk of exposure to wild poliovirus in their home countries. In 2002, a pentavalent (five-component) combination vaccine (called Pediarix) containing IPV was approved for use in the United States. 1988 A global effort to eradicate polio, led by the World Health Organization (WHO), UNICEF, and the Rotary Foundation, began in 1988, and has relied largely on the oral polio vaccine developed by Albert Sabin and Mikhail Chumakov (Sabin-Chumakov vaccine). After 1990 Polio was eliminated in the Americas by 1994. The disease was officially eliminated in 36 Western Pacific countries, including China and Australia, in 2000. Europe was declared polio-free in 2002. Since January 2011, no cases of the disease have been reported in India, hence in February 2012, the country was taken off the WHO list of polio-endemic countries. In March 2014, India was declared a polio-free country.Although poliovirus transmission has been interrupted in much of the world, transmission of wild poliovirus does continue and creates an ongoing risk for the importation of wild poliovirus into previously polio-free regions. If importations of poliovirus occur, outbreaks of poliomyelitis may develop, especially in areas with low vaccination coverage and poor sanitation. As a result, high levels of vaccination coverage must be maintained. In November 2013, the WHO announced a polio outbreak in Syria. In response, the Armenian government put out a notice asking Syrian Armenians under age 15 to get the polio vaccine. As of 2014, polio virus had spread to 10 countries, mainly in Africa, Asia, and the Middle East, with Pakistan, Syria, and Cameroon advising vaccinations to outbound travellers.Polio vaccination programs have been resisted by some people in Pakistan, Afghanistan, and Nigeria - the three countries as of 2017 with remaining polio cases. Almost all Muslim religious and political leaders have endorsed the vaccine, but a fringe minority believes that the vaccines are secretly being used for sterilization of Muslims. The fact that the CIA organized a fake vaccination program in 2011 to help find Osama Bin Laden is an additional cause of distrust. In 2015, the WHO announced a deal with the Taliban to encourage them to distribute the vaccine in areas they control. However, the Pakistani Taliban was not supportive. On 11 September 2016, two unidentified gunmen associated with the Pakistani Taliban, Jamaat-ul-Ahrar, shot Zakaullah Khan, a doctor who was administering polio vaccines in Pakistan. The leader of the Jamaat-ul-Ahrar claimed responsibility for the shooting and stated that the group would continue this type of attack. Such resistance to and scepticism of vaccinations has consequently slowed down the polio eradication process within the two remaining endemic countries. Travel requirements Travellers who wish to enter or leave certain countries must be vaccinated against polio, usually at most 12 months and at least 4 weeks before crossing the border, and be able to present a vaccination record/certificate at the border checks.: 25–27 Most requirements apply only to travel to or from so-called polio-endemic, polio-affected, polio-exporting, polio-transmission, or high-risk countries. As of August 2020, Afghanistan and Pakistan are the only polio-endemic countries in the world (where wild polio has not yet been eradicated). Several countries have additional precautionary polio vaccination travel requirements, for example to and from key at-risk countries, which as of December 2020 include China, Indonesia, Mozambique, Myanmar, and Papua New Guinea. Society and culture Cost As of 2015, the Global Alliance for Vaccines and Immunization supplies the inactivated vaccine to developing countries for as little as €0.75 (about US$0.89) per dose in 10-dose vials. Misconceptions A misconception has been present in Pakistan that polio vaccine contained haram ingredients and could cause impotence and infertility in male children, leading some parents not to have their children vaccinated. This belief is most common in the Khyber Pakhtunkhwa province and the FATA region. Attacks on polio vaccination teams have also occurred, thereby hampering international efforts to eradicate polio in Pakistan and globally. References Further reading Ramsay M, ed. (2013). "Polio: the green book, chapter 26". Immunisation against infectious disease. London: Public Health England. Wallace G, Alexander J (2015). "Chapter 18: Poliomyelitis". In Hamborsky J, Kroger A, Wolfe S (eds.). Epidemiology and Prevention of Vaccine-Preventable Diseases (13th ed.). Washington D.C.: U.S. Centers for Disease Control and Prevention (CDC). ISBN 978-0990449119. Routh JA, Oberste MS, Patel M (2018). "Chapter 12: Poliomyelitis". In Roush SW, Baldy LM, Hall MH (eds.). Manual for the surveillance of vaccine-preventable diseases. Atlanta, Georgia: U.S. Centers for Disease Control and Prevention (CDC). External links "Polio Vaccine Information Statement". Centers for Disease Control and Prevention (CDC). 10 August 2021. History of Vaccines Website – History of Polio History of Vaccines, a project of the College of Physicians of Philadelphia PBS.org – People and Discoveries: Salk Produces Polio Vaccine 1952, Public Broadcasting Service (PBS) "IPOL – Poliovirus Vaccine Inactivated (Monkey Kidney Cell)". U.S. Food and Drug Administration (FDA). 11 December 2019. STN: 103930. Poliovirus Vaccines at the US National Library of Medicine Medical Subject Headings (MeSH)
Topical steroid	Topical steroids are the topical forms of corticosteroids. Topical steroids are the most commonly prescribed topical medications for the treatment of rash, eczema, and dermatitis. Topical steroids have anti-inflammatory properties and are classified based on their skin vasoconstrictive abilities. There are numerous topical steroid products. All the preparations in each class have the same anti-inflammatory properties but essentially differ in base and price. Side effects may occur from long-term topical steroid use. Medical uses Weaker topical steroids are utilized for thin-skinned and sensitive areas, especially areas under occlusion, such as the armpit, groin, buttock crease, and breast folds. Weaker steroids are used on the face, eyelids, diaper area, perianal skin, and intertrigo of the groin or body folds. Moderate steroids are used for atopic dermatitis, nummular eczema, xerotic eczema, lichen sclerosis et atrophicus of the vulva, scabies (after scabiecide) and severe dermatitis. Strong steroids are used for psoriasis, lichen planus, discoid lupus, chapped feet, lichen simplex chronicus, severe poison ivy exposure, alopecia areata, nummular eczema, and severe atopic dermatitis in adults.To prevent tachyphylaxis, a topical steroid is often prescribed to be used on a week on, week off routine. Some recommend using the topical steroid for 3 consecutive days on, followed by 4 consecutive days off. Long-term use of topical steroids can lead to secondary infection with fungus or bacteria (see tinea incognito), skin atrophy, telangiectasia (prominent blood vessels), skin bruising and fragility.The use of the finger tip unit may be helpful in guiding how much topical steroid is required to cover different areas of the body. Adverse effects Hypothalamic–pituitary–adrenal axis (HPA) suppression Cushings syndrome Diabetes mellitus Osteoporosis Topical steroid addiction Allergic contact dermatitis (see steroid allergy) Steroid atrophy Perioral dermatitis: This is a rash that occurs around the mouth and the eye region that has been associated with topical steroids. Ocular effects: Topical steroid drops are frequently used after eye surgery but can also raise intraocular pressure (IOP) and increase the risk of glaucoma, cataract, retinopathy as well as systemic adverse effects. Tachyphylaxis: The acute development of tolerance to the action of a drug after repeated doses. Significant tachyphylaxis can occur by day 4 of therapy. Recovery usually occurs after 3 to 4 days rest. This has led to therapies such as 3 days on, 4 days off; or one week on therapy, and one week off therapy. Delivery-related adverse effects Other local adverse effects: These include facial hypertrichosis, folliculitis, miliaria, genital ulcers, and granuloma gluteale infantum. Long-term use has resulted in Norwegian scabies, Kaposis sarcoma, and other unusual dermatosis. Safety in pregnancy A 2015 meta-analysis of observational studies of pregnancies found no association between mothers use of topical steroids and type of delivery, APGAR score, birth defects, or prematurity. Classification systems Seven-class System The U.S. utilizes 7 classes, which are classified by their ability to constrict capillaries and cause skin blanching. Class I is the strongest, or superpotent. Class VII is the weakest and mildest. Class I Very potent: up to 600 times stronger than hydrocortisone Clobetasol propionate 0.05% (Dermovate) Betamethasone dipropionate 0.25% (Diprolene) Halobetasol propionate 0.05% (Ultravate, Halox) Diflorasone diacetate 0.05% (Psorcon) Class II Fluocinonide 0.05% (Lidex) Halcinonide 0.05% (Halog) Amcinonide 0.05% (Cyclocort) Desoximetasone 0.25% (Topicort) Class III Triamcinolone acetonide 0.5% (Kenalog, Aristocort cream) Mometasone furoate 0.1% (Elocon, Elocom ointment) Fluticasone propionate 0.005% (Cutivate) Betamethasone dipropionate 0.05% (Diprosone) Halometasone 0.05% Class IV Fluocinolone acetonide 0.01-0.2% (Synalar, Synemol, Fluonid) Hydrocortisone valerate 0.2% (Westcort) Hydrocortisone butyrate 0.1% (Locoid) Flurandrenolide 0.05% (Cordran) Triamcinolone acetonide 0.1% (Kenalog, Aristocort A ointment) Mometasone furoate 0.1% (Elocon cream, lotion) Class V Fluticasone propionate 0.05% (Cutivate cream) Desonide 0.05% (Tridesilon, DesOwen ointment) Fluocinolone acetonide 0.025% (Synalar, Synemol cream) Hydrocortisone valerate 0.2% (Westcort cream) Class VI Alclometasone dipropionate 0.05% (Aclovate cream, ointment) Triamcinolone acetonide 0.025% (Aristocort A cream, Kenalog lotion) Fluocinolone acetonide 0.01% (Capex shampoo, Dermasmooth) Desonide 0.05% (DesOwen cream, lotion) Class VII The weakest class of topical steroids. Has poor lipid permeability, and can not penetrate mucous membranes well. Hydrocortisone 2.5% (Hytone cream, lotion, ointment) Hydrocortisone 1% (Many over-the-counter brands) Five-class System Japan rates topical steroids from 1 to 5, with 1 being strongest. Four-class System Many countries, such as the United Kingdom, Germany, the Netherlands, New Zealand, recognize 4 classes. In the United Kingdom and New Zealand I is the strongest, while in Continental Europe, class IV is regarded as the strongest. Class IV (UK/NZ: class I) Very potent (up to 600 times as potent as hydrocortisone) Clobetasol propionate (Dermovate Cream/Ointment, Exel Cream) Betamethasone dipropionate (Diprosone OV Cream/Ointment, Diprovate Cream) Class III (UK/NZ: class II) Potent (50–100 times as potent as hydrocortisone) Betamethasone valerate (Beta Cream/Ointment/Scalp Application, Betnovate Lotion/C Cream/C Ointment, Fucicort) Betamethasone dipropionate (Diprosone Cream/Ointment, Diprovate Cream, Daivobet 50/500 Ointment) Diflucortolone valerate (Nerisone C/Cream/Fatty Ointment/Ointment) Hydrocortisone 17-butyrate (Locoid C/Cream/Crelo Topical Emulsion/Lipocream/Ointment/Scalp Lotion) Mometasone furoate (Elocon Cream/Lotion/Ointment) Methylprednisolone aceponate (Advantan Cream/Ointment) Halometasone 0.05% Class II (UK/NZ: class III) Moderate (2–25 times as potent as hydrocortisone) Clobetasone butyrate (Eumovate Cream) Triamcinolone acetonide (Aristocort Cream/Ointment, Viaderm KC Cream/Ointment, Kenacomb Ointment) Class I (UK/NZ: class IV) Mild Hydrocortisone 0.5–2.5% (DermAid Cream/Soft Cream, DP Lotion-HC 1%, Skincalm, Lemnis Fatty Cream HC, Pimafucort Cream/Ointment) Allergy associations The highlighted steroids are often used in the screening of allergies to topical steroid and systemic steroids. When one is allergic to one group, one is allergic to all steroids in that group. Group A Hydrocortisone, hydrocortisone acetate, cortisone acetate, tixocortol pivalate, prednisolone, methylprednisolone, and prednisone Group B Triamcinolone acetonide, triamcinolone alcohol, amcinonide, budesonide, desonide, fluocinonide, fluocinolone acetonide, and halcinonide Group C Betamethasone, betamethasone sodium phosphate, dexamethasone, dexamethasone sodium phosphate, and fluocortolone Group D Hydrocortisone 17-butyrate, hydrocortisone-17-valerate, alclometasone dipropionate, betamethasone valerate, betamethasone dipropionate, prednicarbate, clobetasone-17-butyrate, Clobetasol-17 propionate, fluocortolone caproate, fluocortolone pivalate, fluprednidene acetate, and mometasone furoate History Corticosteroids were first made available for general use around 1950. See also Topical medication Glucocorticoid Corticosteroid Retrometabolic drug design == References ==
Clemastine	Clemastine, also known as meclastin, is a first-generation H1 histamine antagonist (antihistamine) with anticholinergic properties (drying) and sedative side effects. Like all first-generation antihistamines, it is sedating.Patented in 1960, it came into medical use in 1967. Medical uses Clemastine is used to relieve hay fever and allergy symptoms, including sneezing; runny nose; and red, itchy, tearing eyes. Prescription strength clemastine is also used to relieve the itching and swelling of hives. Side effects Overdosage symptoms are paradoxical, ranging from CNS depression to stimulation. Stimulation is most common in children, and is usually followed by excitement, hallucinations, ataxia, loss of coordination, muscle twitching, athetosis, hyperthermia, cyanosis, convulsions, tremors, and hyperreflexia. This may be followed by postictal depression and cardiovascular/respiratory arrest. Other common overdose symptoms include dry mouth, fixed dilated pupils, flushing of the face, and pyrexia. In adults, overdose usually leads to CNS depression, ranging from drowsiness to coma. Pharmacology Clemastine is an antihistamine with anticholinergic and sedative effects. Antihistamines competitively bind to histamine receptor sites, thus reducing the neurotransmitters effects. Effects of histamine (which are countered by antihistamines) include: Increased capillary permeability Increased capillary dilatation Edema (i.e., swelling) Pruritus (Itch) Gastrointestinal/respiratory smooth muscle constrictionClemastine inhibits both the vasoconstrictor and vasodilator effects of histamine. Depending on the dose, the drug can produce paradoxical effects, including CNS stimulation or depression. Most antihistamines exhibit some type of anticholinergic activity. Antihistamines act by competitively binding to H1-receptor sites, thus blocking the binding of endogenous histamine. Antihistamines do not chemically inactivate or prevent the normal release of histamine. Clemastine does also act as FIASMA (functional inhibitor of acid sphingomyelinase).Clemastine is rapidly absorbed from the gastrointestinal tract and peak plasma concentrations are attained in 2–4 hours. Antihistamines are thought to be metabolized in the liver, mostly by mono-/didemethylation and glucuronide conjugation. It is an inhibitor of cytochrome P450 CYP2D6 and may interfere with other drugs metabolized by this isozyme. Mechanism of action Clemastine is a selective histamine H1 antagonist. It binds to the histamine H1 receptor, thus blocking the action of endogenous histamine, which leads to temporary relief of the negative symptoms caused by histamine. Society and culture Clemastine is an OTC drug, and is available under many names and dosage forms worldwide. Most common brand name is Tavegyl. References External links NIH Medline Plus listing on Clemastine The pharmacokinetics and bioavailability of clemastine and phenylpropanolamine in single-component and combination formulations
Silver sulfadiazine	Silver sulfadiazine, sold under the brand Silvadene among others, is a topical antibiotic used in partial thickness and full thickness burns to prevent infection. Tentative evidence has found other antibiotics to be more effective, and therefore it is no longer generally recommended for second-degree (partial-thickness) burns, but is still widely used to protect third-degree (full-thickness) burns.Common side effects include itching and pain at the site of use. Other side effects include low white blood cell levels, allergic reactions, bluish grey discoloration of the skin, red blood cell breakdown, or liver inflammation. Caution should be used in those allergic to other sulfonamides. It should not be used in pregnant women who are close to delivery. It is not recommended for use in children less than two months of age.Silver sulfadiazine was discovered in the 1960s. It is on the World Health Organizations List of Essential Medicines. It is available as a generic medication. Medical uses Tentative evidence has found other antibiotics to be more effective in the healing of superficial and partial thickness burn injuries; therefore, it is no longer generally recommended. A Cochrane review from 2013 found that most of the trials that met inclusion criteria for the review had methodological shortcomings and thus are of little use in assessing the efficacy of silver sulfadiazine in the healing of burn injuries. Another Cochrane systematic review from 2010 concluded, "There is insufficient evidence to establish whether silver-containing dressings or topical agents promote wound healing or prevent wound infection". Other reviews of the evidence have also concluded, "[the] quality of the trials was limited". Cochrane has raised concerns about delays in time to wound healing when SSD is used. In addition to concerns regarding delayed wound healing, silver sulfadiazine is associated with sloughing of the wound surface that makes reassessment of wound depth difficult, and requires daily reapplication. For this reason, application of silver sulfadiazine is not recommended for most burns due to altered wound appearance and the frequency of required dressing changes. Adverse effects A noninfection-related clear fluid may form on the wounds surface. Burning and painful sensations are not uncommon, but are only temporary. Application to large areas or to severe burns may lead to systemic absorption and lead to adverse effects similar to those of other sulfonamides. About 0.1 to 1.0% of people show hypersensitivity reactions such as rashes or erythema multiforme. This reaction is known from other sulfonamides including antibacterials, thiazide diuretics, and sulfonylurea antidiabetics; but data on the likelihood of cross-allergies are inconsistent. Incorporation of the silver ions can lead to local argyria (discoloration of the skin), especially if the treated area is exposed to ultraviolet light. Generalised argyria with silver accumulation in kidneys, liver, and retina has only been found in association with excessive long-term use, or repeated use on severe and heavily inflamed burns. Possible consequences of generalised argyria include interstitial nephritis and anemia. Interactions Proteases such as trypsin and clostridiopeptidase, which are contained in ointments used for the removal of dead skin on wounds, can be inhibited by silver ions if applied simultaneously. When silver sulfadiazine is absorbed in significant amounts, it can increase effects and side effects of some drugs such as vitamin K antagonists. Pharmacokinetics The chemical is poorly soluble, and has only very limited penetration through intact skin. However, contact with body fluids produces free sulfadiazine which can then be systemically absorbed and distributed; it undergoes glucuronidation in the liver and is also excreted unaltered in urine. Only when applied to large-area (especially second- and third-degree) burns or other lesions is absorption into the body a problem. Names Brand names include Silvadene (a genericized trademark), Silverex, Silverol, Silveleb, Silvazine, Flamazine, Thermazene, BurnHeal, Silvozin Tulle Dressing and SSD. See also Sulfadiazine References External links "Silver Sulfadiazine". Drug Information Portal. U.S. National Library of Medicine.
Cabotegravir/rilpivirine	Cabotegravir/rilpivirine, sold under the brand name Cabenuva, is a co-packaged antiretroviral medication for the treatment of HIV/AIDS. It contains cabotegravir and rilpivirine in a package with two separate injection vials.The most common adverse reactions include injection site reactions, fever or feeling hot (pyrexia), fatigue, headache, musculoskeletal pain, nausea, sleep disorders, dizziness and rash.The co-packaged medication was approved for medical use in the United States in January 2021. It is the first FDA-approved injectable, complete regimen for HIV-infected adults that is administered once a month. It is also approved for use in Canada. In the European Union, the two medications are approved separately. Medical uses Cabotegravir/rilpivirine is indicated as a complete regimen for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults to replace a current antiretroviral regimen in those who are virologically suppressed on a stable antiretroviral regimen with no history of treatment failure. In the European Union, the combination is indicated for maintenance treatment of adults who have undetectable HIV levels in the blood (viral load less than 50 copies/mL) with their current antiretroviral treatment, and when the virus has not developed resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) and integrase strand transfer inhibitors. Contraindications and interactions Cabotegravir/rilpivirine must not be combined with drugs that induce the liver enzyme CYP3A4, because they accelerate the inactivation of rilpivirine, and/or the enzyme UGT1A1, because they accelerate the inactivation of cabotegravir. These mechanisms potentially result in loss of effectiveness. Examples for such drugs are rifampicin, rifapentine, carbamazepine, oxcarbazepine, phenytoin and phenobarbital. Adverse effects The most common side effects include reactions at the injection site (in up to 84% of patients) such as pain and swelling, as well as headache (up to 12%) and fever or feeling hot (in 10%). Less common side effects (under 10%) are depressive disorders, insomnia, rashes, fatigue, musculoskeletal pain, nausea, sleep disorders, and dizziness. Pharmacology Cabotegravir is an integrase strand transfer inhibitor. Rilpivirine is a non-nucleoside reverse transcriptase inhibitor (NNRTI). History The safety and efficacy of cabotegravir/rilpivirine were established through two randomized, open-label, controlled clinical trials (Trial 1/NCT02938520 and Trial 2/NCT02951052) in 1,182 HIV-infected adults who were virologically suppressed (HIV-1 RNA less than 50 copies/milliliter) before initiation of treatment with cabotegravir/rilpivirine. Participants in both trials continued to show virologic suppression at the conclusion of each study, and no clinically relevant change from baseline in CD4+ cell counts was observed. Trials were conducted at 223 sites in 24 countries including the United States.In Trial 1, participants who were never treated for the infection before, received an approved therapy for 20 weeks. Those who did well after this treatment (who had HIV-1 RNA less than 50 copies/milliliter) were then randomized to receive either cabotegravir/rilpivirine (for the first four weeks they received tablets) or to remain on the same therapy for additional 44 weeks. Participants and the health providers knew which treatments have been given.In Trial 2, participants who were previously successfully treated for the infection (who had HIV-1 RNA less than 50 copies/milliliter), were randomized to receive either cabotegravir/rilpivirine (for the first four weeks they received tablets) or to remain on the same therapy for additional 44 weeks. Participants and the health providers knew which treatments have been given.In October 2020, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) recommended the granting of a marketing authorization for rilpivirine and cabotegravir, to be used together for the treatment of people with human immunodeficiency virus type 1 (HIV-1) infection. The two medicines are the first antiretrovirals that come in a long-acting injectable formulation. This means that instead of daily pills, people receive intramuscular injections monthly or every two months. Rilpivirine and cabotegravir were approved for medical use in the European Union in December 2020, as two separate medications.In January 2021, the U.S. Food and Drug Administration (FDA) granted the approval of Cabenuva to ViiV Healthcare.The combination was approved for medical use in Australia in February 2021. References External links "Cabotegravir". Drug Information Portal. U.S. National Library of Medicine. "Rilpivirine". Drug Information Portal. U.S. National Library of Medicine. Clinical trial number NCT02938520 for "Study to Evaluate the Efficacy, Safety, and Tolerability of Long-acting Intramuscular Cabotegravir and Rilpivirine for Maintenance of Virologic Suppression Following Switch From an Integrase Inhibitor in HIV-1 Infected Therapy Naive Participants" at ClinicalTrials.gov Clinical trial number NCT02951052 for "Study Evaluating the Efficacy, Safety, and Tolerability of Switching to Long-acting Cabotegravir Plus Long-acting Rilpivirine From Current Antiretroviral Regimen in Virologically Suppressed HIV-1-infected Adults" at ClinicalTrials.gov
Edex	Edex can refer to several institutions: EDEX, education and career guidance project. Edex Live, a newspaper Prostaglandin E1, medication
Zarah	Zarah may refer to: Zarah (television personality), a Filipino-American, also a singer Zarah Garde-Wilson (born 1978), Australian solicitor Zarah Ghahramani (born 1981), Iranian-born author living in Australia Zarah Leander (1907 – 1981), Swedish actress and singer Zarah, or Ich weiss, es wird einmal ein Wunder geschehen, a song by Nina Hagen Fort Zarah See also Zahra (name) Zara (disambiguation) Zaraah Abrahams, English actress
Hydroxyprogesterone caproate	Hydroxyprogesterone caproate (OHPC), sold under the brand names Proluton and Makena among others, is a progestin medication which is used to prevent preterm birth in pregnant women with a history of the condition and to treat gynecological disorders. It has also been formulated in combination with estrogens for various indications (brand names Gravibinon and Primosiston) and as a form of long-lasting injectable birth control (brand name Chinese Injectable No. 1). It is not used by mouth and is instead given by injection into muscle or fat, typically once per week to once per month depending on the indication.OHPC is generally well tolerated and produces few side effects. Injection site reactions such as pain and swelling are the most common side effect of OHPC. The medication may increase the risk of gestational diabetes when used in pregnant women. OHPC is a progestin, or a synthetic progestogen, and hence is an agonist of the progesterone receptor, the biological target of progestogens like progesterone. It has some antimineralocorticoid activity and no other important hormonal activity. The medication shows a number of differences from natural progesterone.OHPC was discovered in 1953 and was introduced for medical use in 1954 or 1955. It was marketed in the United States under the brand name Delalutin and throughout Europe under the brand name Proluton. The medication was discontinued in the United States in 1999. However, OHPC was subsequently reintroduced in the United States under the brand name Makena for the treatment of preterm birth in 2011. Due to a greatly increased price, a pricing controversy occurred in this country. OHPC was previously available at low cost from compounding pharmacies in the United States, but this became prohibited in 2016. Medical uses Preterm birth The use of OHPC in pregnancy to prevent preterm birth in women with a history of preterm delivery between 20 weeks and 36 weeks and 6 days is supported by the Society of Maternal Fetal Medicine Clinic Guidelines put out in May 2012 as Level I and III evidence, Level A recommendation. Level I evidence refers to a properly powered randomized controlled trial, and level III evidence is support from expert opinion, while a Level A recommendation confers that the recommendation is made based on good and consistent scientific evidence. OHPC 250 mg IM weekly preferably starting at 16–20 weeks until 36 weeks is recommended. In these women, if the transvaginal ultrasound cervical length shortens to <25 mm at < 24 weeks, cervical cerclage may be offered. In the 2013 study the guideline recommendation is based on, there was also a significant decrease of neonatal morbidity including lower rates of necrotizing enterocolitis (0 in the treatment group vs 4 in the control), intraventricular hemorrhage (4 in the treatment group compared with 8 in the control for a relative risk of 0.25), and need for supplemental oxygen (14% in the treatment group vs 24% in the placebo for a relative risk of 0.42). Furthermore, this study contained 463 women, 310 of whom received injection. Of these women, 9 had infants with congenital malformations (2%), but there was no consistent pattern and none involved internal organs. OHPC is currently (as of June 2014) pregnancy category B, meaning there is no evidence of fetal risk with use of this medication during pregnancy. Although this is now the recommendation, this has not always been the case. A review by Marc Keirse of Flinders University concluded that information about the potential harms was lacking. Three clinical studies in singleton pregnancies of 250 mg/week of intramuscular OHPC have all shown a trend for an increase in pregnancy loss due to miscarriage compared to placebo. One of them, a large National Institutes of Health (NIH) study in 2003, looked at the effect of OHPC injections in women at risk for repeat premature birth and found that the treated group experienced premature birth in 37% versus 55% in the controls. A follow-up study of the offspring showed no evidence that OHPC affected the children in the first years of life. Based on these NIH data, OHPC was approved by the Food and Drug Administration (FDA) in 2011 as a medication to reduce the risk of premature birth in selected women at risk. (v.i.) The FDA expressed concern about miscarriage at the 2006 advisory committee meeting; the committee voted unanimously that further study was needed to evaluate the potential association of OHPC with increased risk of second trimester miscarriage and stillbirth. A toxicology study in rhesus monkeys resulted in the death of all rhesus fetuses exposed to 1 and 10 times the human dose equivalent of OHPC. As of 2008, OHPC was a category D progestin according to the FDA (that is, there is evidence of fetal harm). There is speculation that the castor oil in the OHPC formulation may not be beneficial for pregnancy. Of note, the above-mentioned NEJM study by Meirs et al. compares the effect of OHPC (with the castor oil component) to castor oil injection as the placebo. A study published in February 2016 in The Lancet stated the below, amongst other findings: OPPTIMUM strongly suggests that the efficacy of progesterone in improving outcomes is either non-existent or weak. Given the heterogeneity of the preterm labour syndrome we cannot exclude benefit in specific phenotypic or genotypic subgroups of women at risk. However, the subgroups of women who might benefit do not appear to be easily identifiable by current selection strategies, including cervical length measurement and fibronectin testing. Reassuringly, our study suggests that progesterone is safe for those who wish to take it for preterm birth prophylaxis. The overall rate of maternal or child adverse events was similar in the progesterone and placebo groups. There were few differences in the incidence of adverse secondary outcomes in the two groups, with the exception of a higher rate of renal, gastrointestinal, and respiratory complications in childhood in the progesterone groups. Importantly, the absolute rates of these complications was low. Follow-up of other babies exposed in utero to vaginal progesterone would be helpful in determining whether the increased rate of some renal, gastrointestinal, and respiratory complications is a real effect or a type I error. The journal reviewer Richard Lehman, senior Research Fellow at the Department of Primary Health Care at the University of Oxford, made the following notable commentary on the OPPTIMUM study: "Thats it. This story is ended, and nobody need ever use vaginal progesterone again to prevent preterm birth."A Cochrane review on progestogen for preventing preterm birth concluded that there was little evidence that either vaginal or intramuscular progesterone helped to reduce the risk of preterm birth in women with a multiple pregnancy. Gynecological disorders OHPC is used in the treatment of threatened miscarriage, gynecological disorders such as dysmenorrhea, premenstrual syndrome, fibrocystic breast disease, adenosis, and breast pain. In addition, OHPC is used in the treatment of endometrial cancer and has been found to be significantly effective in extending life in both premenopausal and postmenopausal women with the disease. The medication was used widely in the 1950s through the 1970s for such indications, but OHPC more recently has received the most attention in the prevention of preterm birth. Birth control OHPC is available in combination with estradiol valerate as a once-monthly combined injectable contraceptive in a few countries. Other uses OHPC has been used as a component of menopausal hormone therapy in women.OHPC has been used to treat benign prostatic hyperplasia in men, although evidence of effectiveness is marginal and uncertain. It has also been used to treat prostate cancer, at a dosage of 1,500 mg twice per week. The mechanism of action of OHPC in these uses is suppression of testicular androgen production via suppression of luteinizing hormone secretion, which are the result of the progestogenic and antigonadotropic activity of OHPC. However, symptoms of hypogonadism may develop when OHPC is used for this indication, with two-thirds of men reportedly experiencing impotence.OHPC has been used as a component of feminizing hormone therapy for transgender women. Due to micronization, bioidentical progestogens are more commonly used. Available forms OHPC is available alone in the form of ampoules and vials of 125 and 250 mg/mL oil solutions for intramuscular injection (brand names Proluton, Makena). It is also available alone in the form of a 250 mg/mL autoinjector for use by subcutaneous injection (brand name Makena).OHPC is or was available in combination with estradiol valerate in the form of ampoules and vials of 250 mg/mL OHPC and 5 mg/mL estradiol valerate oil solutions for intramuscular injection (brand names Gravibinon, Chinese Injectable No. 1). The medication is or was available in combination with estradiol benzoate in the form of ampoules of 125–250 mg OHPC and 10 mg estradiol benzoate in oil solution for intramuscular injection (brand name Primosiston) as well.: 1045 In addition, OHPC has been marketed in combination with estradiol dipropionate in the form of 50 mg/mL OHPC and 1 mg/mL estradiol dipropionate (brand name EP Hormone Depot) in Japan. Contraindications Contraindications of OHPC include previous or current thrombosis or thromboembolic disease, known or suspected breast cancer, past or present history of other hormone-sensitive cancer, undiagnosed abnormal vaginal bleeding unrelated to pregnancy, cholestatic jaundice of pregnancy, liver tumors or active liver disease, and uncontrolled hypertension. A few relative contraindications also exist for OHPC. Side effects OHPC is generally well tolerated and produces relatively few side effects. Injection site reactions such as pain, soreness, swelling, itching, bruising, and lumps are the most common side effect of OHPC. In contrast to large doses of progesterone however, which produce moderate-to-severe such reactions, OHPC is relatively free from injection site reactions. Side effects of OHPC that occur in greater than or equal to 2% of users include injection site pain (34.8%), injection site swelling (17.1%), urticaria (12.3%), pruritus (7.7%), injection site pruritus (5.8%), nausea (5.8%), injection site nodules (4.5%), and diarrhea (2.3%). Numerically increased rates relative to controls of miscarriage (2.4% vs. 0%), stillbirth (2.0% vs. 1.3%), admission for preterm labor (16.0% vs. 13.8%), preeclampsia or gestational hypertension (8.8% vs. 4.6%), gestational diabetes (5.6% vs. 4.6%), and oligohydramnios (3.6% vs. 1.3%) have been observed with OHPC in clinical trials in which it was given to pregnant women to prevent preterm birth. Overdose There have been no reports of overdose of OHPC. In the event of overdose, treatment should be based on symptoms. OHPC has been studied in humans at high doses of 2,000 to 5,000 mg per week by intramuscular injection, without safety concerns. Interactions OHPC is not likely to affect most cytochrome P450 enzymes at therapeutic concentrations. Drug interaction studies have not been performed with OHPC. Pharmacology Pharmacodynamics OHPC has progestogenic activity, some antimineralocorticoid activity, and no other important hormonal activity. Progestogenic activity OHPC, also known as 17α-hydroxyprogesterone caproate, is closer to progesterone in terms of structure and pharmacology than most other progestins, and is essentially a pure progestogen – that is, a selective agonist of the progesterone receptor (PR) with minimal or no other hormonal activity. However, OHPC has improved pharmacokinetics compared to progesterone, namely a much longer duration with intramuscular injection in oil solution.Administered by intramuscular injection, the endometrial transformation dosage of OHPC per cycle is 250 to 500 mg, and the weekly substitution dosage of OHPC is 250 mg, while the effective dosage of OHPC in the menstrual delay test (Greenblatt) is 25 mg per week. An effective ovulation-inhibiting dosage of OHPC is 500 mg once per month by intramuscular injection. However, the dose of OHPC used in once-a-month combined injectable contraceptives is 250 mg, and this combination is effective for inhibition of ovulation similarly. For comparison, the dose of medroxyprogesterone acetate (MPA; 6α-methyl-17α-hydroxyprogesterone acetate), a close analogue of OHPC, used by intramuscular injection in microcrystalline aqueous suspension in once-a-month combined injectable contraceptives, is 25 mg. It has also been said that given by intramuscular injection, 250 mg OHPC in oil solution is equivalent in progestogenic potency to 50 mg medroxyprogesterone acetate in microcrystalline aqueous suspension. Although the elimination half-life of intramuscular OHPC in oil solution in non-pregnant women is about 8 days, the elimination half-life of intramuscular medroxyprogesterone acetate in microcrystalline aqueous suspension in women is around 50 days. OHPC is also to some degree less potent than the more closely related ester hydroxyprogesterone acetate (OHPA; 17α-hydroxyprogesterone acetate).17α-Hydroxyprogesterone (OHP) has weak progestogenic activity, but C17α esterification results in higher progestogenic activity. Of a variety of different esters, the caproate (hexanoate) ester was found to have the strongest progestogenic activity, and this served as the basis for the development of OHPC, as well as other caproate progestogen esters such as gestonorone caproate. OHPC is a much more potent progestogen than 17α-hydroxyprogesterone, but does not have as high of affinity for the PR as progesterone. OHPC has about 26% and 30% of the affinity of progesterone for the human PR-A and PR-B, respectively. The medication was no more efficacious than progesterone in activating these receptors and eliciting associated gene expression in vitro. Antigonadotropic effects Due to activation of the PR, OHPC has antigonadotropic effects, or produces suppression of the hypothalamic–pituitary–gonadal axis, and can significantly suppress gonadotropin secretion and gonadal sex hormone production at sufficiently high doses. One study found that OHPC by intramuscular injection at a dosage of 200 mg twice weekly for the first two weeks and then 200 mg once weekly for 12 weeks did not significantly influence urinary excretion of estrogens, luteinizing hormone, or follicle-stimulating hormone in men with benign prostatic hyperplasia. In another study that used an unspecified dosage of intramuscular OHPC, testosterone secretion was assessed in a single man and was found to decrease from 4.2 mg/day to 2.0 mg/day (or by approximately 52%) by 6 weeks of treatment, whereas secretion of luteinizing hormone remained unchanged in the man. Yet another study found that 3,000 mg/week OHPC by intramuscular injection suppressed testosterone levels from 640 ng/dL to 320–370 ng/dL (by 42–50%) in a single man with prostate cancer, which was similar to the testosterone suppression with cyproterone acetate or chlormadinone acetate. Gestonorone caproate, a closely related progestin to OHPC with about 5- to 10-fold greater potency in humans, was found to suppress testosterone levels by 75% at a dosage of 400 mg/week in men with prostate cancer. For comparison, orchiectomy decreased testosterone levels by 91%. In general, progestins are able to maximally suppress testosterone levels by about 70 to 80%. The antigonadotropic effects of OHPC and hence its testosterone suppression are the basis of the use of OHPC in the treatment of benign prostatic hyperplasia and prostate cancer in men. Suppression of luteinizing hormone levels by OHPC has also been observed in women. Glucocorticoid activity OHPC is said not to have any glucocorticoid activity. In accordance, OHPC has been found not to alter cortisol levels in humans even with very high doses by intramuscular injection. This is of relevance because medications with significant glucocorticoid activity suppress cortisol levels due to increased negative feedback on the hypothalamic–pituitary–adrenal axis. OHPC has been studied in humans at doses as high as 5,000 mg per week by intramuscular injection, with safety and without glucocorticoid effects observed. The medication does interact with the glucocorticoid receptor however; it has about 4% of the affinity of dexamethasone for the rabbit glucocorticoid receptor. But it acts as a partial agonist of the receptor and has no greater efficacy than progesterone in activating the receptor and eliciting associated gene expression in vitro. Other activities As a pure progestogen, OHPC has no androgenic, antiandrogenic, estrogenic, or glucocorticoid activity. The absence of androgenic and antiandrogenic activity with OHPC is in contrast to most other 17α-hydroxyprogesterone-derivative progestins. Due to its lack of androgenic properties, similarly to progesterone, OHPC does not have any teratogenic effects on the fetus, making it safe for use during pregnancy. Although OHPC has been described as a pure progestogen, there is evidence that it possesses some antimineralocorticoid activity, similarly to progesterone and 17α-hydroxyprogesterone. This includes clinically important diuretic effects and reversal of estrogen-induced fluid retention and edema. Unlike progesterone, OHPC and its metabolites are not anticipated to interact with non-genomic receptors such as membrane progesterone receptors or the GABAA receptor. In accordance, OHPC is not thought to possess the neurosteroid activities of progesterone or its associated sedative effects.In relation to cytochrome P450 enzymes, OHPC has no effect on CYP1A, CYP2D6, CYP2C9, or CYP3A4, but is a modest inducer of CYP2C19. Differences from progesterone There are pharmacodynamic differences between progesterone and OHPC, which may have implications for obstetrical use. These include: Decreased myometrial activity with progesterone in vitro but no effect or increased myometrial activity with OHPC Prevention of cervical ripening with progesterone but unknown effect with OHPC A non-significantly increased rate of stillbirth and miscarriages with OHPC (in one study) A possibly increased incidence of gestational diabetes with OHPC (increased in two studies, no difference in one study) but no such effect with progesterone A significantly increased risk of perinatal adverse effects such as fetal loss and preterm delivery in multiple gestations with OHPC (in two studies)Differences in the metabolism of progesterone and OHPC and differences in the formation and activities of metabolites may be responsible for or involved in these observed biological and pharmacological differences. Progesterone is metabolized by 5α- and 5β-reductases, 3α- and 3β-hydroxysteroid dehydrogenases, and 20α- and 20β-hydroxysteroid dehydrogenase in various tissues. In target tissues, particularly the cervix and myometrium, these enzymes regulate local progesterone concentrations and can activate or inactivate progesterone signaling. In addition, these enzymes catalyze the formation of metabolites of progesterone such as 5β-dihydroprogesterone and allopregnanolone, which signal through their own non-genomic receptors such as membrane progesterone receptors and the GABAA receptor and have their own important effects in pregnancy. As examples, 5β-dihydroprogesterone has been found to play an important role in suppressing myometrial activity while allopregnanolone has potent sedative and anesthetic effects in the mother and especially the fetus and is involved in fetal nervous system development. In contrast to progesterone, OHPC is not metabolized by traditional steroid-transforming enzymes and instead is metabolized exclusively via oxidation at the caproate side chain by cytochrome P450 enzymes. As such, it is not thought to have the same tissue-specific activation and inactivation patterns that progesterone does nor the same non-genomic actions that progesterone and its metabolites possess.Further clinical research is anticipated to provide additional data to help clarify the issue of safety with OHPC. In any case, it has been recommended by the American College of Obstetricians and Gynecologists that pregnant women treated with OHPC receive counseling about its risks and benefits. Pharmacokinetics Absorption In animals, the bioavailability of OHPC with intramuscular injection is nearly 100%, but its oral bioavailability is very low at less than 3%. In women, 70 mg/day oral OHPC has similar endometrial potency as 70 mg/day oral OHPA and 2.5 mg/day oral medroxyprogesterone acetate, indicating that oral OHPC and OHPA have almost 30-fold lower potency than medroxyprogesterone acetate via oral administration. Studies on progestogenic endometrial changes with oral OHPC in women are mixed however, with one finding weak effects with 100 mg/day whereas another found that doses of 250 to 1,000 mg produced no effects. As a result of its low oral potency, OHPC has not been used by the oral route and has instead been administered by intramuscular injection. However, a novel oral formulation of OHPC (developmental code name LPCN-1107) is under development and has been found to be effective, though it required administration twice a day in a clinical study.A depot effect occurs when OHPC is injected intramuscularly or subcutaneously, such that the medication has a prolonged duration of action. Following a single intramuscular injection of 1,000 mg OHPC in five women with endometrial cancer, peak levels of OHPC were 27.8 ± 5.3 ng/mL and the time to peak concentrations was 4.6 ± 1.7 (3–7) days. Following 13 weeks of continuous administration of 1,000 mg OHPC per week, trough levels of OHPC were 60.0 ± 14 ng/mL. The pharmacokinetic parameters of 250 mg OHPC once per week by intramuscular injection have also been studied in pregnant women with singleton and multiple (twin and triplet) gestation. Steady state levels of the medication are achieved within 4 to 12 weeks of administration in pregnant women. The duration of clinical biological effect of OHPC by intramuscular injection has also been studied in women. A single intramuscular injection of 65 to 500 mg OHPC in oil solution has been found to have a duration of action of 5 to 21 days in terms of effect in the uterus and on body temperature in women.OHPC has been found to possess similar pharmacokinetics, including peak levels, time to peak levels, area-under-the-curve levels (i.e., total exposure), and elimination half-life, with administration via intramuscular injection or subcutaneous autoinjection. However, there was a higher incidence of injection site pain with subcutaneous autoinjection than with intramuscular injection (37.3% vs. 8.2%). Distribution OHPC is extensively bound to plasma proteins, of which include albumin. Unlike progesterone and 17α-hydroxyprogesterone, OHPC has very low affinity for corticosteroid-binding globulin (less than 0.01% of that of cortisol). Progesterone and 17α-hydroxyprogesterone have low affinity for sex hormone-binding globulin, and for this reason, only a very small fraction of them (less than 0.5%) is bound to this protein in the circulation. Metabolism OHPC appears to be metabolized primarily by the cytochrome P450 enzymes CYP3A4 and CYP3A5. It may also be metabolized by CYP3A7 in fetal liver and the placenta. Unlike progesterone, OHPC is not metabolized by traditional steroid-transforming enzymes and does not form similar metabolites. The metabolism of OHPC is by reduction, hydroxylation, and conjugation, including glucuronidation, sulfation, and acetylation. The caproate ester of OHPC is not cleaved during metabolism, so 17α-hydroxyprogesterone is not formed from OHPC. As such, OHPC is not a prodrug of 17α-hydroxyprogesterone, nor of progesterone.OHPC has been found to have an elimination half-life of 7.8 days when given by intramuscular injection in an oil-based formulation to non-pregnant women. Its total duration is said to be 10 to 14 days, which is much longer than the duration of intramuscularly administered progesterone in an oil formulation (2 to 3 days). In pregnant women, the elimination half-life of OHPC appears to be longer, about 16 or 17 days. However, in women pregnant with twins rather than a singlet, the elimination half-life of OHPC was found to be shorter than this, at 10 days. OHPC has been detected in pregnant women up to 44 days after the last dose. Elimination OHPC is eliminated 50% in feces and 30% in urine when given by intramuscular injection to pregnant women. Both the free steroid and conjugates are excreted by these routes, with the conjugates more prominent in feces. Veterinary The pharmacokinetics of OHPC in various ungulates including cattle, buffalo, sheep, and goat have been studied. Time–concentration curves Chemistry OHPC, also known as 17α-hydroxyprogesterone caproate or as 17α-hydroxypregn-4-ene-3,20-dione 17α-hexanoate, is a synthetic pregnane steroid and a derivative of progesterone. It is specifically a derivative of 17α-hydroxyprogesterone with a hexanoate (caproate) ester at the C17α position. Analogues of OHPC include other 17α-hydroxyprogesterone derivatives such as algestone acetophenide (dihydroxyprogesterone acetophenide), chlormadinone acetate, cyproterone acetate, hydroxyprogesterone acetate, hydroxyprogesterone heptanoate, medroxyprogesterone acetate, and megestrol acetate, as well as the caproate esters chlormadinone caproate, gestonorone caproate (norhydroxyprogesterone caproate), medroxyprogesterone caproate, megestrol caproate, and methenmadinone caproate. Synthesis Chemical syntheses of OHPC have been described.: 6 History Along with hydroxyprogester
Hydroxyprogesterone caproate	one acetate, OHPC was developed by Karl Junkmann of Schering AG in 1953 and was first reported by him in the medical literature in 1954. It was reportedly first marketed in Japan in 1954 or 1955, and was subsequently introduced as Delalutin in the United States in 1956. Due to its much longer duration than parenteral progesterone, OHPC had largely replaced progesterone in clinical practice by 1975. After decades of use, Squibb, the manufacturer, voluntarily withdrew the Delalutin product in the United States in 1999. Renewed interest in OHPC in the United States was sparked with a large NIH-sponsored study in 2003 that found that OHPC reduced the risk of premature birth in selected at-risk pregnant women. With follow-up data showing no evidence of harmful effects on the offspring, the FDA approved the medication, as sponsored by KV Pharmaceutical as Makena, as an orphan drug in February 2011 to reduce the risk of premature birth in women prior to 37 weeks gestation with a single fetus who had at least one previous premature birth. Society and culture Generic names Hydroxyprogesterone caproate is the generic name of OHPC and its INN, USAN, BANM, and JAN, while hydroxyprogesterone hexanoate was its former BANM.OHPC is often mislabeled as and confused with progesterone and 17α-hydroxyprogesterone. It should also not be confused with hydroxyprogesterone acetate, hydroxyprogesterone heptanoate, or medroxyprogesterone acetate. Brand names OHPC is marketed throughout the world under a variety of brand names including Proluton, Proluton Depot, and Makena (US), among many others. It was also formerly marketed under brand names including Delalutin, Prodrox, and Hylutin among others, but these formulations have since been discontinued. It has been marketed under the brand names Gravibinon and Injectable No. 1 (or Chinese Injectable No. 1) in combination with estradiol valerate and under the brand name Primosiston in combination with estradiol benzoate. Availability OHPC is marketed in the United States and throughout Europe, Asia, and Central and South America. It is notably not available in Canada, the United Kingdom, New Zealand, or South Africa, and only veterinary formulations are available in Australia. OHPC is also marketed in combination with estradiol valerate as a combined injectable contraceptive in a number of countries including in South America, Mexico, Japan, and China. It has been marketed as an injectable preparation in combination with estradiol benzoate in some countries as well. Price controversy With the designation of OHPC as an orphan drug by the FDA and approval of Makena in 2011, the price of OHPC in the United States was going to increase from US$15 to US$1,500 for a single dose, or from about US$300 to between US$25,000 and US$30,000 for a typical single month of treatment. This was about a 100-fold increase in cost, with "minimal added clinical benefit", and was a strongly criticized pricing strategy. The FDA subsequently announced that compounding pharmacies could continue to sell OHPC at their usual cost of approximately US$10 to US$20 per dose without fear of legal reprisals. KV Pharmaceutical also opted to reduced its price of Makena to US$690 per dose. OHPC continued to be available at low cost from compounding pharmacies until late 2016, after which time the FDA published new guidance documents prohibiting compounding pharmacies from selling products that are "essentially copies" of commercially available drug products. Research Cyclical therapy with 150 mg OHPC by intramuscular injection was found to be effective in the treatment of 76 women with persistent, treatment-refractory acne in a preliminary study, with 84% responding to the therapy and experiencing a "good-to-excellent" improvement in symptoms.OHPC was studied by Schering for use as a progestogen-only injectable contraceptive at a dose of 250 to 500 mg once a month by intramuscular injection but produced poor cycle control at these doses and was never marketed.OHPC by itself has been found to have little or no effectiveness in the treatment of breast cancer in women. Conversely, the combination of estradiol valerate and OHPC has been found to be effective in the treatment of breast cancer in women. Initial research based on limited clinical data reported that the breast-cancer response rate with a combination of estradiol valerate and OHPC seemed to be greater than with an estrogen alone (35% vs. 50%). However, subsequent research using the related but more potent progestin gestonorone caproate found that the combination of estradiol valerate and gestonorone caproate had effectiveness that was not significantly different from that of an estrogen alone in the treatment of breast cancer in women.A novel oral formulation of OHPC (developmental code name LPCN-1107) is under development for the prevention of preterm labor. As of September 2017, it is in phase II or phase III clinical trials for this indication. See also Estradiol valerate/hydroxyprogesterone caproate Estradiol benzoate/hydroxyprogesterone caproate Estradiol dipropionate/hydroxyprogesterone caproate References == Further reading ==
Buspirone	Buspirone, sold under the brand name Buspar, among others, is a medication primarily used to treat anxiety disorders, particularly generalized anxiety disorder. Benefits support its short-term use. It is taken by mouth, and it may take up to four weeks to have an effect.Common side effects of buspirone include nausea, headaches, dizziness, and difficulty concentrating. Serious side effects may include hallucinations, serotonin syndrome, and seizures. Its use in pregnancy appears to be safe but has not been well studied, while use during breastfeeding is not recommended. It is a serotonin 5-HT1A receptor agonist.Buspirone was first made in 1968 and approved for medical use in the United States in 1986. It is available as a generic medication. In 2020, it was the 55th most-commonly prescribed medication in the United States, with more than 12 million prescriptions. Medical uses Anxiety Buspirone is used for the short-term and long-term treatment of anxiety disorders or symptoms of anxiety. It is generally preferred over benzodiazepines because it does not activate the receptors that make drugs like alprazolam addictive.Buspirone has no immediate anxiolytic effects, and hence has a delayed onset of action; its full clinical effectiveness may require 2–4 weeks to manifest itself. The drug has been shown to be similarly effective in the treatment of generalized anxiety disorder (GAD) to benzodiazepines including diazepam, alprazolam, lorazepam, and clorazepate. Buspirone is not known to be effective in the treatment of other anxiety disorders besides GAD, although there is some limited evidence that it may be useful in the treatment of social phobia as an adjunct to selective serotonin reuptake inhibitors (SSRIs). Other uses Sexual dysfunction There is some evidence that buspirone on its own may be useful in the treatment of hypoactive sexual desire disorder (HSDD) in women. Miscellaneous Buspirone is not effective as a treatment for benzodiazepine withdrawal, barbiturate withdrawal, or alcohol withdrawal/delirium tremens.SSRI and SNRI antidepressants such as paroxetine and venlafaxine may cause jaw pain/jaw spasm reversible syndrome (although it is not common), and buspirone appears to be successful in treating bruxism on SSRI/SNRI-induced jaw clenching. Contraindications Buspirone has these contraindications: Hypersensitivity to buspirone Metabolic acidosis, as in diabetes Should not be used with MAO inhibitors Severely compromised liver and/or kidney function Side effects Known side effects associated with buspirone include dizziness, headaches, nausea, tinnitus, and paresthesia. Buspirone is relatively well tolerated, and is not associated with sedation, cognitive and psychomotor impairment, muscle relaxation, physical dependence, or anticonvulsant effects. In addition, buspirone does not produce euphoria and is not a drug of abuse. Dyskinesia, akathisia, myoclonus, parkinsonism, and dystonia were reported associated with buspirone. It is unclear if there is a risk of tardive dyskinesia or other movement disorders with buspirone. Overdose Buspirone appears to be relatively benign in cases of single-drug overdose, although no definitive data on this subject appear to be available. In one clinical trial, buspirone was administered to healthy male volunteers at a dosage of 375 mg/day, and produced side effects including nausea, vomiting, dizziness, drowsiness, miosis, and gastric distress. In early clinical trials, buspirone was given at dosages even as high as 2,400 mg/day, with akathisia, tremor, and muscle rigidity observed. Deliberate overdoses with 250 mg and up to 300 mg buspirone have resulted in drowsiness in about 50% of individuals. One death has been reported in a co-ingestion of 450 mg buspirone with alprazolam, diltiazem, alcohol, cocaine. Interactions Buspirone has been shown in vitro to be metabolized by the enzyme CYP3A4. This finding is consistent with the in vivo interactions observed between buspirone and these inhibitors or inducers of cytochrome P450 3A4 (CYP3A4), among others: Itraconazole: Increased plasma level of buspirone Rifampicin: Decreased plasma levels of buspirone Nefazodone: Increased plasma levels of buspirone Haloperidol: Increased plasma levels of buspirone Carbamazepine: Decreased plasma levels of buspirone Grapefruit: Significantly increases the plasma levels of buspirone. See grapefruit–drug interactions. Fluvoxamine: Moderately increase plasma levels of buspirone.Elevated blood pressure has been reported when buspirone has been administered to patients taking monoamine oxidase inhibitors (MAOIs). Pharmacology Pharmacodynamics Buspirone acts as an agonist of the serotonin 5-HT1A receptor with high affinity. It is a partial agonist of both presynaptic 5-HT1A receptors, which are inhibitory autoreceptors, and postsynaptic 5-HT1A receptors. It is thought that the main effects of buspirone are mediated via its interaction with the presynaptic 5-HT1A receptor, thus reducing the firing of serotonin-producing neurons. Buspirone also has lower affinities for the serotonin 5-HT2A, 5-HT2B, 5-HT2C, 5-HT6, and 5-HT7 receptors.In addition to binding to serotonin receptors, buspirone is an antagonist of the dopamine D2 receptor with weak affinity. It preferentially blocks inhibitory presynaptic D2 autoreceptors, and antagonizes postsynaptic D2 receptors only at higher doses. In accordance, buspirone has been found to increase dopaminergic neurotransmission in the nigrostriatal pathway at low doses, whereas at higher doses, postsynaptic D2 receptors are blocked and antidopaminergic effects such as hypoactivity and reduced stereotypy, though notably not catalepsy, are observed in animals. Buspirone has also been found to bind with much higher affinity to the dopamine D3 and D4 receptors, where it is similarly an antagonist.A major metabolite of buspirone, 1-(2-pyrimidinyl)piperazine (1-PP), occurs at higher circulating levels than buspirone itself and is known to act as a potent α2-adrenergic receptor antagonist. This metabolite may be responsible for the increased noradrenergic and dopaminergic activity observed with buspirone in animals. In addition, 1-PP may play an important role in the antidepressant effects of buspirone. Buspirone also has very weak and probably clinically unimportant affinity for the α1-adrenergic receptor. However, buspirone has been reported to have shown "significant and selective intrinsic efficacy" at the α1-adrenergic receptor expressed in a "tissue- and species-dependent manner".Unlike benzodiazepines, buspirone does not interact with the GABAA receptor complex. Pharmacokinetics Buspirone has a low oral bioavailability of 3.9% relative to intravenous injection due to extensive first-pass metabolism. The time to peak plasma levels following ingestion is 0.9 to 1.5 hours. It is reported to have an elimination half-life of 2.8 hours, although a review of 14 studies found that the mean terminal half-life ranged between 2 and 11 hours, and one study even reported a terminal half-life of 33 hours. Buspirone is metabolized primarily by CYP3A4, and prominent drug interactions with inhibitors and inducers of this enzyme have been observed. Major metabolites of buspirone include 5-hydroxybuspirone, 6-hydroxybuspirone, 8-hydroxybuspirone, and 1-PP. 6-Hydroxybuspirone has been identified as the predominant hepatic metabolite of buspirone, with plasma levels that are 40-fold greater than those of buspirone after oral administration of buspirone to humans. The metabolite is a high-affinity partial agonist of the 5-HT1A receptor (Ki = 25 nM) similarly to buspirone, and has demonstrated occupancy of the 5-HT1A receptor in vivo. As such, it is likely to play an important role in the therapeutic effects of buspirone. 1-PP has also been found to circulate at higher levels than those of buspirone itself and may similarly play a significant role in the clinical effects of buspirone. Chemistry Buspirone is a member of the azapirone chemical class, and consists of azaspirodecanedione and pyrimidinylpiperazine components linked together by a butyl chain. Analogues Structural analogues of buspirone include other azapirones like gepirone, ipsapirone, perospirone, and tandospirone. Synthesis Alkylation of 1-(2-pyrimidyl)piperazine (1) with 3-chloro-1-cyanopropane (2, 4-chlorobutyronitrile) gives 3, which is reduced either by hydrogenation over Raney nickel catalyst, or with LAH. The resulting 1° amine (4) from the previous step is then reacted with 3,3-tetramethyleneglutaric anhydride (5, 8-Oxaspiro[4.5]decane-7,9-dione) in order to yield buspirone (6). History Buspirone was first synthesized by a team at Mead Johnson in 1968 but was not patented until 1980. It was initially developed as an antipsychotic acting on the D2 receptor but was found to be ineffective in the treatment of psychosis; it was then used as an anxiolytic instead. In 1986, Bristol-Myers Squibb gained FDA approval for buspirone in the treatment of GAD. The patent expired in 2001, and buspirone is now available as a generic drug. Society and culture Generic names Buspirone is the INN, BAN, DCF, and DCIT of buspirone, while buspirone hydrochloride is its USAN, BANM, and JAN. Brand name Buspirone was primarily sold under the brand name Buspar. Buspar is currently listed as discontinued by the US Federal Drug Administration. In 2010, in response to a citizen petition, the US FDA determined that Buspar was not withdrawn from sale for reasons of safety or effectiveness. 2019 shortage Due to interrupted production at a Mylan Pharmaceuticals plant in Morgantown, West Virginia, the United States experienced a shortage of buspirone in 2019. Research Some tentative research supports other uses such as the treatment of depression and behavioral problems following brain damage. References External links Media related to Buspirone at Wikimedia Commons "Buspirone". Drug Information Portal. U.S. National Library of Medicine.
Aquaphor	Aquaphor is a brand of over-the-counter (OTC) skin care ointments manufactured by Beiersdorf Inc., an affiliate of Beiersdorf AG. Aquaphor is offered in four product ranges: There are two skin protectant ointments. Aquaphor Original Ointment, used as a compounding agent and Aquaphor Advanced Therapy Healing Ointment, sold in mass retail outlets. The other product ranges include: Aquaphor Lip Repair and Lip Repair + Protect SPF 30, and Aquaphor Baby. Aquaphor has been available in the United States market for over 90 years. In accordance with the Food and Drug Administrations OTC Skin Protectant Monograph Aquaphor, containing 41 percent petrolatum (or petroleum jelly), the active ingredient, temporarily protects minor cuts, scrapes, and burns; protects and helps relieve chapped or cracked skin and lips; helps protect from the drying effects of wind and cold weather.Aquaphor is used and recommended by health care professionals for minor post-operative wounds or defects. History 1925: Aquaphor was developed in the Beiersdorf Inc laboratories in the USA. It was trademarked that year by Herman A. Metz, president of Beiersdorf Inc at that time. 1929: Beiersdorf sold Aquaphor’s trade marks to Duke Laboratories in order to manufacture products in the country.1936: Aquaphor’s first product offering was sold to doctors, pharmacists and hospitals in 5 lb. containers. 1960: Aquaphor production was discontinued during World War II and restarted by Duke Laboratiories in 1960. One lb cans and 2 oz tubes were sold to medical professionals.1973: Beiersdorf repurchased all trademarks from Duke Laboratories.1982: Aquaphor tube was introduced and directly sold to consumers for the first time. 1991: A new formulation Aquaphor Advanced Therapy Healing Ointment was launched, an addition to the Aquaphor Original Ointment. 2003: Aquaphor Baby Healing Ointment & Gentle Wash were introduced. 2011: Aquaphor Lip Repair was introduced 2012: Aquaphor Lip Repair + Protect SPF 30 was launched and Aquaphor is launched globally by Beiersdorf affiliates in 25 other countries. 2013: Aquaphor achieved the Good Housekeeping Seal. Properties and ingredients In a study funded by Aquaphors parent company, it was found that their "Healing Ointment" product was associated with (but did not cause) decreased redness around the wound but did not in any way perform better than other products clinically.Aquaphor is not comedogenic and does not contain any fragrances, preservatives, or dyes.Unlike Vaseline (100% petrolatum), which is occlusive, Aquaphor (41% petrolatum) claims to form a semi-occlusive barrier on the skin. If correct, this in theory should enable the transmission of water and oxygen, which is important for wound healing and the formation of a protective moist healing environment. However, no studies have been conducted using this brand to test these healing claims. Key ingredients Petrolatum An active ingredient and OTC skin protectant, petrolatum forms an occlusive barrier on the skin and helps retain moisture.Mineral oil A colorless, odorless, light oil, commonly obtained as a highly refined derivative of crude oil. Baby oil is a perfumed variety of mineral oil. Ceresin A wax derived from the purification of the natural wax ozokerite.Lanolin alcohol A subfraction of lanolin (wool wax), a mixture of hydrocarbons that imparts emulsifying properties and provides emollient (skin smoothing) properties. Lanolin alcohol is composed of cholesterol, other sterols, and free fatty acids. Moisturizers containing Cholesterol and fatty acid mixtures have been shown to provide skin benefits. Since this ingredient is sourced from wool from animals, this product is not suitable for vegans. Glycerin A moisturizing factor (NMF) and humectant that attracts and binds moisture in the stratum corneum (outer-most layer of epidermis), helping to keep it hydrated. It is commonly used as a moisturizing agent in lotions, creams, and cosmetics. Most glycerin used in products in the U.S. comes from animals. If it is natural glycerin, it will typically be labeled ‘plant derived’.Panthenol Also known as pro- Vitamin B5, when applied topically, has humectant properties and conditions the skin.Bisabolol Derived from the Chamomile plant, bisabolol can have anti-inflammatory, anti-pruritic and healing effects in-vivo. See also Medicine portal References External links Official website
Ovide	Ovide may refer to: Ovide, a brand name for the insecticide malathion Ovide, a character in the animated television show Ovide and the Gang People Ovide Alakannuark, Canadian politician Ovide Le Blanc, Canadian politician Ovide Lamontagne, American lawyer and politician Ovide Mercredi, Canadian politician Ovide de Montigny, French-Canadian fur trapper Joseph-Ovide Turgeon, Canadian politician See also Ovid
Temazepam	Temazepam (sold under the brand names Restoril among others) is a medication of the benzodiazepine class which is now generally used to treat severe or debilitating insomnia. Such use should generally be for less than ten days. It is taken by mouth. Temazepam is rapidly absorbed, and significant hypnotic effects begin in less than 30 minutes and can last for up to eight hours. Many studies, some going as far back as the early 1980s out of Australia and the United Kingdom, both of which have had serious temazepam abuse epidemics and related mortality, have all mostly corroborated each other and proven that the potential for abuse and physical dependence is very high, even in comparison to many other benzodiazepines. As a result, prescriptions for hypnotics such as temazepam have seen a dramatic decrease since 2010, while anxiolytics such as alprazolam (Xanax), clonazepam (Rivitrol, Klonopin), and lorazepam (Ativan) have increased or remained stable. Temazepam and similar hypnotics, such as triazolam (Halcion) are generally reserved for severe and debilitating insomnia. They have largely been replaced by z-drugs (zopiclone, zolpidem) and atypical antidepressants (trazodone, mirtazapine) as first line treatment for insomnia. Even when a benzodiazepine is required, in many cases, smaller doses of anxiolytics such as diazepam (Valium) or alprazolam (Xanax) are recommended over hypnotic agents.Common side effects include drowsiness, motor and cognitive impairment, lethargy, confusion, euphoria, and dizziness. Serious side effects may include hallucinations, hypotension, respiratory depression, abuse, anaphylaxis, and suicide. Use is generally not recommended together with alcohol or opioids. If the dose is rapidly decreased withdrawal may occur. Use during pregnancy or breastfeeding is not recommended. Temazepam is a short-acting benzodiazepine and hypnotic. It works by affecting GABA within the brain.Temazepam was patented in 1962 and came into medical use in 1969. It is available as a generic medication. In 2019, it was the 214th most commonly prescribed medication in the United States, with more than 2 million prescriptions. Medical uses In sleep laboratory studies, temazepam significantly decreased the number of nightly awakenings, but has the drawback of distorting the normal sleep pattern. It is officially indicated for severe insomnia and other severe or disabling sleep disorders. The prescribing guidelines in the UK limit the prescribing of hypnotics to two to four weeks due to concerns of tolerance and dependence.The American Academy of Sleep Medicines 2017 clinical practice guidelines recommended the use of temazepam in the treatment of sleep-onset and sleep-maintenance insomnia. It rated the recommendation as weak, the quality of evidence as moderate, and concluded that the potential benefits outweighed the potential harms. The guidelines found that temazepam at a dose of 15 mg reduces sleep latency by 37 minutes (95% CI 21 to 53 minutes), increases total sleep time by 99 minutes (95% CI 63 to 135 minutes), and provides a small improvement to sleep quality. The improvements in sleep latency and total sleep time were numerically much greater than any of the other included sleep medications, including eszopiclone, zopiclone, zolpidem, triazolam, estazolam, quazepam, flurazepam, trazodone, diphenhydramine, gabapentin, among others.The United States Air Force uses temazepam as one of the hypnotics approved as a "no-go pill" to help aviators and special-duty personnel sleep in support of mission readiness. "Ground tests" are necessary prior to required authorization being issued to use the medication in an operational situation, and a 12-hour restriction is imposed on subsequent flight operation. The other hypnotics used as "no-go pills" are zaleplon and zolpidem, which have shorter mandatory recovery periods. Available forms Temazepam is available in the form of 7.5, 15, 22.5, and 30 mg oral capsules in North America (Canada and United States). Although banned in some European countries (Norway, Sweden), it is available in most other European countries and the rest of the world, including in Australia and New Zealand, as 5, 10, 15 and 20 mg tablets or capsules. Contraindications Use of temazepam should be avoided, when possible, in individuals with these conditions: Ataxia (gross lack of coordination of muscle movements) Severe hypoventilation Acute narrow-angle glaucoma Severe hepatic deficiencies (hepatitis and liver cirrhosis decrease elimination by a factor of two) Severe renal deficiencies (e.g. patients on dialysis) Sleep apnea Severe depression, particularly when accompanied by suicidal tendencies Acute intoxication with alcohol, narcotics, or other psychoactive substances Myasthenia gravis (autoimmune disorder causing muscle weakness) Hypersensitivity or allergy to any drug in the benzodiazepine class Special caution needed Temazepam should not be used in pregnancy, as it may cause harm to the fetus. The safety and effectiveness of temazepam has not been established in children; therefore, temazepam should generally not be given to individuals under 18 years of age, and should not be used at all in children under six months old. Benzodiazepines also require special caution if used in the elderly, alcohol- or drug-dependent individuals, and individuals with comorbid psychiatric disorders.Temazepam, similar to other benzodiazepines and nonbenzodiazepine hypnotic drugs, causes impairments in body balance and standing steadiness in individuals who wake up at night or the next morning. Falls and hip fractures are frequently reported. The combination with alcohol increases these impairments. Partial but incomplete tolerance develops to these impairments. The smallest possible effective dose should be used in elderly or very ill patients, as a risk of apnea and/or cardiac arrest exists. This risk is increased when temazepam is given concomitantly with other drugs that depress the central nervous system (CNS). Misuse and dependence Because benzodiazepines can be abused and lead to dependence, their use should be avoided in people in certain particularly high-risk groups. These groups include people with a history of alcohol or drug dependence, people significantly struggling with their mood or people with longstanding mental health difficulties. If temazepam must be prescribed to people in these groups, they should generally be monitored very closely for signs of misuse and development of dependence. Adverse effects In September 2020, the U.S. Food and Drug Administration (FDA) required the boxed warning be updated for all benzodiazepine medicines to describe the risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions consistently across all the medicines in the class. Common Side effects typical of hypnotic benzodiazepines are related to CNS depression, and include somnolence, sedation, dizziness, fatigue, ataxia, headache, lethargy, impairment of memory and learning, longer reaction time and impairment of motor functions (including coordination problems), slurred speech, decreased physical performance, numbed emotions, reduced alertness, muscle weakness, blurred vision (in higher doses), and inattention. Euphoria was rarely reported with its use. According to the U.S. Food and Drug Administration, temazepam had an incidence of euphoria of 1.5%, much more rarely reported than headaches and diarrhea. Anterograde amnesia may also develop, as may respiratory depression in higher doses. A 2009 meta-analysis found a 44% higher rate of mild infections, such as pharyngitis or sinusitis, in people taking Temazepam or other hypnotic drugs compared to those taking a placebo. Less common Hyperhydrosis, hypotension, burning eyes, increased appetite, changes in libido, hallucinations, faintness, nystagmus, vomiting, pruritus, gastrointestinal disturbances, nightmares, palpitation and paradoxical reactions including restlessness, aggression, violence, overstimulation and agitation have been reported, but are rare (less than 0.5%). Before taking temazepam, one should ensure that at least 8 hours are available to dedicate to sleep. Failing to do so can increase the side effects of the drug. Like all benzodiazepines, the use of this drug in combination with alcohol potentiates the side effects, and can lead to toxicity and death. Though rare, residual "hangover" effects after night-time administration of temazepam occasionally occur. These include sleepiness, impaired psychomotor and cognitive functions which may persist into the next day, impaired driving ability, and possible increased risks of falls and hip fractures, especially in the elderly. Tolerance Chronic or excessive use of temazepam may cause drug tolerance, which can develop rapidly, so this drug is not recommended for long-term use. In 1979, the Institute of Medicine (USA) and the National Institute on Drug Abuse stated that most hypnotics lose their sleep-inducing properties after about three to 14 days. In use longer than one to two weeks, tolerance will rapidly develop towards the ability of temazepam to maintain sleep, resulting in a loss of effectiveness. Some studies have observed tolerance to temazepam after as little as one weeks use. Another study examined the short-term effects of the accumulation of temazepam over seven days in elderly inpatients, and found little tolerance developed during the accumulation of the drug. Other studies examined the use of temazepam over six days and saw no evidence of tolerance. A study in 11 young male subjects showed significant tolerance occurs to temazepams thermoregulatory effects and sleep inducing properties after one week of use of 30-mg temazepam. Body temperature is well correlated with the sleep-inducing or insomnia-promoting properties of drugs.In one study, the drug sensitivity of people who had used temazepam for one to 20 years was no different from that of controls. An additional study, in which at least one of the authors is employed by multiple drug companies, examined the efficacy of temazepam treatment on chronic insomnia over three months, and saw no drug tolerance, with the authors even suggesting the drug might become more effective over time.Establishing continued efficacy beyond a few weeks can be complicated by the difficulty in distinguishing between the return of the original insomnia complaint and withdrawal or rebound related insomnia. Sleep EEG studies on hypnotic benzodiazepines show tolerance tends to occur completely after one to four weeks with sleep EEG returning to pretreatment levels. The paper concluded that due to concerns about long-term use involving toxicity, tolerance and dependence, as well as to controversy over long-term efficacy, wise prescribers should restrict benzodiazepines to a few weeks and avoid continuing prescriptions for months or years. A review of the literature found the nonpharmacological treatment options were a more effective treatment option for insomnia due to their sustained improvements in sleep quality. Physical dependence Temazepam, like other benzodiazepine drugs, can cause physical dependence and addiction. Withdrawal from temazepam or other benzodiazepines after regular use often leads to benzodiazepine withdrawal syndrome, which resembles symptoms during alcohol and barbiturate withdrawal. The higher the dose and the longer the drug is taken, the greater the risk of experiencing unpleasant withdrawal symptoms. Withdrawal symptoms can also occur from standard dosages and after short-term use. Abrupt withdrawal from therapeutic doses of temazepam after long-term use may result in a severe benzodiazepine withdrawal syndrome. Gradual and careful reduction of the dosage, preferably with a long-acting benzodiazepine with long half-life active metabolites, such as chlordiazepoxide or diazepam, are recommended to prevent severe withdrawal syndromes from developing. Other hypnotic benzodiazepines are not recommended. A study in rats found temazepam is cross tolerant with barbiturates and is able to effectively substitute for barbiturates and suppress barbiturate withdrawal signs. Rare cases are reported in the medical literature of psychotic states developing after abrupt withdrawal from benzodiazepines, even from therapeutic doses. Antipsychotics increase the severity of benzodiazepine withdrawal effects with an increase in the intensity and severity of convulsions. Patients who were treated in the hospital with temazepam or nitrazepam have continued taking these after leaving the hospital. Hypnotic uses in the hospital were recommended to be limited to five nights use only, to avoid the development of withdrawal symptoms such as insomnia. Interactions As with other benzodiazepines, temazepam produces additive CNS-depressant effects when coadministered with other medications which themselves produce CNS depression, such as barbiturates, alcohol, opiates, tricyclic antidepressants, nonselective MAO inhibitors, phenothiazines and other antipsychotics, skeletal muscle relaxants, antihistamines, and anaesthetics. Administration of theophylline or aminophylline has been shown to reduce the sedative effects of temazepam and other benzodiazepines. Unlike many benzodiazepines, pharmacokinetic interactions involving the P450 system have not been observed with temazepam. Temazepam shows no significant interaction with CYP3A4 inhibitors (e.g. itraconazole, erythromycin). Oral contraceptives may decrease the effectiveness of temazepam and speed up its elimination half-life. Overdose Overdosage of temazepam results in increasing CNS effects, including: Somnolence (difficulty staying awake) Mental confusion Respiratory depression Hypotension Impaired motor functions Impaired or absent reflexes Impaired coordination Impaired balance Dizziness, sedation Coma DeathTemazepam had the highest rate of drug intoxication, including overdose, among common benzodiazepines in cases with and without combination with alcohol in a 1985 study. Temazepam and nitrazepam were the two benzodiazepines most commonly detected in overdose-related deaths in an Australian study of drug deaths. A 1993 British study found temazepam to have the highest number of deaths per million prescriptions among medications commonly prescribed in the 1980s (11.9, versus 5.9 for benzodiazepines overall, taken with or without alcohol).A 1995 Australian study of patients admitted to hospital after benzodiazepine overdose corroborated these results, and found temazepam overdose much more likely to lead to coma than other benzodiazepines (odds ratio 1.86). The authors noted several factors, such as differences in potency, receptor affinity, and rate of absorption between benzodiazepines, could explain this higher toxicity. Although benzodiazepines have a high therapeutic index, temazepam is one of the more dangerous of this class of drugs. The combination of alcohol and temazepam makes death by alcohol poisoning more likely. Pharmacology Pharmacodynamics The main pharmacological action of temazepam is to increase the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABAA receptor. This causes sedation, motor impairment, ataxia, anxiolysis, an anticonvulsant effect, muscle relaxation, and a reinforcing effect.As a medication before surgery, temazepam decreased cortisol in elderly patients. In rats, it triggered the release of vasopressin into paraventricular nucleus of the hypothalamus and decreased the release of ACTH under stress. Pharmacokinetics Oral administration of 15 to 45 mg of temazepam in humans resulted in rapid absorption with significant blood levels achieved in fewer than 30 minutes and peak levels at two to three hours.In a single- and multiple-dose absorption, distribution, metabolism, and excretion (ADME) study, using tritium-labelled drug, temazepam was well absorbed and found to have minimal (8%) first-pass drug metabolism. No active metabolites were formed and the only significant metabolite present in blood was the O-conjugate. The unchanged drug was 96% bound to plasma proteins. The blood-level decline of the parent drug was biphasic, with the short half-life ranging from 0.4 to 0.6 hours and the terminal half-life from 3.5 to 18.4 hours (mean 8.8 hours), depending on the study population and method of determination.Temazepam has very good bioavailability, with almost 100% being absorbed following being taken by mouth. The drug is metabolized through conjugation and demethylation prior to excretion. Most of the drug is excreted in the urine, with about 20% appearing in the faeces. The major metabolite was the O-conjugate of temazepam (90%); the O-conjugate of N-desmethyl temazepam was a minor metabolite (7%). Chemistry Temazepam is a benzodiazepine. It is a white, crystalline substance, very slightly soluble in water, and sparingly soluble in alcohol. Synthesis Pharmacologically active metabolite of diazepam, q.v. N-oxides are prone to undergo the Polonovski rearrangement when treated with acetic anhydride, and this was illustrated by the synthesis of oxazepam. It is not surprising that the N-methyl analogue (1) also undergoes this process, and hydrolysis of the resulting acetate gives temazepam (2). Care must be exacted with the conditions, or the inactive rearrangement product (3) results. History Temazepam was synthesized in 1964, but it came into use in 1981 when its ability to counter insomnia was realized. By the late 1980s, temazepam was one of the most popular and widely prescribed hypnotics on the market and it became one of the most widely prescribed drugs. Society and culture Recreational use Temazepam is a drug with a high potential for misuse.Benzodiazepines have been abused orally and intravenously. Different benzodiazepines have different abuse potential; the more rapid the increase in the plasma level following ingestion, the greater the intoxicating effect and the more open to abuse the drug becomes. The speed of onset of action of a particular benzodiazepine correlates well with the popularity of that drug for abuse. The two most common reasons for preference were that a benzodiazepine was strong and that it gave a good high.A 1995 study found that temazepam is more rapidly absorbed and oxazepam is more slowly absorbed than most other benzodiazepines.A 1985 study found that temazepam and triazolam maintained significantly higher rates of self-injection than a variety of other benzodiazepines. The study tested and compared the abuse liability of temazepam, triazolam, diazepam, lorazepam, oxazepam, flurazepam, alprazolam, chlordiazepoxide, clonazepam, nitrazepam, flunitrazepam, bromazepam, and clorazepate. The study tested self-injection rates on human, baboon, and rat subjects. All test subjects consistently showed a strong preference for temazepam and triazolam over all the rest of the benzodiazepines included in the study. North America In North America, temazepam misuse is not widespread. Other benzodiazepines are more commonly prescribed for insomnia. In the United States, temazepam is the fifth-most prescribed benzodiazepine, however there is a major drop off from the top four most prescribed (alprazolam, lorazepam, diazepam, and clonazepam in that order). Individuals abusing benzodiazepines obtain the drug by getting prescriptions from several doctors, forging prescriptions, or buying diverted pharmaceutical products on the illicit market. North America has never had a serious problem with temazepam misuse, but is becoming increasingly vulnerable to the illicit trade of temazepam. Australia Temazepam is a Schedule 4 drug and requires a prescription. The drug accounts for most benzodiazepine sought by forgery of prescriptions and through pharmacy burglary in Victoria. Due to rife intravenous abuse, the Australian government decided to put it under a more restrictive schedule than it had been, and since March 2004 temazepam capsules have been withdrawn from the Australian market, leaving only 10 mg tablets available.Benzodiazepines are commonly detected by Customs at different ports and airports, arriving by mail, also found occasionally in the baggage of air passengers, mostly small or medium quantities (up to 200–300 tablets) for personal use. From 2003 to 2006, customs detected about 500 illegal importations of benzodiazepines per year, most frequently diazepam. Quantities varied from single tablets to 2,000 tablets. United Kingdom In 1987, temazepam was the most widely abused legal prescription drug in the United Kingdom. The use of benzodiazepines by street-drug abusers was part of a polydrug abuse pattern, but many of those entering treatment facilities were declaring temazepam as their main drug of abuse. Temazepam was the most commonly used benzodiazepine in a study, published 1994, of injecting drug users in seven cities, and had been injected from preparations of capsules, tablets, and syrup. The increase in use of heroin, often mixed with other drugs, which most often included temazepam, diazepam, and alcohol, was a major factor in the increase in drug-related deaths in Glasgow and Edinburgh in 1990–1992. Temazepam use was particularly associated with violent or disorderly behaviours and contact with the police in a 1997 study of young single homeless people in Scotland. The BBC series Panorama featured an episode titled "Temazepam Wars", dealing with the epidemic of temazepam abuse and directly related crime in Paisley, Scotland. The trend was mocked in the 1995 Black Grape song "Temazi Party" (also called "Tramazi Party"). Medical research issues The Journal of Clinical Sleep Medicine published a paper expressing concerns about benzodiazepine receptor agonist drugs, the benzodiazepines and the Z-drugs used as hypnotics in humans. The paper cites a systematic review of the medical literature concerning insomnia medications and states almost all trials of sleep disorders and drugs are sponsored by the pharmaceutical industry, while this is not the case in general medicine or psychiatry. It cites another study that "found that the odds ratio for finding results favorable to industry in industry-sponsored trials was 3.6 times as high as in non–industry-sponsored studies". Issues discussed regarding industry-sponsored studies include: comparison of a drug to a placebo, but not to an alternative treatment; unpublished studies with unfavorable outcomes; and trials organized around a placebo baseline followed by drug treatment, but not counterbalanced with parallel-placebo-controlled studies. Quoting a 1979 report that too little research into hypnotics was independent of the drug manufacturers, the authors conclude, "the public desperately needs an equipoised assessment of hypnotic benefits and risks" and the NIH and VA should provide leadership to that end. Street terms Street terms for temazepam include king kong pills (formerly referred to barbiturates, now more commonly refers to temazepam), jellies, jelly, Edinburgh eccies, tams, terms, mazzies, temazies, tammies, temmies, beans, eggs, green eggs, wobbly eggs, knockouts, hardball, norries, oranges (common term in Australia and New Zealand), rugby balls, ruggers, terminators, red and blue, no-gos, num nums, blackout, green devils, drunk pills, brainwash, mind erasers, neurotrashers, tem-tems (combined with buprenorphine), mommys big helper, vitamin T, big T, TZ, the mazepam, resties (North America) and others. Availability Temazepam is available in English-speaking countries under the following brand names: Euhypnos Normison Norkotral Nortem Remestan Restoril Temaze Temtabs In Spain, the drug is sold as temzpem. In Hungary the drug is sold as Signopam. Legal status In Austria, temazepam is listed in UN71 Schedule III under the Psychotropic Substances Decree of 1997. The drug is considered to have a high potential for abuse and addiction, but has accepted medical use for the treatment of severe insomnia.In Australia, temazepam is a Schedule 4 - Prescription Only medicine. It is primarily used for the treatment of insomnia, and is also seen as pre-anaesthetic medication.In Canada, temazepam is a Schedule IV controlled substance requiring a registered doctors prescription.In Denmark, temazepam is listed as a Class D substance under the Executive Order 698 of 1993 on Euphoric Substances which means it has a high potential for abuse, but is used for medical and scientific purposes.In Finland, temazepam is more tightly controlled than other benzodiazepines. The temazepam product Normison was pulled out of shelves and banned because the liquid inside gelatin capsules had caused a large increase in intravenous temazepam use. The other temazepam product, Tenox, was not affected and remains as prescription medicine. Temazepam intravenous use has not decreased to the level before Normison came to the market.In France, temazepam is listed as a psychotropic substance as are other similar drugs. It is prescribed with a nonrenewable prescription (a new doctor visit every time), available only in 7 or 14-pill packaging for one or two weeks. One brand was withdrawn from the market in 2013.In Hong Kong, temazepam is regulated under Schedule 1 of Hong Kongs Chapter 134 Dangerous Drugs Ordinance. Temazepam can only be used legally by health professionals and for university research purposes. The substance can be given by pharmacists under a prescription. Anyone who supplies the substance without prescription can be fined HKD$10,000. The penalty for trafficking or manufacturing the substance is a $5,000,000-fine and life imprisonment. Possession of the substance for consumption without license from the Department of Health is illegal with a $1,000,000-fine and/or seven years of jail time.In Ireland, temazepam is a Schedule 3 controlled substance with strict restrictions.In the Netherlands, temazepam is available for prescription as 10- or 20-mg tablets and capsules. Formulations of temazepam containing less than 20 mg are included in List 2 of the Opium Law, while formulations containing 20 mg or more of the drug (along with the gel-capsules) are a List 1 substance of the Opium Law, thus subject to more stringent regulation. Besides being used for insomnia, it is also occasionally used as a preanesthetic medication.In Norway, temazepam is not available as a prescription drug. It is regulated as a Class A substance under Norways Narcotics Act.In Portugal, temazepam is a Schedule IV controlled drug under Decree-Law 15/93.In Singapore, temazepam is a Class A controlled drug (Schedule I), making it illegal to possess and requiring a private prescription from a licensed physician to be dispensed. In Slovenia, it is regulated as a Group II (Schedule 2) controlled substance under the Production and Trade in Illicit Drugs Act.In South Africa, temazepam is a Schedule 5 drug, requiring a special prescription, and is restricted to 10– to 30-mg doses.In Sweden, temazepam is classed as a "narcotic" drug listed as both a List II (Schedule II) which denotes it is a drug with limited medicinal use and a high risk of addiction, and is also listed as a List V (Schedule V) substance which denotes the drug is prohibited in Sweden under the Narcotics Drugs Act (1968). Temazepam is banned in Sweden and possession and distribution of even small amounts is punishable by a prison sentence and a fine.In Switzerland, temazepam is a
Temazepam	Class B controlled substance, like all other benzodiazepines. This means it is a prescription-only drug.In Thailand, temazepam is a Schedule II controlled drug under the Psychotropic Substances Act. Possession and distribution of the drug is illegal. In the United Kingdom, temazepam is a Class C controlled drug under the Misuse of Drugs Act 1971 (Schedule 3 under the Misuse of Drugs Regulations 2001). If prescribed privately (not on the NHS), temazepam is available only by a special controlled drug prescription form (FP10PCD) and pharmacies are obligated to follow special procedures for storage and dispensing. Additionally, all manufacturers in the UK have replaced the gel-capsules with solid tablets. Temazepam requires safe custody and up until June 2015 was exempt from CD prescription requirements. In the United States, Temazepam is currently a Schedule IV drug under the international Convention on Psychotropic Substances of 1971 and is only available by prescription. Specially coded prescriptions may be required in certain states. References External links "Temazepam". Drug Information Portal. U.S. National Library of Medicine. Temazepam \| Inchem Panorama document - 1995 - YouTube video
Acetazolamide	Acetazolamide, sold under the trade name Diamox among others, is a medication used to treat glaucoma, epilepsy, altitude sickness, periodic paralysis, idiopathic intracranial hypertension (raised brain pressure of unclear cause), urine alkalinization, and heart failure. It may be used long term for the treatment of open angle glaucoma and short term for acute angle closure glaucoma until surgery can be carried out. It is taken by mouth or injection into a vein. Acetazolamide is a first generation carbonic anhydrase inhibitor and it decreases the ocular fluid and osmolality in the eye to decrease intraocular pressure.Common side effects include numbness, ringing in the ears, loss of appetite, vomiting, and sleepiness. It is not recommended in those with significant kidney problems, liver problems, or who are allergic to sulfonamides. Acetazolamide is in the diuretic and carbonic anhydrase inhibitor families of medication. It works by decreasing the formation of hydrogen ions and bicarbonate from carbon dioxide and water.Acetazolamide came into medical use in 1952. It is on the World Health Organizations List of Essential Medicines. Acetazolamide is available as a generic medication. Medical uses It is used in the treatment of glaucoma, drug-induced edema, heart failure-induced edema, epilepsy and in reducing intraocular pressure after surgery. It has also been used in the treatment of altitude sickness, Ménières disease, increased intracranial pressure and neuromuscular disorders.In epilepsy, the main use of acetazolamide is in menstrual-related epilepsy and as an add on to other treatments in refractory epilepsy. Though various websites on the internet report that acetazolamide can be used to treat dural ectasia in individuals with Marfan Syndrome, the only supporting evidence for this assertion exists from a small study of 14 patients which was not peer-reviewed or submitted for publication. Several published cases of intracranial hypotension related to Marfan syndrome would warrant caution in using acetazolamide in these patients unless there is a clear indication, as it could lower intracranial pressure further. A 2012 review and meta-analysis found that there was "limited supporting evidence" but that acetazolamide "may be considered" for the treatment of central (as opposed to obstructive) sleep apnea.It has also been used to prevent methotrexate-induced kidney damage by alkalinizing the urine, hence speeding up methotrexate excretion by increasing its solubility in urine. There is some evidence to support its use to prevent hemiplegic migraine. Open-Angle Glaucoma Acetazolamide is used in the treatment of open-angle glaucoma. The carbonic anhydrase inhibitor is able to decrease ocular fluid and osmolality of the fluid in the humor of the eye and decrease intraocular pressure in the eye. The medication comes in the form of an oral tablet used for this indication. High altitude sickness Acetazolamide is also used for the treatment of acute mountain sickness. In the prevention or treatment of mountain sickness, acetazolamide inhibits the ability of the kidneys to reabsorb bicarbonate, the conjugate base of carbonic acid. Increasing the amount of bicarbonate excreted in the urine leads to acidification of the blood. Because the body senses CO2 concentration indirectly via blood pH (increase in CO2 causes a decrease in pH), acidifying the blood through decreased renal reabsorption of bicarbonate is sensed as an increase in CO2. This, in turn, causes the body to increase minute ventilation (the amount of air breathed per minute) in order to "breathe off" CO2, which in turn increases the amount of oxygen in the blood. Acetazolamide is not an immediate cure for acute mountain sickness; rather, it speeds up (or, when taking before traveling, forces the body to early start) part of the acclimatization process which in turn helps to relieve symptoms. Acetazolamide is still effective if started early in the course of mountain sickness. As prevention, it is started one day before travel to altitude and continued for the first 2 days at altitude. Pregnancy and lactation Acetazolamide is pregnancy category B3 in Australia, which means that studies in rats, mice and rabbits in which acetazolamide was given intravenously or orally caused an increased risk of fetal malformations, including defects of the limbs. Despite this, there is insufficient evidence from studies in humans to either support or discount this evidence.Limited data are available on the effects of nursing mothers taking acetazolamide. Therapeutic doses create low levels in breast milk and are not expected to cause problems in infants. Side effects Common adverse effects of acetazolamide include the following: paraesthesia, fatigue, drowsiness, depression, decreased libido, bitter or metallic taste, nausea, vomiting, abdominal cramps, diarrhea, black stool, polyuria, kidney stones, metabolic acidosis and electrolyte changes (hypokalemia, hyponatremia). Whereas less common adverse effects include Stevens–Johnson syndrome, anaphylaxis and blood dyscrasias. Contraindications Contraindications include: Hyperchloremic acidosis Hypokalemia (low blood potassium) Hyponatremia (low blood sodium) Adrenal insufficiency Impaired kidney function Hypersensitivity to acetazolamide or other sulphonamides. Marked liver disease or impairment of liver function, including cirrhosis because of the risk of development of hepatic encephalopathy. Acetazolamide decreases ammonia clearance. Interactions It is possible that it might interact with: Amphetamines, because it increases the pH of the renal tubular urine, hence reducing the clearance of amphetamines. Other carbonic anhydrase inhibitors — potential for additive inhibitory effects on carbonic anhydrase and hence potential for toxicity. Ciclosporin, may increase plasma levels of ciclosporin. Antifolates such as trimethoprim, methotrexate, pemetrexed and raltitrexed. Hypoglycemics, acetazolamide can both increase or decrease blood glucose levels. Lithium, increases excretion, hence reducing therapeutic effect. Methenamine compounds, reduces the urinary excretion of methenamines. Phenytoin, reduces phenytoin excretion, hence increasing the potential for toxicity. Primidone, reduces plasma levels of primidone. Hence reducing anticonvulsant effect. Quinidine, reduces urinary excretion of quinidine, hence increasing the potential for toxicity. Salicylates, potential for severe toxicity. Sodium bicarbonate, potential for kidney stone formation. Anticoagulants, cardiac glycosides, may have their effects potentiated by acetazolamide. Mechanism of action Acetazolamide is a carbonic anhydrase inhibitor, hence causing the accumulation of carbonic acid. Carbonic anhydrase is an enzyme found in red blood cells and many other tissues that catalyses the following reaction: H2CO3 ⇌ H2O + CO2hence lowering blood pH, by means of the following reaction that carbonic acid undergoes: H2CO3 ⇌ HCO3− + H+which has a pKa of 6.3.The mechanism of diuresis involves the proximal tubule of the kidney. The enzyme carbonic anhydrase is found here, allowing the reabsorption of bicarbonate, sodium, and chloride. By inhibiting this enzyme, these ions are excreted, along with excess water, lowering blood pressure, intracranial pressure, and intraocular pressure. A general side effect of carbonic anhydrase inhibitors is loss of potassium due to this function. By excreting bicarbonate, the blood becomes acidic, causing compensatory hyperventilation with deep respiration (Kussmaul breathing), increasing levels of oxygen and decreasing levels of carbon dioxide in the blood.In the eye this results in a reduction in aqueous humour.Bicarbonate (HCO3−) has a pKa of 10.3 with carbonate (CO32−), far further from physiologic pH (7.35–7.45), and so it is more likely to accept a proton than to donate one, but it is also far less likely for it to do either, thus bicarbonate will be the major species at physiological pH. Under normal conditions in the proximal convoluted tubule of the kidney, most of the carbonic acid (H2CO3) produced intracellularly by the action of carbonic anhydrase quickly dissociates in the cell to bicarbonate (HCO3−) and an H+ ion (a proton), as previously mentioned. The bicarbonate (HCO3−) exits at the basal portion of the cell via sodium (Na+) symport and chloride (Cl−) antiport and re-enters circulation, where it may accept a proton if blood pH decreases, thus acting as a weak, basic buffer. The remaining H+ left over from the intracellular production of carbonic acid (H2CO3) exits the apical (urinary lumen) portion of the cell by Na+ antiport, acidifying the urine. There, it may join with another bicarbonate (HCO3−) that dissociated from its H+ in the lumen of the urinary space only after exiting the proximal convoluted kidney cells/glomerulus as carbonic acid (H2CO3) because bicarbonate (HCO3−) itself can not diffuse across the cell membrane in its polar state. This will replenish carbonic acid (H2CO3) so that it then may be reabsorbed into the cell as itself or CO2 and H2O (produced via a luminal carbonic anhydrase). As a result of this whole process, there is a greater net balance of H+ in the urinary lumen than bicarbonate (HCO3−), and so this space is more acidic than physiologic pH. Thus, there is an increased likelihood that any bicarbonate (HCO3−) that was left over in the lumen diffuses back into the cell as carbonic acid, CO2, or H2O. In short, under normal conditions, the net effect of carbonic anhydrase in the urinary lumen and cells of the proximal convoluted tubule is to acidify the urine and transport bicarbonate (HCO3−) into the body. Another effect is excretion of Cl− as it is needed to maintain electroneutrality in the lumen, as well as the reabsorption of Na+ into the body. Thus, by disrupting this process with acetazolamide, urinary Na+ and bicarbonate (HCO3−) are increased, and urinary H+ and Cl− are decreased. Inversely, serum Na+ and bicarbonate (HCO3−) are decreased, and serum H+ and Cl− are increased. H2O generally follows sodium, and so this is how the clinical diuretic effect is achieved, which reduces blood volume and thus preload on the heart to improve contractility and reduce blood pressure, or achieve other desired clinical effects of reduced blood volume such as reducing edema or intracranial pressure. History An early description of this compound (as 2-acetylamino-1,3,4-thiadiazole-5-sulfonamide) and its synthesis has been patented. Research Smaller clinical trials have also shown promising results in the treatment of normal pressure hydrocephalus (NPH). References External links "Acetazolamide". Drug Information Portal. U.S. National Library of Medicine.
Simeticone	Simeticone (INN), also known as simethicone (USAN), is an anti-foaming agent used to reduce bloating, discomfort or pain caused by excessive gas. Medical uses Simeticone is used to relieve the symptoms of excessive gas in the gastrointestinal tract, namely bloating, burping, and flatulence. While there is a lack of conclusive evidence that simeticone is effective for this use, ⁣ studies have shown that it can relieve symptoms of functional dyspepsia and functional bloating.It has not been fully established that simeticone is useful to treat colic in babies, and it is not recommended for this purpose. A study in the United Kingdom reported that according to parental perception simeticone helped infant colic in some cases.Simeticone can also be used for suspected postoperative abdominal discomfort in infants. Side effects Simeticone does not have any serious side effects. Two uncommon side effects (occurring in 1 in 100 to 1 in 1,000 patients) are constipation and nausea. Pharmacology Simeticone is a non-systemic surfactant which decreases the surface tension of gas bubbles in the GI tract. This allows gas bubbles to leave the GI tract as flatulence or belching. Simeticone does not reduce or prevent the formation of gas. Its effectiveness has been shown in several in vitro studies. Chemistry Simethicone is a mixture of dimethicone and silicon dioxide. Names The INN name is "simeticone", which was added to the INN recommended list in 1999.Simeticone is marketed under many brand names and in many combination drugs; it is also marketed as a veterinary drug. == References ==
Adoxa	Adoxa is the type genus of flowering plants in the family Adoxaceae. It contains at least 2 species of flowering plant, including the moschatel, for which the family is named. Adoxa moschatellina L. Adoxa xizangensis G.Yao == References ==
Abacavir/lamivudine/zidovudine	Abacavir/lamivudine/zidovudine, sold under the brand name Trizivir, is a fixed-dose combination antiretroviral medication for the treatment of HIV/AIDS. It contains three reverse transcriptase inhibitors patented by GlaxoSmithKline and marketed by a joint venture with Pfizer, ViiV Healthcare: abacavir sulfate (ABC) lamivudine (3TC) zidovudine (AZT or ZDV)It is indicated in the treatment of AIDS/HIV-1. For this purpose, the combination is very useful in pregnant women to decrease the risk of mother-to-child transmission.The most common effects include headache and nausea (feeling sick).Abacavir/lamivudine/zidovudine was approved for use in the United States and the European Union in 2000. In December 2013, Lupin Limited launched a generic version of abacavir/lamivudine/zidovudine. Side effects The most common side effects of abacavir/lamivudine/zidovudine include nausea, vomiting, diarrhea, fatigue, paresthesia and headache. As with many medications targeting reverse transcriptase, body fat redistribution syndrome may occur, causing body fat to center on the upper back and neck, breast, and torso, and potentially decreasing around the legs, arms, and face. IRIS may occur which is when the immune system initially improves, but then deteriorates as a previously ignored infection becomes active. Other serious side effects include: Increased risk of heart attack Lactic acidosis Severe hepatomegaly Lipoatrophy Neutropenia Anemia Hypersensitivity reactions Includes liver failure, renal failure, anaphylaxis, hypotension, and death. See also Abacavir/lamivudine Abacavir/dolutegravir/lamivudine References External links "Abacavir sulfate mixture with lamivudine and zidovudine". Drug Information Portal. U.S. National Library of Medicine.
Pentosan polysulfate	Pentosan polysulfate (PPS) is a medication used for interstitial cystitis. It is a semi-synthetic polysulfated xylan. Medical uses Interstitial cystitis/painful bladder syndrome Pentosan polysulfate may be used either by mouth or in the bladder to treat interstitial cystitis/painful bladder syndrome (IC/PBS). An older review found improvements in pain (36%), urgency (28%), and frequency (54%), but that it does not change the frequency of urination at night. More recent trials, however, found it to be of no benefit. Osteoarthritis PPS has been studied in knee osteoarthritis, though evidence to support such use is poor as of 2003. There is some theoretical evidence that it should help. Adverse effects Patients who have taken PPS orally report a variety of side effects, primarily gastrointestinal complaints such as diarrhea, heartburn, and stomach pain. Hair loss, headache, rash, and insomnia have also been reported. Due to Elmirons anticoagulant effects, some patients report bruising more easily. In some cases, patients are asked to stop taking the medication before any major surgical procedures to reduce the likelihood of bleeding. Recent report based on clinical observation hypothesizes that chronic exposure to PPS can cause retinal toxicity, mimicking pigmentary pattern dystrophy. Mechanism of action In IC, PPS is believed to work by providing a protective coating to the damaged bladder wall. PPS is similar in structure to the natural glycosaminoglycan coating of the inner lining of the bladder, and may replace or repair the lining, reducing its permeability. History The calcium salt of PPS was one of the first reported disease-modifying osteoarthritis drugs (DMOAD). Names The IUPAC name for pentosan polysulfate is [(2R,3R,4S,5R)-2-hydroxy-5-[(2S,3R,4S,5R)-5-hydroxy-3,4-disulfooxyoxan-2-yl]oxy-3-sulfooxyoxan-4-yl] hydrogen sulfate.There are 40 synonyms listed for pentosan polysulfate on PubChem including BAY-946, HOE-946, pentosan sulfuric polyester, polypentose sulfate, polysulfated xylan, PZ-68, SP-54, xylan SP54 and xylan sulfate.Various brand names include Elmiron (as sodium salt), Hemoclar, Anarthron, Fibrase, Fibrocid, Thrombocid and SP54. PPS capsules are sold in India under the brand names Comfora, Pentossan-100, Cystopen and For-IC. In the veterinary field, pentosan polysulfate is sold as Cartrophen Vet and Sylvet by Biopharm Australia, Pentosan by Naturevet Australia, Anarthron by Randlab Australia and Zydax by Parnell. Research Transmissible spongiform encephalopathies PPS is being studied as a potential treatment of Creutzfeldt–Jakob disease (CJD). The rationale for this treatment was unclear but it was subsequently shown in prion-infected mouse neuroblastoma cells that PPS could rapidly reduce the levels of abnormal (scrapie) prion without affecting the normal cellular isoform. As PPS can bind to the cellular isoform of the prion protein, it may stabilise this form and prevent its conversion to the pathological (scrapie) isoform.The treatment of one patient in Northern Ireland and around six other patients in mainland Britain was reported in the press. Other animals Dogs Read et al. (1996) used three different doses of sodium PPS to treat 40 geriatric dogs with well-established clinical signs of chronic osteoarthritis (OA) with a subcutaneous injection. The 3 mg/kg dose was the most effective. In a study conducted with 10 elderly dogs with osteoarthritis given calcium PPS (3 mg/kg intramuscularly) once weekly for four weeks, the improvement in symptoms (seen at 1, 2, 3 and 7 weeks after initiation of therapy) was found to correlate with plasma indices of fibrinolytic activity and lipid profiles. In a study in dogs with OA secondary to cranial cruciate ligament deficiency, although no differences were identified in either functional outcome or radiographic progression using the oral calcium PPS compared with placebo, there were significantly lower levels of proteoglycan breakdown products in the synovial fluid of the osteoarthritic joints. The efficacy of subcutaneous sodium PPS (3 mg/kg) was tested in 40 dogs with cranial cruciate ligament instability and found to hasten recovery, as measured by more rapidly improved ground reaction forces, over 48 weeks. Horses There are few published reports describing the use of PPS for equine joint disease; however, the drug is being used for this indication in Australia. When administered to racing thoroughbreds with chronic osteoarthritis (2 to 3 mg/kg, intramuscularly, once weekly for 4 weeks, then as required), PPS treatment improved but did not eliminate clinical signs of joint disease. Articular cartilage fibrillation was substantially reduced by similar NaPPS treatment intramuscularly in nine horses with experimentally-induced carpal osteoarthritis. Despite limited published studies on the effect of PPS in horses, most surveyed owners and trainers in Australia found the intramuscular PPS treatment to be highly efficacious when used as a prophylactic prior to competition. References External links Prescribing information Archived 2017-01-15 at the Wayback Machine
Lopid	Lopid may refer to: the Lopit people the Lopit language the cholesterol drug gemfibrozil
Olanzapine	Olanzapine (sold under the trade name Zyprexa among others) is an atypical antipsychotic primarily used to treat schizophrenia and bipolar disorder. For schizophrenia, it can be used for both new-onset disease and long-term maintenance. It is taken by mouth or by injection into a muscle.Common side effects include weight gain, movement disorders, dizziness, feeling tired, constipation, and dry mouth. Other side effects include low blood pressure with standing, allergic reactions, neuroleptic malignant syndrome, high blood sugar, seizures, and tardive dyskinesia. In older people with dementia, its use increases the risk of death. Use in the later part of pregnancy may result in a movement disorder in the baby for some time after birth. Although how it works is not entirely clear, it blocks dopamine and serotonin receptors.Olanzapine was patented in 1991 and approved for medical use in the United States in 1996. It is available as a generic medication. In 2019, it was the 185th most commonly prescribed medication in the United States, with more than 3 million prescriptions. Lilly also markets olanzapine in a fixed-dose combination with fluoxetine as olanzapine/fluoxetine (Symbyax). Medical uses Schizophrenia The first-line psychiatric treatment for schizophrenia is antipsychotic medication, with olanzapine being one such medication. Olanzapine appears to be effective in reducing symptoms of schizophrenia, treating acute exacerbations, and treating early-onset schizophrenia. The usefulness of maintenance therapy, however, is difficult to determine, as more than half of people in trials quit before the 6-week completion date. Treatment with olanzapine (like clozapine) may result in increased weight gain and increased glucose and cholesterol levels when compared to most other second-generation antipsychotic drugs used to treat schizophrenia. Comparison The National Institute for Health and Care Excellence, the British Association for Psychopharmacology, and the World Federation of Societies for Biological Psychiatry suggest that little difference in effectiveness is seen between antipsychotics in prevention of relapse, and recommend that the specific choice of antipsychotic be chosen based on a persons preference and the drugs side-effect profile. The U.S. Agency for Healthcare Research and Quality concludes that olanzapine is not different from haloperidol in the treatment of positive symptoms and general psychopathology, or in overall assessment, but that it is superior for the treatment of negative and depressive symptoms. It has a lower risk of causing movement disorders than typical antipsychotics.In a 2013 comparison of fifteen antipsychotic drugs in schizophrenia, olanzapine was ranked third in efficacy. It was 5% more effective than risperidone (fourth), 24-27% more effective than haloperidol, quetiapine, and aripiprazole, and 33% less effective than clozapine (first). A 2013 review of first-episode schizophrenia concluded that olanzapine is superior to haloperidol in providing a lower discontinuation rate, and in short-term symptom reduction, response rate, negative symptoms, depression, cognitive function, discontinuation due to poor efficacy, and long-term relapse, but not in positive symptoms or on the clinical global impressions (CGI) score. In contrast, pooled second-generation antipsychotics showed superiority to first-generation antipsychotics only against the discontinuation, negative symptoms (with a much larger effect seen among industry- compared to government-sponsored studies), and cognition scores. Olanzapine caused less extrapyramidal side effects and less akathisia, but caused significantly more weight gain, serum cholesterol increase, and triglyceride increase than haloperidol.A 2012 review concluded that among ten atypical antipsychotics, only clozapine, olanzapine, and risperidone were better than first-generation antipsychotics. A 2011 review concluded that neither first- nor second-generation antipsychotics produce clinically meaningful changes in CGI scores, but found that olanzapine and amisulpride produce larger effects on the PANSS and BPRS batteries than five other second-generation antipsychotics or pooled first-generation antipsychotics. A 2010 Cochrane systematic review found that olanzapine may have a slight advantage in effectiveness when compared to aripiprazole, quetiapine, risperidone, and ziprasidone. No differences in effectiveness were detected when comparing olanzapine to amisulpride and clozapine. A 2014 meta-analysis of nine published trials having minimum duration six months and median duration 52 weeks concluded that olanzapine, quetiapine, and risperidone had better effects on cognitive function than amisulpride and haloperidol. Bipolar disorder Olanzapine is recommended by the National Institute for Health and Care Excellence as a first-line therapy for the treatment of acute mania in bipolar disorder. Other recommended first-line treatments are haloperidol, quetiapine, and risperidone. It is recommended in combination with fluoxetine as a first-line therapy for acute bipolar depression, and as a second-line treatment by itself for the maintenance treatment of bipolar disorder.The Network for Mood and Anxiety Treatments recommends olanzapine as a first-line maintenance treatment in bipolar disorder and the combination of olanzapine with fluoxetine as second-line treatment for bipolar depression.A review on the efficacy of olanzapine as maintenance therapy in patients with bipolar disorder was published by Dando & Tohen in 2006. A 2014 meta-analysis concluded that olanzapine with fluoxetine was the most effective among nine treatments for bipolar depression included in the analysis. Other uses Olanzapine may be useful in promoting weight gain in underweight adult outpatients with anorexia nervosa. However, no improvement of psychological symptoms was noted.Olanzapine has been shown to be helpful in addressing a range of anxiety and depressive symptoms in individuals with schizophrenia and schizoaffective disorders, and has since been used in the treatment of a range of mood and anxiety disorders. Olanzapine is no less effective than lithium or valproate and more effective than placebo in treating bipolar disorder. It has also been used for Tourette syndrome and stuttering.Olanzapine has been studied for the treatment of hyperactivity, aggressive behavior, and repetitive behaviors in autism.Olanzapine is frequently prescribed off-label for the treatment of insomnia, including difficulty falling asleep and staying asleep, even though such use is not recommended. The daytime sedation experienced with olanzapine is generally comparable to quetiapine and lurasidone, which is a frequent complaint in clinical trials. In some cases, the sedation due to olanzapine impaired the ability of people to wake up at a consistent time every day. Some evidence of efficacy for treating insomnia is seen; however, side effects such as dyslipidemia and neutropenia, which may possibly be observed even at low doses, outweigh any potential benefits for insomnia that is not due to an underlying mental health condition.Olanzapine has been recommended to be used in antiemetic regimens in people receiving chemotherapy that has a high risk for vomiting. Specific populations Pregnancy and lactation Olanzapine is associated with the highest placental exposure of any atypical antipsychotic. Despite this, the available evidence suggests it is safe during pregnancy, although the evidence is insufficiently strong to say anything with a high degree of confidence. Olanzapine is associated with weight gain, which according to recent studies, may put olanzapine-treated patients offspring at a heightened risk for neural tube defects (e.g. spina bifida). Breastfeeding in women taking olanzapine is advised against because olanzapine is secreted in breast milk, with one study finding that the exposure to the infant is about 1.8% that of the mother. Elderly Citing an increased risk of stroke, in 2004, the Committee on the Safety of Medicines in the UK issued a warning that olanzapine and risperidone, both atypical antipsychotic medications, should not be given to elderly patients with dementia. In the U.S., olanzapine comes with a black box warning for increased risk of death in elderly patients. It is not approved for use in patients with dementia-related psychosis. A BBC investigation in June 2008 found that this advice was being widely ignored by British doctors. Evidence suggested that the elderly are more likely to experience weight gain on olanzapine compared to aripiprazole and risperidone. Adverse effects The principal side effect of olanzapine is weight gain, which may be profound in some cases and/or associated with derangement in blood-lipid and blood-sugar profiles (see section metabolic effects). A 2013 meta-analysis of the efficacy and tolerance of 15 antipsychotic drugs (APDs) found that it had the highest propensity for causing weight gain out of the 15 APDs compared with an SMD of 0.74. Extrapyramidal side effects, although potentially serious, are infrequent to rare from olanzapine, but may include tremors and muscle rigidity. Aripiprazole, asenapine, clozapine, quetiapine and olanzapine, in comparison to other antipsychotic drugs, are less frequently associated with hyperprolactinaemia. Although these drugs can cause transient or sustained hyperprolactinaemia, the risk is much lower. Owing to its partial dopaminergic agonist effect, aripiprazole is likely to reduce prolactin levels and, in some patients, can cause hypoprolactinaemia. Although olanzapine causes an early dose-related rise in prolactin, this is less frequent and less marked than that seen with haloperidol, and is usually transient. A rise in prolactin is seen in about half of patients on olanzapine compared to over 90% of those taking risperidone, and enduring increases were less frequent in those taking olanzapine.It is not recommended to be used by IM injection in acute myocardial infarction, bradycardia, recent heart surgery, severe hypotension, sick sinus syndrome, and unstable angina.Several patient groups are at a heightened risk of side effects from olanzapine and antipsychotics in general. Olanzapine may produce nontrivial high blood sugar in people with diabetes mellitus. Likewise, the elderly are at a greater risk of falls and accidental injury. Young males appear to be at heightened risk of dystonic reactions, although these are relatively rare with olanzapine. Most antipsychotics, including olanzapine, may disrupt the bodys natural thermoregulatory systems, thus permitting excursions to dangerous levels when situations (exposure to heat, strenuous exercise) occur.Other side effects include galactorrhea, amenorrhea, gynecomastia, and erectile dysfunction (impotence). Paradoxical effects Olanzapine is used therapeutically to treat serious mental illness. Occasionally, it can have the opposite effect and provoke serious paradoxical reactions in a small subgroup of people, causing unusual changes in personality, thoughts, or behavior; hallucinations and excessive thoughts about suicide have also been linked to olanzapine use. Drug-induced OCD Many different types of medication can create or induce pure obsessive-compulsive disorder (OCD) in patients who have never had symptoms before. A new chapter about OCD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013) now specifically includes drug-induced OCD. Metabolic effects The US Food and Drug Administration (FDA) requires all atypical antipsychotics to include a warning about the risk of developing hyperglycemia and diabetes, both of which are factors in the metabolic syndrome. These effects may be related to the drugs ability to induce weight gain, although some reports have been made of metabolic changes in the absence of weight gain. Studies have indicated that olanzapine carries a greater risk of causing and exacerbating diabetes than another commonly prescribed atypical antipsychotic, risperidone. Of all the atypical antipsychotics, olanzapine is one of the most likely to induce weight gain based on various measures. The effect is dose dependent in humans and animal models of olanzapine-induced metabolic side effects. There are some case reports of olanzapine-induced diabetic ketoacidosis. Olanzapine may decrease insulin sensitivity, though one 3-week study seems to refute this. It may also increase triglyceride levels.Despite weight gain, a large multicenter, randomized National Institute of Mental Health study found that olanzapine was better at controlling symptoms because patients were more likely to remain on olanzapine than the other drugs. One small, open-label, nonrandomized study suggests that taking olanzapine by orally dissolving tablets may induce less weight gain, but this has not been substantiated in a blinded experimental setting. Post-injection delirium/sedation syndrome Postinjection delirium/sedation syndrome (PDSS) is a rare syndrome that is specific to the long-acting injectable formulation of olanzapine, olanzapine pamoate. The incidence of PDSS with olanzapine pamoate is estimated to be 0.07% of administrations, and is unique among other second-generation, long-acting antipsychotics (e.g. paliperidone palmitate), which do not appear to carry the same risk. PDSS is characterized by symptoms of delirium (e.g. confusion, difficulty speaking, and uncoordinated movements) and sedation. Most people with PDSS exhibit both delirium and sedation (83%). Although less specific to PDSS, a majority of cases (67%) involved a feeling of general discomfort. PDSS may occur due to accidental injection and absorption of olanzapine pamoate into the bloodstream, where it can act more rapidly, as opposed to slowly distributing out from muscle tissue. Using the proper, intramuscular-injection technique for olanzapine pamoate helps to decrease the risk of PDSS, though it does not eliminate it entirely. This is why the FDA advises that people who are injected with olanzapine pamoate be watched for 3 hours after administration, in the event that PDSS occurs. Animal toxicology Olanzapine has demonstrated carcinogenic effects in multiple studies when exposed chronically to female mice and rats, but not male mice and rats. The tumors found were in either the liver or mammary glands of the animals. Discontinuation The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotics to avoid acute withdrawal syndrome or rapid relapse. Symptoms of withdrawal commonly include nausea, vomiting, and loss of appetite. Other symptoms may include restlessness, increased sweating, and trouble sleeping. Less commonly, vertigo, numbness, or muscle pains may occur. Symptoms generally resolve after a short time.Tentative evidence indicates that discontinuation of antipsychotics can result in psychosis. It may also result in reoccurrence of the condition that is being treated. Rarely, tardive dyskinesia can occur when the medication is stopped. Overdose Symptoms of an overdose include tachycardia, agitation, dysarthria, decreased consciousness, and coma. Death has been reported after an acute overdose of 450 mg, but also survival after an acute overdose of 2000 mg. Fatalities generally have occurred with olanzapine plasma concentrations greater than 1000 ng/mL post mortem, with concentrations up to 5200 ng/mL recorded (though this might represent confounding by dead tissue, which may release olanzapine into the blood upon death). No specific antidote for olanzapine overdose is known, and even physicians are recommended to call a certified poison control center for information on the treatment of such a case. Olanzapine is considered moderately toxic in overdose, more toxic than quetiapine, aripiprazole, and the SSRIs, and less toxic than the monoamine oxidase inhibitors and tricyclic antidepressants. Interactions Drugs or agents that increase the activity of the enzyme CYP1A2, notably tobacco smoke, may significantly increase hepatic first-pass clearance of olanzapine; conversely, drugs that inhibit CYP1A2 activity (examples: ciprofloxacin, fluvoxamine) may reduce olanzapine clearance. Carbamazepine, a known enzyme inducer, has decreased the concentration/dose ration of olanzapine by 33% compared to olanzapine alone. Another enzyme inducer, ritonavir, has also been shown to decrease the bodys exposure to olanzapine, due to its induction of the enzymes CYP1A2 and uridine 5-diphospho-glucuronosyltransferase (UGT).Probenecid increases the total exposure (area under the curve) and maximum plasma concentration of olanzapine. Although olanzapines metabolism includes the minor metabolic pathway of CYP2D6, the presence of the CYP2D6 inhibitor fluoxetine does not have a clinically significant effect on olanzapines clearance. Pharmacology Pharmacodynamics Olanzapine was first discovered while searching for a chemical analog of clozapine that would not require hematological monitoring. Investigation on a series of thiophene isosteres on 1 of the phenyl rings in clozapine, a thienobenzodiazepine analog (olanzapine) was discovered.Olanzapine has a higher affinity for 5-HT2A serotonin receptors than D2 dopamine receptors, which is a common property of most atypical antipsychotics, aside from the benzamide antipsychotics such as amisulpride along with the nonbenzamides aripiprazole, brexpiprazole, blonanserin, cariprazine, melperone, and perospirone. Olanzapine had the highest affinity of any second-generation antipsychotic towards the P-glycoprotein in one in vitro study. P-glycoprotein transports a myriad of drugs across a number of different biological membranes (found in numerous body systems) including the blood-brain barrier (a semipermeable membrane that filters the contents of blood prior to it reaching the brain); P-GP inhibition could mean that less brain exposure to olanzapine results from this interaction with the P-glycoprotein. A relatively large quantity of commonly encountered foods and medications inhibit P-GP, and pharmaceuticals fairly commonly are either substrates of P-GP, or inhibit its action; both substrates and inhibitors of P-GP effectively increase the permeability of the blood-brain barrier to P-GP substrates and subsequently increase the central activity of the substrate, while reducing the local effects on the GI tract. The mediation of olanzapine in the central nervous system by P-GP means that any other substance or drug that interacts with P-GP increases the risk for toxic accumulations of both olanzapine and the other drug.Olanzapine is a potent antagonist of the muscarinic M3 receptor, which may underlie its diabetogenic side effects. Additionally, it also exhibits a relatively low affinity for serotonin 5-HT1, GABAA, beta-adrenergic receptors, and benzodiazepine binding sites.The antagonistic effects of olanzapine at 5-HT2c, histaminergic H1, and muscarinic M3 receptors have been implicated in weight gain.The mode of action of olanzapines antipsychotic activity is unknown. It may involve antagonism of dopamine and serotonin receptors. Antagonism of dopamine receptors is associated with extrapyramidal effects such as tardive dyskinesia (TD), and with therapeutic effects. Antagonism of muscarinic acetylcholine receptors is associated with anticholinergic side effects such as dry mouth and constipation; in addition, it may suppress or reduce the emergence of extrapyramidal effects for the duration of treatment, but it offers no protection against the development of TD. In common with other second-generation (atypical) antipsychotics, olanzapine poses a relatively low risk of extrapyramidal side effects including TD, due to its higher affinity for the 5HT2A receptor over the D2 receptor.Antagonizing H1 histamine receptors causes sedation and may cause weight gain, although antagonistic actions at serotonin 5-HT2C and dopamine D2 receptors have also been associated with weight gain and appetite stimulation. Pharmacokinetics Metabolism Olanzapine is metabolized by the cytochrome P450 (CYP) system; principally by isozyme 1A2 (CYP1A2) and to a lesser extent by CYP2D6. By these mechanisms, more than 40% of the oral dose, on average, is removed by the hepatic first-pass effect. Clearance of olanzapine appears to vary by sex; women have roughly 25% lower clearance than men. Clearance of olanzapine also varies by race; in self-identified African Americans or Blacks, olanzapines clearance was 26% higher. A difference in the clearance is not apparent between individuals identifying as Caucasian, Chinese, or Japanese. Routine, pharmacokinetic monitoring of olanzapine plasma levels is generally unwarranted, though unusual circumstances (e.g. the presence of drug-drug interactions) or a desire to determine if patients are taking their medicine may prompt its use. Chemistry Olanzapine is unusual in having four well-characterised crystalline polymorphs and many hydrated forms. Chemical synthesis The preparation of olanzapine was first disclosed in a series of patents from Eli Lilly & Co. in the 1990s. In the final two steps, 5-methyl-2-[(2-nitrophenyl)amino]-3-thiophenecarbonitrile was reduced with stannous chloride in ethanol to give the substituted thienobenzodiazepine ring system, and this was treated with methylpiperazine in a mixture of dimethyl sulfoxide and toluene as solvent to produce the drug. Society and culture Regulatory status Olanzapine is approved by the US FDA for: Treatment—in combination with fluoxetine—of depressive episodes associated with bipolar disorder (December 2003).Long-term treatment of bipolar I disorder (January 2004). Long-term treatment—in combination with fluoxetine—of resistant depression (March 2009) Oral formulation: acute and maintenance treatment of schizophrenia in adults, acute treatment of manic or mixed episodes associated with bipolar I disorder (monotherapy and in combination with lithium or sodium valproate) Intramuscular formulation: acute agitation associated with schizophrenia and bipolar I mania in adults Oral formulation combined with fluoxetine: treatment of acute depressive episodes associated with bipolar I disorder in adults, or treatment of acute, resistant depression in adults Treatment of the manifestations of psychotic disorders (September 1996 – March 2000).Short-term treatment of acute manic episodes associated with bipolar I disorder (March 2000) Short-term treatment of schizophrenia instead of the management of the manifestations of psychotic disorders (March 2000) Maintaining treatment response in schizophrenic patients who had been stable for about eight weeks and were then followed for a period of up to eight months (November 2000)The drug became generic in 2011. Sales of Zyprexa in 2008 were $2.2 billion in the US and $4.7 billion worldwide. Controversy and litigation Eli Lilly has faced many lawsuits from people who claimed they developed diabetes or other diseases after taking Zyprexa, as well as by various governmental entities, insurance companies, and others. Lilly produced a large number of documents as part of the discovery phase of this litigation, which started in 2004; the documents were ruled to be confidential by a judge and placed under seal, and later themselves became the subject of litigation.In 2006, Lilly paid $700 million to settle around 8,000 of these lawsuits, and in early 2007, Lilly settled around 18,000 suits for $500 million, which brought the total Lilly had paid to settle suits related to the drug to $1.2 billion.A December 2006 New York Times article based on leaked company documents concluded that the company had engaged in a deliberate effort to downplay olanzapines side effects. The company denied these allegations and stated that the article had been based on cherry-picked documents. The documents were provided to the Times by Jim Gottstein, a lawyer who represented mentally ill patients, who obtained them from a doctor, David Egilman, who was serving as an expert consultant on the case. After the documents were leaked to online peer-to-peer, file-sharing networks by Will Hall and others in the psychiatric survivors movement, who obtained copies, in 2007 Lilly filed a protection order to stop the dissemination of some of the documents, which Judge Jack B. Weinstein of the Brooklyn Federal District Court granted. Judge Weinstein also criticized the New York Times reporter, Gottstein, and Egilman in the ruling. The Times of London also received the documents and reported that as early as 1998, Lilly considered the risk of drug-induced obesity to be a "top threat" to Zyprexa sales. On October 9, 2000, senior Lilly research physician Robert Baker noted that an academic advisory board to which he belonged was "quite impressed by the magnitude of weight gain on olanzapine and implications for glucose."Lilly had threatened Egilman with criminal contempt charges regarding the documents he took and provided to reporters; in September 2007, he agreed to pay Lilly $100,000 in return for the companys agreement to drop the threat of charges.In September 2008, Judge Weinstein issued an order to make public Lillys internal documents about the drug in a different suit brought by insurance companies, pension funds, and other payors.In March 2008, Lilly settled a suit with the state of Alaska, and in October 2008, Lilly agreed to pay $62 million to 32 states and the District of Columbia to settle suits brought under state consumer protection laws.In 2009, Eli Lilly pleaded guilty to a US federal criminal misdemeanor charge of illegally marketing Zyprexa for off-label use and agreed to pay $1.4 billion. The settlement announcement stated "Eli Lilly admits that between September 1999 and March 31, 2001, the company promoted Zyprexa in elderly populations as treatment for dementia, including Alzheimer’s dementia. Eli Lilly has agreed to pay a $515 million criminal fine and to forfeit an additional $100 million in assets."The outcomes described here, and their legal ramifications, were fueled by motions and appeals that were not resolved until 2010. In 2021, Gottstein summarized this tangle of legal activities, and their impact on the political landscape of psychiatry and antipsychiatry in the US, in The Zyprexa Papers. Trade names Olanzapine is generic and available under many trade names worldwide. Dosage forms Olanzapine is marketed in a number of countries, with tablets ranging from 2.5 to 20 mg. Zyprexa (and generic olanzapine) is available as an orally disintegrating "wafer", which rapidly dissolves in saliva. It is also available in 10-mg vials for intramuscular injection. Research Olanzapine has been studied as an antiemetic, particularly for the control of chemotherapy-induced nausea and vomiting (CINV).In general, olanzapine appears to be about as effective as aprepitant for the prevention of CINV, though some concerns remain for its use in this population. For example, concomitant use of metoclopramide or haloperidol increases the risk for extrapyramidal symptoms. Otherwise, olanzapine appears to be fairly well tolerated for this indication, with somnolence being the most common side effect.Olanzapine has been considered as part of an early psychosis approach for schizophrenia. The Prevention through Risk Identification, Management, and Education study, funded by the National Institute of Mental Health and Eli Lilly, tested the hypothesis that olanzapine might prevent the onset of psychosis in people at very high risk for schizophrenia. The study examined 60 patients with prodrom
Olanzapine	al schizophrenia, who were at an estimated risk of 36–54% of developing schizophrenia within a year, and treated half with olanzapine and half with placebo. In this study, patients receiving olanzapine did not have a significantly lower risk of progressing to psychosis. Olanzapine was effective for treating the prodromal symptoms, but was associated with significant weight gain. References External links "Olanzapine". Drug Information Portal. U.S. National Library of Medicine. Alex B (5 January 2007). "Lilly Settles With 18,000 Over Zyprexa". The New York Times.
Bazedoxifene/conjugated estrogens	Bazedoxifene/conjugated estrogens, sold under the brand name Duavee in the US and Duavive in the EU, is a fixed-dose combination medication for the treatment of menopause symptoms and postmenopausal osteoporosis. It contains the selective estrogen receptor modulator bazedoxifene and conjugated estrogens. It is taken by mouth. The combination was approved for medical use in the United States in October 2013, and in the European Union in December 2014. See also List of combined sex-hormonal preparations References External links "Bazedoxifene mixture with conjugated estrogens". Drug Information Portal. U.S. National Library of Medicine.
Amiodarone	Amiodarone is an antiarrhythmic medication used to treat and prevent a number of types of cardiac dysrhythmias. This includes ventricular tachycardia (VT), ventricular fibrillation (VF), and wide complex tachycardia, as well as atrial fibrillation and paroxysmal supraventricular tachycardia. Evidence in cardiac arrest, however, is poor. It can be given by mouth, intravenously, or intraosseously. When used by mouth, it can take a few weeks for effects to begin.Common side effects include feeling tired, tremor, nausea, and constipation. As amiodarone can have serious side effects, it is mainly recommended only for significant ventricular arrhythmias. Serious side effects include lung toxicity such as interstitial pneumonitis, liver problems, heart arrhythmias, vision problems, thyroid problems, and death. If taken during pregnancy or breastfeeding it can cause problems in the fetus. It is a class III antiarrhythmic medication. It works partly by increasing the time before a heart cell can contract again.Amiodarone was first made in 1961 and came into medical use in 1962 for chest pain believed to be related to the heart. It was pulled from the market in 1967 due to side effects. In 1974 it was found to be useful for arrhythmias and reintroduced. It is on the World Health Organizations List of Essential Medicines. It is available as a generic medication. In 2019, it was the 183rd most commonly prescribed medication in the United States, with more than 3 million prescriptions. Medical uses Amiodarone has been used both in the treatment of acute life-threatening arrhythmias as well as the long term suppression of arrhythmias. It is used both in supraventricular arrhythmias and ventricular arrhythmias. Cardiac arrest Defibrillation is the treatment of choice for ventricular fibrillation and pulseless ventricular tachycardia resulting in cardiac arrest. While amiodarone has been used in shock-refractory cases, evidence of benefit is poor. Amiodarone does not appear to improve survival or positive outcomes in those who had a cardiac arrest. Ventricular tachycardia Amiodarone may be used in the treatment of ventricular tachycardia in certain instances. Individuals with hemodynamically unstable ventricular tachycardia should not initially receive amiodarone. These individuals should be cardioverted. Amiodarone can be used in individuals with hemodynamically stable ventricular tachycardia. In these cases, amiodarone can be used regardless of the individuals underlying heart function and the type of ventricular tachycardia; it can be used in individuals with monomorphic ventricular tachycardia, but is contraindicated in individuals with polymorphic ventricular tachycardia as it is associated with a prolonged QT interval which will be made worse with anti-arrhythmic drugs. Atrial fibrillation Individuals who have undergone open heart surgery are at an increased risk of developing atrial fibrillation (or AF) in the first few days post-procedure. In the ARCH trial, intravenous amiodarone (2 g administered over 2 d) has been shown to reduce the incidence of atrial fibrillation after open heart surgery when compared to placebo. However, clinical studies have failed to demonstrate long-term efficacy and have shown potentially fatal side effects such as pulmonary toxicities. While amiodarone is not approved for AF by the FDA, it is a commonly prescribed off-label treatment due to the lack of equally effective treatment alternatives.So-called acute onset atrial fibrillation, defined by the North American Society of Pacing and Electrophysiology (NASPE) in 2003, responds well to short duration treatment with amiodarone. This has been demonstrated in seventeen randomized controlled trials, of which five included a placebo arm. The incidence of severe side effects in this group is low.The benefit of amiodarone in the treatment of atrial fibrillation in the critical care population has yet to be determined but it may prove to be the agent of choice where the patient is hemodynamically unstable and unsuitable for DC cardioversion. It is recommended in such a role by the UK governments National Institute for Health and Clinical Excellence (NICE). Contraindications Women who are pregnant or may become pregnant are strongly advised to not take amiodarone. Since amiodarone can be expressed in breast milk, women taking amiodarone are advised to stop nursing. It is contraindicated in individuals with sinus nodal bradycardia, atrioventricular block, and second or third degree heart block who do not have an artificial pacemaker. Individuals with baseline depressed lung function should be monitored closely if amiodarone therapy is to be initiated. Formulations of amiodarone that contain benzyl alcohol should not be given to neonates, because the benzyl alcohol may cause the potentially fatal "gasping syndrome".Amiodarone can worsen the cardiac arrhythmia brought on by digitalis toxicity. Side effects At oral doses of 400 mg per day or higher, amiodarone can have serious, varied side effects, including toxicity to thyroid, liver, lung, and retinal functions, requiring clinical surveillance and regular laboratory testing. Allergic reactions to amiodarone may occur. Most individuals administered amiodarone on a chronic basis will experience at least one side effect. In some people, daily use of amiodarone at 100 mg oral doses can be effective for arrhythmia control with no or minimal side effects. Lung Side effects of oral amiodarone at doses of 400 mg or higher include various pulmonary effects. The most serious reaction is interstitial lung disease. Risk factors include high cumulative dose, more than 400 milligrams per day, duration over two months, increased age, and preexisting pulmonary disease. Some individuals were noted to develop pulmonary fibrosis after a week of treatment, while others did not develop it after years of continuous use. Common practice is to avoid the agent if possible in individuals with decreased lung function. The most specific test of pulmonary toxicity due to amiodarone is a dramatically decreased DLCO noted on pulmonary function testing. Thyroid Induced abnormalities in thyroid function are common. Both under- and overactivity of the thyroid may occur. Amiodarone is structurally similar to thyroxine and also contains iodine. Both of these contribute to the effects of amiodarone on thyroid function. Amiodarone also causes an anti-thyroid action, via Plummer and Wolff–Chaikoff effects, due its large amount of iodine in its molecule, which causes a particular "cardiac hypothyroidism" with bradycardia and arrhythmia.Thyroid function should be checked at least every six months. Hypothyroidism (slowing of the thyroid) occurs frequently; in the SAFE trial, which compared amiodarone with other medications for the treatment of atrial fibrillation, biochemical hypothyroidism (as defined by a TSH level of 4.5–10 mU/L) occurred in 25.8% of the amiodarone-treated group as opposed to 6.6% of the control group (taking placebo or sotalol). Overt hypothyroidism (defined as TSH >10 mU/L) occurred at 5.0% compared to 0.3%; most of these (>90%) were detected within the first six months of amiodarone treatment. Amiodarone induced thyrotoxicosis (AIT), can be caused due to the high iodine contebt in the drug via the Jod-Basedow effect. This is known as Type 1 AIT, and usually occurs in patients with an underlying predisposition to hyperthyroidism such as Graves disease, within weeks to months after starting amiodarone. Type 1 AIT is usually treated with anti-thyroid drugs or thyroidectomy. Type 2 AIT is caused by a destructive thyroiditis due to a direct toxic effect of amiodarone on thyroid follicular epithelial cells. Type 2 AIT can occur even years after starting amiodarone, is usually self-limited and responds to anti-inflammatory treatment such as corticosteroids. In practice, often the type of AIT is undetermined or presumed as mixed with both treatments combined. Thyroid uptake measurements (I-123 or I-131), which are used to differentiate causes of hyperthyroidism, are generally unreliable in patients who have been taking amiodarone. Because of the high iodine content of amiodarone, the thyroid gland is effectively saturated, thus preventing further uptake of isotopes of iodine. However, a positive radioactive iodine can be used to rule in type 1AIT . Eye Corneal micro-deposits (cornea verticillata, also called vortex or whorl keratopathy) are almost universally present (over 90%) in individuals taking amiodarone longer than 6 months, especially doses greater than 400 mg/day. These deposits typically do not cause any symptoms. About 1 in 10 individuals may complain of a bluish halo. Anterior subcapsular lens deposits are relatively common (50%) in higher doses (greater than 600 mg/day) after 6 months of treatment. Optic neuropathy, nonarteritic anterior ischemic optic neuropathy (N-AION), occurs in 1–2% of people and is not dosage dependent. Bilateral optic disc swelling and mild and reversible visual field defects can also occur. Loss of eyelashes has been linked to amiodarone use. Liver Abnormal liver enzyme results are common in people taking amiodarone. Much rarer are jaundice, hepatomegaly (liver enlargement), and hepatitis (inflammation of the liver).Low-dose amiodarone has been reported to cause pseudo-alcoholic cirrhosis. Skin Long-term administration of amiodarone (usually more than eighteen months) is associated with a light-sensitive blue-grey discoloration of the skin, sometimes called ceruloderma; such patients should avoid exposure to the sun and use sunscreen that protects against ultraviolet-A and -B. The discoloration will slowly improve upon cessation of the medication, however, the skin color may not return completely. Pregnancy and breastfeeding Use during pregnancy may result in a number of problems in the infant including thyroid problems, heart problems, neurological problems, and preterm birth. Use during breastfeeding is generally not recommended though one dose may be okay. Other Long-term use of amiodarone has been associated with peripheral neuropathies.Amiodarone is sometimes responsible for epididymitis. Amiodarone accumulates in the head of the organ and can cause unilateral or bilateral inflammation. It tends to resolve if amiodarone is stopped.Some cases of gynecomastia have been reported with men on amiodarone.A study published in 2013 showed a possible association between amiodarone and an increased risk of cancer, especially in males, with a dose-dependent effect. Interactions The pharmacokinetics of numerous drugs, including many that are commonly administered to individuals with heart disease, are affected by amiodarone. Particularly, doses of digoxin should be halved in individuals taking amiodarone. Amiodarone may also interact with sotalol.Amiodarone potentiates the action of warfarin by inhibiting the clearance of both (S) and (R) warfarin. Individuals taking both of these medications should have their warfarin doses adjusted based on their dosing of amiodarone, and have their anticoagulation status (measured as prothrombin time (PT) and international normalized ratio (INR)) measured more frequently. Dose reduction of warfarin is as follows: 40% reduction if amiodarone dose is 400 mg daily, 35% reduction if amiodarone dose is 300 mg daily, 30% reduction if amiodarone dose is 200 mg daily, and 25% reduction if amiodarone dose is 100 mg daily. The effect of amiodarone on the warfarin concentrations can be as early as a few days after initiation of treatment; however, the interaction may not peak for up to seven weeks. Amiodarone inhibits the action of the cytochrome P450 isozyme family. This reduces the clearance of many drugs, including the following: Ciclosporin Digoxin Flecainide Procainamide Quinidine Sildenafil Simvastatin Theophylline WarfarinIn 2015, Gilead Sciences warned health care providers about people that began taking the hepatitis C drugs ledipasvir/sofosbuvir or sofosbuvir along with amiodarone, who developed abnormally slow heartbeats or died of cardiac arrest. Metabolism Amiodarone is extensively metabolized in the liver by cytochrome P450 3A4 and can affect the metabolism of numerous other drugs. It interacts with digoxin, warfarin, phenytoin, and others. The major metabolite of amiodarone is desethylamiodarone (DEA), which also has antiarrhythmic properties. The metabolism of amiodarone is inhibited by grapefruit juice, leading to elevated serum levels of amiodarone. On 8 August 2008, the FDA issued a warning of the risk of rhabdomyolysis, which can lead to kidney failure or death, when simvastatin is used with amiodarone. This interaction is dose-dependent with simvastatin doses exceeding 20 mg. This drug combination especially with higher doses of simvastatin should be avoided. Excretion Excretion is primarily via the liver and the bile duct with almost no elimination via the kidney and it is not dialyzable. Elimination half-life average of 58 days (ranging from 25 to 100 days [Remington: The Science and Practice of Pharmacy 21st edition]) for amiodarone and 36 days for the active metabolite, desethylamiodarone (DEA). There is 10-50% transfer of amiodarone and DEA in the placenta as well as a presence in breast milk. Accumulation of amiodarone and DEA occurs in adipose tissue and highly perfused organs (i.e. liver, lungs), therefore, if an individual was taking amiodarone on a chronic basis, if it is stopped it will remain in the system for weeks to months. Pharmacology Amiodarone is categorized as a class III antiarrhythmic agent, and prolongs phase 3 of the cardiac action potential, the repolarization phase where there is normally decreased calcium permeability and increased potassium permeability. It has numerous other effects, however, including actions that are similar to those of antiarrhythmic classes Ia, II, and IV. Amiodarone is a blocker of voltage gated potassium (KCNH2) and voltage gated calcium channels (CACNA2D2).Amiodarone slows conduction rate and prolongs the refractory period of the SA and AV nodes. It also prolongs the refractory periods of the ventricles, bundles of His, and the Purkinje fibres without exhibiting any effects on the conduction rate. Amiodarone has been shown to prolong the myocardial cell action potential duration and refractory period and is a non-competitive β-adrenergic inhibitor.It also shows beta blocker-like and calcium channel blocker-like actions on the SA and AV nodes, increases the refractory period via sodium- and potassium-channel effects, and slows intra-cardiac conduction of the cardiac action potential, via sodium-channel effects. It is suggested that amiodarone may also exacerbate the phenotype associated with Long QT-3 syndrome causing mutations such as ∆KPQ. This effect is due to a combination of blocking the peak sodium current, but also contributing to an increased persistent sodium current.Amiodarone chemically resembles thyroxine (thyroid hormone), and its binding to the nuclear thyroid receptor might contribute to some of its pharmacologic and toxic actions. History The original observation that amiodarones progenitor molecule, khellin, had cardioactive properties, was made by the Russian physiologist Gleb von Anrep while working in Cairo in 1946. Khellin is obtained from a plant extract of Khella or Ammi visnaga, a common plant in north Africa. Anrep noticed that one of his technicians had been cured of anginal symptoms after taking khellin, then used for various, non-cardiac ailments. This led to efforts by European pharmaceutical industries to isolate an active compound. Amiodarone was initially developed in 1961 at the Labaz company, Belgium, by chemists Tondeur and Binon, who were working on preparations derived from khellin. It became popular in Europe as a treatment for angina pectoris.As a doctoral candidate at Oxford University, Bramah Singh determined that amiodarone and sotalol had antiarrhythmic properties and belonged to a new class of antiarrhythmic agents (what would become the class III antiarrhythmic agents). Today the mechanisms of action of amiodarone and sotalol have been investigated in more detail. Both drugs have been demonstrated to prolong the duration of the action potential, prolonging the refractory period, by interacting among other cellular function with K+ channels. Based on Singhs work, the Argentinian physician Mauricio Rosenbaum began using amiodarone to treat his patients who have supraventricular and ventricular arrhythmias, with impressive results. Based on papers written by Rosenbaum developing Singhs theories, physicians in the United States began prescribing amiodarone to their patients with potentially life-threatening arrhythmias in the late 1970s. By 1980, amiodarone was commonly prescribed throughout Europe for the treatment of arrhythmias, but in the U.S. amiodarone remained unapproved by the Food and Drug Administration, and physicians were forced to directly obtain amiodarone from pharmaceutical companies in Canada and Europe.The FDA was reluctant to officially approve the use of amiodarone since initial reports had shown increased incidence of serious pulmonary side-effects of the drug. In the mid-1980s, the European pharmaceutical companies began putting pressure on the FDA to approve amiodarone by threatening to cut the supply to American physicians if it was not approved. In December 1985, amiodarone was approved by the FDA for the treatment of arrhythmias. This makes amiodarone one of the few drugs approved by the FDA without rigorous randomized clinical trials. Name Amiodarone may be an acronym for its IUPAC name (2-butyl-1-benzofuran-3-yl)-[4-[2-(diethylamino)ethoxy]-3,5-diiodophenyl]methanone, where ar is a placeholder for phenyl. This is partially supported by dronedarone which is noniodinated benzofuran derivative of amiodarone, where the arylmethanone is conserved. Dosing Amiodarone is available in oral and intravenous formulations. Orally, it is available under the brand names Pacerone (produced by Upsher-Smith Laboratories, Inc.) and Cordarone (produced by Wyeth-Ayerst Laboratories). It is also available under the brand name Aratac (produced by Alphapharm Pty Ltd) in Australia and New Zealand, and further in Australia under the brands Cardinorm and Rithmik as well as a number of generic brands. Also Arycor in South Africa (Produced by Winthrop Pharmaceuticals.). In South America, it is known as Atlansil and is produced by Roemmers. In India, amiodarone is marketed (produced by Cipla Pharmaceutical) under the brand name Tachyra. It is also available in intravenous ampules and vials. The dose of amiodarone administered is tailored to the individual and the dysrhythmia that is being treated. When administered orally, the bioavailability of amiodarone is quite variable. Absorption ranges from 22 to 95%, with better absorption when it is given with food. Administration Amiodarone IV should be administered via a central venous catheter. It has a pH of 4.08. If administered outside of the standard concentration of 900 mg/500mL it should be administered using a 0.22 micron filter to prevent precipitate from reaching the patient. Amiodarone IV is a known vesicant. For infusions of longer than 1 hour, concentrations of 2 mg/mL should not be exceeded unless a central venous catheter is used. References Further reading Siddoway LA (December 2003). "Amiodarone: guidelines for use and monitoring". Am Fam Physician. 68 (11): 2189–2196. PMID 14677664. Archived from the original on 15 May 2008. Retrieved 16 May 2004. External links "Amiodarone". Drug Information Portal. U.S. National Library of Medicine.
Naxitamab	Naxitamab, sold under the brand name Danyelza, is an anti-cancer medication. It is a monoclonal antibody used in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) for people one year of age and older with relapsed or refractory high-risk neuroblastoma in the bone or bone marrow demonstrating a partial response, minor response, or stable disease to prior therapy.The most common adverse reactions include infusion-related reactions, pain, tachycardia (fast heart beats), vomiting, cough, nausea, diarrhea, decreased appetite, hypertension, fatigue, erythema multiforme, peripheral neuropathy, urticaria, pyrexia, headache, injection site reaction, edema, anxiety, localized edema, and irritability.The U.S. Food and Drug Administration (FDA) granted the application for naxitamab priority review, breakthrough therapy, and, orphan drug designations. The FDA issued a priority review voucher for this rare pediatric disease product application and was later granted a priority approval. Medical uses Naxitamab is used in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat people one year of age and older with high-risk neuroblastoma in bone or bone marrow whose tumor did not respond to or has come back after previous treatments and has shown a partial response, minor response, or stable disease to prior therapy. History The application for naxitamab was approved based on two clinical trials (Trial 1/NCT03363373 and Trial 2/NCT01757626) of 97 participants with high-risk neuroblastoma in bone or bone marrow. The trials were conducted at four centers in the United States and in Spain. Both trials enrolled participants who were previously treated for high-risk neuroblastoma in the bone or bone marrow. Some participants were not responding to the previous therapies anymore and some participants experienced the return of the cancer. Participants with cancer that was actively growing after their last therapy were not included in the trial. All participants received naxitamab in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) according to the trial schedule. Society and culture Legal status Naxitamab was approved for medical use in the United States in November 2020. References External links "Naxitamab". Drug Information Portal. U.S. National Library of Medicine. Clinical trial number NCT03363373 for "Naxitamab for High-Risk Neuroblastoma Patients With Primary Refractory Disease or Incomplete Response to Salvage Treatment in Bone and/or Bone Marrow" at ClinicalTrials.gov Clinical trial number NCT01757626 for "Combination Therapy of Antibody Hu3F8 With Granulocyte- Macrophage Colony Stimulating Factor (GM-CSF) in Patients With Relapsed/Refractory High-Risk Neuroblastoma" at ClinicalTrials.gov
Levocetirizine	Levocetirizine, sold under the brand name Xyzal among others, is a second-generation antihistamine used for the treatment of allergic rhinitis (hay fever) and long term hives of unclear cause. It is less sedating than older antihistamines. It is taken by mouth.Common side effects include sleepiness, dry mouth, cough, vomiting, and diarrhea. Use in pregnancy appears safe but has not been well studied and use when breastfeeding is of unclear safety. It is classified as a second-generation antihistamine and works by blocking histamine H1-receptors.Levocetirizine was approved for medical use in the United States in 2007. It is available as a generic medication. In 2019, it was the 193rd most commonly prescribed medication in the United States, with more than 2 million prescriptions. Medical uses Levocetirizine is used for allergic rhinitis. This includes allergy symptoms such as watery eyes, runny nose, sneezing, hives, and itching. Side effects Levocetirizine is referred to as a non-sedating antihistamine as it does not enter the brain in significant amounts and is therefore unlikely to cause drowsiness. Cardiac safety with repolarization may be better than some other antihistamines, as levocetirizine does not significantly prolong the QT interval in healthy individuals. However, some people may still experience some slight sleepiness, headache, mouth dryness, lightheadedness, vision problems (mainly blurred vision), palpitations and fatigue. Pharmacology Levocetirizine is an antihistamine. It acts as an inverse agonist that decreases activity at histamine H1 receptors. This in turn prevents the release of other allergy chemicals and increases the blood supply to the area, providing relief from the typical symptoms of hay fever. Levocetirizine, (R)-(-)-cetirizine, is essentially a chiral switch of (±)-cetirizine. This enantiomer, the eutomer, is more selective and less sedative and the (S)-counterpart, the distomer, is inactive. Chemistry Chemically, levocetirizine is the active levorotary enantiomer of cetirizine, also called the l-enantiomer of cetirizine. It is a member of the diphenylmethylpiperazine group of antihistamines. History Levocetirizine was first launched in 2001 by the Belgian pharmaceutical company UCB (Union Chimique Belge). Society and culture Availability On 31 January 2017, the Food and Drug Administration approved an over-the-counter preparation. Levocetirizine had previously received authorization by the FDA as a prescription drug in 2007, having already been brought to market throughout much of Europe. In India, a prescription-only drug containing levocetirizine hydrochloride and montelukast is sold as Crohist MK. Brand names Preparations of levocetirizine are sold under the following brand names: Xyzal in Australia, Austria, Bulgaria, Croatia, Cyprus, Czech Republic, Finland, France, Hungary, India, Ireland (also Rinozal), Italy, Japan, Lithuania, Netherlands, Poland, Portugal, Romania, Taiwan, Thailand, Turkey, The Philippines, Serbia, Singapore, Slovakia, Slovenia, South Africa, Spain, Switzerland and UK. On May 25, 2007, the United States Food and Drug Administration approved Xyzal, where it is co-marketed by Sanofi-Aventis. Zobral in Cyprus Levobert in India Xusal in Germany and Mexico Xozal in Greece Degraler in Chile Allevo in Egypt Zilola, Histisynt, and Xyzal (UCB) in Hungary Alcet, Curin, and Seasonix in Bangladesh Vozet and Uvnil in India T-Day Syrup in Pakistan Curin in Nepal. Zenaro in the Czech Republic and Slovakia Xuzal and Zival in Chile Cezera, Levosetil, Robenan, and Xyzal in Serbia. Rinozal and Xyzal in Ireland References External links "Levocetirizine". Drug Information Portal. U.S. National Library of Medicine. "Levocetirizine dihydrochloride". Drug Information Portal. U.S. National Library of Medicine.
Daunorubicin	Daunorubicin, also known as daunomycin, is a chemotherapy medication used to treat cancer. Specifically it is used for acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myelogenous leukemia (CML), and Kaposis sarcoma. It is administeted by injection into a vein. A liposomal formulation known as liposomal daunorubicin also exists.Common side effects include hair loss, vomiting, bone marrow suppression, and inflammation of the inside of the mouth. Other severe side effects include heart disease and tissue death at the site of injection. Use in pregnancy may harm the fetus. Daunorubicin is in the anthracycline family of medication. It works in part by blocking the function of topoisomerase II.Daunorubicin was approved for medical use in the United States in 1979. It is on the World Health Organizations List of Essential Medicines. It was originally isolated from bacteria of the Streptomyces type. Medical uses It slows or stops the growth of cancer cells in the body. Treatment is usually performed together with other chemotherapy drugs (such as cytarabine), and its administration depends on the type of tumor and the degree of response. In addition to its major use in treating AML, daunorubicin is also used to treat neuroblastoma. Daunorubicin has been used with other chemotherapy agents to treat the blastic phase of chronic myelogenous leukemia. Daunorubicin is also used as the starting material for semi-synthetic manufacturing of doxorubicin, epirubicin and idarubicin. Mechanism of action Similar to doxorubicin, daunorubicin interacts with DNA by intercalation and inhibition of macromolecular biosynthesis. This inhibits the progression of the enzyme topoisomerase II, which relaxes supercoils in DNA for transcription. Daunorubicin stabilizes the topoisomerase II complex after it has broken the DNA chain for replication, preventing the DNA double helix from being resealed and thereby stopping the process of replication. On binding to DNA, daunomycin intercalates, with its daunosamine residue directed toward the minor groove. It has the highest preference for two adjacent G/C base pairs flanked on the 5 side by an A/T base pair. Crystallography shows that daunomycin induces a local unwinding angle of 8°, and other conformational disturbances of adjacent and second-neighbour base pairs. It can also induce histone eviction from chromatin upon intercalation. History In the 1950s, an Italian research company, Farmitalia Research Laboratories, began an organized effort to isolate anticancer compounds from soil-based microbes. A soil sample was isolated from the area surrounding the Castel del Monte, a 13th-century castle in Apulia. A new strain of Streptomyces peucetius which produced a red pigment was isolated, and an antibiotic was produced from this bacterium that was found to have good activity against murine tumors. Since a group of French researchers discovered the same compound at about the same time, the two teams named the compound daunorubicin, combining the name Dauni, a pre-Roman tribe that occupied the area of Italy where the compound was isolated, with the French word for ruby, rubis, describing the color. Clinical trials began in the 1960s, and the drug saw success in treating acute leukemia and lymphoma. However, by 1967, it was recognized that daunorubicin could produce fatal cardiac toxicity.In 2015–16, a team at Ohio State University "showed that, by carefully manipulating strands of viral DNA, an origami structure with complex folds can be created in just 10 minutes. Incredibly, these structures are only 100 nanometers across – that’s 1,000 times smaller than the width of a human hair. Small volumes of daunorubicin can be wrapped up in these minuscule pods, which can then be released into a leukemia cell-filled environment." Route of administration Daunorubicin should only be administered in a rapid intravenous infusion. It should not be administered intramuscularly or subcutaneously, since it may cause extensive tissue necrosis. It should also never be administered intrathecally (into the spinal canal), as this will cause extensive damage to the nervous system and may lead to death. Daunorubicin has been used intravitreally (inside the eye) for the purposes of preventing proliferative vitreoretinopathy, a common complication following retinal detachment surgery, but has not been found to be effective and is not used for any other ophthalmic purposes at this time. See also Doxorubicin Idarubicin References External links "Daunorubicin". Drug Information Portal. U.S. National Library of Medicine.
Alitretinoin	Alitretinoin, or 9-cis-retinoic acid, is a form of vitamin A. It is also used in medicine as an antineoplastic (anti-cancer) agent developed by Ligand Pharmaceuticals. It is a first generation retinoid. Ligand gained Food and Drug Administration (FDA) approval for alitretinoin in February 1999. Medical uses Kaposi’s sarcoma In the United States, topical alitretinoin is indicated for the treatment of skin lesions in AIDS-related Kaposis sarcoma. Alitretinoin is not indicated when systemic therapy against Kaposis sarcoma is required. It has received EMA (11 October 2000) and FDA (2 March 1999) approval for this indication. Chronic hand eczema Alitretinoin has been granted prescription rights in the UK (08/09/2008) for in chronic hand eczema as used by mouth. In May 2009 the National Institute for Health and Clinical Excellence (NICE) issued preliminary guidance on the use of alitretinoin for the treatment of severe chronic hand eczema in adults. The recommendation stated that only patients with severe chronic hand eczema who are unresponsive to potent topical corticosteroids, oral immunosuppressants or phototherapy should receive the drug. Final NICE guidance is expected in August 2009. Adverse effects Systemic use Very common (>10% frequency): Headache Hypertriglyceridemia High density lipoprotein decreased HypercholesterolemiaCommon (1-10% frequency): Uncommon (0.1-1% frequency): Rare (<0.1% frequency): Benign intracranial hypertension VasculitisUnknown frequency: Topical use Very common (>10% frequency): Rash (77%) Pain (34%) Itchiness (11%)Common (1-10% frequency): Exfoliative dermatitis Oedema Skin changes Paraesthesia Contraindications Pregnancy is an absolute contraindication as with most other vitamin A products, it should also be avoided when it comes to systemic use in any women that is of childbearing potential and not taking precautions to prevent pregnancy. Toctino (the oral capsule formulation of alitretinoin) contains soya oil and sorbitol. Patients who are allergic to peanut, soya or with rare hereditary fructose intolerance should not take this medicine. It is also contraindicated in nursing mothers. The oral formulation of alitretinoin is contraindicated in patients with: Interactions It is a CYP3A4 substrate and hence any inhibitor or inducer of this enzyme may alter plasma levels of alitretinoin. It should not be given to patients with excess vitamin A in their system as there is a potential for its actions on the retinoid X receptor to be exacerbated. It may also interact with tetracyclines to cause benign intracranial hypertension. Overdose Alitretinoin is a form of vitamin A. Alitretinoin has been administered in oncological clinical studies at dosages of more than 10-times of the therapeutic dosage given for chronic hand eczema. The adverse effects observed were consistent with retinoid toxicity, and included severe headache, diarrhoea, facial flushing and hypertriglyceridemia. These effects were reversible. Mechanism of action Alitretinoin is believed to be the endogenous ligand (a substance that naturally occurs in the body that activates this receptor) for retinoid X receptor, but it also activates the retinoic acid receptor. References External links "Alitretinoin". Drug Information Portal. U.S. National Library of Medicine.
Clonazepam	Clonazepam, sold under the brand name Klonopin among others, is a medication used to prevent and treat seizures, panic disorder, anxiety, and the movement disorder known as akathisia. It is a tranquilizer of the benzodiazepine class. It possesses anxiolytic, anticonvulsant, sedative, hypnotic, and skeletal muscle relaxant properties. It is typically taken by mouth. Effects begin within one hour and last between six and twelve hours.Common side effects include sleepiness, poor coordination, and agitation. Long-term use may result in tolerance, dependence, and withdrawal symptoms if stopped abruptly. Dependence occurs in one-third of people who take clonazepam for longer than four weeks. There is an increased risk of suicide, particularly in people who are already depressed. If used during pregnancy it may result in harm to the fetus. Clonazepam binds to GABAA receptors, thus increasing the effect of the chief inhibitory neurotransmitter γ-aminobutyric acid (GABA).Clonazepam was patented in 1960 and went on sale in 1975 in the United States from Roche. It is available as a generic medication. In 2020, it was the 44th most commonly prescribed medication in the United States, with more than 14 million prescriptions. In many areas of the world it is commonly used as a recreational drug. Medical uses Clonazepam is prescribed for short term management of epilepsy, anxiety, and panic disorder with or without agoraphobia. Seizures Clonazepam, like other benzodiazepines, while being a first-line treatment for acute seizures, is not suitable for the long-term treatment of seizures due to the development of tolerance to the anticonvulsant effects. Clonazepam has been found effective in treating epilepsy in children, and the inhibition of seizure activity seemed to be achieved at low plasma levels of clonazepam. As a result, clonazepam is sometimes used for certain rare childhood epilepsies; however, it has been found to be ineffective in the control of infantile spasms. Clonazepam is mainly prescribed for the acute management of epilepsies. Clonazepam has been found to be effective in the acute control of non-convulsive status epilepticus; however, the benefits tended to be transient in many people, and the addition of phenytoin for lasting control was required in these patients.It is also approved for treatment of typical and atypical absences (seizures), infantile myoclonic, myoclonic, and akinetic seizures. A subgroup of people with treatment resistant epilepsy may benefit from long-term use of clonazepam; the benzodiazepine clorazepate may be an alternative due to its slow onset of tolerance. Anxiety disorders Panic disorder with or without agoraphobia. Clonazepam has also been found effective in treating other anxiety disorders, such as social phobia, but this is an off-label use.The effectiveness of clonazepam in the short-term treatment of panic disorder has been demonstrated in controlled clinical trials. Some long-term trials have suggested a benefit of clonazepam for up to three years without the development of tolerance but these trials were not placebo-controlled. Clonazepam is also effective in the management of acute mania. Muscle disorders Restless legs syndrome can be treated using clonazepam as a third-line treatment option as the use of clonazepam is still investigational. Bruxism also responds to clonazepam in the short-term. Rapid eye movement sleep behavior disorder responds well to low doses of clonazepam. The treatment of acute and chronic akathisia induced by neuroleptics, also called antipsychotics. Spasticity related to amyotrophic lateral sclerosis. Alcohol withdrawal syndrome Other Benzodiazepines, such as clonazepam, are sometimes used for the treatment of mania or acute psychosis-induced aggression. In this context, benzodiazepines are given either alone, or in combination with other first-line drugs such as lithium, haloperidol or risperidone. The effectiveness of taking benzodiazepines along with antipsychotic medication is unknown, and more research is needed to determine if benzodiazepines are more effective than antipsychotics when urgent sedation is required. Hyperekplexia Many forms of parasomnia and other sleep disorders are treated with clonazepam. It is not effective for preventing migraines. Contraindications Coma Current alcohol use disorder Current substance use disorder Respiratory depression. Adverse effects In September 2020, the U.S. Food and Drug Administration (FDA) required the boxed warning be updated for all benzodiazepine medicines to describe the risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions consistently across all the medicines in the class. Common Sedation Euphoria Motor impairment Less common Confusion Irritability and aggression Psychomotor agitation Lack of motivation Loss of libido Impaired motor functionImpaired coordination Impaired balance Dizziness Cognitive impairmentsHallucinations. Short-term memory loss Anterograde amnesia (common with higher doses) Some users report hangover-like symptoms of drowsiness, headaches, sluggishness, and irritability upon waking up if the medication was taken before sleep. This is likely the result of the medications long half-life, which continues to affect the user after waking up. While benzodiazepines induce sleep, they tend to reduce the quality of sleep by suppressing or disrupting REM sleep. After regular use, rebound insomnia may occur when discontinuing clonazepam. Benzodiazepines may cause or worsen depression. Occasional Dysphoria Induction of seizures or increased frequency of seizures Personality changes Behavioural disturbances Ataxia Rare Suicide through disinhibition Psychosis Incontinence Liver damage Paradoxical behavioural disinhibition (most frequently in children, the elderly, and in persons with developmental disabilities) Rage Excitement ImpulsivityThe long-term effects of clonazepam can include depression, disinhibition, and sexual dysfunction. Drowsiness Clonazepam, like other benzodiazepines, may impair a persons ability to drive or operate machinery. The central nervous system depressing effects of the drug can be intensified by alcohol consumption, and therefore alcohol should be avoided while taking this medication. Benzodiazepines have been shown to cause dependence. Patients dependent on clonazepam should be slowly titrated off under the supervision of a qualified healthcare professional to reduce the intensity of withdrawal or rebound symptoms. Withdrawal-related Anxiety Irritability Insomnia Tremors Headaches Stomach pain Hallucinations Suicidal thoughts or urges Depression Fatigue Dizziness Sweating Confusion Potential to exacerbate existing panic disorder upon discontinuation Seizures similar to delirium tremens (with long-term use of excessive doses)Benzodiazepines such as clonazepam can be very effective in controlling status epilepticus, but, when used for longer periods of time, some potentially serious side-effects may develop, such as interference with cognitive functions and behavior. Many individuals treated on a long-term basis develop a dependence. Physiological dependence was demonstrated by flumazenil-precipitated withdrawal. Use of alcohol or other CNS depressants while taking clonazepam greatly intensifies the effects (and side effects) of the drug. A recurrence of symptoms of the underlying disease should be separated from withdrawal symptoms. Tolerance and withdrawal Like all benzodiazepines, clonazepam is a GABA-positive allosteric modulator. One-third of individuals treated with benzodiazepines for longer than four weeks develop a dependence on the drug and experience a withdrawal syndrome upon dose reduction. High dosage and long-term use increase the risk and severity of dependence and withdrawal symptoms. Withdrawal seizures and psychosis can occur in severe cases of withdrawal, and anxiety and insomnia can occur in less severe cases of withdrawal. A gradual reduction in dosage reduces the severity of the benzodiazepine withdrawal syndrome. Due to the risks of tolerance and withdrawal seizures, clonazepam is generally not recommended for the long-term management of epilepsies. Increasing the dose can overcome the effects of tolerance, but tolerance to the higher dose may occur and adverse effects may intensify. The mechanism of tolerance includes receptor desensitization, down regulation, receptor decoupling, and alterations in subunit composition and in gene transcription coding.Tolerance to the anticonvulsant effects of clonazepam occurs in both animals and humans. In humans, tolerance to the anticonvulsant effects of clonazepam occurs frequently. Chronic use of benzodiazepines can lead to the development of tolerance with a decrease of benzodiazepine binding sites. The degree of tolerance is more pronounced with clonazepam than with chlordiazepoxide. In general, short-term therapy is more effective than long-term therapy with clonazepam for the treatment of epilepsy. Many studies have found that tolerance develops to the anticonvulsant properties of clonazepam with chronic use, which limits its long-term effectiveness as an anticonvulsant.Abrupt or over-rapid withdrawal from clonazepam may result in the development of the benzodiazepine withdrawal syndrome, causing psychosis characterised by dysphoric manifestations, irritability, aggressiveness, anxiety, and hallucinations. Sudden withdrawal may also induce the potentially life-threatening condition, status epilepticus. Anti-epileptic drugs, benzodiazepines such as clonazepam in particular, should be reduced in dose slowly and gradually when discontinuing the drug to mitigate withdrawal effects. Carbamazepine has been tested in the treatment of clonazepam withdrawal but was found to be ineffective in preventing clonazepam withdrawal-induced status epilepticus from occurring. Overdose Excess doses may result in: Difficulty staying awake Mental confusion Impaired motor functions Impaired reflexes Impaired coordination Impaired balance Dizziness Respiratory depression Low blood pressure ComaComa can be cyclic, with the individual alternating from a comatose state to a hyper-alert state of consciousness, which occurred in a four-year-old boy who overdosed on clonazepam. The combination of clonazepam and certain barbiturates (for example, amobarbital), at prescribed doses has resulted in a synergistic potentiation of the effects of each drug, leading to serious respiratory depression.Overdose symptoms may include extreme drowsiness, confusion, muscle weakness, and fainting. Detection in biological fluids Clonazepam and 7-aminoclonazepam may be quantified in plasma, serum, or whole blood in order to monitor compliance in those receiving the drug therapeutically. Results from such tests can be used to confirm the diagnosis in potential poisoning victims or to assist in the forensic investigation in a case of fatal overdosage. Both the parent drug and 7-aminoclonazepam are unstable in biofluids, and therefore specimens should be preserved with sodium fluoride, stored at the lowest possible temperature and analyzed quickly to minimize losses. Special precautions The elderly metabolize benzodiazepines more slowly than younger people and are also more sensitive to the effects of benzodiazepines, even at similar blood plasma levels. Doses for the elderly are recommended to be about half of that given to younger adults and are to be administered for no longer than two weeks. Long-acting benzodiazepines such as clonazepam are not generally recommended for the elderly due to the risk of drug accumulation.The elderly are especially susceptible to increased risk of harm from motor impairments and drug accumulation side effects. Benzodiazepines also require special precaution if used by individuals that may be pregnant, alcohol- or drug-dependent, or may have comorbid psychiatric disorders. Clonazepam is generally not recommended for use in elderly people for insomnia due to its high potency relative to other benzodiazepines.Clonazepam is not recommended for use in those under 18. Use in very young children may be especially hazardous. Of anticonvulsant drugs, behavioural disturbances occur most frequently with clonazepam and phenobarbital.Doses higher than 0.5–1 mg per day are associated with significant sedation.Clonazepam may aggravate hepatic porphyria.Clonazepam is not recommended for patients with chronic schizophrenia. A 1982 double-blinded, placebo-controlled study found clonazepam increases violent behavior in individuals with chronic schizophrenia.Clonazepam has similar effectiveness to other benzodiazepines at often a lower dose. Interactions Clonazepam decreases the levels of carbamazepine, and, likewise, clonazepams level is reduced by carbamazepine. Azole antifungals, such as ketoconazole, may inhibit the metabolism of clonazepam. Clonazepam may affect levels of phenytoin (diphenylhydantoin). In turn, Phenytoin may lower clonazepam plasma levels by increasing the speed of clonazepam clearance by approximately 50% and decreasing its half-life by 31%. Clonazepam increases the levels of primidone and phenobarbital.Combined use of clonazepam with certain antidepressants, anticonvulsants (such as phenobarbital, phenytoin, and carbamazepine), sedative antihistamines, opiates, and antipsychotics, nonbenzodiazepines (such as zolpidem), and alcohol may result in enhanced sedative effects. Pregnancy There is some medical evidence of various malformations (for example, cardiac or facial deformations when used in early pregnancy); however, the data is not conclusive. The data are also inconclusive on whether benzodiazepines such as clonazepam cause developmental deficits or decreases in IQ in the developing fetus when taken by the mother during pregnancy. Clonazepam, when used late in pregnancy, may result in the development of a severe benzodiazepine withdrawal syndrome in the neonate. Withdrawal symptoms from benzodiazepines in the neonate may include hypotonia, apnoeic spells, cyanosis, and impaired metabolic responses to cold stress.The safety profile of clonazepam during pregnancy is less clear than that of other benzodiazepines, and if benzodiazepines are indicated during pregnancy, chlordiazepoxide and diazepam may be a safer choice. The use of clonazepam during pregnancy should only occur if the clinical benefits are believed to outweigh the clinical risks to the fetus. Caution is also required if clonazepam is used during breastfeeding. Possible adverse effects of use of benzodiazepines such as clonazepam during pregnancy include: miscarriage, malformation, intrauterine growth retardation, functional deficits, carcinogenesis, and mutagenesis. Neonatal withdrawal syndrome associated with benzodiazepines include hypertonia, hyperreflexia, restlessness, irritability, abnormal sleep patterns, inconsolable crying, tremors, or jerking of the extremities, bradycardia, cyanosis, suckling difficulties, apnea, risk of aspiration of feeds, diarrhea and vomiting, and growth retardation. This syndrome can develop between three days to three weeks after birth and can have a duration of up to several months. The pathway by which clonazepam is metabolized is usually impaired in newborns. If clonazepam is used during pregnancy or breastfeeding, it is recommended that serum levels of clonazepam are monitored and that signs of central nervous system depression and apnea are also checked for. In many cases, non-pharmacological treatments, such as relaxation therapy, psychotherapy, and avoidance of caffeine, can be an effective and safer alternative to the use of benzodiazepines for anxiety in pregnant women. Pharmacology Mechanism of action Clonazepam enhances the activity of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the central nervous system to give its anticonvulsant, skeletal muscle relaxant, and anxiolytic effects. It acts by binding to the benzodiazepine site of the GABA receptors, which enhances the electric effect of GABA binding on neurons, resulting in an increased influx of chloride ions into the neurons. This further results in an inhibition of synaptic transmission across the central nervous system.Benzodiazepines do not have any effect on the levels of GABA in the brain. Clonazepam has no effect on GABA levels and has no effect on gamma-aminobutyric acid transaminase. Clonazepam does, however, affect glutamate decarboxylase activity. It differs from other anticonvulsant drugs it was compared to in a study.Clonazepams primary mechanism of action is the modulation of GABA function in the brain, by the benzodiazepine receptor, located on GABAA receptors, which, in turn, leads to enhanced GABAergic inhibition of neuronal firing. Benzodiazepines do not replace GABA, but instead enhance the effect of GABA at the GABAA receptor by increasing the opening frequency of chloride ion channels, which leads to an increase in GABAs inhibitory effects and resultant central nervous system depression. In addition, clonazepam decreases the utilization of 5-HT (serotonin) by neurons and has been shown to bind tightly to central-type benzodiazepine receptors. Because clonazepam is effective in low milligram doses (0.5 mg clonazepam = 10 mg diazepam), it is said to be among the class of "highly potent" benzodiazepines. The anticonvulsant properties of benzodiazepines are due to the enhancement of synaptic GABA responses, and the inhibition of sustained, high-frequency repetitive firing.Benzodiazepines, including clonazepam, bind to mouse glial cell membranes with high affinity. Clonazepam decreases release of acetylcholine in the feline brain and decreases prolactin release in rats. Benzodiazepines inhibit cold-induced thyroid-stimulating hormone (also known as TSH or thyrotropin) release. Benzodiazepines act via micromolar benzodiazepine binding sites as Ca2+ channel blockers and significantly inhibit depolarization-sensitive calcium uptake in experimentation on rat brain cell components. This has been conjectured as a mechanism for high-dose effects on seizures in the study.Clonazepam is a 2-chlorinated derivative of nitrazepam, which increases its potency due to electron-attracting effect of the halogen in the ortho-position. Pharmacokinetics Clonazepam is lipid-soluble, rapidly crosses the blood–brain barrier, and penetrates the placenta. It is extensively metabolised into pharmacologically inactive metabolites, with only 2% of the unchanged drug excreted in the urine. Clonazepam is metabolized extensively via nitroreduction by cytochrome P450 enzymes, including CYP3A4. Erythromycin, clarithromycin, ritonavir, itraconazole, ketoconazole, nefazodone, cimetidine, and grapefruit juice are inhibitors of CYP3A4 and can affect the metabolism of benzodiazepines. It has an elimination half-life of 19–60 hours. Peak blood concentrations of 6.5–13.5 ng/mL were usually reached within 1–2 hours following a single 2 mg oral dose of micronized clonazepam in healthy adults. In some individuals, however, peak blood concentrations were reached at 4–8 hours.Clonazepam passes rapidly into the central nervous system, with levels in the brain corresponding with levels of unbound clonazepam in the blood serum. Clonazepam plasma levels are very unreliable amongst patients. Plasma levels of clonazepam can vary as much as tenfold between different patients.Clonazepam has plasma protein binding of 85%. Clonazepam passes through the blood–brain barrier easily, with blood and brain levels corresponding equally with each other. The metabolites of clonazepam include 7-aminoclonazepam, 7-acetaminoclonazepam and 3-hydroxy clonazepam. These metabolites are excreted by the kidney.It is effective for 6–8 hours in children, and 6–12 in adults. Society and culture Recreational use A 2006 US government study of hospital emergency department (ED) visits found that sedative-hypnotics were the most frequently implicated pharmaceutical drug in visits, with benzodiazepines accounting for the majority of these. Clonazepam was the second most frequently implicated benzodiazepine in ED visits. Alcohol alone was responsible for over twice as many ED visits as clonazepam in the same study. The study examined the number of times the non-medical use of certain drugs was implicated in an ED visit. The criteria for non-medical use in this study were purposefully broad, and include, for example, drug abuse, accidental or intentional overdose, or adverse reactions resulting from legitimate use of the medication. Formulations Clonazepam was approved in the United States as a generic drug in 1997 and is now manufactured and marketed by several companies. Clonazepam is available as tablets and orally disintegrating tablets (wafers) an oral solution (drops), and as a solution for injection or intravenous infusion. Brand names It is marketed under the trade name Rivotril by Roche in Argentina, Australia, Austria, Bangladesh, Belgium, Brazil, Bulgaria, Canada, Colombia, Costa Rica, Croatia, the Czech Republic, Denmark, Estonia, Germany, Hungary, Iceland, Ireland, Italy, China, Mexico, the Netherlands, Norway, Portugal, Peru, Pakistan, Romania, Serbia, South Africa, South Korea, Spain, Turkey, and the United States; Emcloz, Linotril and Clonotril in India and other parts of Europe; under the name Riklona in Indonesia and Malaysia; and under the trade name Klonopin by Roche in the United States. Other names, such as Antelepsin, Clonoten, Ravotril, Rivotril, Iktorivil, Clonex (Israel), Paxam, Petril, Naze, Zilepam and Kriadex, are used throughout the world. References Further reading Poisons Information Monograph - Clonazepam External links "Clonazepam". Drug Information Portal. U.S. National Library of Medicine.
Bempedoic acid/ezetimibe	Bempedoic acid/ezetimibe, sold under the brand name Nexlizet among others, is a fixed-dose combination medication used for the treatment of high cholesterol. It is a combination of bempedoic acid and ezetimibe.The most common side effects are hyperuricemia (high blood levels of uric acid) and constipation.Bempedoic acid is an adenosine triphosphate-citrate lyase (ACL) inhibitor and ezetimibe is a cholesterol absorption inhibitor. Bempedoic acid works by blocking an enzyme in the liver called adenosine triphosphate citrate lyase, which is involved in making cholesterol. Ezetimibe works by binding to a gut protein called Niemann-Pick C1 Like 1, preventing cholesterol from being absorbed into the blood from the gut.The combination was approved for medical use in the United States in February 2020, and in the European Union in March 2020. Medical uses In the US bempedoic acid/ezetimibe is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease who require additional lowering of LDL-C.In the EU bempedoic acid/ezetimibe is indicated in adults with primary hypercholesterolemia (heterozygous familial and non-familial) or mixed dyslipidemia, as an adjunct to diet: in combination with a statin in people unable to reach LDL-C goals with the maximum tolerated dose of a statin in addition to ezetimibe alone in people who are either statin-intolerant or for whom a statin is contraindicated, and are unable to reach LDL-C goals with ezetimibe alone, in people already being treated with the combination of bempedoic acid and ezetimibe as separate tablets with or without statin. Contraindications It the European Union it must not be used in pregnant or breast-feeding women. Use during pregnancy is not recommended in the US. History The European Medicines Agency (EMA) recommended approval of bempedoic acid/ezetimibe (Nustendi) in the EU in January 2020.Bempedoic acid/ezetimibe was approved in the United States in February 2020, and in the European Union in March 2020.Two studies showed that bempedoic acid and ezetimibe effectively reduced LDL cholesterol levels in participants with hypercholesterolemia and heart disease or who were at high risk of heart disease. High cholesterol is a risk factor for heart disease.The first study involved 382 participants also taking the maximum tolerated doses of statins. After three months, LDL cholesterol levels were reduced by 36% in participants taking bempedoic acid and ezetimibe compared with a reduction of 23% with ezetimibe alone, 17% with bempedoic acid alone and an increase of around 2% with placebo (a dummy treatment).The second study involved 269 participants with high cholesterol levels who were not able to take a statin or were taking a low dose of a statin. All the participants were also taking ezetimibe. After three months, LDL cholesterol levels were reduced by 23% in participants taking bempedoic acid in addition to ezetimibe compared with an increase of around 5% in participants taking placebo and ezetimibe. References External links "Bempedoic acid". Drug Information Portal. U.S. National Library of Medicine. "Ezetimibe". Drug Information Portal. U.S. National Library of Medicine. Clinical trial number NCT03337308 for "A Study Evaluating the Safety and Efficacy of Bempedoic Acid Plus Ezetimibe Fixed-Dose Combination Compared to Bempedoic Acid, Ezetimibe, and Placebo in Patients Treated With Maximally Tolerated Statin Therapy" at ClinicalTrials.gov
Minoxidil	Minoxidil, sold under the brand name Rogaine among others, is a medication used for the treatment of high blood pressure and pattern hair loss. It is an antihypertensive vasodilator. It is available as a generic medication by prescription in oral tablet form and over the counter as a topical liquid or foam. Medical uses Minoxidil, when used for hypertension, is generally reserved for use in severe hypertension patients who can not respond to at least two agents and a diuretic. Minoxidil is also generally administered with a loop diuretic to prevent the sodium and potassium retention. It may also cause a reflex tachycardia and thus is prescribed with a beta blocker. Minoxidil, applied topically, is widely used for the treatment of hair loss. It is effective in helping promote hair growth in people with androgenic alopecia regardless of sex. Minoxidil must be used indefinitely for continued support of existing hair follicles and the maintenance of any experienced hair regrowth.Low-dose oral minoxidil is used off-label against hair loss.Its effect in people with alopecia areata is unclear. However, the association of oral minoxidil with Janus Kinase inhibitors (JAK inhibitors), termed oral adjuvant minoxidil, seems to increase hair regrowth in patients refractory to JAK inhibitor monotherapy. Side effects Topically applied minoxidil is generally well tolerated, but common side effects include itching of the eye, itching, redness or irritation at the treated area, and unwanted hair growth elsewhere on the body. Exacerbation of hair loss/alopecia has been reported. Other side effects may include rash, itching, difficulty breathing, swelling of the mouth, face, lips, or tongue, chest pain, dizziness, fainting, tachycardia, headache, sudden and unexplained weight gain, or swelling of the hands and feet. Rare side effects are erectile dysfunction, depression, anxiety, decreased libido, and skin disorders. Temporary hair loss is a common side effect of minoxidil treatment, a process referred to as "shedding."Alcohol and propylene glycol present in some topical preparations may dry the scalp, resulting in dandruff and contact dermatitis. Cases of allergic reactions to minoxidil or the non-active ingredient propylene glycol, which is found in some topical minoxidil formulations, have been reported. Side effects of oral minoxidil may include swelling of the face and extremities, rapid heartbeat, or lightheadedness. Cardiac lesions, such as focal necrosis of the papillary muscle and subendocardial areas of the left ventricle, have been observed in laboratory animals treated with minoxidil. Pseudoacromegaly is an extremely rare side effect reported with large doses of oral minoxidil.In 2013 or 2014 a seven-year-old girl was admitted to a childrens hospital in Toulouse in France after accidentally ingesting a teaspoon of Alopexy (a brand name for minoxidil in France). The child vomited constantly after ingestion and showed hypotension and tachycardia for 40 hours. The authors of the report on the incident stressed that the product should be kept out of reach of children, and urged manufacturers to consider more secure child-resistant packaging.Minoxidil may cause hirsutism, although it is exceedingly rare and reversible by discontinuation of the drug. Pharmacology Mechanism of action The mechanism by which minoxidil promotes hair growth is not fully understood. Minoxidil is an adenosine 5-triphosphate-sensitive potassium channel opener, causing hyperpolarization of cell membranes. Theoretically, by widening blood vessels and opening potassium channels, it allows more oxygen, blood, and nutrients to the follicles. Moreover, minoxidil contains a nitric oxide moiety and may act as a nitric oxide agonist. This may cause follicles in the telogen phase to shed, which are then replaced by thicker hairs in a new anagen phase. Minoxidil is a prodrug that is converted by sulfation via the sulfotransferase enzyme SULT1A1 to its active form, minoxidil sulfate. The effect of minoxidil is mediated by adenosine, which triggers intracellular signal transduction via both adenosine A1 receptors and two sub-types of adenosine A2 receptors (A2A and A2B receptors). Minoxidil acts as an activator of the Kir6/SUR2 channel upon selective binding to SUR2. The expression of SUR2B in dermal papilla cells might play a role in the production of adenosine. Minoxidil induces cell growth factors such as VEGF, HGF, IGF-1 and potentiates HGF and IGF-1 actions by the activation of uncoupled sulfonylurea receptor on the plasma membrane of dermal papilla cells.A number of in vitro effects of minoxidil have been described in monocultures of various skin and hair follicle cell types including stimulation of cell proliferation, inhibition of collagen synthesis, and stimulation of vascular endothelial growth factor, prostaglandin synthesis and leukotriene B4 expression.Minoxidil causes a redistribution of cellular iron through its apparent capacity to bind this metal ion. By binding iron in a Fenton-reactive form, intracellular hydroxyl radical production would ensue, but hydroxyl would be immediately trapped and scavenged by the minoxidil to generate a nitroxyl radical. It is presumed that this nitroxyl radical will be capable of reduction by glutathione to reform minoxidil. Such a process would cycle until the minoxidil is otherwise metabolized and would result in rapid glutathione depletion with glutathione disulphide formation and therefore with concomitant consumption of NADPH/ NADH and other reducing equivalents. Minoxidil inhibited PHD by interfering with the normal function of ascorbate, a cofactor of the enzyme, leading to a stabilization of HIF-1α protein and a subsequent activation of HIF-1. In an in vivo angiogenesis assay, millimolar minoxidil increased blood vessel formation in a VEGF-dependent manner. Minoxidil inhibition of PHD occurs via interrupting ascorbate binding to iron. The structural feature of positioning amines adjacent to nitric oxide may confer the ability of millimolar minoxidil to chelate iron, thereby inhibiting PHD. Minoxidil is capable of tetrahydrobiopterin inhibition as a cofactor for nitric oxide synthase.Minoxidil stimulates prostaglandin E2 production by activating COX-1 and prostaglandin endoperoxide synthase-1 but inhibits prostacyclin production. Additionally, expression of the prostaglandin E2 receptor, the most upregulated target gene in the β-catenin pathway of DP cells, was enhanced by minoxidil, which may enable hair follicles to grow continuously and maintain the anagen phase.Due to anti-fibrotic activity of minoxidil inhibition of enzyme lysyl hydroxylase present in fibroblast may result in synthesis of a hydroxylysine-deficient collagen. Minoxidil can also potentially stimulate elastogenesis in aortic smooth muscle cells, and in skin fibroblasts in a dose-dependent manner. In hypertensive rats, minoxidil increases elastin level in the mesenteric, abdominal, and renal arteries by a decrease in "elastase" enzyme activity in these tissues. In rats, potassium channel openers decrease calcium influx which inhibits elastin gene transcription through extracellular signal-regulated kinase 1⁄2 (ERK 1/2)-activator protein 1 signaling pathway. ERK 1/2 increases, through elastin gene transcription, adequately cross-linked elastic fiber content synthetized by smooth muscle cells, and decreases the number of cells in the aorta.Minoxidil possesses alpha 2-adrenoceptor agonist activity, stimulates the peripheral sympathetic nervous system (SNS) by way of carotid and aortic baroreceptor reflexes. Minoxidil administration also brings an increase in plasma renin activity, largely due to the aforementioned activation of the SNS. This activation of the renin-angiotensin axis further prompts increased biosynthesis of aldosterone; whereas plasma and urinary aldosterone levels are increased early in the course of treatment with minoxidil, over time these values tend to normalize presumably because of accelerated metabolic clearance of aldosterone in association with hepatic vasodilation.Minoxidil may be involved in the inhibition of serotonergic (5-HT2) receptors.Minoxidil might increase blood-tumor barrier permeability in a time-dependent manner by down-regulating tight junction protein expression and this effect could be related to ROS/RhoA/PI3K/PKB signal pathway. Minoxidil significantly increases ROS concentration when compared to untreated cells. In vitro Minoxidil treatment resulted in a 0.22 fold change for 5α-R2 (p < 0.0001). This antiandrogenic effect of minoxidil, shown by significant downregulation of 5α-R2 gene expression in HaCaT cells, may be one of its mechanisms of action in alopecia.Minoxidil is less effective when the area of hair loss is large. In addition, its effectiveness has largely been demonstrated in younger men who have experienced hair loss for less than 5 years. Minoxidil use is indicated for central (vertex) hair loss only. Two clinical studies are being conducted in the US for a medical device that may allow patients to determine if they are likely to benefit from minoxidil therapy.Conditions such as Cantú syndrome have been shown to mimic the pharmacological properties of minoxidil. Chemistry Minoxidil is an odorless, white to off-white, crystalline powder (crystals from methanol-acetonitrile). When heated to decomposition it emits toxic fumes of nitrogen oxides. It decomposes at 259-261 °C.Solubility (mg/ml): propylene glycol 75, methanol 44, ethanol 29, 2-propanol 6.7, dimethylsulfoxide 6.5, water 2.2, chloroform 0.5, acetone <0.5, ethyl acetate <0.5, diethyl ether <0.5, benzene <0.5, acetonitrile <0.5. p K a = {\displaystyle \mathrm {p} K_{{\ce {a}}}=} 4.61 Commercially available minoxidil topical solution should be stored at a temperature of 20-25 °C. Extemporaneous formulations of minoxidil have been reported to have variable stability, depending on the vehicle and method of preparation, and the FDA requests that physicians and pharmacists refrain from preparing extemporaneous topical formulations using commercially available minoxidil tablets. Minoxidil tablets should be stored in well-closed containers at 15-30 °C. Minoxidil, 6-amino-1,2-dihydro-1-hydroxy-2-imino-4-piperidinopyrimidine, is synthesized from barbituric acid, the reaction of which with phosphorous oxychloride gives 2,4,6-trichloropyrimidine. Upon reaction with ammonium, this turns into 2,4-diamino-6-chloropyrimidine. Next, the resulting 2,4-diamino-6-chloropyrimidine undergoes reaction with 2,4-dichlorophenol in the presence of potassium hydroxide, giving 2,4-diamino-6-(2,4-dichlorophenoxy)-pyrimidine. Oxidation of this product with 3-chloroperbenzoic acid gives 2,4-diamino-6-(2,4-dichlorophenoxy)pyrimidine-3-oxide, the 2,4-dichlorophenoxyl group of which is replaced with a piperidine group at high temperature, giving minoxidil.Another synthesis approach is depicted here: Compounds related to minoxidil include kopexil (diaminopyrimidine oxide). History Initial application Minoxidil was developed in the late 1950s by the Upjohn Company (later became part of Pfizer) to treat ulcers. In trials using dogs, the compound did not cure ulcers, but proved to be a powerful vasodilator. Upjohn synthesized over 200 variations of the compound, including the one it developed in 1963 and named minoxidil. These studies resulted in the U.S. Food and Drug Administration (FDA) approving minoxidil (with the brand name Loniten) in the form of oral tablets to treat high blood pressure in 1979. Hair growth When Upjohn received permission from the U.S. Food and Drug Administration (FDA) to test the new drug as medicine for hypertension they approached Charles A. Chidsey MD, Associate Professor of Medicine at the University of Colorado School of Medicine. He conducted two studies, the second study showing unexpected hair growth. Puzzled by this side-effect, Chidsey consulted Guinter Kahn (who while a dermatology resident at the University of Miami had been the first to observe and report hair development on patients using the minoxidil patch) and discussed the possibility of using minoxidil for treating hair loss. Kahn along with his colleague Paul J. Grant MD had obtained a certain amount of the drug and conducted their own research, since they were first to make the side effect observation. Neither Upjohn or Chidsey at the time were aware of the side effect of hair growth. The two doctors had been experimenting with a 1% solution of minoxidil mixed with several alcohol-based liquids. Both parties filed patents to use the drug for hair loss prevention, which resulted in a decade-long trial between Kahn and Upjohn, which ended with Kahns name included in a consolidated patent (U.S. #4,596,812 Charles A Chidsey, III and Guinter Kahn) in 1986 and royalties from the company to both Kahn and Grant.Meanwhile, the effect of minoxidil on hair loss prevention was so clear that in the 1980s physicians were prescribing Loniten off-label to their balding patients.In August 1988, the FDA approved the drug for treating baldness in men under the brand name "Rogaine" (FDA rejected Upjohns first choice, Regain, as misleading). The agency concluded that although "the product will not work for everyone", 39% of the men studied had "moderate to dense hair growth on the crown of the head".In 1991, Upjohn made the product available for women.On February 12, 1996, the FDA approved both the over-the-counter sale of the medication and the production of generic formulations of minoxidil. Upjohn replied to that by lowering prices to half the price of the prescription drug and by releasing a prescription 5% formula of Rogaine in 1997. In 1998, a 5% formulation of minoxidil was approved for nonprescription sale by the FDA. The 5% aerosol foam formula was approved for medical use in the US in 2006. The generic versions of the 5% aerosol foam formula were approved in 2017.In 2017, JAMA published a study of pharmacy prices in four states for 41 over-the-counter minoxidil products which were "gender-specified." The authors found that the mean price for minoxidil solutions was the same for women and men even though the womens formulations were 2% and the mens were 5%, while the mean price for minoxidil foams, which were all 5%, was 40% higher for women. The authors noted this was the first time gender-based pricing had been shown for a medication. Society and culture Brand names As of June 2017, Minoxidil was marketed under many trade names worldwide: Alomax, Alopek, Alopexy, Alorexyl, Alostil, Aloxid, Aloxidil, Anagen, Apo-Gain, Axelan, Belohair, Boots Hair Loss Treatment, Botafex, Capillus, Carexidil, Coverit, Da Fei Xin, Dilaine, Dinaxcinco, Dinaxil, Ebersedin, Eminox, Folcare, Guayaten, Hair Grow, Hair-Treat, Hairgain, Hairgaine, Hairgrow, Hairway, Headway, Inoxi, Ivix, Keranique, Lacovin, Locemix, Loniten, Lonnoten, Lonolox, Lonoten, Loxon, M E Medic, Maev-Medic, Mandi, Manoxidil, Mantai, Mens Rogaine, Minodil, Minodril, Minostyl, Minovital, Minox, Minoxi, Minoxidil, Minoxidilum, Minoximen, Minoxiten, Minscalp, Mintop, Modil, Morr, Moxidil, Neo-Pruristam, Neocapil, Neoxidil, Nherea, Noxidil, Oxofenil, Pilfud, Pilogro, Pilomin, Piloxidil,Re-Stim, Re-Stim+, Recrea, Regain, Regaine, Regaxidil, Regro, Regroe, Regrou, Regrowth, Relive, Renobell Locion, Reten, Rexidil, Rogaine, Rogan, Si Bi Shen, Splendora, Superminox, Trefostil, Tricolocion, Tricoplus, Tricovivax, Tricoxane, Trugain, Tugain, Unipexil, Vaxdil, Vius, Womens Regaine, Xenogrow, Xtreme Boost, Xtreme Boost+, Xue Rui, Ylox, and Zeldilon. It was also marketed as combination drug with amifampridine under the brand names Gainehair and Hair 4 U, and as a combination with tretinoin and clobetasol under the brand name Sistema GB. Veterinary safety Minoxidil is suspected to be highly toxic to cats, even in small doses, as there are reported cases of cats dying shortly after coming in contact with minimal amounts of the substance. See also Diazoxide Dutasteride Finasteride Kopexil, an analog of minoxidil missing the piperidine substituent Pinacidil References External links "Minoxidil". Drug Information Portal. U.S. National Library of Medicine. "Minoxidil Topical". MedlinePlus.
Iron(II) sulfate	Iron(II) sulfate (British English: iron(II) sulphate) or ferrous sulfate denotes a range of salts with the formula FeSO4·xH2O. These compounds exist most commonly as the heptahydrate (x = 7) but several values for x are known. The hydrated form is used medically to treat iron deficiency, and also for industrial applications. Known since ancient times as copperas and as green vitriol (vitriol is an archaic name for sulfate), the blue-green heptahydrate (hydrate with 7 molecules of water) is the most common form of this material. All the iron(II) sulfates dissolve in water to give the same aquo complex [Fe(H2O)6]2+, which has octahedral molecular geometry and is paramagnetic. The name copperas dates from times when the copper(II) sulfate was known as blue copperas, and perhaps in analogy, iron(II) and zinc sulfate were known respectively as green and white copperas.It is on the World Health Organizations List of Essential Medicines. In 2019, it was the 103rd most commonly prescribed medication in the United States, with more than 6 million prescriptions. Uses Industrially, ferrous sulfate is mainly used as a precursor to other iron compounds. It is a reducing agent, and as such is useful for the reduction of chromate in cement to less toxic Cr(III) compounds. Historically ferrous sulfate was used in the textile industry for centuries as a dye fixative. It is used historically to blacken leather and as a constituent of iron gall ink. The preparation of sulfuric acid (oil of vitriol) by the distillation of green vitriol (Iron(II) sulfate) has been known for at least 700 years. Medical use Plant growth Iron(II) sulfate is sold as ferrous sulfate, a soil amendment for lowering the pH of a high alkaline soil so that plants can access the soils nutrients.In horticulture it is used for treating iron chlorosis. Although not as rapid-acting as ferric EDTA, its effects are longer-lasting. It can be mixed with compost and dug into the soil to create a store which can last for years. Ferrous sulfate can be used as a lawn conditioner. It can also be used to eliminate silvery thread moss in golf course putting greens. Pigment and craft Ferrous sulfate can be used to stain concrete and some limestones and sandstones a yellowish rust color.Woodworkers use ferrous sulfate solutions to color maple wood a silvery hue. Green vitriol is also a useful reagent in the identification of mushrooms. Historical uses Ferrous sulfate was used in the manufacture of inks, most notably iron gall ink, which was used from the middle ages until the end of the 18th century. Chemical tests made on the Lachish letters (c. 588–586 BCE) showed the possible presence of iron. It is thought that oak galls and copperas may have been used in making the ink on those letters. It also finds use in wool dyeing as a mordant. Harewood, a material used in marquetry and parquetry since the 17th century, is also made using ferrous sulfate. Two different methods for the direct application of indigo dye were developed in England in the 18th century and remained in use well into the 19th century. One of these, known as china blue, involved iron(II) sulfate. After printing an insoluble form of indigo onto the fabric, the indigo was reduced to leuco-indigo in a sequence of baths of ferrous sulfate (with reoxidation to indigo in air between immersions). The china blue process could make sharp designs, but it could not produce the dark hues of other methods. In the second half of the 1850s ferrous sulfate was used as a photographic developer for collodion process images. Hydrates Iron(II) sulfate can be found in various states of hydration, and several of these forms exist in nature. FeSO4·H2O (mineral: szomolnokite, relatively rare) FeSO4·4H2O (mineral: rozenite, white, relatively common, may be dehydratation product of melanterite) FeSO4·5H2O (mineral: siderotil, relatively rare) FeSO4·6H2O (mineral: ferrohexahydrite, relatively rare) FeSO4·7H2O (mineral: melanterite, blue-green, relatively common) The tetrahydrate is stabilized when the temperature of aqueous solutions reaches 56.6 °C (133.9 °F). At 64.8 °C (148.6 °F) these solutions form both the tetrahydrate and monohydrate.Mineral forms are found in oxidation zones of iron-bearing ore beds, e.g. pyrite, marcasite, chalcopyrite, etc. They are also found in related environments, like coal fire sites. Many rapidly dehydrate and sometimes oxidize. Numerous other, more complex (either basic, hydrated, and/or containing additional cations) Fe(II)-bearing sulfates exist in such environments, with copiapite being a common example. Production and reactions In the finishing of steel prior to plating or coating, the steel sheet or rod is passed through pickling baths of sulfuric acid. This treatment produces large quantities of iron(II) sulfate as a by-product. Fe + H2SO4 → FeSO4 + H2Another source of large amounts results from the production of titanium dioxide from ilmenite via the sulfate process. Ferrous sulfate is also prepared commercially by oxidation of pyrite: 2 FeS2 + 7 O2 + 2 H2O → 2 FeSO4 + 2 H2SO4It can be produced by displacement of metals less reactive than Iron from solutions of their sulfate: CuSO4 + Fe → FeSO4 + Cu Reactions Upon dissolving in water, ferrous sulfates form the metal aquo complex [Fe(H2O)6]2+, which is an almost colorless, paramagnetic ion. On heating, iron(II) sulfate first loses its water of crystallization and the original green crystals are converted into a white anhydrous solid. When further heated, the anhydrous material decomposes into sulfur dioxide and sulfur trioxide, leaving a reddish-brown iron(III) oxide. Thermolysis of iron(II) sulfate begins at about 680 °C (1,256 °F). 2 FeSO 4 → Δ Fe 2 O 3 + SO 2 + SO 3 {\displaystyle {\ce {2FeSO_4->[\Delta]Fe_2O_3 + SO_2 + SO_3}}} Like other iron(II) salts, iron(II) sulfate is a reducing agent. For example, it reduces nitric acid to nitrogen monoxide and chlorine to chloride: 6 FeSO4 + 3 H2SO4 + 2 HNO3 → 3 Fe2(SO4)3 + 4 H2O + 2 NO 6 FeSO4 + 3 Cl2 → 2 Fe2(SO4)3 + 2 FeCl3Its mild reducing power is of value in organic synthesis. It is used as the iron catalyst component of Fentons reagent. Ferrous sulfate can be detected by the cerimetric method, which is the official method of the Indian Pharmacopoeia. This method includes the use of ferroin solution showing a red to light green colour change during titration. See also Iron(III) sulfate (ferric sulfate), the other common simple sulfate of iron. Copper(II) sulfate Ammonium iron(II) sulfate, also known as Mohrs salt, the common double salt of ammonium sulfate with iron(II) sulfate. Chalcanthum Ephraim Seehl known as an early manufacturer of Iron(II) sulfate, which he called green vitriol. References External links "Ferrous sulfate". Drug Information Portal. U.S. National Library of Medicine.
Iron(II) fumarate	Iron(II) fumarate, also known as ferrous fumarate, is the iron(II) salt of fumaric acid, occurring as a reddish-orange powder, used to supplement iron intake. It has the chemical formula C4H2FeO4. Pure ferrous fumarate has an iron content of 32.87%, therefore one tablet of 300 mg iron fumarate will contain 98.6 mg of iron (548% Daily Value based on 18 mg RDI). Iron supplement Ferrous fumarate is often taken orally as an iron supplement to treat or prevent iron deficiency anaemia. See also Iron - Nutrition == References ==
Disulfiram	Disulfiram is a medication used to support the treatment of chronic alcoholism by producing an acute sensitivity to ethanol (drinking alcohol). Disulfiram works by inhibiting the enzyme acetaldehyde dehydrogenase, causing many of the effects of a hangover to be felt immediately following alcohol consumption. Disulfiram plus alcohol, even small amounts, produces flushing, throbbing in the head and neck, a throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pain, palpitation, dyspnea, hyperventilation, fast heart rate, low blood pressure, fainting, marked uneasiness, weakness, vertigo, blurred vision, and confusion. In severe reactions there may be respiratory depression, cardiovascular collapse, abnormal heart rhythms, heart attack, acute congestive heart failure, unconsciousness, convulsions, and death.In the body, alcohol is converted to acetaldehyde, which is then broken down by acetaldehyde dehydrogenase. When the dehydrogenase enzyme is inhibited, acetaldehyde builds up, causing unpleasant side effects. Disulfiram should be used in conjunction with counseling and support. Medical uses Disulfiram is used as a second-line treatment, behind acamprosate and naltrexone, for alcohol dependence.Under normal metabolism, alcohol is broken down in the liver by the enzyme alcohol dehydrogenase to acetaldehyde, which is then converted by the enzyme acetaldehyde dehydrogenase to a harmless acetic acid derivative (acetyl coenzyme A). Disulfiram blocks this reaction at the intermediate stage by blocking acetaldehyde dehydrogenase. After alcohol intake under the influence of disulfiram, the concentration of acetaldehyde in the blood may be five to 10 times higher than that found during metabolism of the same amount of alcohol alone. As acetaldehyde is one of the major causes of the symptoms of a "hangover", this produces immediate and severe negative reaction to alcohol intake. About 5 to 10 minutes after alcohol intake, the patient may experience the effects of a severe hangover for a period of 30 minutes up to several hours. Symptoms include flushing of the skin, accelerated heart rate, shortness of breath, nausea, vomiting, throbbing headache, visual disturbance, mental confusion, postural syncope, and circulatory collapse.Disulfiram should not be taken if alcohol has been consumed in the last 12 hours. There is no tolerance to disulfiram: the longer it is taken, the stronger its effects. As disulfiram is absorbed slowly through the digestive tract and eliminated slowly by the body, the effects may last for up to two weeks after the initial intake; consequently, medical ethics dictate that patients must be fully informed about the disulfiram-alcohol reaction.Disulfiram does not reduce alcohol cravings, so a major problem associated with this drug is extremely poor compliance. Methods to improve compliance include subdermal implants, which release the drug continuously over a period of up to 12 weeks, and supervised administration practices, for example, having the drug regularly administered by ones spouse.Although disulfiram remained the most common pharmaceutical treatment of alcohol abuse until the end of the 20th century, today it is often replaced or accompanied with newer drugs, primarily the combination of naltrexone and acamprosate, which directly attempt to address physiological processes in the brain associated with alcohol abuse. Side effects The most common side effects in the absence of alcohol are headache, and a metallic or garlic taste in the mouth, though more severe side effects may occur. Tryptophol, a chemical compound that induces sleep in humans, is formed in the liver after disulfiram treatment. Less common side effects include decrease in libido, liver problems, skin rash, and nerve inflammation. Liver toxicity is an uncommon but potentially serious side effect, and risk groups e.g. those with already impaired liver function should be monitored closely. That said, the rate of disulfiram-induced hepatitis are estimated to be in between 1 per 25,000 to 1 in 30,000, and rarely the primary cause for treatment cessation. Cases of disulfiram neurotoxicity have also occurred, causing extrapyramidal and other symptoms. Disulfiram can produce neuropathy in daily doses of less than the usually recommended 500 mg. Nerve biopsies showed axonal degeneration and the neuropathy is difficult to distinguish from that associated with ethanol abuse. Disulfiram neuropathy occurs after a variable latent period (mean 5 to 6 months) and progresses steadily. Slow improvement may occur when the drugs use is stopped; often there is complete recovery eventually.Disulfiram disrupts metabolism of several other compounds, including paracetamol (acetaminophen), theophylline and caffeine. However, in most cases, this disruption is mild and presents itself as a 20–40% increase in the half-life of the compound at typical dosages of disulfiram. Similarly acting substances In medicine, the term "disulfiram effect" refers to an adverse effect of a particular medication in causing an unpleasant hypersensitivity to alcohol, similar to the effect caused by disulfiram administration.Examples: Antibiotics (nitroimidazoles), e.g. metronidazole First-generation sulfonylureas, e.g. tolbutamide and chlorpropamide Several cephalosporin drugs, including cefoperazone, cefamandole and cefotetan, that have a N-methylthio-tetrazole moiety Griseofulvin, an oral antifungal drug Procarbazine Temposil, or citrated calcium carbimide, has the same function as disulfiram, but is weaker and safer. Coprine, which metabolizes to 1-aminocyclopropanol, a chemical having the same metabolic effects as disulfiram. It occurs naturally in the otherwise edible common ink cap mushroom (Coprinopsis atramentaria), hence its colloquial name "tipplers bane". Similar reactions have been recorded with Clitocybe clavipes and Suillellus luridus, although the agent in those species is unknown. History The synthesis of disulfiram, originally known as tetraethylthiuram disulfide, was first reported in 1881. By around 1900, it was introduced to the industrial process of sulfur vulcanization of rubber and became widely used. In 1937 a rubber factory doctor in the US published a paper noting that workers exposed to disulfiram had negative reactions to alcohol and could be used as a drug for alcoholism; the effects were also noticed in workers at Swedish rubber boot factory.In the early 1940s it had been tested as a treatment for scabies, a parasitic skin infection, as well as intestinal worms.Around that time, during the German occupation of Denmark, Erik Jacobsen and Jens Hald at the Danish drug company Medicinalco picked up on that research and began exploring the use of disulfiram to treat intestinal parasites. The company had a group of enthusiastic self-experimenters that called itself the "Death Battalion", and in the course of testing the drug on themselves, accidentally discovered that drinking alcohol while the drug was still in their bodies made them mildly sick.: 98–105 They made that discovery in 1945, and did nothing with it until two years later, when Jacobsen gave an impromptu talk and mentioned that work, which was discussed afterwards in newspapers at the time, leading them to further explore the use of the drug for that purpose.: 98–105 That work included small clinical trials with Oluf Martensen-Larsen, a doctor who worked with alcoholics. They published their work starting in 1948.The chemists at Medicinalco discovered a new form of disulfiram while trying to purify a batch that had been contaminated with copper. This form turned out to have better pharmacological properties, and the company patented it and used that form for the product that was introduced as Antabus (later anglicized to Antabuse).This work led to renewed study of the human metabolism of ethanol. It was already known that ethanol was mostly metabolized in the liver, with it being converted first to acetaldehyde and then acetaldehyde to acetic acid and carbon dioxide, but the enzymes involved were not known. By 1950 the work led to the knowledge that ethanol is oxidized to acetaldehyde by alcohol dehydrogenase and acetaldehyde is oxidized to acetic acid by aldehyde dehydrogenase (ALDH), and that disulfiram works by inhibiting ALDH, leading to a buildup of acetaldehyde, which is what causes the negative effects in the body.The drug was first marketed in Denmark and as of 2008, Denmark is the country where it is most widely prescribed. It was approved by the FDA in 1951. The FDA later approved other drugs for treatment of alcoholism, namely naltrexone in 1994 and acamprosate in 2004. Society and culture Though the Occupational Safety and Health Administration (OSHA) in the US has not set a permissible exposure limit (PEL) for disulfiram in the workplace, the National Institute for Occupational Safety and Health has set a recommended exposure limit (REL) of 2 mg/m3 and recommended that workers avoid concurrent exposure to ethylene dibromide. Research Disulfiram has been studied as a possible treatment for cancer, parasitic infections, anxiety disorder, and latent HIV infection.Disulfiram has shown reversing of retinitis pigmentosa in rats. Cancer When disulfiram creates complexes with metals (dithiocarbamate complexes), it is a proteasome inhibitor and as of 2016 it had been studied in in vitro experiments, model animals, and small clinical trials as a possible treatment for liver metastasis, metastatic melanoma, glioblastoma, non-small cell lung cancer, and prostate cancer. Various clinical trials of copper depletion agents have been carried out. Parasitic infections In the body, disulfiram is rapidly metabolized to diethyldithiocarbamate (ditiocarb), which binds to metal ions such as zinc or copper to form zinc or copper diethyldithiocarbamate (zinc or copper ditiocarb). The zinc diethyldithiocarbamate (zinc-ditiocarb) metabolite of disulfiram is extremely potent against the diarrhea and liver abscess-causing parasite Entamoeba histolytica and might be active against other deadly parasites. HIV Disulfiram has also been identified by systematic high-throughput screening as a potential HIV latency reversing agent (LRA). Reactivation of latent HIV infection in patients is part of an investigational strategy known as "shock and kill" which may be able to reduce or eliminate the HIV reservoir. Recent phase II dose-escalation studies in patients with HIV who are controlled on antiretroviral therapy have observed an increase in cell-associated unspliced HIV RNA with increasing exposure to disulfiram and its metabolites. Disulfiram is also being investigated in combination with vorinostat, another investigational latency reversing agent, to treat HIV. COVID-19 Disulfiram has been shown to inhibit the papain-like proteases of MERS-CoV and SARS-CoV. It has been examined in a small inconclusive retrospective observational study for its effects on COVID-19 symptoms and is currently in Phase 2 clinical trials. References External links "Disulfiram". Drug Information Portal. U.S. National Library of Medicine. Toxicity, Mushroom - Disulfiramlike Toxins at eMedicine CDC - NIOSH Pocket Guide to Chemical Hazards
Ciclopirox	Ciclopirox (sometimes known by the abbreviation CPX) is a synthetic antifungal agent for topical dermatologic treatment of superficial mycoses. It is most useful against tinea versicolor. It is sold under many brand names worldwide. Medical uses Ciclopirox is indicated for the treatment of tinea pedis and tinea corporis due to Trichophyton rubrum, Trichophyton mentagrophytes and Epidermophyton floccosum, as well as seborrheic dermatitis. It is not to be used in the eyes or vagina, and nursing women should consult their doctors before use, since it is not known whether ciclopirox passes into human milk. A burning sensation may be felt when first applying ciclopirox on the skin. Nail infections In addition to other formulations, ciclopirox is used in lacquers for topical treatment of onychomycosis (fungal infections of the nails). A meta-analysis of the six trials of nail infections available in 2009 concluded that they provided evidence that topical ciclopirox had poor cure rates, and that amorolfine might be substantially more effective, but more research was required. "Combining data from 2 trials of ciclopiroxolamine versus placebo found treatments failure rates of 61% and 64% for ciclopiroxolamine. These outcomes followed long treatment times (48 weeks) and this makes ciclopiroxolamine a poor choice for nail infections. Better results were observed with the use of amorolfine lacquer; 6% treatment failure rates were found after 1 month of treatment but these data were collected on a very small sample of people and these high rates of success might be unreliable."Efinaconazole, an azole antifungal, led to cure rates two or three times better than the next-best topical treatment, ciclopirox. Pharmacology Pharmacodynamics In contrast to the azoles and other antimycotic drugs, the mechanism of action of ciclopirox is poorly understood. However, loss of function of certain catalase and peroxidase enzymes has been implicated as the mechanism of action, as well as various other components of cellular metabolism. In a study conducted to further elucidate ciclopiroxs mechanism, several Saccharomyces cerevisiae mutants were screened and tested. Results from interpretation of the effects of both the drug treatment and mutation suggested that ciclopirox may exert its effect by disrupting DNA repair, cell division signals and structures (mitotic spindles) as well as some elements of intracellular transport.It is currently being investigated as an alternative treatment to ketoconazole for seborrhoeic dermatitis as it suppresses growth of the yeast Malassezia furfur. Initial results show similar efficacy to ketoconazole with a relative increase in subjective symptom relief due to its inherent anti-inflammatory properties. Chemistry Ciclopirox is a N-hydroxypyridone. Structurally, ciclopirox is the N-oxide of a 2-hydroxypyridine derivative and therefore can be termed a hydroxypyridine antifungal agent. Additionally, the structure as drawn above is the lactam tautomer and indicates the molecule being an N-hydroxy-2-pyridone. Hence the classification of ciclopirox as a 2-pyridone antifungal agent. Ciclopirox is used clinically as ciclopirox olamine, the olamine salt of ciclopirox. == References ==
Hydrocortisone valerate	Hydrocortisone valerate is a synthetic glucocorticoid corticosteroid and a corticosteroid ester. == References ==
Tetrahydrobiopterin	Tetrahydrobiopterin (BH4, THB), also known as sapropterin (INN), is a cofactor of the three aromatic amino acid hydroxylase enzymes, used in the degradation of amino acid phenylalanine and in the biosynthesis of the neurotransmitters serotonin (5-hydroxytryptamine, 5-HT), melatonin, dopamine, norepinephrine (noradrenaline), epinephrine (adrenaline), and is a cofactor for the production of nitric oxide (NO) by the nitric oxide synthases. Chemically, its structure is that of a (dihydropteridine reductase) reduced pteridine derivative (quinonoid dihydrobiopterin). Medical use Tetrahydrobiopterin is available as a tablet for oral administration in the form of sapropterin dihydrochloride (BH42HCL). It was approved for use in the United States as a tablet in December 2007 and as a powder in December 2013. It was approved for use in the European Union in December 2008, Canada in April 2010, and Japan in July 2008. It is sold under the brand names Kuvan and Biopten. The typical cost of treating a patient with Kuvan is US$100,000 per year. BioMarin holds the patent for Kuvan until at least 2024, but Par Pharmaceutical has a right to produce a generic version by 2020.Sapropterin is indicated in tetrahydrobiopterin deficiency caused by GTP cyclohydrolase I (GTPCH) deficiency, or 6-pyruvoyltetrahydropterin synthase (PTPS) deficiency. Also, BH42HCL is FDA approved for use in phenylketonuria (PKU), along with dietary measures. However, most people with PKU have little or no benefit from BH4*2HCL. Adverse effects The most common adverse effects, observed in more than 10% of people, include headache and a running or obstructed nose. Diarrhea and vomiting are also relatively common, seen in at least 1% of people. Interactions No interaction studies have been conducted. Because of its mechanism, tetrahydrobiopterin might interact with dihydrofolate reductase inhibitors like methotrexate and trimethoprim, and NO-enhancing drugs like nitroglycerin, molsidomine, minoxidil, and PDE5 inhibitors. Combination of tetrahydrobiopterin with levodopa can lead to increased excitability. Functions Tetrahydrobiopterin has multiple roles in human biochemistry. The major one is to convert amino acids such as phenylalanine, tyrosine, and tryptophan to precursors of dopamine and serotonin, major monoamine neurotransmitters. It works as a cofactor, being required for an enzymes activity as a catalyst, mainly hydroxylases. Cofactor for tryptophan hydroxylases Tetrahydrobiopterin is a cofactor for tryptophan hydroxylase (TPH) for the conversion of L-tryptophan (TRP) to 5-hydroxytryptophan (5-HTP). Cofactor for phenylalanine hydroxylase Phenylalanine hydroxylase (PAH) catalyses the conversion of L-phenylalanine (PHE) to L-tyrosine (TYR). Therefore, a deficiency in tetrahydrobiopterin can cause a toxic buildup of L-phenylalanine, which manifests as the severe neurological issues seen in phenylketonuria. Cofactor for tyrosine hydroxylase Tyrosine hydroxylase (TH) catalyses the conversion of L-tyrosine to L-DOPA (DOPA), which is the precursor for dopamine. Dopamine is a vital neurotransmitter, and is the precursor of norepinephrine and epinephrine. Thus, a deficiency of BH4 can lead to systemic deficiencies of dopamine, norepinephrine, and epinephrine. In fact, one of the primary conditions that can result from GTPCH-related BH4 deficiency is dopamine-responsive dystonia; currently, this condition is typically treated with carbidopa/levodopa, which directly restores dopamine levels within the brain. Cofactor for nitric oxide synthase Nitric oxide synthase (NOS) catalyses the conversion of a guanidino nitrogen of L-arginine (L-Arg) to nitric oxide (NO). Among other things, nitric oxide is involved in vasodilation, which improves systematic blood flow. The role of BH4 in this enzymatic process is so critical that some research points to a deficiency of BH4 – and thus, of nitric oxide – as being a core cause of the neurovascular dysfunction that is the hallmark of circulation-related diseases such as diabetes. Cofactor for ether lipid oxidase Ether lipid oxidase (alkylglycerol monooxygenase, AGMO) catalyses the conversion of 1-alkyl-sn-glycerol to 1-hydroxyalkyl-sn-glycerol. History Tetrahydrobiopterin was discovered to play a role as an enzymatic cofactor. The first enzyme found to use tetrahydrobiopterin is phenylalanine hydroxylase (PAH). Biosynthesis and recycling Tetrahydrobiopterin is biosynthesized from guanosine triphosphate (GTP) by three chemical reactions mediated by the enzymes GTP cyclohydrolase I (GTPCH), 6-pyruvoyltetrahydropterin synthase (PTPS), and sepiapterin reductase (SR).BH4 can be oxidized by one or two electron reactions, to generate BH4 or BH3 radical and BH2, respectively. Research shows that ascorbic acid (also known as ascorbate or vitamin C) can reduce BH3 radical into BH4, preventing the BH3 radical from reacting with other free radicals (superoxide and peroxynitrite specifically). Without this recycling process, uncoupling of the endothelial nitric oxide synthase (eNOS) enzyme and reduced bioavailability of the vasodilator nitric oxide occur, creating a form of endothelial dysfunction. Ascorbic acid is oxidized to dehydroascorbic acid during this process, although it can be recycled back to ascorbic acid. Folic acid and its metabolites seem to be particularly important in the recycling of BH4 and NOS coupling. Research Other than PKU studies, tetrahydrobiopterin has participated in clinical trials studying other approaches to solving conditions resultant from a deficiency of tetrahydrobiopterin. These include autism, depression, ADHD, hypertension, endothelial dysfunction, and chronic kidney disease. Experimental studies suggest that tetrahydrobiopterin regulates deficient production of nitric oxide in cardiovascular disease states, and contributes to the response to inflammation and injury, for example in pain due to nerve injury. A 2015 BioMarin-funded study of PKU patients found that those who responded to tetrahydrobiopterin also showed a reduction of ADHD symptoms. Depression In psychiatry, tetrahydrobiopterin has been hypothesized to be involved in the pathophysiology of depression, although evidence is inconclusive to date. Autism In 1997, a small pilot study was published on the efficacy of tetrahydrobiopterin (BH4) on relieving the symptoms of autism, which concluded that it "might be useful for a subgroup of children with autism" and that double-blind trials are needed, as are trials which measure outcomes over a longer period of time. In 2010, Frye et al. published a paper which concluded that it was safe, and also noted that "several clinical trials have suggested that treatment with BH4 improves ASD symptomatology in some individuals." Cardiovascular disease Since nitric oxide production is important in regulation of blood pressure and blood flow, thereby playing a significant role in cardiovascular diseases, tetrahydrobiopterin is a potential therapeutic target. In the endothelial cell lining of blood vessels, endothelial nitric oxide synthase is dependent on tetrahydrobiopterin availability. Increasing tetrahydrobiopterin in endothelial cells by augmenting the levels of the biosynthetic enzyme GTPCH can maintain endothelial nitric oxide synthase function in experimental models of disease states such as diabetes, atherosclerosis, and hypoxic pulmonary hypertension. However, treatment of people with existing coronary artery disease with oral tetrahydrobiopterin is limited by oxidation of tetrahydrobiopterin to the inactive form, dihydrobiopterin, with little benefit on vascular function. Neuroprotection in prenatal hypoxia Depletion of tetrahydrobiopterin occurs in the hypoxic brain and leads to toxin production. Preclinical studies in mice reveal that treatment with oral tetrahydrobiopterin therapy mitigates the toxic effects of hypoxia on the developing brain, specifically improving white matter development in hypoxic animals. Programmed cell death GTPCH (GCH1) and tetrahydrobiopterin were found to have a secondary role protecting against cell death by ferroptosis in cellular models by limiting the formation of toxic lipid peroxides. Tetrahydrobiopterin acts as a potent, diffusable antioxidant that resists oxidative stress and enables cancer cell survival via promotion of angiogenesis. References Further reading External links "Sapropterin". Drug Information Portal. U.S. National Library of Medicine. "Sapropterin dihydrochloride". Drug Information Portal. U.S. National Library of Medicine.
Ledipasvir/sofosbuvir	Ledipasvir/sofosbuvir, sold under the trade name Harvoni among others, is a medication used to treat hepatitis C. It is a fixed-dose combination of ledipasvir and sofosbuvir. Cure rates are 94% to 99% in people infected with hepatitis C virus (HCV) genotype 1. Some evidence also supports use in HCV genotype 3 and 4. It is taken daily by mouth for 8–24 weeks.It is generally well tolerated. Common side effects include muscle pains, headache, nausea, rash, and cough. It is unclear if use in pregnancy is safe for the baby. Ledipasvir works by decreasing the activity of NS5A and sofosbuvir works by decreasing the activity of NS5B polymerase.Ledipasvir/sofosbuvir was approved for medical use in the United States, in the European Union, and in Canada in 2014. It is on the World Health Organizations List of Essential Medicines. Medical uses Cure rates are 94% to 99% in people infected with genotype 1 (46% of HCV cases). It has also been evaluated for the treatment of infection with other hepatitis C genotypes, and has shown promising results in genotypes 3 and 4 (making up 30% and less than 22% of HCV cases respectively). Resistance NS5A mutations Multiple mutations of HCV replicons are necessary to cause a significant effect in resistance due to multiple mechanisms of action. In general, HCV genotype 1a is less resistant to mutation than genotype 1b.For genotype 1b a single amino acid substitution (e.g. L31V) in the replicon had less than a 100 fold increase in resistance to the ledipasvir in Harvoni, while a two amino acid substitution had over a 1000 fold increase in resistance. Genotype 1a had a similar but more substantial increase in resistance with each respective increase in amino acid substitution with resistance associated substitutions at K24R, M28T/V, Q30R/H/K/L, L31M, and or Y93H/N.NS5A polymorphisms also have an effect on viral resistance with the most common resistance-associated amino acid substitutions detected at Q30R, Y93H or N, and L31M in patients with a rapid virological response (RVR). The specific baseline NS5A resistance-associated polymorphisms observed in clinical trials were M28T/V, Q30H, Q30R, L31M, H58P, Y93H, and Y93N in genotype 1a and L28M, A92T, and Y93H in genotype 1b. Patients with multiple baseline NS5A polymorphisms tend to have higher relapse rates when using ledipasvir/sofosbuvir. The difference in relapse rates between treatment naive and treatment experience groups with baseline NS5A polymorphisms ranges from 1% after a 12-week regimen and 0% after a 24-week regimen respectively. NS5B mutations A single amino acid substitution S282T contributes to viral resistance and decreases the activity of sofosbuvir in ledipasvir/sofosbuvir by approximately 2 to 18 fold. Cross resistance No cross resistance was seen in the combination of ledipasvir and sofosbuvir in ION phase 1,2 and, 3 clinical trials as ledipasvir was fully active against sofosbuvir-resistance-associated substitutions and vice versa. Side effects More than 10% of people taking ledipasvir/sofosbuvir have headaches or fatigue; rashes, nausea, diarrhea, and insomnia occur in between 1% and 10% of people taking it.More severe reactions are connected with allergic reactions to the medications and cardiovascular problems. Harvoni side effects are considered relatively mild compared to older interferon-based treatment. Ledipasvir/sofosbuvir could cause hepatitis B re-activation in people co-infected with hepatitis B and C viruses. The European Medicines Agency recommended screening all people for hepatitis B before starting ledipasvir/sofosbuvir for hepatitis C in order to minimize the risk of hepatitis B reactivation. Drug interactions Ledipasvir/sofosbuvir is a substrate for the drug transporters P-Glycoprotein (P-gp) and breast cancer resistance protein (BCRP). Intestinal absorption of these drug transporter substrates may be decreased by inducers such as rifampin and St. Johns wort .Patients are also advised to stay away from H2 receptor antagonists (H2RA) and proton-pump inhibitors (PPI) because they decrease the concentration of ledipasvir (its solubility is pH-dependent and is higher under acidic conditions). Therefore, it is advised to take a PPI at least two hours after ledipasvir/sofosbuvir with a dose less than or equal to 20 mg daily and H2RAs with a dose of less than or equal to 40 mg twice daily.Ledipasvir/sofosbuvir should additionally be avoided when taking amiodarone or other drugs that lower heart rate; there is a serious risk of the heart slowing or stopping when ledipasvir/sofosbuvir is used with such drugs. Mechanisms of action The most commonly associated mechanism associated with ledipasvir/sofosbuvir is the hyperphosphorylation of NS5A, a viral polymerase important in proper viral assembly and interferes with proper liver metabolism. Ledipasvir/sofosbuvir inhibits the proper viral assembly by re-positioning NS5As sub-cellular localization.NS5B, a viral polymerase that can initiate RNA synthesis de novo, is also allosterically inhibited by ledipasvir/sofosbuvir.NS5A and NS5B inhibitors in combination have a synergistic effect. Pharmacokinetics Sofosbuvir is absorbed fast in the plasma with a peak concentration (Cmax) at 0.8 to 1 hour after the administered dosage and undergoes extra hepatic metabolism with 61 to 65% bound to human plasma proteins. It is then predominantly converted to the inactive phosphate free circulating metabolite GS-331007 (eliminated 76% through renal passive filtration) which has a median peak plasma concentration at 3.5 to 4 hours after the medication is ingested. Sofosbuvir does not appear to be affected by different levels of macronutrients when compared with fasting states.Ledipasvir has a maximum concentration at 4 to 4.5 hours after ingestion and is not affected by macronutrients. It is more than 98% protein bound and is predominantly eliminated fecally, with minimal metabolism in the liver. Elimination The median terminal half life after a dosage of ledipasvir/sofosbuvir for 90 mg of [14C]-Ledipasvir is 47 hours; for 400 mg of [14C]-Sofosbuvir it is 0.5 hours (after the initial distribution of medication in body tissue) and 27 hours (the eventual excretion of the medication). Note: The maximum concentration is 32% higher in healthy individuals than those infected with Hepatitis C. Note: The maximum concentration is 24% higher in healthy individuals than those infected with Hepatitis C. Blood detection An analytical method based on LC tandem MS has been developed for the simultaneous extraction and determination of ledipasvir/sofosbuvir in human plasma using antiviral daclatasvir as an internal standard. Average extraction recoveries for sofosbuvir and ledipasvir were 91.61% and 88.93% respectively. Society and culture One manufacturer is Gilead Sciences. References External links "Ledipasvir mixture with sofosbuvir". Drug Information Portal. U.S. National Library of Medicine.
Pyrantel	Pyrantel is a medication used to treat a number of parasitic worm infections. This includes ascariasis, hookworm infections, enterobiasis (pinworm infection), trichostrongyliasis, and trichinellosis. It is taken by mouth.Side effects include nausea, headache, dizziness, trouble sleeping, and rash. A lower dose should be used in people with liver disease. While it does not appear to be harmful during pregnancy, it has not been studied for this use. It is unclear if it is safe for use during breastfeeding. It is in the antihelmintic family of medications. It works by paralyzing worms.Pyrantel was initially described in 1965. It is on the World Health Organizations List of Essential Medicines. Pyrantel is available as a generic medication. It costs less than US$25 per course of treatment in the United States. It may also be used to treat worms in a number of other animals. Pregnancy and breastfeeding Pyrantel pamoate is considered a pregnancy category C drug for use during pregnancy for humans, but is in category A for canines and felines. Pyrantel is considered safe to use in nursing animals. Mechanism of action Pyrantel pamoate acts as a depolarizing neuromuscular blocking agent, thereby causing sudden contraction, followed by paralysis, of the helminths. This has the result of causing the worm to "lose its grip" on the intestinal wall and be passed out of the system by natural process. Since Pyrantel is poorly absorbed by the hosts intestine, the host is unaffected by the small dosage of medication used. Spastic (tetanic) paralyzing agents, in particular pyrantel pamoate, may induce complete intestinal obstruction in a heavy worm load. This obstruction is usually in the form of a worm impaction and happens when a very small, but heavily parasitized animal is treated and tries to pass a large number of dislodged worms at once. Worms usually pass in normal stool or with diarrhea, straining, and occasional vomiting. Names There are a number of brands, including "Reeses Pinworm Medicine", "Pin-X", "Pin-Rid","PYRANTRIN", "COMBANTRIN", "Anthel", "Helmintox", "Helmex", "Strongid" and Drontal Cat. References External links "Pyrantel". Drug Information Portal. U.S. National Library of Medicine.
Codeine/paracetamol	Codeine/paracetamol, also known as codeine/acetaminophen and co-codamol, is a compound analgesic consisting of a combination of codeine phosphate and paracetamol (acetaminophen). Codeine/paracetamol is used for the relief of mild to moderate pain when paracetamol or non-steroidal anti-inflammatory drug (NSAIDs) such as ibuprofen, aspirin or naproxen alone do not sufficiently relieve symptoms.In 2019, it was the 173rd most commonly prescribed medication in the United States, with more than 3 million prescriptions. Combination products containing codeine are available over the counter in Barbados, United Kingdom, Israel and Costa Rica. Of the European Union (EU) member states, 12 countries (Bulgaria, Cyprus, Denmark, Estonia, France, Ireland, Latvia, Lithuania, Malta, Poland, Romania, Slovenia) allow the sale of OTC codeine solid dosage forms. Side effects The most common side effects of co-codamol are constipation and feeling sick (nausea) or sleepy. Other side effects may include blood from mouth, skin rashes, dizziness, sedation, shortness of breath, hypersensitivity reaction, fainting (syncope or near syncope), confusion, loss of short-term memory, changes in blood, allergic reactions, euphoria, dysphoria, abdominal pain, itchiness, easy bruising, bleeding gums, vivid dreams, dry mouth and addiction.Genetic differences between people give rise to differing rates of metabolism of codeine to morphine. In about 5% of people this may happen particularly fast, leading to higher levels of morphine being passed through breast milk in amounts potentially able to cause fatal respiratory depression of a breastfed baby. References External links "Acetaminophen mixture with codeine phosphate". Drug Information Portal. U.S. National Library of Medicine.
Foscarnet	Foscarnet (phosphonomethanoic acid), known by its brand name Foscavir, is an antiviral medication which is primarily used to treat viral infections involving the Herpesviridae family. It is classified as a pyrophosphate analog DNA polymerase inhibitor. Foscarnet is the conjugate base of a chemical compound with the formula HO2CPO3H2 (Trisodium phosphonoformate).Foscarnet was approved for medical use in 1991. Medical use This phosphonic acid derivative (marketed by Clinigen as foscarnet sodium under the trade name Foscavir) is an antiviral medication used to treat herpes viruses, including drug-resistant cytomegalovirus (CMV) and herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2). It is particularly used to treat CMV retinitis. Foscarnet can be used to treat highly treatment-experienced patients with HIV as part of salvage therapy. Mechanism of action Foscarnet is a structural mimic of the anion pyrophosphate that selectively inhibits the pyrophosphate binding site on viral DNA polymerases at concentrations that do not affect human DNA polymerases.In individuals treated with the DNA polymerase inhibitors acyclovir or ganciclovir, HSV or CMV particles can develop mutant protein kinases (thymidine kinase or UL97 protein kinase, respectively) that make them resistant to these antiviral drugs. However, unlike acyclovir and ganciclovir, foscarnet is not activated by viral protein kinases, making it useful in acyclovir- or ganciclovir-resistant HSV and CMV infections.However, acyclovir- or ganciclovir-resistant mutants with alterations in viral DNA polymerase may also be resistant to foscarnet. Administration Foscarnet is administered by intravenous infusion or intravitreous injection. Side effects Nephrotoxicity — increase in serum creatinine levels and renal injury can occur in patients receiving foscarnet. Other nephrotoxic drugs should be avoided. Nephrotoxicity is usually reversible and can be reduced by dosage adjustment and adequate hydration. Electrolyte disturbances — hypocalcemia and hypomagnesemia can occur and regular monitoring of electrolytes is necessary to avoid clinical toxicity. Genital ulceration — a less common reported side effect which occurs more in men and usually during induction use of foscarnet. It is most likely a contact dermatitis due to high concentrations of foscarnet in urine. It usually resolves rapidly following discontinuation of the drug. CNS — less common side effects of perioral paresthesia, irritability and altered mental states. References Sources Dennis L. Kasper, Eugene Braunwald. "Harrisons Manual of Medicine", 16th Edition, Mcgraw-hill, (2005), p. 2244. External links "Foscarnet". Drug Information Portal. U.S. National Library of Medicine. "Foscarnet sodium". Drug Information Portal. U.S. National Library of Medicine.
My Way	"My Way" is a song popularized in 1969 by Frank Sinatra set to the music of the French song "Comme dhabitude" composed by Jacques Revaux with lyrics by Gilles Thibaut and Claude François and first performed in 1967 by Claude François. Its English lyrics were written by Paul Anka and are unrelated to the original French song. The song was a success for a variety of performers including Sinatra, Elvis Presley, and Sid Vicious. Sinatras version of "My Way" spent 75 weeks in the UK Top 40, which is 2nd place all-time. Background In 1967, Jacques Revaux wrote a ballad named "For Me", with English lyrics about a couple falling out of love. According to Revaux, the demo was then sent to Petula Clark, Dalida, and Claude François, to no avail. Revaux rejected a version by Hervé Villard and reworked the track into Comme dhabitude ("As usual") with the help of Claude François. It was released in November 1967 and was at the top of the French pop chart for one week in February 1968.Paul Anka heard the French original, while on holiday in the south of France. He flew to Paris to negotiate the rights to the song. He acquired adaptation, recording, and publishing rights for the nominal but formal consideration of one dollar, subject to the provision that the melodys composers would retain their original share of royalty rights with respect to whatever versions Anka or his designates created or produced. Some time later, Anka had a dinner in Florida with Frank Sinatra and "a couple of Mob guys" during which Sinatra said: "Im quitting the business. Im sick of it; Im getting the hell out." Back in New York, Anka re-wrote the original French song for Sinatra, subtly altering the melodic structure and changing the lyrics: At one oclock in the morning, I sat down at an old IBM electric typewriter and said, If Frank were writing this, what would he say? And I started, metaphorically, And now the end is near. I read a lot of periodicals, and I noticed everything was my this and my that. We were in the me generation and Frank became the guy for me to use to say that. I used words I would never use: I ate it up and spit it out. But thats the way he talked. I used to be around steam rooms with the Rat Pack guys—they liked to talk like Mob guys, even though they would have been scared of their own shadows. Anka finished the song at 5 in the morning: "I called Frank up in Nevada—he was at Caesars Palace – and said, Ive got something really special for you." Anka asserted: "When my record company caught wind of it, they were very pissed that I didnt keep it for myself. I said, Hey, I can write it, but Im not the guy to sing it. It was for Frank, no one else."Despite this, Anka would record the song in 1969 very shortly after Sinatras recording was released. Anka recorded it four other times as well: in 1996 (as a duet with Gabriel Byrne, performed in the movie Mad Dog Time); in 1998 in Spanish as "A Mi Manera" (duet with Julio Iglesias); in 2007 (as a duet with Jon Bon Jovi); and in 2013 (as a duet with Garou).On December 30, 1968, Frank Sinatra recorded his version of the song in one take, featuring session drummer Buddy Saltzman among the band. “My Way” was released in early 1969 on the My Way LP and as a single. It reached No. 27 on the Billboard Hot 100 chart and No. 2 on the Easy Listening chart in the US. In the UK, the single achieved a still unmatched record, becoming the recording with the most weeks inside the Top 40, spending 75 weeks from April 1969 to September 1971. It spent a further 49 weeks in the Top 75 but never bettered the No. 5 slot achieved upon its first chart run.Although this work became Frank Sinatras signature song, his daughter Tina says the singer came to hate the song: "He didnt like it. That song stuck and he couldnt get it off his shoe. He always thought that song was self-serving and self-indulgent." Charts Certifications Versions David Bowie reportedly wrote the first English language lyrics to Claude Françoiss original tune, though the lyrics and performance were only informally recorded and never commercially published. Dorothy Squires In the midst of Sinatras multiple runs on the UK Singles Chart, Welsh singer Dorothy Squires also released a rendition of "My Way" in Summer 1970. Her recording reached number 25 on the UK Singles Chart and re-entered the chart twice more during that year. Elvis Presley Elvis Presley began performing the song in concert during the mid-1970s, despite Ankas suggestions that the song did not suit him. Nevertheless, on January 12 and 14, 1973, Presley sang the song during his satellite show Aloha from Hawaii Via Satellite, beamed live and on deferred basis (for European audiences, who also saw it in prime time), to 43 countries via Intelsat. On October 3, 1977, several weeks after Presleys death, his live recording of "My Way" (recorded for the Elvis In Concert CBS-TV special on June 21, 1977) was released as a single. In the U.S., it reached number 22 on the Billboard Hot 100 pop singles chart in late 1977/early 1978 (higher than Frank Sinatras peak position), number 6 on the Billboard Adult Contemporary chart, and went gold for its successful sales of over a million copies. The following year the single reached number 2 on the Billboard Country singles chart but went all the way to number 1 on the rival Cash Box Country Singles chart. In the UK, it reached number 9 on the UK Singles Chart. Presleys version is featured in the climax of the 2001 film 3000 Miles to Graceland with Kurt Russell and Kevin Costner. (Paul Anka appears in a cameo as a casino pit boss who loathes Presley.) Presleys studio version of the song, recorded in 1971, was included on the fourth disc of "Walk a Mile in My Shoes: The Essential 70s Masters". Certifications Sid Vicious Sex Pistols bassist Sid Vicious did a punk rock version of the song, in which a large body of the words were changed and the arrangement was sped up. The orchestral backing was arranged by Simon Jeffes. Interviewed in 2007, Paul Anka said he had been "somewhat destabilized by the Sex Pistols version. It was kind of curious, but I felt he [Sid Vicious] was sincere about it."Vicious and his girlfriend, Nancy Spungen, changed many of the words when it was recorded, including use of the swear words "cunt" and "fuck" as well as the word "queer" (slang for a gay man). Viciouss reference to a "prat who wears hats" was an in-joke directed towards Viciouss friend and Sex Pistols bandmate Johnny Rotten, who was fond of wearing different kinds of hats he would pick up at rummage sales. Leonard Cohen said of the song: I never liked this song except when Sid Vicious did it. Sung straight, it somehow deprives the appetite of a certain taste we’d like to have on our lips. When Sid Vicious did it, he provided that other side to the song; the certainty, the self-congratulation, the daily heroism of Sinatra’s version is completely exploded by this desperate, mad, humorous voice. I can’t go round in a raincoat and fedora looking over my life saying I did it my way — well, for 10 minutes in some American bar over a gin and tonic you might be able to get away with it. But Sid Vicious’s rendition takes in everybody; everybody is messed up like that, everybody is the mad hero of his own drama. It explodes the whole culture this self-presentation can take place in, so it completes the song for me. The 1986 film Sid and Nancy features a scene where Gary Oldman, portraying Vicious, performs his version of "My Way" while filming the songs music video.Viciouss version of this song appears in Martin Scorseses 1990 film GoodFellas, where it plays over the end credits. Margaret Mackie and Jamie Lee Morley In December 2019 footage of Margaret Mackie, a resident of Northcare Suites Care Home in Edinburgh who suffers from dementia, performing "My Way" with staff member Jamie Lee Morley, went viral after being posted online by Mackies daughter.Morley later arranged to have the song professionally recorded and it was released in January 2020 as a charity single to raise funds for The Alzheimers Society and Dementia UK. The single peaked at number seven in the iTunes top 40 UK Pop Songs live chart and number five in the Amazon best seller chart. Yuzo Kayama In Japan, Yuzo Kayama who is usually called the Japanese Frank Sinatra, performed My Way in 2008 in English. On April 23 and 30, 2015, as part of 2 vocal overdubbed sessions, Yuzo Kayama performed My Way with the earlier record of Frank Sinatra as a duet. Adaptations Besides translations more or less faithful to the original, some artists have set unrelated lyrics to the same tune. Jozsef Gregor the renowned Hungarian bass-baritone/basso buffo recorded the song with Andras Ruszanovs Hungarian love themed lyrics version in 1996. Two years later, he sang this version in one of the most popular TV show in Budapest, since then this version has been permanently on the playlists of numerous radio stations in Hungary. Mexican singer Vicente Fernandez did a Spanish language version, named "A Mi Manera". Public use The song is popularly associated with nostalgia to an individuals lifetime of events. Surveys beginning in 2005 have often reported that "My Way" has been the song most frequently played at funeral services in the UK. "My Way" is also a popular karaoke song around the world. However, it has been reported to cause numerous incidents of violence and homicide among karaoke singers in the Philippines, referred to in the media as the My Way killings, which has led to the song being banned in many Filipino bars.The songs association with Sinatra led to Mikhail Gorbachevs policy of allowing other states in the Warsaw Pact to make their own policy decisions being nicknamed the Sinatra Doctrine, referencing My Ways lyrics about doing things your own way. The term was first used by Foreign Ministry spokesman Gennadi Gerasimov in 1987, who was quoted as saying "We now have the Frank Sinatra doctrine. He has a song, I Did It My Way. So every country decides on its own which road to take". References External links Song lyrics
Rabeprazole	Rabeprazole, sold under the brand name Aciphex, among others, is a medication that decreases stomach acid. It is used to treat peptic ulcer disease, gastroesophageal reflux disease, and excess stomach acid production such as in Zollinger–Ellison syndrome. It may also be used in combination with other medications to treat Helicobacter pylori. Effectiveness is similar to other proton pump inhibitors (PPIs). It is taken by mouth.Common side effects include constipation, feeling weak, and throat inflammation. Serious side effects may include osteoporosis, low blood magnesium, Clostridium difficile infection, and pneumonia. Use in pregnancy and breastfeeding is of unclear safety. It works by blocking H+/K+-ATPase in the parietal cells of the stomach.Rabeprazole was patented in 1986, and approved for medical use in 1997. It is available as a generic medication. In 2017, it was the 279th most commonly prescribed medication in the United States, with more than one million prescriptions. Medical uses Rabeprazole, like other proton pump inhibitors such as omeprazole, is used for the purposes of gastric acid suppression. This effect is beneficial for the treatment and prevention of conditions in which gastric acid directly worsens symptoms, such as duodenal and gastric ulcers. In the setting of gastroesophageal reflux disease (GERD), whose pathophysiology is characterized by prolonged exposure to gastric acid in the esophagus (often due to changes in stomach and/or esophagus anatomy, such as those induced by abdominal obesity), acid suppression can provide symptomatic relief. Acid suppression is also useful when gastric production of acid is increased, including conditions with excess gastric acid secretion (hypersecretory conditions) like Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic mastocytosis.Rabeprazole is also useful alongside antibiotic therapy for the treatment of the pathogen Helicobacter pylori, which otherwise thrives in acidic environments. Notably, H. pylori eradication with antibiotics and rabeprazole was also shown to prevent development of second gastric cancer in a randomized trial in high-risk South Korean patients with early stomach cancer treated by endoscopy.Thus, rabeprazole is US Food and Drug Administration (FDA) approved for the treatment of symptomatic GERD in adolescents and adults, healing duodenal ulcers in adults, eradication of Helicobacter pylori, and pathologic hypersecretory conditions. Available forms Rabeprazole is available in 10 and 20 mg, delayed-release tablets (pictured below). Rabeprazole-based products, like other proton pump inhibitor products, have to be formulated in delayed-release tablets to protect the active medication from being degraded by the acid of the stomach before being absorbed. Specific populations Pediatrics Rabeprazoles only pediatric indication is for the treatment of symptomatic GERD in adolescents (12 years-old and up). Pregnancy Studies using animals models to investigate the likelihood for rabeprazole to cause harm to fetuses have not yet shown evidence of harm, though avoidance of rabeprazole during pregnancy (especially during the critical development period of the first trimester) is considered to be the safest possible route until human studies clarify the exact risk. Lactation It is expected that rabeprazole will be secreted into human breast milk, though the clinical impact of this is still unknown. Avoiding rabeprazole during breastfeeding confers to lowest possible risk. Geriatrics Advanced age does not appear to clinically impact rabeprazoles metabolism. However, elevations in the maximum plasma concentration and the total drug exposure (area under the curve, AUC) have occurred. Japanese ancestry In a study on rabeprazoles pharmacokinetics, the AUC was elevated by approximately 50–60% in men of Japanese ancestry compared to men in the United States. See the pharmacogenetics section below for a pharmacogenetic explanation of these findings. Kidney or liver problems In people that have kidney or liver problems, these problems do not appear to affect rabeprazoles metabolism in a clinically meaningful way. This includes individuals on dialysis for kidney problems. Severe liver problems like cirrhosis of the liver do affect rabeprazoles elimination half-life, but not to a degree of dangerous accumulation. In a review of patients taking rabeprazole while having end-stage kidney disease and mild-to-moderate severity, chronic compensated cirrhosis of the liver, the alteration in rabeprazoles metabolism was not clinically meaningful. Contraindications Rabeprazole is contraindicated in the following populations and situations: people with a known hypersensitivity to rabeprazole, substituted benzimidazoles (which are chemically similar to rabeprazole, like omeprazole), or any other component of the capsule formulation (e.g. certain dyes) concurrent use of rilpivirine, a medication used to treat HIV infection Hypersensitivity Syndrome An allergy to a PPI like rabeprazole may take the form of type I hypersensitivity or delayed hypersensitivity reactions. A selective (pattern C—see below for a discussion of cross-reactivity patterns) type I hypersensitivity reaction to rabeprazole resulting in anaphylaxis has been reported, as well as several whole group hypersentivities. Cross-reactivity Hypersensitivity to PPIs can take the form of whole group hypersensitivity, pattern A, B, or C. Whole group hypersentivity occurs when a person is cross-reactive to all PPIs; that is, all PPIs will induce the allergy. In pattern A, a person may be allergic to omeprazole, esomeprazole, and pantoprazole, but not to lansoprazole and rabeprazole. This is thought to be due to the structural similarities between omeprazole, esomeprazole, and pantoprazole, contrasted with lansoprazole and rabeprazole. Pattern B is the opposite, reflecting people that are allergic to lansoprazole and rabeprazole, but not to omeprazole, esomeprazole, and pantoprazole. Pattern C, in the context of rabeprazole, would reflect a person that is allergic to only rabeprazole, but not to other PPIs (omeprazole, esomeprazole, pantoprazole, and lansoprazole). Rilpivirine Rilpivirine, a non-nucleoside reverse transcriptase inhibitor used in the treatment of HIV, is contraindicated with all PPIs because of their acid-suppressing effect. PPIs suppress acid, thereby raising the pH of (alkalizing) the stomachs contents. Rilpivirine is best absorbed under acidic conditions. Therefore, rabeprazole would be expected to decrease the absorption of rilpivirine, decrease the concentration of rilpivirine in the blood, and possibly lead to therapeutic failure and resistance to the medication/class. Adverse effects In general, rabeprazole is fairly well tolerated, even up to five years after clinical trial follow-up. The side effect profile is similar to that of omeprazole. The most common side effects include headache, nausea, and diarrhea. Rare side effects include rashes, flu-like symptoms, and infections (including by the gastrointestinal pathogen Clostridium difficile). Rare instances of rabeprazole-induced liver injury (also known as hepatotoxicity) have been reported. Characteristic proton-pump inhibitor hepatoxicity usually occurs within the first four weeks of starting the medication.Rabeprazole is associated with elevated serum gastrin levels, which are thought to be dependent upon the degree of CYP2C19 metabolism the drug undergoes. In comparison, rabeprazole is not as significantly metabolized by this enzyme compared to other medications in the same class, like omeprazole. Elevated serum gastrin may be associated with gastric cancer.Acid suppression via rabeprazole can decrease the absorption of vitamin B12 and magnesium, leading to deficiency.Very serious side effects have been reported in people taking rabeprazole, but these effects have not been "correlated directly" with the use of rabeprazole. These include Stevens–Johnson syndrome, serious hematological abnormalities, coma, and death. Other possible side effects, common to other PPIs medications in the same class, include bone fractures due to osteoporosis and serious infections with Clostridium difficile. Overdose No signs and symptoms have been reported in overdoses of rabeprazole up to 80 mg, but case examples are limited. Notably, rabeprazole has been used in higher doses for the treatment of hypersecretory conditions like Zollinger-Ellison syndrome (up to 120 mg daily).Animal experiments with ultra-high doses of rabeprazole have demonstrated lethality through unknown mechanisms. The lethal overdose syndrome in animals is characterized by convulsion and coma. Interactions Drug-drug interactions Rabeprazole does not interfere with the plasma concentration of drugs that are also metabolized by the same enzymes (i.e. CYP2C19) that it is metabolized by. Therefore, it is not expected to react with CYP2C19 substrates like theophylline, warfarin, diazepam, and phenytoin. However, the acid-suppression effects of rabeprazole, like other PPIs, may interfere with the absorption of drugs that require acid, such as ketoconazole and digoxin.There is some evidence that omeprazole and esomeprazole, two medications in the same class as rabeprazole, can disturb the conversion of an anticoagulant medication called clopidogrel to its active metabolite. However, because this is thought to be mediated by the effect of omeprazole and esomeprazole on CYP2C19, the enzyme that activates clopidogrel, this drug interaction is not expected to occur as strongly with rabeprazole. However, whether the effect of omeprazole and esomeprazole on clopidogrels metabolism actually leads to poor clinical outcomes is still a matter of intense debate among healthcare professionals.Clinically serious drug-drug interactions may involve the acid-suppression effects of rabeprazole. For example, rabeprazole should not be used concomitantly with rilpivirine, an anti-HIV therapy, which requires acid for absorption. Lowered plasma concentrations of rilpivirine could lead to progression of HIV infection. Other drugs that require acid for absorption include antifungal drugs like ketoconazole and itraconazole, digoxin, iron, mycophenolate, and tyrosine kinase inhibitors like erlotinib, dasatinib, and nilotinib. There is no clinically relevant drug interaction between rabeprazole and antacids. Food-drug interactions Food does not affect the amount of rabeprazole that enters the body, but it does delay its onset of effect by about 1.7 hours. Pharmacology Mechanism of action Rabeprazoles mechanism of action first involves getting absorbed into the parietal cells of the stomach, which are the cells that are responsible for secreting hydrochloric acid (HCl). At this point, rabeprazole is inactive. However, rabeprazole is then secreted into the secretory canaliculus of the parietal cells, which is the space from which acid secretion occurs. Here, acid secretion is mediated by the energy-dependent acid pumps, called hydrogen potassium adenosine triphosphatase (H+/K+ ATPase) pumps. These enzymatic pumps have cysteine amino acid residues. After being activated by gastric (stomach) acid to a reactive sulfenamide intermediate, rabeprazole permanently binds the cysteine residues, forming covalent, disulfide bonds. This action fundamentally alters the configuration of the acid pump, thereby inhibiting its activity. Thus, acid can no longer be secreted into the gastric lumen (the empty space of the stomach), and the pH of the stomach increases (decrease in the concentration of hydrogen ions, H+). Due to the permanent inhibition of the individual proton pump that each molecule of rabeprazole has bound to, acid secretion is effectively suppressed until new proton pumps are produced by the parietal cells.Rabeprazole, like other medications in the same class, cannot inhibit the H+/K+ ATPase pumps found in lysosomes, a cellular organelle that degrades biological molecules, because the pumps found in these organelles lack the cysteine residues involved in rabeprazoles mechanism of action.A unique feature of rabeprazoles mechanism of action in inhibiting acid secretion involves its activation. The pKa (the pH at which 50% of the drug becomes positively charged) of rabeprazole is around 5.0, meaning that it doesnt take a lot of acid to activate it. While this theoretically translates into a faster onset of action for rabeprazoles acid-inhibiting effect, the clinical implications of this fact have yet to be elucidated. Pharmacokinetics Rabeprazoles bioavailability is approximately 52%, meaning that 52% of orally administered dose is expected to enter systemic circulation (the bloodstream). Once in the blood, rabeprazole is approximately 96.3%-97% bound to plasma proteins. The biological half-life of rabeprazole in humans is approximately one hour. It takes about 3.5 hours for rabeprazole to reach the maximum concentration in human plasma after a single orally administered dose. Oral absorption is independent of the dose administered.Rabeprazole is extensively metabolized by the liver. 90% of the drug is rendered into metabolites by the liver, which are then excreted by the kidneys. 10% of the dose is excreted in the feces. The drug metabolizing enzymes primarily responsible for rabeprazoles metabolism are CYP2C19 and CYP3A4. However, rabeprazole is mainly metabolized through non-enzymatic reduction to a thioether metabolite. Some of rabeprazoles metabolites include the following: a thioether carboxylic acid metabolite, a thioether glucuronide metabolite, and a sulfone metabolite. The most common metabolites excreted in the urine are the mercapturic acid conjugate and carboxylic acid. A diagram of rabeprazoles phase I metabolism is shown below. Pharmacogenetics The effect of rabeprazole may vary based upon the genetics of the individual taking the medication. People may have differences in their capacity to metabolize rabeprazole to an inactive metabolite. This may be mediated through genetic differences in the gene that encodes for the metabolic enzyme CYP2C19. For example, people that are poor CYP2C19 metabolizers (i.e. their version of CYP2C19 is less effective than average) will have trouble metabolizing rabeprazole, allowing the active rabeprazole to stay in the body, where it can exert its effect, longer than intended. Conversely, extensive CYP2C19 metabolizers (i.e. the average metabolic capacity of CYP2C19) will extensively metabolize rabeprazole, as expected. The poor metabolizing CYP2C19 phenotype is found in roughly 3–5% of Caucasian people, and in 17–20% of people of Asian ancestry. In a study on men of Japanese ancestry, this has translated to an average increase of total drug exposure by 50–60% compared to men in the United States.However, rabeprazoles metabolism is primarily non-enzymatic (it is often inactivated chemically, without the participation of the bodys natural drug metabolizing enzymes). Therefore, while a persons CYP2C19 phenotype will affect rabeprazoles metabolism, it is not expected to dramatically affect the efficacy of the medication. Chemistry Rabeprazole is classified as a substituted benzimidazole, like omeprazole, lansoprazole, and pantoprazole. Rabeprazole possess properties of both acids and bases, making it an amphotere. The acid dissociation constant (pKa) of the pyridine nitrogen is about equal to 5. Synthesis The above synthesis pathway begins with 2,3-dimethypyridine N-oxide (1). Nitration of 2,3-dimethylpyridine N-oxide affords the nitro derivative (the addition of NO2) (2) The newly introduced nitro group is then displaced by the alkoxide from 3-methoxypropanol to yield the corresponding ether (3). Treatment with acetic anhydride results in the Polonovski reaction. Saponification followed by treatment with thionyl chloride then chlorinates the primary alcohol (5). Reaction with benzimidazole-2-thiol (6) followed by oxidation of the resulting thioether to the sulfoxide yields the final product: rabeprazole (8). Physiochemical properties Rabeprazole is characterized as a white to yellowish-white solid in its pure form. It is soluble in a number of solvents. Rabeprazole is very soluble in water and methanol, freely soluble in ethanol, chloroform, and ethyl acetate, and is insoluble in ether and n-hexane. It is unstable under humid conditions. History Rabeprazole was first marketed in Europe in 1998. In 1999, one year later, rabeprazole was approved for use in the United States. Development Developed by Eisai Medical Research by the research names E3810 and LY307640, the pre-investigational new drug application was submitted on October 28, 1998. The final investigational new drug application was submitted August 6, 1999. On August 19, 1999, rabeprazole was approved in the US for multiple gastrointestinal indications. The approval for the treatment of symptomatic gastroesophageal reflux disease was on February 12, 2002. Society and culture Legal status Rabeprazole is approved in the United States and the United Kingdom for prescription use only. Rabeprazole was approved in India in December 2001. It was approved in Japan in 1997, and in all European Union member countries since. Brand names Rabeprazole has been sold in a number of brand names: Research An alternative formulation of rabeprazole, termed "rabeprazole-ER" (extended release) has been developed. The purpose of the formulation was to increase the half-life of rabeprazole, which normally is very short in humans. Rabeprazole-ER was a 50 mg capsule composed of five non-identical 10 mg tablets that were designed to release rabeprazole at differing intervals throughout the gastrointestinal system. However, because two high quality clinical trials failed to demonstrate a benefit of rabeprazole-ER versus esomeprazole (another common PPI) for healing grade C or D erosive esophagitis, the development of rabeprazole-ER ceased. References External links "Rabeprazole". Drug Information Portal. U.S. National Library of Medicine.
Atovaquone	Atovaquone, sold under the brand name Mepron, is a quinone antimicrobial medication for the prevention and treatment of Pneumocystis jirovecii pneumonia (PCP).Atovaquone is a chemical compound that belongs to the class of naphthoquinones. Atovaquone is a hydroxy-1,4-naphthoquinone, an analog of both ubiquinone and lawsone, with antipneumocystic activity. Medical uses Atovaquone is a medication used to treat or prevent: For pneumocystis pneumonia (PCP), it is used in mild cases, although it is not approved for treatment of severe cases. For toxoplasmosis, the medication has antiparasitic and therapeutic effects. For malaria, it is one of the two components (along with proguanil) in the drug Malarone. Malarone has fewer side effects and is more expensive than mefloquine. Resistance has been observed. For babesia, it is often used in conjunction with oral azithromycin.Trimethoprim/sulfamethoxazole (TMP-SMX, Bactrim) is generally considered first-line therapy for PCP (not to be confused with sulfadiazine and pyrimethamine, which is first line for toxoplasmosis). However, atovaquone may be used in patients who cannot tolerate, or are allergic to, sulfonamide medications such as TMP-SMX. In addition, atovaquone has the advantage of not causing myelosuppression, which is an important issue in patients who have undergone bone marrow transplantation. Atovaquone is given prophylactically to kidney transplant patients to prevent PCP in cases where Bactrim is contraindicated for the patient. Malaria Atovaquone, as a combination preparation with proguanil, has been commercially available from GlaxoSmithKline since 2000 as Malarone for the treatment and prevention of malaria. Research COVID-19 Preliminary research found that atovaquone could inhibit the replication of SARS-CoV-2 in vitro. Clinical trials of atovaquone for the treatment of COVID-19 are planned, and ongoing in USA in December 2021.Atovaquone has also been found to inhibit human coronavirus OC43 and feline coronavirus in vitro. Veterinary use Atovaquone is used in livestock veterinary cases of babesiosis in cattle, especially if imidocarb resistance is a concern. References Further reading Kessl JJ, Hill P, Lange BB, Meshnick SR, Meunier B, Trumpower BL (January 2004). "Molecular basis for atovaquone resistance in Pneumocystis jirovecii modeled in the cytochrome bc(1) complex of Saccharomyces cerevisiae". J. Biol. Chem. 279 (4): 2817–24. doi:10.1074/jbc.M309984200. PMID 14576156. External links "Atovaquone". Drug Information Portal. U.S. National Library of Medicine.
Tirbanibulin	Tirbanibulin, sold under the brand name Klisyri, is a medication for the treatment of actinic keratosis (AKs) on the face or scalp.The most common side effects include local skin reactions, application site pruritus, and application site pain.Tirbanibulin was approved for medical use in the United States in December 2020, and in the European Union in July 2021. The U.S. Food and Drug Administration (FDA) considers it to be a first-in-class medication.It functions as a mitotic inhibitor by inhibiting tubulin polymerization and Src kinase signaling can be potentially effective in deferring the development of AKs to squamous cell carcinoma in situ. Medical uses Tirbanibulin is indicated for the topical treatment of actinic keratosis of the face or scalp. Mechanism of Action Tirbanibulin, chemically known as N-benzyl-2-(5-(4-(2-morpholinoethoxy)phenyl) pyridine-2-yl) acetamide, is a microtubule and non–ATP-competitive inhibitor. The drug in various ways mimics the mechanisms of chemotherapy by suspending the protooncogenic Src tyrosine kinase signaling pathway. Notably, it promotes G2/M arrest during cell cycle, upregulates p53, and triggers apoptosis via caspase-3 stimulation and poly (ADP-ribose) polymerase cleavage. Side effects In several studies tirbanibulin has been observed to induce skin reactions at the site of application, ranging from mild to severe erythema, flaking, ulceration, and pain.As of now, there has been no extensive research conducted on the risks of tirbanibulin usage by specific human populations (i.e., pregnant populations). There also has been no significant differences observed in safety or effectiveness of the drug between geriatric or pediatric populations. History The U.S. Food and Drug Administration (FDA) approved tirbanibulin based on evidence from two clinical trials (Trial 1/ NCT03285477 and Trial 2/NCT03285490) of 702 adults with actinic keratosis on the face or scalp. The trials were conducted at 62 sites in the United States. Participants received once daily treatment with either tirbanibulin or inactive control ointment for 5 consecutive days to the single predetermined area where they had actinic keratosis. Neither the participants nor the health care providers knew which treatment was being given until after the trial was completed. The benefit of tirbanibulin in comparison to control was assessed after 57 days by comparing the percentage of participants who did not have any actinic keratosis on the treatment area (100% clearance). Society and culture Legal status On 20 May 2021, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) adopted a positive opinion, recommending the granting of a marketing authorization for tirbanibulin, intended for the treatment of actinic keratosis. The applicant for this medicinal product is Almirall, S.A. Tirbanibulin was approved for medical use in the European Union in July 2021. References External links "Tirbanibulin". Drug Information Portal. U.S. National Library of Medicine. Clinical trial number NCT03285477 for "A Multi-Center Study to Evaluate the Efficacy and Safety of KX2-391 Ointment 1% on AK on Face or Scalp (AK003)" at ClinicalTrials.gov Clinical trial number NCT03285490 for "A Multi-Center Study to Evaluate the Efficacy and Safety of KX2-391 Ointment 1% on AK on Face or Scalp (AK004)" at ClinicalTrials.gov
Chloroprocaine	Chloroprocaine (trade name Nesacaine, Nesacaine-MPF) (often in the hydrochloride salt form as the aforementioned trade names) is a local anesthetic given by injection during surgical procedures and labor and delivery. Chloroprocaine vasodilates; this is in contrast to cocaine which vasoconstricts. Chloroprocaine is an ester anesthetic. Medical uses Chloroprocaine is used for regional anaesthesia including spinal anaesthesia, caudal anaesthesia and epidural anesthesiaIt is also indicated for local anaesthesia including brachial plexus block, cervical nerve block, occipital nerve block. mandibular nerve block or maxillary nerve block for dental anesthesia, ophthalmic anesthesia via infraorbital nerve block, ulnar nerve block, paravertebral block, intercostal nerve block, sciatic nerve block, stellate ganglion block, lumbar sympathetic block and interdigital block.It is also used for obstetric anesthesia including pudendal nerve block and paracervical block.Chloroprocaine is also indicated for ocular surface anesthesia. Subarachnoid block Chloroprocaine was developed to meet the need for a short-acting spinal anaesthetic that is reliable and has a favourable safety profile to support the growing need for day-case surgery. Licensed in Europe for surgical procedures up to 40 minutes, chloroprocaine is an ester-type local anaesthetic with the shortest duration of action of all the established local anaesthetics. It has a significantly shorter duration of action than lidocaine and is significantly less toxic. Chloroprocaine has a motor block lasting for 40 minutes, a rapid onset time of 3–5 minutes (9.6 min ± 7.3 min at 40 mg dose; 7.9 min ± 6.0 min at 50 mg dose) and a time to ambulation of 90 minutes without complications, especially lacking transient neurologic symptomatology. These data are based upon a retrospective review of 672 patients suitable for spinal anaesthesia in surgical procedures less than 60 minutes duration using 30–40 mg chloroprocaine. The results showed good surgical anaesthesia, a fast onset time, and postoperative mobilization after 90 minutes without complications.The use of chloroprocaine in the subarachnoid space has been questioned. In the early 1980s, several cases were reported of neurological deficits after inadvertent intrathecal injections intended for epidural delivery. These doses were an order of magnitude higher than is currently used for intrathecal delivery. It is also thought that these deficits were also related to the preservative sodium bisulfate, although this is also controversial.In recent years, several studies have been published on the safe use of intrathecal chloroprocaine when appropriate dosage is used and with preservative-free preparations.It is currently approved for intrathecal use in the United States and in Europe. Obstetrics Amide-linked local anesthetic agents, such as lidocaine and bupivacaine, can become "trapped" in their ionized forms on the fetal side of the placenta, so their net transfer across the placenta is increased. An ester-linked local anesthetic agent, such as 2-chloroprocaine, is rapidly metabolized, and placental transfer is limited. Since the metabolism of 2-chloroprocaine by fetal plasma is slower than in maternal plasma, the potential for ion trapping exists. Fetal pH is slightly lower than maternal (7.32 to 7.38), thus most unionized drugs are "ion trapped" to a degree, even in a healthy fetus. Chloroprocaine (pKa 8.7) is the drug of choice for epidural analgesia and a decompensating fetus, because it does not participate in ion trapping. Placental transfer of 2-chloroprocaine is not influenced by fetal acidosis.The in vitro half-life of chloroprocaine is 21 seconds for maternal and 43 seconds for fetal blood. In patients who are homozygous atypical for plasma cholinesterase, chloroprocaine typically exists for two minutes in circulation. Synthesis The hydrochloride salt of 4-amino-2-chlorobenzoyl chloride is made by the reaction of 2-chloro-4-aminobenzoic acid with thionyl chloride. Synthesis of this drug is then accomplished by directly reacting the product of the last step with the hydrochloride salt of 2-diethylaminoethanol. References External links "Chloroprocaine". Drug Information Portal. U.S. National Library of Medicine.
Dakins solution	Dakins solution is a dilute solution of sodium hypochlorite (0.4% to 0.5%) and other stabilizing ingredients, traditionally used as an antiseptic, e.g. to cleanse wounds in order to prevent infection. The preparation was for a time called also Carrel–Dakin solution or Carrel–Dakin fluid. Use Carrel and Dakin used a variety of apparatuses to infuse the solution continuously over the wounds. In modern typical usage, the solution is applied to the wound once daily for lightly to moderately exudative wounds, and twice daily for heavily exudative wounds or highly contaminated wounds.The healthy skin surrounding the wound should preferably be protected with a moisture barrier ointment (e.g., petroleum jelly) or skin sealant as needed to prevent irritation. History The solution takes the name from British chemist Henry Drysdale Dakin (1880–1952) who developed it in 1916, during World War I, while he was stationed at a field hospital in Compiègne. He worked there in collaboration with French physician Alexis Carrel, and the particular use they made of the solution is known as the Carrel–Dakin method for wound treatment. Sodium hypochlorite solution had been developed as a bleaching agent around 1820 by the French chemist Antoine Labarraque, as a cheaper substitute for Claude Berthollets potassium hypochlorite solution, produced as Eau de Javel since the late 18th century. Around that time, he also discovered the disinfectant properties of his Eau de Labarraque, which was quickly adopted for that purpose. His work greatly improved medical practice, public health, and the sanitary conditions in hospitals, slaughterhouses, and all industries dealing with animal products. However, those products were too concentrated and alkaline for use on wounds, as they strongly irritated healthy tissues.Almost a century later Carrel and Dakin observed that few doctors at the time practiced asepsis, and moreover there were no studies of the effectiveness of various antiseptics for wounds. They set out to look for a substance that did not irritate skin, yet had sufficient bactericidal power. Dakin tested more than 200 substances, measuring their action on tissues and bacteria. He found chloramines to be the best, for being stable, non-toxic, and not very irritating, yet powerful bactericides, presumably due to their release of hypochlorous acid. However, the difficulty of procuring them led him to choose "hypochlorite of soda" as a practical alternative.Between the two World Wars, the preparation was often called "Carrel–Dakin solution," even though Dakin did the bulk of the research work that led to its formulation. The name of Carrel was dropped after World War II, presumably due to his active involvement in eugenics movements and the advocacy of elimination of "inferior" humans.Since penicillin became established as an antibiotic in 1943, use of Dakins solution and other topical antiseptics for wound treatment has declined, and their use is frowned upon in modern medical care. However, the solution continues to be used (as of 2013) due to its broad activity against aerobic and anaerobic organisms, including fungi and antibiotic-resistant organisms, its very low cost, and its wide availability. In emergency situations, it can be produced on the field from liquid bleach and sodium bicarbonate. Formulation Dakins original solution contained sodium hypochlorite (0.4% to 0.5%), prepared by treating calcium hypochlorite with sodium carbonate ("washing soda"). The solution left after removal of the insoluble calcium carbonate still contained some soda. Boric acid (4%) was then added as a buffering agent to maintain a pH of between 9 and 10. Dakin found that alkalinity outside this range was too irritating. The solution, while unstable, remains effective for at least a week, if made to the correct pH.Other formulations have been developed over time. In 1916, Marcel Daufresne substituted sodium bicarbonate for Dakins boric acid as buffering agent. This formulation is the basis of current commercial products.The concentration chosen by Dakin (0.5%) was the maximum highest concentration found tolerable to the skin. It is the concentration recommended by the U.S. Center for Disease Control (CDC) as a household disinfectant. In one study, bactericidal effects of sodium hypochlorite solution were observed at concentrations as low as 0.025%, without any tissue toxicity in vivo or in vitro. It recommended that concentration be adopted as a "modified Dakins solution" for wound dressing. See also Chlorine-releasing compound Hydrogen peroxide Povidone-iodine Phenol ("carbolic acid") Eusol == References ==
Testosterone enanthate	Testosterone enanthate, sold under the brand names Delatestryl and Xyosted among others, is an androgen and anabolic steroid (AAS) medication which is used mainly in the treatment of low testosterone levels in men. It is also used in hormone therapy for transgender men. It is given by injection into muscle or subcutaneously usually once every one to four weeks.Side effects of testosterone enanthate include symptoms of masculinization like acne, increased hair growth, voice changes, and increased sexual desire. The drug is a synthetic androgen and anabolic steroid and hence is an agonist of the androgen receptor (AR), the biological target of androgens like testosterone and dihydrotestosterone (DHT). It has strong androgenic effects and moderate anabolic effects, which make it useful for producing masculinization and suitable for androgen replacement therapy. Testosterone enanthate is a testosterone ester and a long-lasting prodrug of testosterone in the body. Because of this, it is considered to be a natural and bioidentical form of testosterone.Testosterone enanthate was introduced for medical use in 1954. Along with testosterone cypionate, testosterone undecanoate, and testosterone propionate, it is one of the most widely used testosterone esters. In addition to its medical use, testosterone enanthate is used to improve physique and performance. The drug is a controlled substance in many countries and so non-medical use is generally illicit. Medical uses Testosterone enanthate is used primarily in androgen replacement therapy. It is the most widely used form of testosterone in androgen replacement therapy. The medication is specifically approved, in the United States, for the treatment of hypogonadism in men, delayed puberty in boys, and breast cancer in women. It is also used in masculinizing hormone therapy for transgender men. Side effects Side effects of testosterone enanthate include virilization among others. Approximately 10 percent of testosterone enanthate will be converted to dihydrotestosterone in normal men. Dihydrotestosterone (DHT) can promote masculine characteristics in both males and females. These masculine characteristics include: clitoral hypertrophy, androgenic alopecia, growth of body hair and deepening of the vocal cords. Dihydrotestosterone also plays an important role in male sexual function and may also be a contributing factor of ischemic priapism in males as shown in a study conducted on the use of finasteride to treat ischemic priapism in males. Testosterone enanthate can also lead to an increase in igf-1 and igf-bp. Testosterone enanthate can also be converted to estradiol by aromatase, which may lead to gynecomastia in males. Aromatase inhibitors can help to prevent the estrogenic activity of testosterone enanthate in the body. Pharmacology Pharmacodynamics Testosterone enanthate is a prodrug of testosterone and is an androgen and anabolic–androgenic steroid (AAS). That is, it is an agonist of the androgen receptor (AR). Pharmacokinetics Testosterone enanthate has an elimination half-life of 4.5 days and a mean residence time of 8.5 days when used as a depot intramuscular injection. It requires frequent administration of approximately once per week, and large fluctuations in testosterone levels result with it, with levels initially being elevated and supraphysiological. Chemistry Testosterone enanthate, or testosterone 17β-heptanoate, is a synthetic androstane steroid and a derivative of testosterone. It is an androgen ester; specifically, it is the C17β enanthate (heptanoate) ester of testosterone. History Testosterone enanthate was described as early as 1952 and was first introduced for medical use in the United States in 1954 under the brand name Delatestryl. Society and culture Generic names Testosterone enanthate is the generic name of the drug and its USAN and BAN. It has also referred to as testosterone heptanoate. Brand names Testosterone enanthate is marketed primarily under the brand name Delatestryl.It is or has been marketed under a variety of other brand names as well, including, among others: Andro LA Andropository Cypionat Cypoprime Depandro Durathate Everone Testocyp Testostroval Testrin Testro LA Xyosted pharmaqo labs Availability Testosterone enanthate is available in the United States and widely elsewhere throughout the world. Testosterone enanthate (testosterone heptanoate) is often available in concentrations of 200 mg per milliliter of fluid. Legal status Testosterone enanthate, along with other AAS, is a schedule III controlled substance in the United States under the Controlled Substances Act and a schedule IV controlled substance in Canada under the Controlled Drugs and Substances Act. Research As of October 2017, an auto-injection formulation of testosterone enanthate was in preregistration for the treatment of hypogonadism in the United States. Xyosted On October 1, 2018, the U.S. Food and Drug Administration (FDA) announced the approval of Xyosted. Xyosted, a product of Antares Pharma, Inc., is a single-use disposable auto-injector that dispenses testosterone enanthate. Xyosted is the first FDA-approved subcutaneous testosterone enanthate product for testosterone replacement therapy in adult males. == References ==
Bendroflumethiazide	Bendroflumethiazide, formerly bendrofluazide, trade name Aprinox, is a thiazide diuretic used to treat hypertension. Bendroflumethiazide is a thiazide diuretic which works by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT). Water is lost as a result of more sodium reaching the collecting ducts. Bendroflumethiazide has a role in the treatment of mild heart failure although loop diuretics are better for reducing overload. The main use of bendroflumethiazide currently is in hypertension (part of the effect is due to vasodilation). It was patented in 1958 and approved for medical use in 1960. Adverse effects Common adverse effects: feeling dizzy due to orthostatic hypotension dry mouth or feeling thirsty nausea stomach ache fatigue diarrhea or constipation joint pain due to goutRare adverse effects: thrombocytopenia agranulocytosis photosensitivity rash pancreatitis chronic kidney disease Alcohol Bendroflumethiazide is known to have an adverse interaction with alcohol. It is advised that those using this diuretic should abstain from alcohol consumption during use, as it is possible to experience a sudden drop in blood pressure, especially if standing up (an effect known as orthostatic hypotension). Other considerations Bendroflumethiazide should not be used by pregnant women, or women who have just given birth. Due to the nature of the medication, it is possible for it to pass into the breast milk and consequently to the child. It is also known that bendroflumethiazide suppresses the production of breast milk. Pregnant or lactating women with hypertension may need to discuss with their prescriber as to which alternative treatment may be more suitable. Bendroflumethiazide may also impair the users motor skills, therefore it is important to be aware of its effects and to take caution when operating machinery of driving. == References ==
Susoctocog alfa	Susoctocog alfa, sold under the brand name Obizur, is a medication used for the treatment of bleeding episodes in adults with acquired haemophilia, a bleeding disorder caused by the spontaneous development of antibodies that inactivate factor VIII.Susoctocog alfa was approved for medical use in the United States in October 2014, and for medical use in the European Union in November 2015.Factor VIII is one of the proteins needed for normal clotting of the blood. References External links "Susoctocog alfa". Drug Information Portal. U.S. National Library of Medicine.
Trihexyphenidyl	Trihexyphenidyl (THP, benzhexol, trihex, marketed as Artane and others) is an antispasmodic drug used to treat stiffness, tremors, spasms, and poor muscle control. It is an agent of the antimuscarinic class and is often used in management of Parkinsons disease. It was approved by the FDA for the treatment of Parkinsons in the US in 2003.It is on the World Health Organizations List of Essential Medicines. Medical uses Trihexyphenidyl is used for the symptomatic treatment of Parkinsons disease in mono and combination therapy. It is active in postencephalitic, arteriosclerotic, and idiopathic forms. The drug is also commonly used to treat extrapyramidal side effects occurring during antipsychotic treatment. It reduces the frequency and duration of oculogyric crises as well as of dyskinetic movements and spastic contractions. Trihexyphenidyl may improve psychotic depression and mental inertia frequently associated with Parkinsons disease and symptomatic problems caused by antipsychotic treatment.The drug cannot cure Parkinsons disease, but may provide substantial alleviation of symptoms. An estimated 50–75% of people with Parkinsons disease will react positively and experience a 20–30% symptomatic improvement. To increase therapeutic activity, trihexyphenidyl is often given concomitantly with levodopa or other antimuscarinic or antihistaminic (e.g. diphenhydramine) agents. Combination therapy with dopamine agonists such as cabergoline is also possible. This is often termed a multidimensional approach. It has also been prescribed for essential tremor and akathisia. Contraindications Contradindications include: Hypersensitivity to trihexyphenidyl Narrow angle glaucoma Ileus (disruption of the normal propulsive ability of the intestine) Caution: People with obstructive diseases of the urogenital tract, people with a known history of seizures and those with potentially dangerous tachycardia People under 18 years of age should not be treated due to a lack of clinical experience. People should allow a period to adjust to the dose when first starting trihexyphenidyl and when the dose has been increased or added to a regimen with other drugs because acute somnolence and accumulated fatigue can make it particularly dangerous to operate an automobile, heavy machinery etc. Adverse effects Dose-dependent side effects are frequent, but typically lessen over time as the body adapts to the medication. All of the following symptoms considered, Artane has been shown to dramatically and consistently improve neurologic defects in people aged 16–86 over the course of five years. People who are older or who have psychiatric conditions may become confused or develop delirium. Side effects include but are not limited to: Central nervous system: drowsiness, vertigo, headache, and dizziness are frequent. With high doses nervousness, agitation, anxiety, delirium, and confusion are noted. Trihexyphenidyl may be abused due to a short acting mood-elevating and euphoric effect. The normal sleep architecture may be altered (REM sleep depression). Trihexyphenidyl may lower the seizure-threshold. Peripheral side effects: dry mouth, impaired sweating, abdominal discomfort, nausea, and constipation are frequent. Tachycardia or heart palpitations (fast heart rate) may be noted. Allergic reactions are rare, but may occur. Many of these peripheral symptoms, especially considering an acute increase in anxiety with various physical complaints, as well as evidence of orthostatic hypotension and tachycardia are indicative of withdrawal, especially in people with psychiatric conditions Eyes: trihexyphenidyl causes mydriasis with or without photophobia. It may precipitate narrow angle glaucoma or cause blurred vision. Tolerance may develop during therapy which requires dose adjustments. Striated musculature and weight gain.Trihexyphenidyl is a pregnancy category C drug. It is advised to only use with caution if benefits outweigh risks. Overdose Trihexyphenidyl (THP) and other antiparkinsonian drugs are known to be substances of abuse. This is true both in abusers of other substances and in chronic schizophrenics, the latter being infrequent abusers of other drugs. Trihexyphenidyl mimics an atropine intoxication with mydriasis, dryness of mucous membranes, red face, atonic states of bowels and bladder, and hyperthermia in high doses. Central consequences are agitation, confusion, and hallucinations. An untreated overdose may be fatal, particularly in children. Premortal signs are respiratory depression and cardiac arrest. A specific antagonist is physostigmine which combines a peripheral and a central action. Carbachol can be used to treat atonic bowel and bladder. The vital functions should be monitored and stabilized. It may be necessary to treat hyperthermia with cooling blankets. Clinical case reports have repeatedly shown overdose of trihexyphenidyl alongside other substances. Interactions Other anticholinergic drugs (e.g. spasmolytics, antihistamines, TCAs) : Side effects of trihexyphenidyl may be increased. Quinidine : Increased anticholinergic action (particular on AV conduction). Antipsychotics : Long term use of trihexyphenidyl may mask or increase the risk of tardive dyskinesia. Pethidine (meperidine) : Central effects and side effects of pethidine may be increased. Metoclopramide : Action of metoclopramide is decreased. Alcohol : Risk of serious intoxication. Pharmacology The exact mechanism of action in parkinsonian syndromes is not precisely understood, but it is known that trihexyphenidyl blocks efferent impulses in parasympathetically innervated structures like smooth muscles (spasmolytic activity), salivary glands, and eyes (mydriasis). In higher doses direct central inhibition of cerebral motor centers may contribute. In very high doses central toxicity as seen in atropine overdose is noted. It binds to the M1 muscarinic receptor and possibly the dopamine receptor. Trihexyphenidyl is rapidly absorbed from the gastrointestinal tract. The onset of action is within 1 hour after oral dosing. The peak activity is noted after 2 to 3 hours. The duration of action of one single dose is 6 to 12 hours in a dose dependent manner. It is excreted in the urine, probably as unchanged drug. More precise data in animals and humans have so far not been determined. History Artane, or its generic form Trihexyphenidyl HCL, was approved by the FDA on June 25, 2003 for the clinical use of all types of parkinsonism. However, it has been clinically relevant in trials pertaining to Parkinsons disease since 1949. Artane is an anticholinergic drug which is prescribed by doctors throughout the world. It is also abused, typically in combination with other drugs or delicate pharmaceutical agents. Prisons in Iraq were among the places where abuse was obvious, along with within communities of Iraqi soldiers. Society and culture Recreational use In a 2008 news report, trihexyphenidyl was seen to be used for recreational purposes among Iraqi soldiers and police, among other prescription drugs. The report states that the drugs were taken to relieve combat stress. Although that may be the case for some, others used Artane as a substitute or more intense version of LSD. This was especially prevalent in the 1960s, according to a report in "The New Yorker". Similarly to those in Iraqi forces, some of the appeal was that the individual may retain partial control while under the influence.The neurologist Oliver Sacks reports using the drug recreationally in the 1960s. He recalled taking "a large dose" knowing full well the drug was intended for people with Parkinsons. More recounts of Dr. Sacks experiences — including experimentation with mescaline, psilocybin, LSD, and probably DMT — have been compared in his book Hallucinations. During the 1970s, trihexyphenidyl(trade name Parkan) was the most popular recreationally used prescription drug in Hungary. Chemistry Trihexyphenidyl can be synthesized in two ways, one linear and one convergent synthesis. In the first way, the initial 2-(1-piperidino)propiophenone is synthesized in turn by the aminomethylation of acetophenone using paraformaldehyde and piperidine in a Mannich reaction. In the second step the 2-(1-piperidino)propiophenone is reacted with cyclohexylmagnesium bromide in a Grignard reaction. Stereochemistry Trihexyphenidyl has a chiral center and two enantiomers. Medications are racemates. Research Equivocal preliminary results from small studies exist for: Other dyskinesias Huntingtons chorea Spasmodic torticollis Dystonia See also Biperiden (bicyclic ring) Cycrimine (cyclopentanyl instead of cyclohexanyl) Gamfexine Procyclidine References This article incorporates public domain material from Toxnet:Trihexyphenidyl. United States Department of Health and Human Services. Retrieved 8 May 2017.
Niacin	Niacin, also known as nicotinic acid, is an organic compound and a form of vitamin B3, an essential human nutrient. It can be manufactured by plants and animals from the amino acid tryptophan. Niacin is obtained in the diet from a variety of whole and processed foods, with highest contents in fortified packaged foods, meat, poultry, red fish such as tuna and salmon, lesser amounts in nuts, legumes and seeds. Niacin as a dietary supplement is used to treat pellagra, a disease caused by niacin deficiency. Signs and symptoms of pellagra include skin and mouth lesions, anemia, headaches, and tiredness. Many countries mandate its addition to wheat flour or other food grains, thereby reducing the risk of pellagra.The amide derivative nicotinamide (niacinamide) is a component of the coenzymes nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP+). Although niacin and nicotinamide are identical in their vitamin activity, nicotinamide does not have the same pharmacological, lipid-modifying effects or side effects as niacin, i.e., when niacin takes on the -amide group, it does not reduce cholesterol nor cause flushing. Nicotinamide is recommended as a treatment for niacin deficiency because it can be administered in remedial amounts without causing the flushing, considered an adverse effect.Niacin is also a prescription medication. Amounts far in excess of the recommended dietary intake for vitamin functions will lower blood triglycerides and low density lipoprotein cholesterol (LDL-C), and raise blood high density lipoprotein cholesterol (HDL-C, often referred to as "good" cholesterol). There are two forms: immediate-release and sustained-release niacin. Initial prescription amounts are 500 mg/day, increased over time until a therapeutic effect is achieved. Immediate-release doses can be as high as 3,000 mg/day; sustained-release as high as 2,000 mg/day. Despite the proven lipid changes, niacin has not been found useful for decreasing the risk of cardiovascular disease in those already on a statin. A 2010 review had concluded that niacin was effective as a mono-therapy, but a 2017 review incorporating twice as many trials concluded that prescription niacin, while affecting lipid levels, did not reduce all-cause mortality, cardiovascular mortality, myocardial infarctions, nor fatal or non-fatal strokes. Prescription niacin was shown to cause hepatotoxicity and increase risk of type 2 diabetes. Niacin prescriptions in the U.S. had peaked in 2009, at 9.4 million, declining to 1.3 million by 2017.Niacin has the formula C6H5NO2 and belongs to the group of the pyridinecarboxylic acids. As the precursor for nicotinamide adenine dinucleotide and nicotinamide adenine dinucleotide phosphate, niacin is involved in DNA repair. Definition Niacin is both a vitamin, i.e., an essential nutrient, marketed as a dietary supplement, and in the US, a prescription medicine. As a vitamin, it is precursor of the coenzymes nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP). These compounds are coenzymes for many dehydrogenases, participating in many hydrogen transfer processes. NAD is important in catabolism of fat, carbohydrate, protein, and alcohol, as well as cell signaling and DNA repair, and NADP mostly in anabolism reactions such as fatty acid and cholesterol synthesis. Vitamin intake recommendations made by several countries are that intakes of 14–18 mg/day are sufficient to meet the needs of healthy adults. Niacin or nicotinamide (niacinamide) are used for prevention and treatment of pellagra, a disease caused by lack of the vitamin. When niacin is used as a medicine to treat elevated cholesterol and triglycerides, daily doses range from 500 to 3,000 mg/day. High-dose nicotinamide does not have this medicinal effect. Vitamin deficiency Severe deficiency of niacin in the diet causes the disease pellagra, characterized by diarrhea, sun-sensitive dermatitis involving hyperpigmentation and thickening of the skin (see image), inflammation of the mouth and tongue, delirium, dementia, and if left untreated, death. Common psychiatric symptoms include irritability, poor concentration, anxiety, fatigue, loss of memory, restlessness, apathy, and depression. The biochemical mechanism(s) for the observed deficiency-caused neurodegeneration are not well understood, but may rest on: A) the requirement for nicotinamide adenine dinucleotide (NAD+) to suppress the creation of neurotoxic tryptophan metabolites, B) inhibition of mitochondrial ATP generation, resulting in cell damage; C), activation of the poly (ADP-ribose) polymerase (PARP) pathway, as PARP is a nuclear enzyme involved in DNA repair, but in the absence of NAD+ can lead to cell death; D) reduced synthesis of neuro-protective brain-derived neurotrophic factor or its receptor tropomyosin receptor kinase B; or E) changes to genome expression directly due to the niacin deficiency.Niacin deficiency is rarely seen in developed countries, and it is more typically associated with poverty, malnutrition or malnutrition secondary to chronic alcoholism. It also tends to occur in less developed areas where people eat maize (corn) as a staple food, as maize is the only grain low in digestible niacin. A cooking technique called nixtamalization i.e., pretreating with alkali ingredients, increases the bioavailability of niacin during maize meal/flour production. For this reason, people who consume corn as tortillas or hominy are at less risk of niacin deficiency. For treating deficiency, the World Health Organization (WHO) recommends administering niacinamide(i.e. nicotinamide) instead of niacin, to avoid the flushing side effect commonly caused by the latter. Guidelines suggest using 300 mg/day for three to four weeks. Dementia and dermatitis show improvement within a week. Because deficiencies of other B-vitamins may be present, the WHO recommends a multi-vitamin in addition to the niacinamide.Hartnup disease is a hereditary nutritional disorder resulting in niacin deficiency. It is named after an English family with a genetic disorder that resulted in a failure to absorb the essential amino acid tryptophan, tryptophan being a precursor for niacin synthesis. The symptoms are similar to pellagra, including red, scaly rash and sensitivity to sunlight. Oral niacin or niacinamide is given as a treatment for this condition in doses ranging from 50 to 100 mg twice a day, with a good prognosis if identified and treated early. Niacin synthesis is also deficient in carcinoid syndrome, because of metabolic diversion of its precursor tryptophan to form serotonin. Measuring vitamin status Plasma concentrations of niacin and niacin metabolites are not useful markers of niacin status. Urinary excretion of the methylated metabolite N1-methyl-nicotinamide is considered reliable and sensitive. The measurement requires a 24-hour urine collection. For adults, a value of less than 5.8 μmol/day represent deficient niacin status and 5.8 to 17.5 μmol/day represents low. According to the World Health Organization, an alternative mean of expressing urinary N1-methyl-nicotinamide is as mg/g creatinine in a 24-hour urine collection, with deficient defined as <0.5, low 0.5-1.59, acceptable 1.6-4.29, and high >4.3 Niacin deficiency occurs before the signs and symptoms of pellagra appear. Erythrocyte nicotinamide adenine dinucleotide (NAD) concentrations potentially provide another sensitive indicator of niacin depletion, although definitions of deficient, low and adequate have not been established. Lastly, plasma tryptophan decreases on a low niacin diet because tryptophan converts to niacin. However, low tryptophan could also be caused by a diet low in this essential amino acid, so it is not specific to confirming vitamin status. Dietary recommendations The U.S. Institute of Medicine (renamed National Academy of Medicine in 2015) updated Estimated Average Requirements (EARs) and Recommended Dietary Allowances (RDAs) for niacin in 1998, also Tolerable upper intake levels (ULs). In lieu of an RDA, Adequate Intakes (AIs) are identified for populations for which there is not sufficient evidence to identify a dietary intake level that is sufficient to meet the nutrient requirements of most people. (see table). The European Food Safety Authority (EFSA) refers to the collective set of information as Dietary Reference Values (DRV), with Population Reference Intake (PRI) instead of RDA, and Average Requirement instead of EAR. For the EU, AIs and ULs have the same definition as in the US, except that units are milligrams per megajoule (MJ) of energy consumed rather than mg/day. For women (including those pregnant or lactating), men and children the PRI is 1.6 mg per megajoule. As the conversion is 1 MJ = 239 kcal, an adult consuming 2390 kilocalories should be consuming 16 mg niacin. This is comparable to US RDAs (14 mg/day for adult women, 16 mg/day for adult men).ULs are established by identifying amounts of vitamins and minerals that cause adverse effects, and then selecting as an upper limit amounts that are the "maximum daily intake unlikely to cause adverse health effects." Regulatory agencies from different countries do not always agree. For the US, 30 or 35 mg for teenagers and adults, less for children. The EFSA UL for adults is set at 10 mg/day - about one-third of the US value. For all of the government ULs, the term applies to niacin as a supplement consumed as one dose, and is intended as a limit to avoid the skin flush reaction. This explains why for EFSA, the recommended daily intake can be higher than the UL.Both the DRI and DRV describe amounts needed as niacin equivalents (NE), calculated as 1 mg NE = 1 mg niacin or 60 mg of the essential amino acid tryptophan. This is because the amino acid is utilized to synthesize the vitamin.For U.S. food and dietary supplement labeling purposes the amount in a serving is expressed as a percent of Daily Value (%DV). For niacin labeling purposes 100% of the Daily Value is 16 mg. Prior to 27 May 2016 it was 20 mg, revised to bring it into agreement with the RDA. Compliance with the updated labeling regulations was required by 1 January 2020 for manufacturers with US$10 million or more in annual food sales, and by 1 January 2021 for manufacturers with lower volume food sales. A table of the old and new adult daily values is provided at Reference Daily Intake. Sources Niacin is found in a variety of whole and processed foods, including fortified packaged foods, meat from various animal sources, seafoods, and spices. In general, animal-sourced foods provide about 5–10 mg niacin per serving, although dairy foods and eggs have little. Some plant-sourced foods such as nuts, legumes and grains provide about 2–5 mg niacin per serving, although in some grain products this naturally present niacin is largely bound to polysaccharides and glycopeptides, making it only about 30% bioavailable. Fortified food ingredients such as wheat flour have niacin added, which is bioavailable. Among whole food sources with the highest niacin content per 100 grams: Vegetarian and vegan diets can provide adequate amounts if products such as nutritional yeast, peanuts, peanut butter, tahini, brown rice, mushrooms, avocado and sunflower seeds are included. Fortified foods and dietary supplements can also be consumed to ensure adequate intake. Food preparation Niacin naturally found in food is susceptible to destruction from high heat cooking, especially in the presence of acidic foods and sauces. It is soluble in water, and so may also be lost from foods boiled in water. Food fortification Countries fortify foods with nutrients to address known deficiencies. As of 2020, 54 countries required food fortification of wheat flour with niacin or niacinamide; 14 also mandate fortification of maize flour, and 6 mandate fortification of rice. From country to country, niacin fortification ranges from 1.3 to 6.0 mg/100 g. As a dietary supplement In the United States, niacin is sold as a non-prescription dietary supplement with a range of 100 to 1000 mg per serving. These products often have a Structure/Function health claim allowed by the US Food & Drug Administration (FDA). An example would be "Supports a healthy blood lipid profile." The American Heart Association strongly advises against the substitution of dietary supplement niacin for prescription niacin because of potentially serious side effects, which means that niacin should only be used under the supervision of a health care professional, and because manufacture of dietary supplement niacin is not as well-regulated by the FDA as prescription niacin. More than 30 mg niacin consumed as a dietary supplement can cause skin flushing. Face, arms and chest skin turns a reddish color because of vasodilation of small subcutaneous blood vessels, accompanied by sensations of heat, tingling and itching. These signs and symptoms are typically transient, lasting minutes to hours; they are considered unpleasant rather than toxic. As lipid-modifying medication In the United States, prescription niacin, in immediate-release and slow-release forms, is used to treat primary hyperlipidemia and hypertriglyceridemia. It is used either as a monotherapy or in combination with other lipid-modifying drugs. Dosages start at 500 mg/day and are often gradually increased to as high as 3000 mg/day for immediate release or 2000 mg/day for slow release (also referred to as sustained release) to achieve the targeted lipid changes (lower LDL-C and triglycerides, and higher HDL-C). Prescriptions in the US peaked in 2009, at 9.4 million and had declined to 1.3 million by 2017. In late 2017, Avondale, having acquired the rights to Niacor from Upsher Smith, raised the price of the drug by more than 800%.Systematic reviews found no effect of prescription niacin on all-cause mortality, cardiovascular mortality, myocardial infarctions, nor fatal or non-fatal strokes despite raising HDL cholesterol. Reported side effects include an increased risk of new-onset type 2 diabetes. Mechanisms Niacin reduces synthesis of low-density lipoprotein cholesterol (LDL-C), very low-density lipoprotein cholesterol (VLDL-C), lipoprotein(a) and triglycerides, and increases high-density lipoprotein cholesterol (HDL-C). The lipid-therapeutic effects of niacin are partly mediated through the activation of G protein-coupled receptors, including hydroxycarboxylic acid receptor 2 (HCA2)and hydroxycarboxylic acid receptor 3 (HCA3), which are highly expressed in body fat. HCA2 and HCA3 inhibit cyclic adenosine monophosphate (cAMP) production and thus suppress the release of free fatty acids (FFAs) from body fat, reducing their availability to the liver to synthesize the blood-circulating lipids in question. A decrease in free fatty acids also suppresses liver expression of apolipoprotein C3 and PPARg coactivator-1b, thus increasing VLDL-C turnover and reducing its production. Niacin also directly inhibits the action of diacylglycerol O-acyltransferase 2 (DGAT2) a key enzyme for triglyceride synthesis.The mechanism behind niacin increasing HDL-C is not totally understood, but seems to occur in various ways. Niacin increases apolipoprotein A1 levels by inhibiting the breakdown of this protein, which is a component of HDL-C. It also inhibits HDL-C hepatic uptake by suppressing production of the cholesterol ester transfer protein (CETP) gene. It stimulates the ABCA1 transporter in monocytes and macrophages and upregulates peroxisome proliferator-activated receptor gamma, resulting in reverse cholesterol transport. Combined with statins Extended release niacin was combined with the lovastatin trade-named Advicor, and with simvastatin, trade-named Simcor as prescription drug combinations. Advicor was approved by the U.S. Food and Drug Administration (FDA) in 2001. Simcor was approved in 2008. Subsequently, large outcome trials using these niacin and statin therapies were unable to demonstrate incremental benefit of niacin beyond statin therapy alone. The FDA withdrew approval of both drugs in 2016. The reason given: "Based on the collective evidence from several large cardiovascular outcome trials, the Agency has concluded that the totality of the scientific evidence no longer supports the conclusion that a drug-induced reduction in triglyceride levels and/or increase in HDL-cholesterol levels in statin-treated patients results in a reduction in the risk of cardiovascular events." The drug company discontinued the drugs. Contraindications Prescription immediate release (Niacor) and extended release (Niaspan) niacin are contraindicated for people with either active or a history of liver disease because both, but especially Niaspan, have been associated with instances of serious, on occasion fatal, liver failure. Both products are contraindicated for people with existing peptic ulcer disease, or other bleeding problems because niacin lowers platelet count and interferes with blood clotting. Both products are also contraindicated for women who are pregnant or expecting to become pregnant because safety during pregnancy has not been evaluated in human trials. These products are contraindicated for women who are lactating because it is known that niacin is excreted into human milk, but the amount and potential for adverse effects in the nursing infant are not known. Women are advised to either not nurse their child or discontinue the drug. High-dose niacin has not been tested or approved for use in children under 16 years. Adverse effects The most common adverse effects of medicinal niacin (500–3000 mg) are flushing (e.g., warmth, redness, itching or tingling) of the face, neck and chest, headache, abdominal pain, diarrhea, dyspepsia, nausea, vomiting, rhinitis, pruritus and rash. These can be minimized by initiating therapy at low dosages, increasing dosage gradually, and avoiding administration on an empty stomach.The acute adverse effects of high-dose niacin therapy (1–3 grams per day) – which is commonly used in the treatment of hyperlipidemias – can further include hypotension, fatigue, glucose intolerance and insulin resistance, heartburn, blurred or impaired vision, and macular edema. With long-term use, the adverse effects of high-dose niacin therapy (750 mg per day) also include liver failure (associated with fatigue, nausea, and loss of appetite), hepatitis, and acute liver failure; these hepatotoxic effects of niacin occur more often when extended-release dosage forms are used. The long-term use of niacin at greater than or equal to 2 grams per day also significantly increases the risk of cerebral hemorrhage, ischemic stroke, gastrointestinal ulceration and bleeding, diabetes, dyspepsia, and diarrhea. Flushing Flushing – a short-term dilatation of skin arterioles, causing reddish skin color – usually lasts for about 15 to 30 minutes, although sometimes can persist for weeks. Typically, the face is affected, but the reaction can extend to neck and upper chest. The cause is blood vessel dilation due to elevation in prostaglandin GD2 (PGD2) and serotonin. Flushing was often thought to involve histamine, but histamine has been shown not to be involved in the reaction. Flushing is sometimes accompanied by a prickly or itching sensation, in particular, in areas covered by clothing.Prevention of flushing requires altering or blocking the prostaglandin-mediated pathway. Aspirin taken half an hour before the niacin prevents flushing, as does ibuprofen. Taking niacin with meals also helps reduce this side effect. Acquired tolerance will also help reduce flushing; after several weeks of a consistent dose, most people no longer experience flushing. Slow- or "sustained"-release forms of niacin have been developed to lessen these side effects. Liver damage Niacin in medicinal doses can cause modest elevations in serum transaminase and unconjugated bilirubin, both biomarkers of liver injury. The increases usually resolve even when drug intake is continued. However, less commonly, the sustained release form of the drug can lead to serious hepatotoxicity, with onset in days to weeks. Early symptoms of serious liver damage include nausea, vomiting and abdominal pain, followed by jaundice and pruritus. The mechanism is thought to be a direct toxicity of elevated serum niacin. Lowering dose or switching to the immediate release form can resolve symptoms. In rare instances the injury is severe, and progresses to liver failure. Diabetes The high doses of niacin used to treat hyperlipidemia have been shown to elevate fasting blood glucose in people with type 2 diabetes. Long-term niacin therapy was also associated with an increase in the risk of new-onset type 2 diabetes. Other adverse effects High doses of niacin can also cause niacin maculopathy, a thickening of the macula and retina, which leads to blurred vision and blindness. This maculopathy is reversible after niacin intake ceases. Niaspan, the slow-release product, has been associated with a reduction in platelet content and a modest increase in prothrombin time. Pharmacology Pharmacodynamics Activating HCA2 has effects other than lowering serum cholesterol and triglyceride concentrations: antioxidative, anti-inflammatory, antithrombotic, improved endothelial function and plaque stability, all of which counter development and progression of atherosclerosis.Niacin inhibits cytochrome P450 enzymes CYP2E1, CYP2D6 and CYP3A4. Niacin produces a rise in serum unconjugated bilirubin in normal individuals and in those with Gilberts Syndrome. However, in the Gilberts Syndrome, the rise in bilirubin is higher and clearance is delayed longer than in normal people. One test used to aid in diagnosing Gilberts Syndrome involves intravenous administration of nicotinic acid (niacin) in a dose of 50 mg over a period of 30 seconds. Pharmacokinetics Both niacin and niacinamide are rapidly absorbed from the stomach and small intestine. Absorption is facilitated by sodium-dependent diffusion, and at higher intakes, via passive diffusion. Unlike some other vitamins, the percent absorbed does not decrease with increasing dose, so that even at amounts of 3-4 grams, absorption is nearly complete. With a one gram dose, peak plasma concentrations of 15 to 30 μg/mL are reached within 30 to 60 minutes. Approximately 88% of an oral pharmacologic dose is eliminated by the kidneys as unchanged niacin or nicotinuric acid, its primary metabolite. The plasma elimination half-life of niacin ranges from 20 to 45 minutes.Niacin and nicotinamide are both converted into the coenzyme NAD. NAD converts to NADP by phosphorylation in the presence of the enzyme NAD+ kinase. High energy requirements (brain) or high turnover rate (gut, skin) organs are usually the most susceptible to their deficiency. In the liver, niacinamide is converted to storage nicotinamide adenine dinucleotide (NAD). As needed, liver NAD is hydrolyzed to niacinamide and niacin for transport to tissues, there reconverted to NAD to serve as an enzyme cofactor. Excess niacin is methylated in the liver to N1-methylnicotinamide (NMN) and excreted in urine as such or as the oxidized metabolite N1-methyl-2-pyridone-5-carboxamide (2-pyridone). Decreased urinary content of these metabolites is a measure of niacin deficiency. Production Biosynthesis In addition to absorbing niacin from diet, niacin can be synthesized from the essential amino acid tryptophan, a five-step process with the penultimate compound being quinolinic acid (see figure). Some bacteria and plants utilize aspartic acid in a pathway that also goes to quinolinic acid. For humans, the efficiency of conversion is estimated as requiring 60 mg of tryptophan to make 1 mg of niacin. Riboflavin, vitamin B6 and iron are required for the process. Pellagra is a consequence of a corn-dominant diet because the niacin in corn is poorly bioavailable and corn proteins are low in tryptophan compared to wheat and rice proteins. Industrial synthesis Nicotinic acid was first synthesized in 1867 by oxidative degradation of nicotine. Niacin is prepared by hydrolysis of nicotinonitrile, which, as described above, is generated by oxidation of 3-picoline. Oxidation can be effected by air, but ammoxidation is more efficient. In the latter process, nicotinonitrile is produced by ammoxidation of 3-methylpyridine. Nitrile hydratase is then used to catalyze nicotinonitrile to nicotinamide, which can be converted to niacin. Alternatively, ammonia, acetic acid and paraldehyde are used to make 5-ethyl-2-methyl-pyridine, which is then oxidized to niacin. New "greener" catalysts are being tested using manganese-substituted aluminophosphates that use acetyl peroxyborate as non-corrosive oxidant, avoiding producing nitrogen oxides as do traditional ammoxidations.The demand for commercial production includes for animal feed and for food fortification meant for human consumption. According to Ullmanns Encyclopedia of Industrial Chemistry, worldwide 31,000 tons of nicotinamide were sold in 2014. Chemistry This colorless, water-soluble solid is a derivative of pyridine, with a carboxyl group (COOH) at the 3-position. Other forms of vitamin B3 include the corresponding amide nicotinamide (niacinamide), where the carboxyl group has been replaced by a carboxamide group (CONH2). Preparations Niacin is incorporated into multi-vitamin and sold as a single-ingredient dietary supplement. The latter can be immediate or slow release.Nicotinamide (niacinamide) is used to treat niacin deficiency because it does not cause the flushing adverse reaction seen with niacin. Nicotinamide may be toxic to the liver at doses exceeding 3 g/day for adults.Prescription products can be immediate release (Niacor, 500 mg tablets) or extended release (Niaspan, 500 and 1000 mg tablets). Niaspan has a film coating that delays release of the niacin, resulting in an absorption over a period of 8–12 hours. This reduces vasodilation and flushing side effects, but increases the risk of hepatotoxicity compared to the immediate release drug.Prescription niacin in combination with statin drugs (discontinued) is described above. A combination of niacin and laropiprant had been approved for use in Europe and marketed as Tredaptive. Laropiprant is a prostaglandin D2 binding drug shown to reduce niacin-induced vasodilation and flushing side effects. A clinical trial showed no additional efficacy of Tredaptive in lowering cholesterol when used together with other statin drugs, but did show an increase in other side effects. The study resulted in the withdrawal of Tredaptive from the international market. One form of dietary supplement sold in the US is inositol hexanicotinate (IHN), also called inositol
Niacin	nicotinate. This is inositol that has been esterified with niacin on all six of inositols alcohol groups. IHN is usually sold as "flush-free" or "no-flush" niacin in units of 250, 500, or 1000 mg/tablets or capsules. In the US, it is sold as an over-the-counter formulation, and often is marketed and labeled as niacin, thus misleading consumers into thinking they are getting an active form of the medication. While this form of niacin does not cause the flushing associated with the immediate-release products, there is not enough evidence to recommend IHN to treat hyperlipidemia. History Niacin as a chemical compound was first described by chemist Hugo Weidel in 1873 in his studies of nicotine, but that predated by many years the concept of food components other than protein, fat and carbohydrates that were essential for life. Vitamin nomenclature was initially alphabetical, with Elmer McCollum calling these fat-soluble A and water-soluble B. Over time, eight chemically distinct, water-soluble B vitamins were isolated and numbered, with niacin as vitamin B3. Corn (maize) became a staple food in the southeast United States and in parts of Europe. A disease that was characterized by dermatitis of sunlight-exposed skin was described in Spain in 1735 by Gaspar Casal. He attributed the cause to poor diet. In northern Italy it was named "pellagra" from the Lombard language (agra = holly-like or serum-like; pell = skin). In time, the disease was more closely linked specifically to corn. In the US, Joseph Goldberger was assigned to study pellagra by the Surgeon General of the United States. His studies confirmed a corn-based diet as the culprit, but he did not identify the root cause.Nicotinic acid was extracted from liver by biochemist Conrad Elvehjem in 1937. He later identified the active ingredient, referring to it as "pellagra-preventing factor" and the "anti-blacktongue factor." It was also referred to as "vitamin PP", "vitamin P-P" and "PP-factor", all derived from the term "pellagra-preventive factor". In the late 1930s, studies by Tom Douglas Spies, Marion Blankenhorn, and Clark Cooper confirmed that niacin cured pellagra in humans. The prevalence of the disease was greatly reduced as a result.In 1942, when flour enrichment with nicotinic acid began, a headline in the popular press said "Tobacco in Your Bread." In response, the Council on Foods and Nutrition of the American Medical Association approved of the Food and Nutrition Boards new names niacin and niacin amide for use primarily by non-scientists. It was thought appropriate to choose a name to dissociate nicotinic acid from nicotine, to avoid the perception that vitamins or niacin-rich food contains nicotine, or that cigarettes contain vitamins. The resulting name niacin was derived from nicotinic acid + vitamin.Carpenter found in 1951, that niacin in corn is biologically unavailable, and can be released only in very alkaline lime water of pH 11. This explains why a Latin-American culture that used alkali-treated cornmeal to make tortilla was not at risk for niacin deficiency.In 1955, Altschul and colleagues described large amounts of niacin as having a lipid-lowering property. As such, niacin is the oldest known lipid-lowering drug. Lovastatin, the first statin drug, was first marketed in 1987. Research In animal models and in vitro, niacin produces marked anti-inflammatory effects in a variety of tissues – including the brain, gastrointestinal tract, skin, and vascular tissue – through the activation of hydroxycarboxylic acid receptor 2 (HCA2), also known as niacin receptor 1 (NIACR1). Unlike niacin, nicotinamide does not activate NIACR1; however, both niacin and nicotinamide activate the G protein-coupled estrogen receptor (GPER) in vitro. References External links "Niacin". Drug Information Portal. U.S. National Library of Medicine.
Salsalate	Salsalate is a medication that belongs to the salicylate and nonsteroidal anti-inflammatory drug (NSAID) classes. Salsalate is the generic name of a prescription drug marketed under the brandnames Mono-Gesic, Salflex, Disalcid, and Salsitab. Other generic and brand name formulations may be available. Mechanism of action Relative to other NSAIDs, salsalate has a weak inhibitory effect on the cyclooxygenase enzyme and decreases the production of several proinflammatory chemical signals such as interleukin-6, TNF-alpha, and C-reactive protein.The mechanism through which salsalate is thought to reduce the production of these inflammatory chemical signals is through the inhibition of IκB kinase resulting in decreased action of NF-κB genes. This mechanism is thought to be responsible for salsalates insulin-sensitizing and blood sugar lowering properties. Medical uses Salsalate may be used for inflammatory disorders such as rheumatoid arthritis or noninflammatory disorders such as osteoarthritis. Safety The risk of bleeding is a common concern with use of the NSAID class of medications. However, the bleeding risk associated with salsalate is lower than that associated with aspirin use. Research Salsalate has been proposed for the prevention and treatment of type 2 diabetes mellitus due to its ability to lower insulin resistance associated with inflammation and may be useful in prediabetes. However, the use of salsalate to prevent the progression from prediabetes to type 2 diabetes mellitus has received limited study. History Salsalate had been suggested as possible treatment for diabetes as early as 1876. Synthesis == References ==
Nikki	Nikki may refer to: Arts and entertainment Fictional characters Nikki (Barbie), a fashion doll in the Barbie toy line Nikki (comics), a Marvel Comics character Nikki and Paulo, from the TV series Lost Nikki, the mascot of Swapnote Nikki, the main character from Dork Diaries Music Nikki (album), by Nikki Yanofsky, 2010 Nikki, an album by Quruli, 2005 "Nikki" (song), by Forever the Sickest Kids, 2013 "Nikki", a song by Logic from Under Pressure, 2014 "Nikki", an instrumental composition by Burt Bacharach Other media Nikki (DC Thomson), a 1980s girls comic Nikki (TV series), a 2000s American series starring Nikki Cox Nikki, Wild Dog of the North, a 1961 Walt Disney film People Nikki (given name), including a list of people with the name Singers Nikki (singer), Japanese-American singer Nikki (Malaysian singer), Nikki Palikat (born 1985), a finalist in the first season of Malaysian Idol Nigar Jamal (born 1980) or Nikki, English-Azerbaijani singer Other uses Nikki (drug), marketing name of a birth control pill Nikki, Benin, a city, arrondissement and commune See also Nicci (disambiguation) Nicki (disambiguation) Nicky (disambiguation) Nickey (disambiguation) Nickie (disambiguation) Nique (disambiguation) All pages with titles beginning with Nikki All pages with titles containing Nikki Nikii Daas NikkieTutorials Nikky Finney Nikky Niky
Calan	Calan may refer to Calan (band), a Welsh band Calan, Morbihan, a town in Brittany, France Calan, a trade name for the drug Verapamil Călan, a town in Hunedoara County, Romania Alline Calandrini (born 1988), known as Calan, a Brazilian footballer
Isoprenaline	Isoprenaline, or isoproterenol (brand name: Isoprenaline Macure), is a medication used for the treatment of bradycardia (slow heart rate), heart block, and rarely for asthma. It is a non-selective β adrenoceptor agonist that is the isopropylamine analog of epinephrine (adrenaline). Medical uses It is used to treat heart block and episodes of Adams–Stokes syndrome that are not caused by ventricular tachycardia or fibrillation, in emergencies for cardiac arrest until electric shock can be administered, for bronchospasm occurring during anesthesia, and as an adjunct in the treatment of hypovolemic shock, septic shock, low cardiac output (hypoperfusion) states, congestive heart failure, and cardiogenic shock.Historically, it was used to treat asthma via metered aerosol or nebulizing devices; it was also available in sublingual, oral, intravenous, and intramuscular formulations. The U.S. National Asthma Education and Prevention Program Expert Panel recommends against its use as a nebulizer for acute bronchoconstriction.Isoprenaline can also ameliorate the impairment of intestinal stem cells mediated by β2-adrenoreceptors after chemotherapy. Contraindications It should not be used in people with tachyarrhythmias, tachycardia or heart block caused by digitalis poisoning, ventricular arrhythmias which require inotropic therapy, or with angina. Adverse effects Adverse effects of isoprenaline include nervousness, headache, dizziness, nausea, visual blurring, tachycardia, palpitations, angina, Adams-Stokes attacks, pulmonary edema, hypertension, hypotension, ventricular arrhythmias, tachyarrhythmias, difficulty breathing, sweating, mild tremors, weakness, flushing, and pallor. Isoproterenol has been reported to cause insulin resistance leading to diabetic ketoacidosis. Pharmacology The adverse effects of isoprenaline are also related to the drugs cardiovascular effects. Isoprenaline can produce tachycardia (an elevated heart rate), which predisposes people who take it to cardiac arrhythmias. Pharmacodynamics Isoprenaline is a β1 and β2 adrenoreceptor agonist and has almost no activity on alpha adrenergic receptors. Its agonist effects at TAAR1 provide it with pharmacodynamic effects that resemble those of the endogenous trace amines, like tyramine.Isoprenalines effects on the cardiovascular system (non-selective) relate to its actions on cardiac β1 receptors and β2 receptors on smooth muscle within the tunica media of arterioles. Isoprenaline has positive inotropic and chronotropic effects on the heart. β2 adrenoceptor stimulation in arteriolar smooth muscle induces vasodilation. Its inotropic and chronotropic effects elevate systolic blood pressure, while its vasodilatory effects tend to lower diastolic blood pressure. The overall effect is to decrease mean arterial pressure due to the β2 receptors vasodilation.The isopropylamine group in isoprenaline makes it selective for β receptors. The free catechol hydroxyl groups keep it susceptible to enzymatic metabolism. Pharmacokinetics The plasma half-life for isoprenaline is approximately two minutes. Chemistry It is structurally related to epinephrine. History It was first approved in the US in 1947. Between 1963 and 1968 in England, Wales, Scotland, Ireland, Australia, and New Zealand there was an increase in deaths among people using isoprenaline to treat asthma. This was attributed to overdose: the inhalers produced in that area were dispensing five times the dosage dispensed by inhalers produced in the US and Canada, where the deaths were not observed. Society and culture Brands As of June 2017, isoprenaline was marketed under many brand names worldwide and as two different salts: Aleudrina, Asthpul, Iludrin, Isomenyl, Isoprenalin, Isoprenalina, Isoprenalina, Isoprenalina, Isoprenaline, Isoprenaline Macure, Isoprénaline, Isoprénaline, Isoprenaline hydrochloride, Isoprenaline sulfate, Isoprenalinesulfaat, Isoprenalinsulfat, Isoprenalinum, Isopropydine, Isopropylnoradrenaline, Isoproterenol, Isoproterenol, Isoproterenol, Isoproterenol hydrochloride, Isoproterenol sulfate, Isuprel, Isuprel, Neo-Epinine, Neodrenal, Proternol, Saventrine, and Win 5162. It is also marketed as a combination drug with cromoglicic acid as Frenal Compositum, in combination with pronase as Isopal P, and in combination with atropine as Stmerin D. == References ==
Iloprost	Iloprost is a medication used to treat pulmonary arterial hypertension (PAH), scleroderma, Raynauds phenomenon and other diseases in which the blood vessels are constricted and blood cannot flow to the tissues. This damages the tissues and causes high blood pressure. There is ongoing research into using it as a frostbite treatment. Iloprost works by opening (dilating) the blood vessels to allow the blood to flow through again. It was developed by the pharmaceutical company Schering AG and is marketed by Bayer Schering Pharma AG in Europe and Actelion Pharmaceuticals in the USA. Iloprost is given via inhalation, and a therapeautic benefit of the drug is that a very low dose is required because of the deposition in the lung. Iloprost has few systemic side effects for that reason. Clinical pharmacology Iloprost is a synthetic analogue of prostacyclin PGI2. Iloprost dilates systemic and pulmonary arterial vascular beds. It also affects platelet aggregation but the relevance of this effect to the treatment of pulmonary hypertension is unknown. The two diastereoisomers of iloprost differ in their potency in dilating blood vessels, with the 4S isomer substantially more potent than the 4R isomer. While Iloprost is an analog of PGI2 that activates PGI2s receptor, the prostacyclin receptor, to stimulate vasodilation, it has little selectivity in that it binds to and activates all four receptors for prostaglandin E2 viz., prostaglandin EP1 receptor, prostaglandin EP2 receptor, prostaglandin EP3 receptor, and prostaglandin EP4 receptor. Activation of the EP2 and EP4 receptors cause vasodilation but activation of the EP3 receptor causes vasoconstriction. Dosage and administration Inhaled In the U.S., iloprost is inhaled specifically using the I-Neb AAD or Prodose AAD delivery systems. In Europe iloprost has been approved for use with two compressed air nebulizers with AAD delivery systems (Halolite and Prodose) as well as with two ultrasonic nebulizers Ventaneb and I-Neb. Ventavis is supplied in 1 mL single-use glass ampules containing either 10 μg/mL or 20 μg/mL. The 20 μg/mL concentration is intended for patients who are maintained at the 5 μg dose and who have repeatedly experienced extended treatment times which could result in incomplete dosing. Transitioning patients to the 20 μg/mL concentration using the I-neb AAD System will decrease treatment times to help maintain patient compliance.The approved dosing regimen for iloprost is 6 to 9 times daily (no more than every 2 hours) during waking hours, according to individual need and tolerability. The significant clinical effects observed in the pivotal study of patients with PAH were achieved with a median dose of 30 μg per day (range: 12.5 to 45 μg delivered at the mouthpiece), corresponding to 6 daily inhalations of 5 μg. The majority of patients (> 80%) in the pivotal study used this median dose or a higher dose with an excellent treatment compliance after 12 weeks. The first inhaled dose of iloprost should be 2.5 μg (as delivered at the mouthpiece). If this dose is well tolerated, dosing should be increased to 5 μg and maintained at that dose. Any patient who cannot tolerate the 5 μg dose should be maintained at 2.5 μg. Each inhalation treatment requires one entire single-use ampule. Each single-use ampule delivers a concentration of 10 μg/mL to the medication chamber of either the I-Neb AAD or Prodose AAD System, and delivers a nominal dose of either 2.5 μg or 5.0 μg to the mouthpiece. After each inhalation session, any solution remaining in the medication chamber should be discarded. Use of the remaining solution, even if the reservoir is "topped off" with fresh medication, will result in unpredictable dosing. Patients should follow the manufacturers instructions for cleaning the I-Neb AAD or Prodose AAD System components after each dose administration. Complete information regarding use of iloprost in specific populations (e.g. nursing mothers, pediatrics, patients with hepatic or renal impairment), drug interactions, and overdosage can be found in full prescribing information. Intravenous Iloprost is also available in an intravenous form, developed and marketed by Schering AG under the trade name Ilomedine. IV iloprost is usually administered diluted, via a peripheral vein or central venous catheter. The diluted iloprost should be delivered by an accurate rate delivery system such as a syringe driver. Doses vary with individuals as side effects are better tolerated by some patients than others. The duration of the treatment is typically 3 days. This is usually repeated every 8 to 12 weeks. Contraindications unstable angina; within 6 months of myocardial infarction; decompensated cardiac failure (unless under close medical supervision); severe arrhythmias; congenital or acquired heart-valve defects; within 3 months of cerebrovascular events; pulmonary veno-occlusive disease; conditions which increase risk of bleeding. Common side effects In clinical studies, common adverse reactions due to inhaled iloprost included: vasodilation (flushing, 27%), cough (39%), headache (30%), flu syndrome (14%), nausea (13%), neck spasms (12%), hypotension (11%), insomnia (8%), and fainting (syncope) (8%); other serious adverse events reported with the use of Ventavis included congestive heart failure, chest pain, supraventricular tachycardia, dyspnea, swelling of the limbs (especially around the ankles and feet), and kidney failure.Serious adverse events reported with the use of inhaled iloprost include congestive heart failure, chest pain, supraventricular tachycardia, shortness of breath, peripheral edema, and kidney failure. Warnings Iloprost as Ventavis is intended for inhalation administration only via the I-Neb AAD or Prodose AAD Systems, pulmonary drug delivery devices. It has not been studied with any other nebulizers. Vital signs should be monitored while initiating inhaled iloprost therapy. Dose adjustments or a change in therapy should be considered if exertional syncope occurs. Inhaled iloprost should not be initiated in patients with systolic blood pressure lower than 85 mm Hg. Iloprost should be stopped immediately if signs of pulmonary edema occur. This may be a sign of pulmonary venous hypertension. Iloprost has not been evaluated in patients with chronic obstructive pulmonary disease (COPD), severe asthma, or with acute pulmonary infections. Should signs of pulmonary edema occur when inhaled iloprost is administered in patients with pulmonary hypertension, the treatment should be stopped immediately. This may be a sign of pulmonary venous hypertension. See also Pulmonary arterial hypertension (PAH) Raynauds phenomenon Scleroderma References Ventavis Package insert prescribing information available in PDF format. Olschewski, Horst; Simonneau, Gerald; Galiè, Nazzareno; Higenbottam, Timothy; Naeije, Robert; Rubin, Lewis J.; Nikkho, Sylvia; Speich, Rudolf; Hoeper, Marius M.; Behr, Jürgen; Winkler, Jörg; Sitbon, Olivier; Popov, Wladimir; Ghofrani, H. Ardeschir; Manes, Alessandra; Kiely, David G.; Ewert, Ralph; Meyer, Andreas; Corris, Paul A.; Delcroix, Marion; Gomez-Sanchez, Miguel; Siedentop, Harald; Seeger, Werner (August 1, 2002). "Inhaled Iloprost for Severe Pulmonary Hypertension". New England Journal of Medicine. 347 (5): 322–329. doi:10.1056/NEJMoa020204. PMID 12151469. ATS 2005. The International Conference of the American Thoracic Society. 20–25 May 2005. San Diego, CA. Meizer, Roland; Meraner, Dominik; Meizer, Elisbeth; Radda, Christian; Landsiedl, Franz; Aigner, Nicolas (Jan 2009). "Outcome of painful bone marrow edema of the femoral head following treatment with parenteral iloprost". Indian Journal of Orthopaedics. 43 (1): 36–9. doi:10.4103/0019-5413.45321. PMC 2739485. PMID 19753177. External links "Iloprost". Drug Information Portal. U.S. National Library of Medicine.
Peginterferon alfa-2a	Pegylated interferon alfa-2a, sold under the brand name Pegasys among others, is medication used to treat hepatitis C and hepatitis B. For hepatitis C it is typically used together with ribavirin and cure rates are between 24 and 92%. For hepatitis B it may be used alone. It is given by injection under the skin.Side effects are common. They may include headache, feeling tired, depression, trouble sleeping, hair loss, nausea, pain at the site of injection, and fever. Severe side effects may include psychosis, autoimmune disorders, blood clots, or infections. Use with ribavirin is not recommended during pregnancy. Pegylated interferon alfa-2a is in the alpha interferon family of medications. It is pegylated to protect the molecule from breakdown.Pegylated interferon alfa-2a was approved for medical use in the United States in 2002. It is on the World Health Organizations List of Essential Medicines. Medical uses This drug is approved around the world for the treatment of chronic hepatitis C (including people with HIV co-infection, cirrhosis, normal levels of ALT) and has recently been approved (in the EU, U.S., China and many other countries) for the treatment of chronic hepatitis B. It is also used in the treatment of certain T-cell lymphomas, particularly mycosis fungoides. Peginterferon alfa-2a is a long acting interferon. Interferons are proteins released in the body in response to viral infections. Interferons are important for fighting viruses in the body, for regulating reproduction of cells, and for regulating the immune system. Host genetic factors For genotype 1 hepatitis C treated with pegylated interferon alfa-2a or pegylated interferon alfa-2b combined with ribavirin, it has been shown that genetic polymorphisms near the human IL28B gene, encoding interferon lambda 3, are associated with significant differences in response to the treatment. This finding, originally reported in Nature, showed genotype 1 hepatitis C patients carrying certain genetic variant alleles near the IL28B gene are more likely to achieve sustained virological response after the treatment than others. Another report in Nature demonstrated the same genetic variants are also associated with the natural clearance of the genotype 1 hepatitis C virus. Other infections Has also been used for Middle East respiratory syndrome and hepatitis E. Manufacture It is pegylated with a branched 40 kg/mol PEG chain. The drug has been manufactured under the brand name Pegasys by Roche Pharmaceuticals. Due to changes in clinical practice - antiviral hepatitis drugs such as sofosbuvir have become much more important - Roche announced in 2020 that it would withdraw Pegasys from the market worldwide, but subsequently sold the worldwide rights to pharma&, an Austrian / Swiss pharmaceutical company that ensures supply in the medium and long term almost worldwide (excluding China and Japan). Research A Cochrane Review sought to determine whether interferon alfa-2a could be used as a treatment for individuals with neovascular age-related macular degeneration. They found no evidence of improved visual acuity with potential harm. References External links "Peginterferon alfa-2a". Drug Information Portal. U.S. National Library of Medicine. Pegasys at the US National Library of Medicine Medical Subject Headings (MeSH)
Triprolidine	Triprolidine is an over-the-counter antihistamine with anticholinergic properties. It is used to combat the symptoms associated with allergies and is sometimes combined with other cold medications designed to provide general relief for flu-like symptoms. As with many antihistamines, the most common side effect is drowsiness.It was patented in 1948 and came into medical use in 1953. See also Benztropine Pseudoephedrine UK-9040 == References ==
Fludroxycortide	Fludroxycortide (INN, BAN, JAN), also known as flurandrenolide (USAN) and flurandrenolone, is a synthetic topical corticosteroid and is used as an anti-inflammatory treatment for use on skin irritations. Trade names include Haelan (Typharm, UK) and Cordran (by Watson Pharmaceuticals, US).Fludroxycortide is available in ointment, cream and as an impregnated tape (Haelan tape, Cordran tape). Licensed indications in the United Kingdom include recalcitrant dermatoses. == References ==
Orciprenaline	Orciprenaline, also known as metaproterenol, is a bronchodilator used in the treatment of asthma. Orciprenaline is a moderately selective β2 adrenergic receptor agonist that stimulates receptors of the smooth muscle in the lungs, uterus, and vasculature supplying skeletal muscle, with minimal or no effect on α adrenergic receptors. The pharmacologic effects of β adrenergic agonist drugs, such as orciprenaline, are at least in part attributable to stimulation through β adrenergic receptors of intracellular adenylyl cyclase, the enzyme which catalyzes the conversion of ATP to cAMP. Increased cAMP levels are associated with relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity from many cells, especially from mast cells. Possible side effects tremor nervousness dizziness weakness headache nausea tachycardiaRare side effects that could be life-threateningincreased difficulty breathing rapid or increased heart rate irregular heartbeat chest pain or discomfort Brand names Alupent Metaprel Orcibest == References ==
RVSV-ZEBOV vaccine	Recombinant vesicular stomatitis virus–Zaire Ebola virus (rVSV-ZEBOV), also known as Ebola Zaire vaccine live and sold under the brand name Ervebo, is an Ebola vaccine for adults that prevents Ebola caused by the Zaire ebolavirus. When used in ring vaccination, rVSV-ZEBOV has shown a high level of protection. Around half the people given the vaccine have mild to moderate adverse effects that include headache, fatigue, and muscle pain.rVSV-ZEBOV is a recombinant, replication-competent viral vector vaccine. It consists of rice-derived recombinant human serum albumin and live attenuated recombinant vesicular stomatitis virus (VSV), which has been genetically engineered to express the main glycoprotein from the Zaire ebolavirus so as to provoke a neutralizing immune response to the Ebola virus.The vaccine was approved for medical use in the European Union and the United States in 2019. It was created by scientists at the National Microbiology Laboratory in Winnipeg, Manitoba, Canada, which is part of the Public Health Agency of Canada (PHAC). PHAC licensed it to a small company, Newlink Genetics, which started developing the vaccine; Newlink in turn licensed it to Merck in 2014. It was used in the DR Congo in a 2018 outbreak in Équateur province, and has since been used extensively in the 2018–20 Kivu Ebola outbreak, with over 90,000 people vaccinated. Medical use Nearly 800 people were ring vaccinated on an emergency basis with VSV-EBOV when another Ebola outbreak occurred in Guinea in March 2016. In 2017, in the face of a new outbreak of Ebola in the Democratic Republic of the Congo, the Ministry of Health approved the vaccines emergency use, but it was not immediately deployed. Effectiveness In April 2019, following a large-scale ring-vaccination scheme in the DRC outbreak, the WHO published the preliminary results of its research, in association with the DRCs Institut National pour la Recherche Biomedicale, into the effectiveness of the ring vaccination program, stating that the rVSV-ZEBOV-GP vaccine had been 97.5% effective at stopping Ebola transmission, relative to no vaccination. Side effects Systemic side effects include headache, feverishness, fatigue, joint and muscle pain, nausea, arthritis, rash, and abnormal sweating. Injection-site side events include injection-site pain, swelling, and redness. Biochemistry rVSV-ZEBOV is a live, attenuated recombinant vesicular stomatitis virus (VSV) in which the gene for the native envelope glycoprotein (P03522) is replaced with that from the Ebola virus (P87666), Kikwit 1995 Zaire strain. Manufacturing of the vaccine for the Phase I trial was done by IDT Biologika. Manufacturing of vaccine for the Phase III trial was done by Merck, using the Vero cell line, which Merck already used to make its RotaTeq vaccine against rotavirus. History Scientists working for the Public Health Agency of Canada (PHAC) created the vaccine, and PHAC applied for a patent in 2003. From 2005, to 2009, three animal trials on the virus were published, all of them funded by the Canadian and U.S. governments. In 2005, a single intramuscular injection of the EBOV or MARV vaccine was found to induce completely protective immune responses in nonhuman primates (crab-eating macaques) against corresponding infections with the otherwise typically lethal EBOV or MARV.In 2010, PHAC licensed the intellectual property on the vaccine to a small U.S. company called Bioprotection Systems, which was a subsidiary of Newlink Genetics, for US $205,000 and "low single-digit percentage" royalties. Newlink had funding from the U.S. Defense Threat Reduction Agency to develop vaccines.In December 2013, the largest-ever Ebola epidemic started in West Africa, specifically, in Guinea. On August 12, the WHO ruled that offering people infected with Ebola the RVSV-ZEBOV vaccine (which at the time was untested on humans) was ethical, and the Canadian government donated 500 doses of the vaccine to the WHO. In October 2014, Newlink had no vaccine in production and no human trials underway, and there were calls for the Canadian government to cancel the contract. In September or October 2014, Newlink formed a steering committee among the interested parties, including PHAC, the NIH, and the WHO, to plan the clinical development of the vaccine.In October 2014, Newlink Genetics began a Phase I clinical trial of rVSV-ZEBOV on healthy human subjects to evaluate the immune response, identify any side effects and determine the appropriate dosage. Phase I trials took place in Gabon, Kenya, Germany, Switzerland, the US, and Canada. In November 2014, Newlink exclusively licensed rights to the vaccine to Merck for US $50 million plus royalties.The Phase I study started with a high dose which caused arthritis and skin reactions in some people, and the vaccine was found replicating in the synovial fluid of the joints of the affected people; the clinical trial was halted because of that, then recommenced with a lower dose.In March 2015, a Phase II clinical trial and a Phase III started in Guinea at the same time; the Phase II trial focused on frontline health workers, while the Phase III trial was a ring vaccination in which close contacts of people who had contracted Ebola virus were vaccinated with VSV-EBOV.In January 2016, the GAVI Alliance signed an agreement with Merck under which Merck agreed to provide VSV-EBOV vaccine for future outbreaks of Ebola and GAVI paid Merck US$5 million; Merck will use the funds to complete clinical trials and obtain regulatory approval. As of that date, Merck had submitted an application to the World Health Organization (WHO) through their Emergency Use Assessment and Listing (EUAL) program to allow for use of the vaccine in the case of another epidemic. It was used on an emergency basis in Guinea in March 2016.Results of the Phase III Guinea trial were published in December 2016. It was widely reported in the media that vaccine was safe and appeared to be nearly 100% effective, but the vaccine remained unavailable for commercial use as of December 2016.In April 2017, scientists from the U.S. National Academy of Medicine (NAM) published a review of the response to the Ebola outbreak that included a discussion of how clinical trial candidates were selected, how trials were designed and conducted, and reviewed the data resulting from the trials. The committee found that data from the Phase III Guinea trial were difficult to interpret for several reasons. The trial had no placebo arm; it was omitted for ethical reasons and everyone involved, including the committee, agreed with the decision. This left only a delayed treatment group to serve as a control, but this group was eliminated after an interim analysis showed high levels of protection, which left the trial even more underpowered. The committee found that under an intention-to-treat analysis, the rVSV-ZEBOV vaccine might have had no efficacy, agreed with the authors of the December 2016 report that it probably had some efficacy, but found statements that it had substantial or 100% efficacy to be unsupportable.In April 2019, following a large-scale ring-vaccination scheme in the DRC outbreak, preliminary results showed that the vaccine had been 97.5% effective at stopping Ebola transmission, relative to no vaccination.In September 2019, the U.S. Food and Drug Administration (FDA) accepted Mercks Biologics License Application and granted priority review for the vaccine.In October 2019, the European Medicines Agency (EMA) recommended granting conditional marketing authorization for the rVSV-ZEBOV-GP vaccine.In November 2019, the European Commission granted a conditional marketing authorization to Ervebo and the World Health Organization (WHO) prequalified an Ebola vaccine for the first time, indicating that the vaccine met WHO standards for quality, safety and efficacy, and allowing UN agencies and GAVI to procure vaccine for distributions.In December 2019, Ervebo was approved for use in the United States.The approval of Ervebo was supported by a study conducted in Guinea during the 2014-2016 outbreak in individuals 18 years of age and older. The study was a randomized cluster (ring) vaccination study in which 3,537 contacts, and contacts of contacts, of individuals with laboratory-confirmed Ebola virus disease (EVD) received either "immediate" or 21-day "delayed" vaccination with Ervebo. This noteworthy design was intended to capture a social network of individuals and locations that might include dwellings or workplaces where a patient spent time while symptomatic, or the households of individuals who had contact with the patient during that persons illness or death. In a comparison of cases of EVD among 2,108 individuals in the "immediate" vaccination arm and 1,429 individuals in the "delayed" vaccination arm, Ervebo was determined to be 100% effective in preventing Ebola cases with symptom onset greater than ten days after vaccination. No cases of EVD with symptom onset greater than ten days after vaccination were observed in the "immediate" cluster group, compared with ten cases of EVD in the 21-day "delayed" cluster group.In additional studies, antibody responses to Ervebo were assessed in 477 individuals in Liberia, approximately 500 individuals in Sierra Leone and approximately 900 individuals in Canada, Spain and the U.S. The antibody responses among those in the study conducted in Canada, Spain and the U.S. were similar to those among individuals in the studies conducted in Liberia and Sierra Leone.The safety of Ervebo was assessed in approximately 15,000 individuals in Africa, Europe and North America. The most commonly reported side effects were pain, swelling and redness at the injection site, as well as headache, fever, joint and muscle aches and fatigue.The application for Ervebo in the United States was granted priority review, a tropical disease priority review voucher, and breakthrough therapy designation. The U.S. Food and Drug Administration (FDA) granted approval for Ervebo to Merck & Co., Inc.Merck discontinued development of the related rVSV vaccines for Marburg virus (rVSV-MARV) and Sudan ebolavirus (rVSV-SUDV). Merck returned the rights on these vaccines back to Public Health Agency of Canada. The knowledge on developing rVSV vaccines which Merck gained with GAVI funding remains Mercks, and cannot be used by anyone else wishing to develop a rVSV vaccine. Ebola 2018 2018 Democratic Republic of the Congo Ebola virus outbreak During an outbreak in the Democratic Republic of the Congo in 2018, the ZEBOV vaccine was used, and what was once contact tracing which numbered 1,706 individuals (ring vaccination which totaled 3,330) was reduced to zero on June 28, 2018. The outbreak completed the required 42-day cycle on July 24. 2018 Kivu Ebola outbreak On August 1, an EVD outbreak was declared in North Kivu DRC. After six months the current totals stand at 735 total cases and 371 deaths; violence in the region has helped the spread of the virus.Preliminary results show ring vaccination with the vaccine has been highly effective at reducing Ebola transmission. References Further reading "Scientists hail 100% effective Ebola vaccine". National Health Service. England. August 3, 2015. Archived from the original on November 15, 2019. Retrieved November 15, 2019. Marzi A, Robertson SJ, Haddock E, et al. (August 14, 2015). "VSV-EBOV rapidly protects macaques against infection with the 2014/15 Ebola virus outbreak strain". Science. 349 (6249): 739–42. doi:10.1126/science.aab3920. ISSN 0036-8075. PMID 26249231. External links "Ebola Vaccine VSVDG-ZEBOV". Drug Information Portal. U.S. National Library of Medicine. Ebola Vaccines at the US National Library of Medicine Medical Subject Headings (MeSH)
Rolaids	Rolaids is an American brand of calcium and magnesium-based antacid produced by Chattem. It was invented by American chemist Irvine W. Grote in the late 1920s, and originated with manufacturing in Chattanooga, Tennessee, under one of Chattems forerunner companies, which manufactured the brand for Warner-Lambert; Warner-Lambert merged with Pfizer in 2000. In 2006, McNeil Consumer Healthcare, a subsidiary of Johnson & Johnson, acquired the brand from Pfizer Consumer Healthcare. In 2013, McNeil sold the brand to Sanofi, following a two-year period where the brand was pulled off the market due to product recalls resulting from quality control and manufacturing issues that also left former fellow antacid brand Pepcid ACs "chewables" product and other fellow McNeil products like some varieties of Tylenol off store shelves for the same period. Rolaids returned to the market at the beginning of September 2013 under Chattem ownership with new packaging, trade dress, and a new liquid variety. Rolaids tablets come in many different flavors, including original peppermint, cherry, freshmint, fruit, tropical, punch, cool mint, berry, and apple. 2010 recall McNeil Consumer Healthcare voluntarily recalled Rolaids products in the Americas, the United Arab Emirates (UAE), and Fiji on January 15, 2010, in consultation with the FDA. The company initiated the recall following an investigation of consumer reports of an unusual moldy, musty, or mildewlike odor that, in a small number of cases, was associated with temporary and nonserious gastrointestinal events. These events included nausea, stomach pain, vomiting, and diarrhea. At that time, the Rolaids website carried the following statement regarding product availability: "You may have noticed that ROLAIDS® products are not available at your local retailers. We are changing some of our manufacturing facilities where our products are made, a process that will take time to complete. We apologize for the inconvenience this may be causing you. Your health and comfort are important to us, and we assure you we are working hard to get ROLAIDS® product back on store shelves."Another recall was issued around December 9, 2010, as a result of foreign objects that contained metal and wood particles. The foreign materials were caused by a third-party manufacturer during the production process. Several people complained when they took the product; they also had vomiting, strange taste, and tooth and gum injury. After this recall, beyond the small "candy aisle" rolls and chewable lines, the Rolaids line of products was drastically reduced and disappeared from most American retailers until Chattem returned the product to the market in the fall of 2013. Advertising Rolaids best-known commercial from the 1970s featured the famous tag line: "How do you spell relief?" "R-O-L-A-I-D-S"In connection with the famous slogan, Rolaids sponsored the Major League Baseball award for top relief pitchers called the Rolaids Relief Man of the Year Award. The award was given yearly from 1976 through 2012. Rolaids softchews Pfizer released a new version of Rolaids on April 6, 2006, branded Extra Strength Rolaids Plus Gas Relief Softchews. The product was produced as an alternative for people averse to the chalky consistency of regular Rolaids. They were widely advertised in multiple media formats. Rolaids Softchews were originally developed and test marketed in Oklahoma City under the brand name Remegel by Warner Lambert in 1984. Medical information The active ingredients are calcium carbonate (550 mg) and magnesium hydroxide (110 mg). The inactive ingredients are dextrose, flavoring, magnesium stearate, polyethylene glycol, pregelatinized starch, sucralose and sucrose. The new Chattem varieties have increased the amount of the active ingredients in the product, up to 1000 mg of calcium carbonate and 200 mg of magnesium hydroxide for the "ultra strength" varieties. Minor side effects may include constipation or stomach cramps. Serious side effects include loss of appetite, vomiting, dizziness, and headache. References External links Official website
Co-amilozide	Co-amilozide (BAN) is a non-proprietary combination of amiloride and hydrochlorothiazide. Co-amilozide is used in the treatment of hypertension and congestive heart failure with the tendency of the thiazide to cause low potassium levels (hypokalaemia) offset by the potassium-sparing effects of amiloride. Formulation Two strengths of co-amilozide are currently available in the UK: 2.5 mg amiloride and 25 mg hydrochlorothiazide, BAN of Co-amilozide 2.5/25 (brand name Moduret 25) 5 mg amiloride and 50 mg hydrochlorothiazide, BAN of Co-amilozide 5/50 (brand name Moduretic)In North America: Moduretic (U.S., Canada) Moduretic 5-50 (U.S., Canada) Novamilor (Canada) Side effects The most common side effect is headache (about 8% of people taking it) and nausea, loss of appetite, weakness, rash and dizziness (each about 3%).Common side effects (1/10 - 1/100) include: General: weakness, fatigue, loss of appetite, headache, dizziness. Circulatory system: arrhythmia. Gastrointestinal: nausea, diarrhea, abdominal pain. Skin: exanthema, itching. Respiratory system: shortness of breath, cough. Metabolic: elevated blood sugar in diabetic patients, elevated uric acid levels in the blood. Musculoskeletal: pain in the limbs. == References ==
Trastuzumab deruxtecan	Trastuzumab deruxtecan, sold under the brand name Enhertu, is an antibody-drug conjugate consisting of the humanized monoclonal antibody trastuzumab (Herceptin) covalently linked to the topoisomerase I inhibitor deruxtecan (a derivative of exatecan). It is licensed for the treatment of breast cancer or gastric or gastroesophageal adenocarcinoma. Trastuzumab binds to and blocks signaling through epidermal growth factor receptor 2 (HER2/neu) on cancers that rely on it for growth. Additionally, once bound to HER2 receptors, the antibody is internalized by the cell, carrying the bound deruxtecan along with it, where it interferes with the cells ability to make DNA structural changes and replicate its DNA during cell division, leading to DNA damage when the cell attempts to replicate itself, destroying the cell.It was approved for medical use in the United States in December 2019, in Japan in March 2020, in the European Union in January 2021, and in Australia in October 2021.Trastuzumab deruxtecan is the first approved therapy by the US Food and Drug Administration (FDA) targeted to people with the HER2-low breast cancer subtype subset of HER2-negative breast cancer. Medical uses Trastuzumab deruxtecan is indicated for the treatment of adults with unresectable (unable to be removed with surgery) or metastatic (when cancer cells spread to other parts of the body) HER2-positive breast cancer who have received two or more prior anti-HER2-based regimens in the metastatic setting and for adults with locally advanced or metastatic HER2-positive gastric or gastroesophageal junction adenocarcinoma who have received a prior trastuzumab-based regimen.In May 2022, the indication was revised to include the treatment of adults with unresectable or metastatic HER2-positive breast cancer who have received a prior anti-HER2-based regimen either in the metastatic setting, or in the neoadjuvant or adjuvant setting and have developed disease recurrence during or within six months of completing therapy.In August 2022, the indication was revised to include the treatment of unresectable or metastatic HER2-low breast cancer. Side effects and label warnings The most common side effects are nausea, fatigue, vomiting, alopecia (hair loss), constipation, decreased appetite, anemia (hemoglobin in blood is below the reference range), decreased neutrophil count (white blood cells that help lead your bodys immune system response to fight infection), diarrhea, leukopenia (other white blood cells that help the immune system), cough and decreased platelet count (component of blood whose function is to react to bleeding from blood vessel injury by clumping, thereby initiating a blood clot).The prescribing information for trastuzumab deruxtecan includes a boxed warning about the risk of interstitial lung disease (a group of lung conditions that causes scarring of lung tissues) and embryo-fetal toxicity. Interstitial lung disease and pneumonitis, including cases resulting in death, have been reported with trastuzumab deruxtecan. History The FDA approved trastuzumab deruxtecan based on the results of one clinical trial enrolling 184 female participants with HER2-positive, unresectable and/or metastatic breast cancer who had received two or more prior anti-HER2 therapies in the metastatic setting. These participants were heavily pretreated in the metastatic setting, receiving between two and 17 therapies prior to receiving trastuzumab deruxtecan. Participants in the clinical trial received trastuzumab deruxtecan every three weeks and tumor imaging was obtained every six weeks. The overall response rate was 60.3%, which reflects the percentage of participants who had a certain amount of tumor shrinkage with a median duration of response of 14.8 months.Efficacy was evaluated in a multicenter, open-label, randomized trial (DESTINY-Gastric01, NCT03329690) in participants with HER2-positive locally advanced or metastatic gastric or GEJ adenocarcinoma who had progressed on at least two prior regimens, including trastuzumab, a fluoropyrimidine- and a platinum-containing chemotherapy. A total of 188 participants were randomized (2:1) to receive trastuzumab deruxtecan 6.4 mg/kg intravenously every three weeks or physician’s choice of either irinotecan or paclitaxel monotherapy.Efficacy was based on DESTINY-Breast03 (NCT03529110), a multicenter, open-label, randomized trial that enrolled 524 participants with HER2-positive, unresectable, and/or metastatic breast cancer who received prior trastuzumab and taxane therapy for metastatic disease or developed disease recurrence during or within six months of completing neoadjuvant or adjuvant therapy. Participants were randomized 1:1 to receive either trastuzumab deruxtecan or trastuzumab emtansine by intravenous infusion every three weeks until unacceptable toxicity or disease progression. Randomization was stratified by hormone receptor status, prior treatment with pertuzumab, and history of visceral disease.The FDA approved trastuzumab deruxtecan for the treatment of HER2-low breast cancer based on DESTINY-Breast04, a randomized, multicenter, open label clinical trial that enrolled 557 adult participants with unresectable or metastatic HER2-low breast cancer. The trial included two cohorts: 494 hormone receptor positive (HR+) participants and 63 hormone receptor negative (HR-) participants. Of these participants, 373 randomly received trastuzumab deruxtecan by intravenous infusion every three weeks and 184 randomly received physicians choice of chemotherapy (eribulin, capecitabine, gemcitabine, nab paclitaxel, or paclitaxel). The results showed improvement in both progression-free survival and overall survival in people with unresectable or metastatic HER2-low breast cancer. Society and culture Legal status The U.S. Food and Drug Administration (FDA) approved trastuzumab deruxtecan in December 2019. The application for trastuzumab deruxtecan was granted accelerated approval, fast track designation, and breakthrough therapy designation. The FDA granted the approval of Enhertu to Daiichi Sankyo.On 10 December 2020, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) adopted a positive opinion, recommending the granting of a conditional marketing authorization for the medicinal product Enhertu, intended for the treatment of metastatic HER2-positive breast cancer. Trastuzumab deruxtecan was reviewed under EMAs accelerated assessment program. The applicant for this medicinal product is Daiichi Sankyo Europe GmbH. Trastuzumab deruxtecan was approved for medical use in the European Union in January 2021.In January 2021, the U.S. Food and Drug Administration (FDA) granted accelerated approval to trastuzumab deruxtecan for the treatment of adults with locally advanced or metastatic HER2-positive gastric or gastroesophageal (GEJ) adenocarcinoma who have received a prior trastuzumab-based regimen.In October 2021, the Therapeutic Goods Administration of Australia approved trastuzumab deruxtecan for provisional registration indicated for the treatment of adults with unresectable or metastatic HER2-positive breast cancer who have received two or more prior anti HER2-based regimens. References Further reading Iwata TN, Sugihara K, Wada T, et al. (October 2019). "[Fam-] trastuzumab deruxtecan (DS-8201a)-induced antitumor immunity is facilitated by the anti-CTLA-4 antibody in a mouse model". PLOS ONE. 14 (10): e0222280. Bibcode:2019PLoSO..1422280I. doi:10.1371/journal.pone.0222280. PMC 6772042. PMID 31574081. Modi S, Saura C, Yamashita T, et al. (February 2020). "Trastuzumab Deruxtecan in Previously Treated HER2-Positive Breast Cancer". N. Engl. J. Med. 382 (7): 610–621. doi:10.1056/NEJMoa1914510. PMC 7458671. PMID 31825192. External links "Trastuzumab_deruxtecan". Drug Information Portal. U.S. National Library of Medicine. Deruxtecan shows structure Clinical trial number NCT03329690 for "DS-8201a in Human Epidermal Growth Factor Receptor 2 (HER2)-Expressing Gastric Cancer [DESTINY-Gastric01]" at ClinicalTrials.gov Clinical trial number NCT03529110 for "DS-8201a Versus T-DM1 for Human Epidermal Growth Factor Receptor 2 (HER2)-Positive, Unresectable and/or Metastatic Breast Cancer Previously Treated With Trastuzumab and Taxane [DESTINY-Breast03]" at ClinicalTrials.gov
Ciprofloxacin/dexamethasone	Ciprofloxacin/dexamethasone (Ciprodex) is an antibiotic/steroid combination medication. It contains the synthetic broad-spectrum antibacterial agent, ciprofloxacin hydrochloride (0.3%), combined with the anti-inflammatory corticosteroid, dexamethasone (0.1%), in a sterile, preserved suspension for otic use. Ciprofloxacin, a fluoroquinolone antibiotic, has shown in vitro activity against many Gram-positive and Gram-negative bacteria including Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Pseudomonas aeruginosa. Dexamethasone acts as an anti-inflammatory corticosteroid. Medical uses Ciprodex is indicated for use in the treatment of acute otitis media and acute otitis externa (swimmers ear) in people aged six months and older. Mechanism of action Ciprofloxacin functions as a bactericide by interfering with DNA gyrase, an enzyme with a key role in the synthesis of bacterial DNA. Dexamethasone is used in combination in order to aid in the reducing inflammatory responses that often accompany bacterial infection. Clinical trials In clinical trials, the median time to cessation of ear pain in Ciprodex was five days in a sample population of 909 participants. However, the clinical trial failed to demonstrate any significant benefit of using the combination of active ingredients in Ciprodex over ciprofloxacin alone, in regards to ear pain. Ciprodex was superior to ciprofloxacin in regards to time to cessation of otorrhea. Phase I The most reported adverse effects of phase I studies included headache, rhinitis, pain, dyspepsia, and dysmenorrhea. Investigators did not believe that any of these were directly treatment-related, as many of these events are considered symptoms or manifestations of the underlying illness. Phase II and III Treatment-related adverse effects in AOE studies were determined in phase II and III trials. This includes ear pruritus, ear debris, superimposed ear infection, ear congestion, ear pain, and erythema. Similar effects were demonstrated in AOMT studies. Overall, Ciprodex was determined as a safe and well-tolerated drug for the treatment of AOE and AOMT. The proposed dosage for all patients was also effective and safe. Cure rates for pediatrics were slightly higher than adults in AOE studies. Drug interactions Drug interactions have not been studied with Ciprodex. Commercialization Ciprodex, owned by Alcon Laboratories, Inc., is protected by multiple patents and will be restricted from generic manufacturing until 2025. Ciprodex is the number 1 topical antibiotic ear drop prescribed since 2007 by ENTs and pediatricians. There have been 18 million prescriptions filled for Ciprodex since 2003, making it the world leading marketed ear drops for AOE.In October 2015, Alcon sued Dr. Reddys Laboratories (DLR) for allegedly infringing on Ciprodex patents. A judge in the UK upheld the Alcon patent. References External links "Ciprofloxacin mixture with dexamethasone". Drug Information Portal. U.S. National Library of Medicine.
Capital expenditure	Capital expenditure or capital expense (capex or CAPEX) is the money an organization or corporate entity spends to buy, maintain, or improve its fixed assets, such as buildings, vehicles, equipment, or land. It is considered a capital expenditure when the asset is newly purchased or when money is used towards extending the useful life of an existing asset, such as repairing the roof.Capital expenditures contrast with operating expenses (opex), which are ongoing expenses that are inherent to the operation of the asset. Opex includes items like electricity or cleaning. The difference between opex and capex may not be immediately obvious for some expenses; for instance, repaving the parking lot may be thought of inherent to the operation of a shopping mall. The dividing line for items like these is that the expense is considered capex if the financial benefit of the expenditure extends beyond the current fiscal year. Usage Capital expenditures are the funds used to acquire or upgrade a companys fixed assets, such as expenditures towards property, plant, or equipment (PP&E). In the case when a capital expenditure constitutes a major financial decision for a company, the expenditure must be formalized at an annual shareholders meeting or a special meeting of the Board of Directors. In accounting, a capital expenditure is added to an asset account, thus increasing the assets basis (the cost or value of an asset adjusted for tax purposes). Capex is commonly found on the cash flow statement under "Investment in Plant, Property, and Equipment" or something similar in the Investing subsection. Accounting rules For tax purposes, capex is a cost that cannot be deducted in the year in which it is paid or incurred and must be capitalized. The general rule is that if the acquired propertys useful life is longer than the taxable year, then the cost must be capitalized. The capital expenditure costs are then amortized or depreciated over the life of the asset in question. Further to the above, capex creates or adds basis to the asset or property, which once adjusted, will determine tax liability in the event of sale or transfer. In the US, Internal Revenue Code §§263 and 263A deal extensively with capitalization requirements and exceptions.Included in capital expenditures are amounts spent on: acquiring fixed, and in some cases, intangible assets repairing an existing asset so as to improve its useful life upgrading an existing asset if it results in a superior fixture preparing an asset to be used in business restoring property or adapting it to a new or different use starting or acquiring a new businessAn ongoing question for the accounting of any company is whether certain costs incurred should be capitalized or expensed. Costs which are expensed in a particular month simply appear on the financial statement as a cost incurred that month. Costs that are capitalized, however, are amortized or depreciated over multiple years. Capitalized expenditures show up on the balance sheet. Most ordinary business costs are either expensable or capitalizable, but some costs could be treated either way, according to the preference of the company. Capitalized interest if applicable is also spread out over the life of the asset. Sometimes an organization needs to apply for a line of credit to build another asset, it can capitalize the related interest cost. Accounting Rules spreads out a couple of stipulations for capitalizing interest cost. Organizations can possibly capitalize the interest given that they are building the asset themselves; they cant capitalize interest on an advance to buy the asset or pay another person to develop it. Organizations can just perceive interest cost as they acquire costs to develop the asset. The counterpart of capital expenditure is operating expense or operational cost (opex). See also Operating expense (operational expenditure, opex) Total cost of ownership (TCO) Contract management software Capital cost Cash flow statement Income statement Balance sheet Expenses versus capital expenditures == References ==
Glucose/fructose/phosphoric acid	Glucose/fructose/phosphoric acid (trade name Emetrol) is an over-the-counter antiemetic taken to relieve nausea and vomiting. Made by WellSpring Pharmaceutical Corporation, it was formerly distributed by McNeil Consumer Healthcare. History Emetrol was created by Kinney and Company of Columbus, Indiana and was first used in 1949.It is a phosphorated carbohydrate solution, and comes in syrup form. Contraindications Since Emetrol contains fructose it is contraindicated for people with hereditary fructose intolerance (HFI). In diabetes patients, it can cause potentially harmful hyperglycaemia (high blood sugar). References External links Official site
Sojourn	Sojourn may refer to: Books and periodicals Sojourn (comics), a CrossGen comic book series Sojourn (journal), a journal of social and cultural issues in Southeast Asia Sojourn (novel), the 1991 novel in the Dark Elf Trilogy by R. A. Salvatore The Sojourn, a 2011 novel by Andrew Krivak Music Sojourn (album), a 1977 album by Mickey Tucker "Sojourn", a song by Natasha Bedingfield from Unwritten Sojourn Music, an American Christian music group Other uses "Sojourn" (American Horror Story), a television episode Sojourn, a predecessor of TorilMUD, a text-based online role-playing game Sevoflurane, trade name Sojourn, an inhalational anaesthetic Sojourn Shelton (born 1994), American football player See also Sojourner (disambiguation)
Hepatitis A and B vaccine	Combined hepatitis A and B vaccine, is used to provide protection against hepatitis A and hepatitis B. It is given by injection into muscle.It is used in areas where hepatitis A and B are endemic, for travelers, people with hepatitis C or chronic liver disease, and those at high risk of sexually transmitted diseases.The combined vaccine is as safe and protective as if given as separate hepatitis A and B vaccines. It is generally well-tolerated. Common side effects are mild and include redness and pain at the injection site, where a small lump may appear. Feeling faint or tired, or a headache may occur. Other side effects include numbness, tingling, rash, bruising, abnormal bleeding such as from the nose or gums, weak muscle or pain. Severe side effects are rare and include an allergic reaction and seizures.It is widely available. Administration schedule Routine Twinrix vaccination is administered by intramuscular injection in the deltoid area using a schedule of three separate doses at 0, 1, and 6 months ([minimum intervals: 4 weeks between doses 1 and 2, 5 months between doses 2 and 3]). In some circumstances, an accelerated dosing schedule of 0, 7 and 21 to 30 days followed by a booster at 12 months can be used and was shown to have similar efficacy as the traditional schedule. Efficacy The U.S. Centers for Disease Control and Prevention (CDC) reports that clinical trials found the following levels of protection against Hepatitis A and Hepatitis B one month after each dose: A: 93.8%, 98.8%, 99.9% B: 30.8%, 78.2%, 98.5%GlaxoSmithKline claims that its studies found 70% of subjects had antibodies against hepatitis B a month after just the first dose, however.Twinrix should not be used for postexposure prophylaxis, because no data are available on the efficacy of combination vaccine for prophylaxis after exposure to HAV. Availability Twinrix is a brand manufactured by GlaxoSmithKline Biologicals. The full generic name is hepatitis A inactivated & hepatitis B (recombinant) vaccine. Twinrix is administered over three doses. The name was created because it is a mixture of two earlier vaccines — Havrix, an inactivated-virus Hepatitis A vaccine, and Engerix-B, a recombinant Hepatitis B vaccine. Twinrix first entered the market in early 1997.In the United States, Twinrix is approved by the Food and Drug Administration (FDA) for those aged 18 and older. In some countries outside the United States, notably Canada and in the European Union, Twinrix is known as Twinrix Adult or Ambirix and a pediatric formulation, called Twinrix Junior or Twinrix Paediatric, is available. Society and culture Economics By being a combination it may reduce administrative costs and achieve a better uptake of the vaccine. Names Brand names include Twinrix, Twinrix Junior, Twinrix paediatric, Ambirix, and Bilive. References External links "Twinrix". Food and Drug Administration (FDA). 3 October 2019.
Epoetin alfa	Epoetin alfa is a human erythropoietin produced in cell culture using recombinant DNA technology. Authorised by the European Medicines Agency on 28 August 2007, it stimulates erythropoiesis (increasing red blood cell levels) and is used to treat anemia, commonly associated with chronic kidney failure and cancer chemotherapy. Epoetin is manufactured and marketed by Amgen under the brand name Epogen. Johnson & Johnson subsidiary Janssen Biotech (formerly Ortho Biotech Products, LP), sells the same drug under the name Procrit, pursuant to a product license agreement. The average cost per patient in the U.S. was $8,447 in 2009. Darbepoetin alfa (rINN) is a glycosylation analog of erythropoietin containing two additional N-linked carbohydrate chains, also manufactured and marketed by Amgen, with a brand name of Aranesp. The Food and Drug Administration (FDA) warnings and safety precautions for Procrit, Epogen and Aranesp are identical. For several years, epoetin alfa has accounted for the single greatest drug expenditure paid by the U.S. Medicare system; in 2010, the program paid $2 billion for the drug. Raising hemoglobin levels has been found in some studies to be associated with higher risks of thrombotic events, strokes and death.It is on the World Health Organizations List of Essential Medicines. Medical uses Erythropoietin is available as a therapeutic agent produced by recombinant DNA technology in mammalian cell culture. It is used in treating anemia resulting from chronic kidney disease and myelodysplasia, from the treatment of cancer (chemotherapy and radiation). Anemia caused by kidney disease For people who require dialysis or have chronic kidney disease, iron should be given with erythropoietin, depending on some laboratory parameters such as ferritin and transferrin saturation. Dialysis patients in the U.S. are most often given Epogen; other brands of epoetin may be used in other countries.Erythropoietin is also used to treat anemia in people with chronic kidney disease who are not on dialysis (those in Stage 3 or 4 disease and those living with a kidney transplant). There are two types of erythropoietin for people with anemia due to chronic kidney disease (not on dialysis). Anemia caused by cancer In March 2008, a panel of advisers for the U.S. Food and Drug Administration (FDA) supported keeping erythropoiesis-stimulating agents (ESAs) produced by Amgen and Johnson & Johnson on the market for use in cancer patients. The FDA has focused its concern on study results from some clinical trials showing an increased risk of death and tumor growth in chemotherapy patients taking the anti-anemia drugs. Anemia in critically ill people Erythropoietin is used to treat people with anemia resulting from critical illness. In a randomized controlled trial, erythropoietin was shown to not change the number of blood transfusions required by critically ill patients. A surprising finding in this study was a small mortality reduction in patients receiving erythropoietin. This result was statistically significant after 29 days but not at 140 days. The mortality difference was most marked in patients admitted to the ICU for trauma. The authors provide several hypotheses for potential etiologies of this reduced mortality, but, given the known increase in thrombosis and increased benefit in trauma patients as well as marginal nonsignificant benefit (adjusted hazard ratio of 0.9) in surgery patients, it could be speculated that some of the benefit might be secondary to the procoagulant effect of erythropoietin. Regardless, this study suggests further research may be necessary to see which critical care patients, if any, might benefit from administration of erythropoietin. Any benefit of erythropoietin use must be weighed against the increased likelihood of thrombosis, which has been demonstrated in numerous trials. Neurological diseases Erythropoietin has been hypothesized to be beneficial in treating certain neurological diseases such as schizophrenia and stroke. Some research has suggested that erythropoietin improves the survival rate in children with cerebral malaria, which is caused by the malaria parasites blockage of blood vessels in the brain. However, the possibility that erythropoietin may be neuroprotective is inconsistent with the poor transport of the chemical into the brain and the low levels of erythropoietin receptors expressed on neuronal cells. Psychiatric diseases Randomized clinical control trials have shown promising results of EPO in improving cognition which is often intractable with the current treatment of mood disorders and schizophrenia.These domains include speed of complex cognitive processing across attention,memory and executive function. Preterm infants Infants born early often require transfusions with red blood cells and have low levels of erythropoietin. Erythropoietin has been studied as a treatment option to reduce anemia in preterm infants. Treating infants less than 8 days with erythropoietin old may slightly reduce the need for red blood cell transfusions, but increases the risk of retinopathy. Due to the limited clinical benefit and increased risk of retinopathy, early or late erythropoietin treatment is not recommended for preterm infants. Adverse effects Epoetin alfa is generally well tolerated. Common side effects include high blood pressure, headache, disabling cluster migraine (resistant to remedies), joint pain, and clotting at the injection site. Rare cases of stinging at the injection site, skin rash, and flu-like symptoms (joint and muscle pain) have occurred within a few hours following administration. More serious side effects, including allergic reactions, seizures and thrombotic events (e.g., heart attacks, strokes, and pulmonary embolism) rarely occur. Chronic self-administration of the drug has been shown to cause increases in blood hemoglobin and hematocrit to abnormally high levels, resulting in dyspnea and abdominal pain.Erythropoietin is associated with an increased risk of adverse cardiovascular complications in patients with kidney disease if it is used to target an increase of hemoglobin levels above 13.0 g/dl.Early treatment (before an infant is 8 days old) with erythropoietin correlated with an increase in the risk of retinopathy of prematurity in premature and anemic infants, raising concern that the angiogenic actions of erythropoietin may exacerbate retinopathy. Since anemia itself increases the risk of retinopathy, the correlation with erythropoietin treatment may be incidental. Safety advisories in anemic cancer patients Amgen sent a "dear doctor" letter in January 2007 that highlighted results from a recent anemia of cancer trial, and warned doctors to consider use in that off-label indication with caution.Amgen advised the U.S. Food and Drug Administration (FDA) regarding the results of the DAHANCA 10 clinical trial. The DAHANCA 10 data monitoring committee found that three-year loco-regional cancer control in subjects treated with Aranesp was significantly worse than for those not receiving Aranesp (p=0.01).In response to these advisories, the FDA released a Public Health Advisory on 9 March 2007, and a clinical alert for doctors on 16 February 2007, about the use of erythropoiesis-stimulating agents (ESAs) such as epogen and darbepoetin. The advisory recommended caution in using these agents in cancer patients receiving chemotherapy or off chemotherapy, and indicated a lack of clinical evidence to support improvements in quality of life or transfusion requirements in these settings. In addition, on 9 March 2007, drug manufacturers agreed to new black box warnings about the safety of these drugs. On 22 March 2007, a congressional inquiry into the safety of erythropoietic growth factors was reported in the news media. Manufacturers were asked to suspend drug rebate programs for physicians and to also suspend marketing the drugs to patients. Several publications and FDA communications have increased the level of concern related to adverse effects of ESA therapy in selected groups. In a revised black box warning, the FDA notes significant risks, advising that ESAs should be used only in patients with cancer when treating anemia specifically caused by chemotherapy, and not for other causes of anemia. Further, the warning states that ESAs should be discontinued once the patients chemotherapy course has been completed. Interactions Drug interactions with erythropoietin include: Major: lenalidomide—risk of thrombosis Moderate: cyclosporine—risk of high blood pressure may be greater in combination with EPO. EPO may lead to variability in blood levels of cyclosporine. Minor: ACE inhibitors may interfere with hematopoiesis by decreasing the synthesis of endogenous erythropoietin or decreasing bone marrow production of red blood cells. Society and culture The publication of an editorial questioning the benefits of high-dose epoetin was canceled by the marketing branch of a journal after being accepted by the editorial branch highlighting concerns of conflict of interest in publishing.In 2011, author Kathleen Sharp published a book, Blood Feud: The Man Who Blew the Whistle on One of the Deadliest Prescription Drugs Ever, alleging drug maker Johnson & Johnson encouraged doctors to prescribe epoetin in high doses, particularly for cancer patients, because this would increase sales by hundreds of millions of dollars. Former sales representatives Mark Duxbury and Dean McClennan, claimed that the bulk of their business selling epoetin to hospitals and clinics was Medicare fraud, totaling US$3 billion. Biosimilars In August 2007, Binocrit, Epoetin Alfa Hexal, and Abseamed were approved for use in the European Union. References External links "Epoetin alfa". Drug Information Portal. U.S. National Library of Medicine.
Thioridazine	Thioridazine (Mellaril or Melleril) is a first generation antipsychotic drug belonging to the phenothiazine drug group and was previously widely used in the treatment of schizophrenia and psychosis. The branded product was withdrawn worldwide in 2005 because it caused severe cardiac arrhythmias. However, generic versions are still available in the US. Indications Thioridazine was voluntarily discontinued by its manufacturer, Novartis, worldwide because it caused severe cardiac arrhythmias.Its primary use in medicine was the treatment of schizophrenia. It was also tried with some success as a treatment for various psychiatric symptoms seen in people with dementia, but chronic use of thioridazine and other anti-psychotics in people with dementia is not recommended. Side effects For further information see: Phenothiazine Thioridazine prolongs the QTc interval in a dose-dependent manner. It produces significantly less extrapyramidal side effects than most first-generation antipsychotics, likely due to its potent anticholinergic effect. Its use, along with the use of other typical antipsychotics, has been associated with degenerative retinopathies(specifically retinitis pigmentosa). It has a higher propensity for causing anticholinergic side effects coupled with a lower propensity for causing extrapyramidal side effects and sedation than chlorpromazine, but also has a higher incidence of hypotension and cardiotoxicity. It is also known to possess a relatively high liability for causing orthostatic hypotension compared to other antipsychotics. Similarly to other first-generation antipsychotics it has a relatively high liability for causing prolactin elevation. It is moderate risk for causing weight gain. As with all antipsychotics thioridazine has been linked to cases of tardive dyskinesia (an often permanent neurological disorder characterised by slow, repetitive, purposeless and involuntary movements, most often of the facial muscles, that is usually brought on by years of continued treatment with antipsychotics, especially the first-generation (or typical) antipsychotics such as thioridazine) and neuroleptic malignant syndrome (a potentially fatal complication of antipsychotic treatment). Blood dyscrasias such as agranulocytosis, leukopenia and neutropenia are possible with thioridazine treatment. Thioridazine is also associated with abnormal retinal pigmentation after many years of use. Thioridazine has been correlated to rare instances of clinically apparent acute cholestatic liver injury. Pharmacology Thioridazine has the following binding profile: Note: The Binding affinities given are towards cloned human receptors unless otherwise specified Acronyms used HB – Human brain receptor RC – Cloned rat receptor ND – No data Metabolism Thioridazine is a racemic compound with two enantiomers, both of which are metabolized, according to Eap et al., by CYP2D6 into (S)- and (R)-thioridazine-2-sulfoxide, better known as mesoridazine, and into (S)- and (R)-thioridazine-5-sulfoxide. Mesoridazine is in turn metabolized into sulforidazine. Thioridazine is an inhibitor of CYP1A2 and CYP3A4. History The manufacturer Novartis/Sandoz/Wander of the brands of thioridazine, Mellaril in the US and Canada and Melleril in Europe, discontinued the drug worldwide in June 2005. Antibiotic activity Thioridazine is known to kill extensively drug-resistant tuberculosis and to make methicillin-resistant Staphylococcus aureus sensitive to β-lactam antibiotics. A possible mechanism of action for the drugs antibiotic activity is via the inhibition of bacterial secretion pumps. The β-lactam antibiotic resistance is due to the secretion β-lactamase a protein that destroys antibiotics. If the bacteria cannot secrete the β-lactamase, then the antibiotic will be effective. The drug has been successfully used in the treatment of granulomatous amoebic encephalitis in conjunction with more conventional amoebicidal medications. References Further reading Dean L (2017). "Thioridazine Therapy and CYP2D6 Genotypes". In Pratt VM, McLeod HL, Rubinstein WS, et al. (eds.). Medical Genetics Summaries. National Center for Biotechnology Information (NCBI). PMID 28520378. Bookshelf ID: NBK424018. External links "Thioridazine". Drug Information Portal. U.S. National Library of Medicine. Antipsychotic Mellaril Removed from Market Schizophrenia Daily News Blog.
Hydrogen peroxide - urea	Hydrogen peroxide - urea (also called Hyperol, artizone, urea hydrogen peroxide, and UHP) is a solid composed of equal amounts of hydrogen peroxide and urea. This compound is a white crystalline solid which dissolves in water to give free hydrogen peroxide. Hydrogen peroxide - urea contains solid and water-free hydrogen peroxide, which offers a higher stability and better controllability than liquid hydrogen peroxide when used as an oxidizing agent. Often called carbamide peroxide in the dental office, it is used as a source of hydrogen peroxide for bleaching, disinfection, and oxidation. Production For the preparation of the complex, urea is dissolved in 30% hydrogen peroxide (molar ratio 2:3) at temperatures below 60 °C. upon cooling this solution, hydrogen peroxide - urea precipitates in the form of small platelets.Determination of the hydrogen peroxide content by titration with potassium permanganate solution gives a value of 35.4% which corresponds to 97.8% of the theoretical maximum value. The remaining impurity consists of urea. Akin to water of crystallization, hydrogen peroxide cocrystallizes with urea with the stoichiometry of 1:1. The compound is simply produced (on a scale of several hundred tonnes a year) by the dissolution of urea in excess concentrated hydrogen peroxide solution, followed by crystallization. The laboratory synthesis is analogous. Structure and properties The solid state structure of this adduct has been determined by neutron diffraction.Hydrogen peroxide-urea is a readily water-soluble, odorless, crystalline solid, which is available as white powder or colorless needles or platelets. Upon dissolving in various solvents, the 1:1 complex dissociates back to urea and hydrogen peroxide. So just like hydrogen peroxide, the (erroneously) so-called adduct is an oxidizer but the release at room temperature in the presence of catalysts proceeds in a controlled manner. Thus the compound is suitable as a safe substitute for the unstable aqueous solution of hydrogen peroxide. Because of the tendency for thermal decomposition, which accelerates at temperatures above 82 °C, it should not be heated above 60 °C, particularly in pure form. The solubility of commercial samples varies from 0.05 g/mL to more than 0.6 g/mL. Applications Disinfectant and bleaching agent Hydrogen peroxide - urea is mainly used as a disinfecting and bleaching agent in cosmetics and pharmaceuticals. As a drug, this compound is used in some preparations for the whitening of teeth. It is also used to relieve minor inflammation of gums, oral mucosal surfaces and lips including canker sores and dental irritation, and to emulsify and disperse earwax.Carbamide peroxide is also suitable as a disinfectant, e.g. for germ reduction on contact lens surfaces or as an antiseptic for mouthwashes, ear drops or for superficial wounds and ulcers. Reagent in organic synthesis In the laboratory, it is used as a more easily handled replacement for hydrogen peroxide. It has proven to be a stable, easy-to-handle and effective oxidizing agent which is readily controllable by a suitable choice of the reaction conditions. It delivers oxidation products in an environmentally friendly manner and often in high yields especially in the presence of organic catalysts such as cis-butenedioic anhydride or inorganic catalysts such as sodium tungstate. It converts thiols selectively to disulfides, secondary alcohols to ketones, sulfides to sulfoxides and sulfones, nitriles to amides, and N-heterocycles to amine oxides. Hydroxybenzaldehydes are converted to dihydroxybenzenes (Dakin reaction) and give, under suitable conditions, the corresponding benzoic acids. It oxidizes ketones to esters, in particular cyclic ketones, such as substituted cyclohexanones or cyclobutanones to give lactones (Baeyer-Villiger oxidation). The epoxidation of various alkenes in the presence of benzonitrile yields oxiranes in yields of 79 to 96%. The oxygen atom transferred to the alkene originates from the peroxoimide acid formed intermediately from benzonitrile. The resulting imidic acid tautomerizes to the benzamide. Safety The compound acts as a strong oxidizing agent and can cause skin irritation and severe eye damage. See also Sodium percarbonate References External links "Hydrogen peroxide urea adduct, UHP". Organic Chemistry Portal. "Carbamide Peroxide Monograph". Drugs.com.
Resinol	Resinol is a skin protectant and topical analgesic that is made by ResiCal Inc. from Orchard Park, New York. It is an over-the-counter drug that can currently be purchased in 1.25 or 3.3 ounce (35 or 94 g) jars by contacting a local pharmacys drug wholesaler to order the item or on the Internet. History Resinol was developed by Dr. Merville Hamilton Carter (1857-1939) in his private practice as treatment for his patients in Baltimore, Maryland during the late 19th century. In 1895, Carter, along with his brother Allan L. Carter and his cousin Henry Stier Dulaney founded the Resinol Chemical Company and began to mass-produce the ointment and other medical products. After over forty years of selling Resinol, the company had John H. Buffham & Co. as an outlet in Great Britain and was a successful global distributor. Henry LeRoy Carter Sr., the son of Dr. Carter, began running the company after the deaths of his father and other staff members. The companys sales began to decline in the 1940s, and after the death of Henry LeRoy Carter Sr. in 1951, his son Henry LeRoy Carter Jr. took the place of his father and grandfather as president of the Resinol Chemical Company. At that time, the company focused more on soap manufacturing, but continued to sell Resinol. For the rest of the 20th century, Resinols popularity continued to dwindle. It was purchased by ResiCal Inc. in 2002, which at the time was headed by D. Brooks Cole. Label Information Resinol is used to treat several different types of skin ailments. It is used to prevent and temporarily protect chafed, chapped, or cracked skin, temporarily relieve pain and itching caused by minor burns, minor cuts and scrapes, minor skin irritations and sunburn, and dry the oozing and weeping of irritation caused by contact with poison ivy, poison oak, and poison sumac. Adults and children that are two years of age or older should apply Resinol to affected area of skin no more than three to four times a day. A physician should be asked if an application would be appropriate for a child younger than two years. Resinol is for external uses only. When using it, avoid contact with eyes and do not apply over large areas of the body. Discontinue use and ask a physician if any condition worsens where applied, symptoms last more than seven days, or symptoms clear up and reappear within a few days. Keep out of reach of children. If swallowed, get medical help or contact a poison control center immediately. The active ingredients used in Resinol are a 55% solution of petroleum jelly and a 2% solution of resorcinol. Calamine, corn starch, lanolin, and zinc oxide comprise the inactive ingredients. Past Formulations In the 1980s, Resinol ointment was manufactured by the Mentholatum Company of Buffalo, New York 14213, a maker of liniment. Its ingredients statement then read Zinc Oxide 12% (an antibacterial agent and sunscreen); Calamine 6%; Resorcinol 2% (also an antibacterial). In the 1960s, Resinol came in an opaque, white glass jar with a metal lid. It was made by the Resinol Chemical Company of Baltimore, Maryland 21201, and the label listed the following ingredients: Resorcinol; Oil of Cade (Cade is a species of prickly juniper native to the regions surrounding the Mediterranean; the oil gave the unguent a medicinal odor); Prepared Calamine; Zinc Oxide; Bismuth Subnitrate (now used mostly in veterinary medicine); Boric Acid (antibacterial); Lanolin; Petrolatum References External links ResiCal Inc. Official Resinol Website
Lanthanum	Lanthanum is a chemical element with the symbol La and atomic number 57. It is a soft, ductile, silvery-white metal that tarnishes slowly when exposed to air. It is the eponym of the lanthanide series, a group of 15 similar elements between lanthanum and lutetium in the periodic table, of which lanthanum is the first and the prototype. Lanthanum is traditionally counted among the rare earth elements. Like most other rare earth elements, the usual oxidation state is +3. Lanthanum has no biological role in humans but is essential to some bacteria. It is not particularly toxic to humans but does show some antimicrobial activity. Lanthanum usually occurs together with cerium and the other rare earth elements. Lanthanum was first found by the Swedish chemist Carl Gustaf Mosander in 1839 as an impurity in cerium nitrate – hence the name lanthanum, from the Ancient Greek λανθάνειν (lanthanein), meaning to lie hidden. Although it is classified as a rare earth element, lanthanum is the 28th most abundant element in the Earths crust, almost three times as abundant as lead. In minerals such as monazite and bastnäsite, lanthanum composes about a quarter of the lanthanide content. It is extracted from those minerals by a process of such complexity that pure lanthanum metal was not isolated until 1923. Lanthanum compounds have numerous applications as catalysts, additives in glass, carbon arc lamps for studio lights and projectors, ignition elements in lighters and torches, electron cathodes, scintillators, gas tungsten arc welding electrodes, and other things. Lanthanum carbonate is used as a phosphate binder in cases of high levels of phosphate in the blood seen with kidney failure. Characteristics Physical Lanthanum is the first element and prototype of the lanthanide series. In the periodic table, it appears to the right of the alkaline earth metal barium and to the left of the lanthanide cerium. Its placement has been disputed, but most who study the matter along with a 2021 IUPAC provisional report consider lanthanum to be best placed as the first of the f-block elements. The 57 electrons of a lanthanum atom are arranged in the configuration [Xe]5d16s2, with three valence electrons outside the noble gas core. In chemical reactions, lanthanum almost always gives up these three valence electrons from the 5d and 6s subshells to form the +3 oxidation state, achieving the stable configuration of the preceding noble gas xenon. Some lanthanum(II) compounds are also known, but they are much less stable.Among the lanthanides, lanthanum is exceptional as it has no 4f electrons as a single gas-phase atom. Thus it is only very weakly paramagnetic, unlike the strongly paramagnetic later lanthanides (with the exceptions of the last two, ytterbium and lutetium, where the 4f shell is completely full). However, the 4f shell of lanthanum can become partially occupied in chemical environments and participate in chemical bonding. For example, the melting points of the trivalent lanthanides (all but europium and ytterbium) are related to the extent of hybridisation of the 6s, 5d, and 4f electrons (lowering with increasing 4f involvement), and lanthanum has the second-lowest melting point among them: 920 °C. (Europium and ytterbium have lower melting points because they delocalise about two electrons per atom rather than three.) This chemical availability of f orbitals justifies lanthanums placement in the f-block despite its anomalous ground-state configuration (which is merely the result of strong interelectronic repulsion making it less profitable to occupy the 4f shell, as it is small and close to the core electrons).The lanthanides become harder as the series is traversed: as expected, lanthanum is a soft metal. Lanthanum has a relatively high resistivity of 615 nΩm at room temperature; in comparison, the value for the good conductor aluminium is only 26.50 nΩm. Lanthanum is the least volatile of the lanthanides. Like most of the lanthanides, lanthanum has a hexagonal crystal structure at room temperature. At 310 °C, lanthanum changes to a face-centered cubic structure, and at 865 °C, it changes to a body-centered cubic structure. Chemical As expected from periodic trends, lanthanum has the largest atomic radius of the lanthanides. Hence, it is the most reactive among them, tarnishing quite rapidly in air, turning completely dark after several hours and can readily burn to form lanthanum(III) oxide, La2O3, which is almost as basic as calcium oxide. A centimeter-sized sample of lanthanum will corrode completely in a year as its oxide spalls off like iron rust, instead of forming a protective oxide coating like aluminium, scandium, yttrium, and lutetium. Lanthanum reacts with the halogens at room temperature to form the trihalides, and upon warming will form binary compounds with the nonmetals nitrogen, carbon, sulfur, phosphorus, boron, selenium, silicon and arsenic. Lanthanum reacts slowly with water to form lanthanum(III) hydroxide, La(OH)3. In dilute sulfuric acid, lanthanum readily forms the aquated tripositive ion [La(H2O)9]3+: this is colorless in aqueous solution since La3+ has no d or f electrons. Lanthanum is the strongest and hardest base among the rare earth elements, which is again expected from its being the largest of them.Some lanthanum(II) compounds are also known, but they are much less stable. Therefore, in officially naming compounds of lanthanum its oxidation number always is to be mentioned. Isotopes Naturally occurring lanthanum is made up of two isotopes, the stable 139La and the primordial long-lived radioisotope 138La. 139La is by far the most abundant, making up 99.910% of natural lanthanum: it is produced in the s-process (slow neutron capture, which occurs in low- to medium-mass stars) and the r-process (rapid neutron capture, which occurs in core-collapse supernovae). It is the only stable isotope of lanthanum. The very rare isotope 138La is one of the few primordial odd–odd nuclei, with a long half-life of 1.05×1011 years. It is one of the proton-rich p-nuclei which cannot be produced in the s- or r-processes. 138La, along with the even rarer 180mTa, is produced in the ν-process, where neutrinos interact with stable nuclei. All other lanthanum isotopes are synthetic: with the exception of 137La with a half-life of about 60,000 years, all of them have half-lives less than a day, and most have half-lives less than a minute. The isotopes 139La and 140La occur as fission products of uranium. Compounds Lanthanum oxide is a white solid that can be prepared by direct reaction of its constituent elements. Due to the large size of the La3+ ion, La2O3 adopts a hexagonal 7-coordinate structure that changes to the 6-coordinate structure of scandium oxide (Sc2O3) and yttrium oxide (Y2O3) at high temperature. When it reacts with water, lanthanum hydroxide is formed: a lot of heat is evolved in the reaction and a hissing sound is heard. Lanthanum hydroxide will react with atmospheric carbon dioxide to form the basic carbonate.Lanthanum fluoride is insoluble in water and can be used as a qualitative test for the presence of La3+. The heavier halides are all very soluble deliquescent compounds. The anhydrous halides are produced by direct reaction of their elements, as heating the hydrates causes hydrolysis: for example, heating hydrated LaCl3 produces LaOCl.Lanthanum reacts exothermically with hydrogen to produce the dihydride LaH2, a black, pyrophoric, brittle, conducting compound with the calcium fluoride structure. This is a non-stoichiometric compound, and further absorption of hydrogen is possible, with a concomitant loss of electrical conductivity, until the more salt-like LaH3 is reached. Like LaI2 and LaI, LaH2 is probably an electride compound.Due to the large ionic radius and great electropositivity of La3+, there is not much covalent contribution to its bonding and hence it has a limited coordination chemistry, like yttrium and the other lanthanides. Lanthanum oxalate does not dissolve very much in alkali-metal oxalate solutions, and [La(acac)3(H2O)2] decomposes around 500 °C. Oxygen is the most common donor atom in lanthanum complexes, which are mostly ionic and often have high coordination numbers over 6: 8 is the most characteristic, forming square antiprismatic and dodecadeltahedral structures. These high-coordinate species, reaching up to coordination number 12 with the use of chelating ligands such as in La2(SO4)3·9H2O, often have a low degree of symmetry because of stereo-chemical factors.Lanthanum chemistry tends not to involve π bonding due to the electron configuration of the element: thus its organometallic chemistry is quite limited. The best characterized organolanthanum compounds are the cyclopentadienyl complex La(C5H5)3, which is produced by reacting anhydrous LaCl3 with NaC5H5 in tetrahydrofuran, and its methyl-substituted derivatives. History In 1751, the Swedish mineralogist Axel Fredrik Cronstedt discovered a heavy mineral from the mine at Bastnäs, later named cerite. Thirty years later, the fifteen-year-old Wilhelm Hisinger, from the family owning the mine, sent a sample of it to Carl Scheele, who did not find any new elements within. In 1803, after Hisinger had become an ironmaster, he returned to the mineral with Jöns Jacob Berzelius and isolated a new oxide which they named ceria after the dwarf planet Ceres, which had been discovered two years earlier. Ceria was simultaneously independently isolated in Germany by Martin Heinrich Klaproth. Between 1839 and 1843, ceria was shown to be a mixture of oxides by the Swedish surgeon and chemist Carl Gustaf Mosander, who lived in the same house as Berzelius: he separated out two other oxides which he named lanthana and didymia. He partially decomposed a sample of cerium nitrate by roasting it in air and then treating the resulting oxide with dilute nitric acid. That same year, Axel Erdmann, a student also at the Karolinska Institute, discovered lanthanum in a new mineral from Låven island located in a Norwegian fjord. Finally, Mosander explained his delay, saying that he had extracted a second element from cerium, and this he called didymium. Although he didnt realise it, didymium too was a mixture, and in 1885 it was separated into praseodymium and neodymium. Since lanthanums properties differed only slightly from those of cerium, and occurred along with it in its salts, he named it from the Ancient Greek λανθάνειν [lanthanein] (lit. to lie hidden). Relatively pure lanthanum metal was first isolated in 1923. Occurrence and production Lanthanum is the third-most abundant of all the lanthanides, making up 39 mg/kg of the Earths crust, behind neodymium at 41.5 mg/kg and cerium at 66.5 mg/kg. It is almost three times as abundant as lead in the Earths crust. Despite being among the so-called "rare earth metals", lanthanum is thus not rare at all, but it is historically so named because it is rarer than "common earths" such as lime and magnesia, and historically only a few deposits were known. Lanthanum is considered a rare earth metal because the process to mine it is difficult, time-consuming, and expensive. Lanthanum is rarely the dominant lanthanide found in the rare earth minerals, and in their chemical formulae it is usually preceded by cerium. Rare examples of La-dominant minerals are monazite-(La) and lanthanite-(La). The La3+ ion is similarly sized to the early lanthanides of the cerium group (those up to samarium and europium) that immediately follow in the periodic table, and hence it tends to occur along with them in phosphate, silicate and carbonate minerals, such as monazite (MIIIPO4) and bastnäsite (MIIICO3F), where M refers to all the rare earth metals except scandium and the radioactive promethium (mostly Ce, La, and Y). Bastnäsite is usually lacking in thorium and the heavy lanthanides, and the purification of the light lanthanides from it is less involved. The ore, after being crushed and ground, is first treated with hot concentrated sulfuric acid, evolving carbon dioxide, hydrogen fluoride, and silicon tetrafluoride: the product is then dried and leached with water, leaving the early lanthanide ions, including lanthanum, in solution.The procedure for monazite, which usually contains all the rare earths as well as thorium, is more involved. Monazite, because of its magnetic properties, can be separated by repeated electromagnetic separation. After separation, it is treated with hot concentrated sulfuric acid to produce water-soluble sulfates of rare earths. The acidic filtrates are partially neutralized with sodium hydroxide to pH 3–4. Thorium precipitates out of solution as hydroxide and is removed. After that, the solution is treated with ammonium oxalate to convert rare earths to their insoluble oxalates. The oxalates are converted to oxides by annealing. The oxides are dissolved in nitric acid that excludes one of the main components, cerium, whose oxide is insoluble in HNO3. Lanthanum is separated as a double salt with ammonium nitrate by crystallization. This salt is relatively less soluble than other rare earth double salts and therefore stays in the residue. Care must be taken when handling some of the residues as they contain 228Ra, the daughter of 232Th, which is a strong gamma emitter. Lanthanum is relatively easy to extract as it has only one neighbouring lanthanide, cerium, which can be removed by making use of its ability to be oxidised to the +4 state; thereafter, lanthanum may be separated out by the historical method of fractional crystallization of La(NO3)3·2NH4NO3·4H2O, or by ion-exchange techniques when higher purity is desired.Lanthanum metal is obtained from its oxide by heating it with ammonium chloride or fluoride and hydrofluoric acid at 300-400 °C to produce the chloride or fluoride: La2O3 + 6 NH4Cl → 2 LaCl3 + 6 NH3 + 3 H2OThis is followed by reduction with alkali or alkaline earth metals in vacuum or argon atmosphere: LaCl3 + 3 Li → La + 3 LiClAlso, pure lanthanum can be produced by electrolysis of molten mixture of anhydrous LaCl3 and NaCl or KCl at elevated temperatures. Applications The first historical application of lanthanum was in gas lantern mantles. Carl Auer von Welsbach used a mixture of lanthanum oxide and zirconium oxide, which he called Actinophor and patented in 1886. The original mantles gave a green-tinted light and were not very successful, and his first company, which established a factory in Atzgersdorf in 1887, failed in 1889.Modern uses of lanthanum include: One material used for anodic material of nickel-metal hydride batteries is La(Ni3.6Mn0.4Al0.3Co0.7). Due to high cost to extract the other lanthanides, a mischmetal with more than 50% of lanthanum is used instead of pure lanthanum. The compound is an intermetallic component of the AB5 type. NiMH batteries can be found in many models of the Toyota Prius sold in the US. These larger nickel-metal hydride batteries require massive quantities of lanthanum for the production. The 2008 Toyota Prius NiMH battery requires 10 to 15 kilograms (22 to 33 lb) of lanthanum. As engineers push the technology to increase fuel efficiency, twice that amount of lanthanum could be required per vehicle. Hydrogen sponge alloys can contain lanthanum. These alloys are capable of storing up to 400 times their own volume of hydrogen gas in a reversible adsorption process. Heat energy is released every time they do so; therefore these alloys have possibilities in energy conservation systems. Mischmetal, a pyrophoric alloy used in lighter flints, contains 25% to 45% lanthanum. Lanthanum oxide and the boride are used in electronic vacuum tubes as hot cathode materials with strong emissivity of electrons. Crystals of LaB6 are used in high-brightness, extended-life, thermionic electron emission sources for electron microscopes and Hall-effect thrusters. Lanthanum trifluoride (LaF3) is an essential component of a heavy fluoride glass named ZBLAN. This glass has superior transmittance in the infrared range and is therefore used for fiber-optical communication systems. Cerium-doped lanthanum bromide and lanthanum chloride are the recent inorganic scintillators, which have a combination of high light yield, best energy resolution, and fast response. Their high yield converts into superior energy resolution; moreover, the light output is very stable and quite high over a very wide range of temperatures, making it particularly attractive for high-temperature applications. These scintillators are already widely used commercially in detectors of neutrons or gamma rays. Carbon arc lamps use a mixture of rare earth elements to improve the light quality. This application, especially by the motion picture industry for studio lighting and projection, consumed about 25% of the rare-earth compounds produced until the phase out of carbon arc lamps. Lanthanum(III) oxide (La2O3) improves the alkali resistance of glass and is used in making special optical glasses, such as infrared-absorbing glass, as well as camera and telescope lenses, because of the high refractive index and low dispersion of rare-earth glasses. Lanthanum oxide is also used as a grain-growth additive during the liquid-phase sintering of silicon nitride and zirconium diboride. Small amounts of lanthanum added to steel improves its malleability, resistance to impact, and ductility, whereas addition of lanthanum to molybdenum decreases its hardness and sensitivity to temperature variations. Small amounts of lanthanum are present in many pool products to remove the phosphates that feed algae. Lanthanum oxide additive to tungsten is used in gas tungsten arc welding electrodes, as a substitute for radioactive thorium. Various compounds of lanthanum and other rare-earth elements (oxides, chlorides, etc.) are components of various catalysis, such as petroleum cracking catalysts. Lanthanum-barium radiometric dating is used to estimate age of rocks and ores, though the technique has limited popularity. Lanthanum carbonate was approved as a medication (Fosrenol, Shire Pharmaceuticals) to absorb excess phosphate in cases of hyperphosphatemia seen in end-stage kidney disease. Lanthanum fluoride is used in phosphor lamp coatings. Mixed with europium fluoride, it is also applied in the crystal membrane of fluoride ion-selective electrodes. Like horseradish peroxidase, lanthanum is used as an electron-dense tracer in molecular biology. Lanthanum-modified bentonite (or phoslock) is used to remove phosphates from water in lake treatments. Lanthanum telluride (La3Te4) is considered to be applied in the field of radioisotope power system (nuclear power plant) due to its significant conversion capabilities. The transmuted elements and isotopes in the segment will not react with the material itself, thus presenting no harm to the safety of the power plant. Though iodine, which can be generated during transmutation, is suspected to react with La3Te4 segment, the quantity of iodine is small enough to possess threat to the power system. Biological role Lanthanum has no known biological role in humans. The element is very poorly absorbed after oral administration and when injected its elimination is very slow. Lanthanum carbonate (Fosrenol) was approved as a phosphate binder to absorb excess phosphate in cases of end stage renal disease.While lanthanum has pharmacological effects on several receptors and ion channels, its specificity for the GABA receptor is unique among trivalent cations. Lanthanum acts at the same modulatory site on the GABA receptor as zinc, a known negative allosteric modulator. The lanthanum cation La3+ is a positive allosteric modulator at native and recombinant GABA receptors, increasing open channel time and decreasing desensitization in a subunit configuration dependent manner.Lanthanum is an essential cofactor for the methanol dehydrogenase of the methanotrophic bacterium Methylacidiphilum fumariolicum SolV, although the great chemical similarity of the lanthanides means that it may be substituted with cerium, praseodymium, or neodymium without ill effects, and with the smaller samarium, europium, or gadolinium giving no side effects other than slower growth. Precautions Lanthanum has a low to moderate level of toxicity and should be handled with care. The injection of lanthanum solutions produces hyperglycemia, low blood pressure, degeneration of the spleen and hepatic alterations. The application in carbon arc light led to the exposure of people to rare earth element oxides and fluorides, which sometimes led to pneumoconiosis. As the La3+ ion is similar in size to the Ca2+ ion, it is sometimes used as an easily traced substitute for the latter in medical studies. Lanthanum, like the other lanthanides, is known to affect human metabolism, lowering cholesterol levels, blood pressure, appetite, and risk of blood coagulation. When injected into the brain, it acts as a painkiller, similarly to morphine and other opiates, though the mechanism behind this is still unknown. Prices The price for a (metric) ton [1000 kg] of Lanthanum oxide 99% (FOB China in USD/Mt) is given by the Institute of Rare Earths Elements and Strategic Metals as below $2,000 for most of the period from early 2001 to September 2010 (at $10,000 in the short term in 2008); it rose steeply to $140,000 in mid-2011 and fell back just as rapidly to $38,000 by early 2012. The average price for the last six months (March to August 2022) is given by the Institute as follows: Lanthanum Oxide - 99.9%min FOB China - 1305 EUR/mt and for Lanthanum Metal - 99%min FOB China - 3784 EUR/mt. See also \| CASNo_Ref = Y \| CASNo = 7439-91-0 \| UNII_Ref = Y \| UNII = 6I3K30563S References Bibliography Greenwood, Norman N.; Earnshaw, Alan (1984). Chemistry of the Elements. Oxford: Pergamon Press. ISBN 978-0-08-022057-4. Further reading The Industrial Chemistry of the Lanthanons, Yttrium, Thorium and Uranium, by R. J. Callow, Pergamon Press, 1967 Extractive Metallurgy of Rare Earths, by C. K. Gupta and N. Krishnamurthy, CRC Press, 2005 Nouveau Traite de Chimie Minerale, Vol. VII. Scandium, Yttrium, Elements des Terres Rares, Actinium, P. Pascal, Editor, Masson & Cie, 1959 Chemistry of the Lanthanons, by R. C. Vickery, Butterworths 1953
Colestipol	Colestipol (trade names Colestid, Cholestabyl) is a bile acid sequestrant used to lower blood cholesterol, specifically low-density lipoprotein (LDL). It is also used to reduce stool volume and frequency, and in the treatment of chronic diarrhea.Like cholestyramine, colestipol works in the gut by trapping bile acids and preventing them from being reabsorbed. This leads to decreased enterohepatic recirculation of bile acids, increased synthesis of new bile acids by the liver from cholesterol, decreased liver cholesterol, increased LDL receptor expression, and decreasing LDL in blood. Side effects The following notable side effects may occur: gastrointestinal tract disturbances, especially (mild, occasionally severe) constipation sometimes increase in VLDL and triglyceride synthesis Interactions Colestipol can bind to a number of drugs and nutrients in the gut and inhibit or delay their absorption. Such substances include: thiazide diuretics, furosemide gemfibrozil benzylpenicillin, tetracycline digoxin lipid-soluble vitamins (A, D, E, K) Contraindications Colestipol is contraindicated in hypertriglyceridemia (high level of triglycerides in the blood). Chemistry Colestipol is a copolymer of diethylenetriamine (DETA) —or tetraethylenepentamine according to some sources— and epichlorohydrin. The structure drawing (top right) shows the DETA moieties in blue and the epichlorohydrin moieties in red. == Notes and references ==
Sodium nitrite/sodium thiosulfate	Sodium nitrite/sodium thiosulfate, sold under the brand name Nithiodote, is a fixed-dose combination medication used as an antidote for cyanide poisoning. It contains sodium thiosulfate and sodium nitrite. It is given by intravenous infusion into a vein.It was approved for medical use in the United States in January 2011. Medical uses Sodium nitrite/sodium thiosulfate is indicated for the treatment of acute cyanide poisoning. See also Sodium nitrite Sodium thiosulfate References External links "Sodium nitrite mixture with sodium thiosulfate". Drug Information Portal. U.S. National Library of Medicine.
Cyclopentolate	Cyclopentolate is a muscarinic antagonist. It is commonly used as an eye drop during pediatric eye examinations to dilate the eye (mydriatic) and prevent the eye from focusing/accommodating (cycloplegic). Cyclopentolate or atropine can also be administered to reverse muscarinic and central nervous system effects of indirect cholinomimetic (anti-AChase) administration. It is on the World Health Organizations List of Essential Medicines.After instillation of cyclopentolate, pupil dilation (mydriasis) typically lasts up to 24 hours, while paralysis of the ciliary muscle (cycloplegia) typically lasts 6-24 hours. During this time, patients may be more light sensitive than normal and may notice close objects blurred (and possibly distant objects blurred, depending on the patients visual system). Cyclopentolate is often chosen as a milder, shorter-lasting, cycloplegic alternative to atropine, another cycloplegic agent which lasts much longer. Tropicamide is an even shorter-lasting cycloplegic than cyclopentolate, but is less reliable for finding latent hyperopia. Cyclopentolate drops act rapidly to dilate the pupil.The side and adverse effects of cyclopentolate are similar to the side and adverse effects of other anticholinergic medications. Because of that, extra caution should be taken when prescribing cyclopentolate to patients who are already taking other anticholinergic drugs. A possible ocular (eye-related) side effect is increase in pressure inside the eye, which is of particular concern when there is a predisposition toward or a presence of glaucoma. Other ocular side effects can include burning sensations, discomfort with bright light (photophobia), blurred vision, irritation, inflammation of the eye mucous membranes (conjunctivitis), inflammation of the cornea of the eye (keratitis), and other issues. Nonocular (not eye-related) side and adverse effects can include neuropsychiatric symptoms like subtle concentration and memory problems, subtle decision-making problems, drowsiness, and more pronounced disorientation to time and place, confusion, disturbances of speech and movement, hyperactivity, restlessness, and seizures. Temporary psychosis can develop that includes hallucinations, particularly when higher doses are used in children or older adults on other anticholinergic medications. Patients with dementia of the Alzheimers type can experience worsening of their dementia symptoms. Additional side and adverse effects can include skin flushing, skin rashes, gastrointestinal problems, increased heart beat (tachycardia), increased body temperature (hyperpyrexia), blood vessel dilation, urinary retention, dry mouth and reduced sweating, and reduced bronchial secretions. Severe poisoning with cyclopentolate may result in coma, paralysis of breathing, and death. Cyclopentolate derivatives can be used as an antidote for organophosphate poisoning.Lethality of cyclopentolate has been studied in rodents. The LD50 (the dose at which 50% of animals die from the drug) is approximately 4000 mg/kg in rats and 960 mg/kg in mice. Readily recognizable symptoms of overdose include tachycardia, dizziness, dry mouth, behavioral disturbances, uncoordination, and drowsiness. Cycloplegia is necessary in cases of suspected latent hyperopia (or "over-focusing") so that an ophthalmologist or optometrist can accurately measure how much a person has to flex their focusing muscle (accommodation) in order to see in the distance and up-close. Correction of latent hyperopia in children can often prevent, or sometimes correct, unwanted eye turns (strabismus), some forms of refractive amblyopia, and may alleviate eye strain or frontal headaches caused by prolonged near-work. Cycloplegia is also helpful in relieving accommodative spasm. History Cyclopentolate was first synthesized in 1952 as a chemical analogue of atropine. It was one of several derivatives of an analogue to tropic acid which were tested for pharmacological action "in a search for new and better antispasmodic agents."Brand names for cyclopentolate include Cyclogyl, Cylate, Mydrilate, and Pentolair. References Further reading John P.Whitcher; Paul Riordan-Eva (2007-10-18). Vaughan & Asburys general ophthalmology (17th ed.). McGraw-Hill Medical. p. 63. ISBN 978-0071443142.
Piperacillin	Piperacillin is a broad-spectrum β-lactam antibiotic of the ureidopenicillin class. The chemical structure of piperacillin and other ureidopenicillins incorporates a polar side chain that enhances penetration into Gram-negative bacteria and reduces susceptibility to cleavage by Gram-negative beta lactamase enzymes. These properties confer activity against the important hospital pathogen Pseudomonas aeruginosa. Thus piperacillin is sometimes referred to as an "anti-pseudomonal penicillin". When used alone, piperacillin lacks strong activity against the Gram-positive pathogens such as Staphylococcus aureus, as the beta-lactam ring is hydrolyzed by the bacterias beta-lactamase.It was patented in 1974 and approved for medical use in 1981. Piperacillin is most commonly used in combination with the beta-lactamase inhibitor tazobactam (piperacillin/tazobactam), which enhances piperacillins effectiveness by inhibiting many beta lactamases to which it is susceptible. However, the co-administration of tazobactam does not confer activity against MRSA, as penicillin (and most other beta lactams) do not avidly bind to the penicillin-binding proteins of this pathogen. The World Health Organization classifies piperacillin as critically important for human medicine. Medical uses Piperacillin is used almost exclusively in combination with the beta lactamase inhibitor tazobactam for the treatment of serious, hospital-acquired infections. This combination is among the most widely used drug therapies in United States non-federal hospitals, accounting for $388M in spending in spite of being a low-cost generic drug.Piperacillin-tazobactam is recommended as part of a three-drug regimen for the treatment of hospital-acquired pneumonia suspected as being due to infection by multi-drug resistant pathogens. It is also one of several antibacterial drugs recommended for the treatment of infections known to be caused by anaerobic Gram-negative rods.Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as initial empiric treatment for people with suspected neutropenic sepsis.Piperacillin is used to treat patients diagnosed with various internal infections such as abdominal, bacteremia, gynecological, respiratory, and urinary, mainly caused by Pseudomonas aeruginosa and other infectious bacteria. They are primarily used in current and former neutropenic patients, and patients with biliary tract infections. Other uses include applications in surgical infection prophylaxis; in biliary surgery, a single dose of piperacillin is administered intravenously to inhibit the development of acute cholangitis and prevent wound infections. The combination of piperacillin and an aminoglycoside is commonly used to treat severe infections, but due to the incompatibilities in drug interaction, they are administered separately. Pneumonia The piperacillin-tazobactam (piptaz) antibiotic commonly used with an aminoglycoside retains similar levels of drug safety and efficacy as other antibiotic combinations such as ceftazidime with the aminoglycoside tobramycin in the treatment of patients with hospital acquired pneumonia. In a clinical comparison primarily targeting patients not initially placed in intensive care units, piperacillin-tazobactam was found to produce higher clinical and microbiological rates of success. By contrast, the drug efficacy of ceftazidime and piperacillin-tazobactam resulted in similar response rates (61.5% and 63.9 respectively) when tobramycin was added into both groups. Identical evaluations are shown when compared to the imipenem and tobramycin combination, where the administration of piperacillin-tazobactam on patients (especially those under mechanical ventilation) was only consisted of a slightly higher response rate. Administration Piperacillin is not absorbed orally, and must therefore be given by intravenous or intramuscular injection. It has been shown that the bactericidal actions of the drug do not increase with concentrations of piperacillin higher than 4-6 x MIC, which means that the drug is concentration-independent in terms of its actions. Piperacillin has instead shown to offer higher bactericidal activity when its concentration remains above the MIC for longer periods of time (50% time>MIC showing the highest activity). This higher activity present in continuous dosing has not been directly linked to clinical outcomes, but however does show promise of lowering possibility of resistance and decreasing mortality.Extending the time of piperacillin-tazobactam infusion allows the drugs to maintain the necessary concentrations needed within the body to prevent bacterial growth, enhancing bactericidal activity. The studies supporting this theory generally administered ~3.375g of piperacillin-tazobactam every 8 hours during a 4-hour infusion, while for organisms with higher minimum inhibitory concentrations, ~4.5g of piperacillin-tazobactam was administered every 6 hours during a 3-hour infusion.The recommended doses provided by the BNFC for infants with hospital-acquired infections are 90 mg/kg every 8 hours for infants, a maximum of 4.5g every 6 hours for children, and 4.5g every 8 hours for children aged 12 and above. A dosage of 90 mg/kg every 6 hours is suggested for infants and children diagnosed with neutropenia. Adverse effects Common side effects associated with the administration of piperacillin-tazobactam include: Gastrointestinal: constipation, diarrhea, nausea, vomiting Dermatologic: erythema, pain, phlebitis, rash Neurologic: headaches, insomniaProlonged periods of piperacillin-tazobactam therapy have been associated with the potential development of hematologic adversities such as leukopenia (16.3%), neutropenia (10%), and eosinophilia (10%) in adult patients. The combination of piperacillin-tazobactam with other antibiotics was found to be a major risk factor for leukopenia as well. Additionally, the chances of developing these illnesses increases in younger patients with fewer conditions, prolonging their time to recover.Other cases of adverse effects include instances of renal dysfunction, hepatitis, hyperactivity, anemia, abnormalities in coagulation, and hypokalemia. Allergic reactions can be induced from the side chains of β-lactam antibiotics such as amoxicillin, or antibodies surrounding the nucleus of penicillin. Interactions The combination of piperacillin and tazobactam, commonly branded as Zosyn, improves their overall bactericidal activity as amino-benzylpenicillins and ureidopencillins work synergistically with β-lactamase inhibitors. Concurrent use or unregulated dosages of piperacillin results in increasing levels of piperacillin within the body, prolonging neuromuscular transmission blockages created by non-depolarizing muscle relaxants, and disruptions in urine tests for glucose. Some compounds that may interfere with the bactericidal activity of piperacillin include chloramphenicol, macrolides, and sulfonamides. Following two studies conducted in 1986 and 2006, piperacillin was found to inhibit the removal of methotrexate in animal kidneys. Furthermore, in the presence of piperacillin-tazobactam, the decay time for methotrexate triples in comparison to the normal half-life, leaving the patient exposed to cytotoxic effects produced by the chemical agent. While penicillin antibiotics generally work synergistically with aminoglycosides by enhancing their penetration of bacterial membranes, they can also work adversely by inactivating them. A reformulation of ethylenediaminetetraacetic acid and piperacillin-tazobactam has produced results showing an increase in their affinity with amikacin and gentamicin in vitro, enabling the process of simultaneous Y-site infusion to occur. However, tobramycin was found to be incompatible as a combination through Y-site infusion. Pharmacology Piperacillin irreversibly binds to the enzyme penicillin-binding proteins, inhibiting the biosynthesis of bacterial cell walls. Mechanism of action As a β-lactam antibiotic, piperacillin inhibits penicillin-binding proteins, preventing the spread of bacteria and infections. Responsible for catalyzing the cross-linkage between peptidoglycan strands that protect the bacterial cell from osmotic rupture, penicillin-binding proteins are unique to bacterial organisms, where every known bacteria with a peptidoglycan cell wall consists of homologous sub-families. By sharing a similar stereochemistry with the substrates that bind to penicillin-binding proteins, piperacillin is able to bind to serine residues found at the active site of the enzyme through the formation of a covalent complex, preventing other substrates from binding. Moreover, this leads to the release of autolysins that break down the bacterias cell wall.Some β-lactamase enzymes also consist of residue at their active site, enabling them to hydrolyze the β-lactam ring found within these antibiotics. However, this hydrolytic activity is inhibited when piperacillin works in conjunction with tazobactam. Tazobactam binds to these enzymes to form a stable acyl-enzyme complex; similar to one formed during the hydrolysis of the β-lactam ring. Thus, protecting piperacillin from hydrolysis.The inclusion of a β-lactamase inhibitor does not always increase drug efficacy. Some bacteria may produce certain types of β-lactamase such as AmpC, which are intrinsically resistant to tazobactam. Mechanisms of resistance A major mechanism of resistance against piperacillin-tazobactam is Gram-negative bacteria producing β-lactamases. Other currently known mechanisms include mutations in the active site of penicillin-binding proteins, changes in membrane efflux, or bacteria permeability. Some enzymes, such as extended-spectrum β-lactamase (ESBL) have evolved from narrow-spectrum β-lactamases due to genetic mutations, increasing their capabilities to hydrolyze much broader spectrum penicillin. Due to prior conflicting reports on the drugs affinity with ESBL-producing bacteria, piperacillin-tazobactam treatment for such is not recommended. Antibiotic resistance occurs sporadically, conferred by the continuous use of piperacillin-tazobactam in situations where it may prove to be ineffective, leading to cases where plasmid-mediated β-lactamases are being produced in bacteria that do not naturally produce it.Some Gram-positive bacteria penicillin-binding proteins such as Enterococcus faecium (PBP-5) or Staphylococcus aureus (PBP-2a) are intrinsically antibiotic resistant, consisting of relatively low affinity with piperacillin and therefore high resistance to piperacillin-tazobactam. Furthermore, mutations in penicillin-binding proteins cause fluctuations in piperacillin affinity, whereas Streptococcus pneumoniae (PBP-2b) autolytic response is significantly reduced due to decreased affinity with piperacillin. Although membrane permeability changes are less common as a mechanism of resistance, studies investigating Klebsiella pneumoniae have reported a correlation between decreased permeability of piperacillin and increased SHV-1 β-lactamase production. Pharmacokinetics Piperacillin is generally available in their stable form as crystallized potassium or sodium salt, quickly losing bactericidal activity upon dissolution due to their short half-lives. As the gastrointestinal tract does not absorb piperacillin and tazobactam, they are dissolved in a solution before being administered to a patient, through parenteral means. Excreted through renal mechanisms like glomerular or tubular filtration as a component of urine, uncontrolled dosages of the drug can cause renal dysfunction and competitive inhibition of excretion, delaying piperacillin-tazobactam excretion, and endangering patients to drug exposure. Although the distribution of the drug remained the same, the half-life for elimination increased by three to five folds for patients diagnosed with renal dysfunction. Measured by creatinine clearance (CrCl), patients with less than 30ml/min of clearance had significantly reduced levels of piperacillin/tazobactam excretion, measuring down to 35% of the initial dosage, while the area under the curve (AUC) for piperacillin increased by about three folds for those with less than 20ml/min. A reduced dosage or alteration in the interval of administration is recommended for patients lying under 40ml/min of CrCl, depending on the severity of dysfunction. Renal is the main pathway for drug elimination for both tazobactam and piperacillin in the body. While there are other non-renal means of drug elimination like Hepatobiliary excretion, they occur less frequently. A substantial amount (~80%) of piperacillin found in urine when excreted through glomerular and tubular filtration is unmetabolized. Tazobactam renal elimination may be significantly reduced through piperacillin interaction, dropping from 63.7% to 56.8% of the administered dose over a 24-hour period. Piperacillin may be actively diffused through filtration into the biliary tract during renal clearing, indicated by a generally higher concentration of piperacillin than tazobactam in the bile. The metabolites that make up the remaining percentage in the excreted urine are composed of M1 (inactive) and N-desethyl-piperacillin (active), formed from the division of β-lactam rings of both tazobactam and piperacillin respectively.Due to the hydrophilic nature of piperacillin-tazobactam, a volume distribution of ~15 L amounting to various sites (tissues) is desired, as hydrophilic compounds are not able to pass through plasma membranes as easily as hydrophobic compounds. Concentrations often in the range of 90 MIC or above are located in specific areas including the gallbladder, lung, muscle, and skin, making up 16 - 85% of the plasma concentrations. The concentration of piperacillin-tazobactam is especially lower in fatty tissue, making up less than 10% of the plasma concentrations. Pharmacodynamics Compared to concentration dependent bactericidal antibiotics like aminoglycosides and fluoroquinolones, the antibacterial activity of β-lactam antibiotics are generally more time dependent. Unlike the former, when piperacillin-tazobactam concentrations exceed minimum inhibitory concentrations (MIC) of a pathogen by five folds, the exponential relationship between concentration and activity begins to level off. Otherwise, piperacillin-tazobactam bactericidal efficacy is shown to consist of a strong association with the duration of time the concentration exceeds minimum inhibitory concentrations (T>MIC). When the T>MIC in the serum equates to 60 - 70% of the frequency for drug administration (dosing interval), maximal activity is achieved against Gram-negative bacteria, while for Gram-positive bacteria it occurs at around 40 - 50%.Within a 24-hour period in one clinical study, a T>MIC surpassing 60% was found for piperacillin-susceptible bacteria including Escherichia coli, Klebsiella pneumoniae and Staphylococcus aureus in two dosing regimes (4.5g every 8 hours and 3.375g every 8 hours).The evidence for this was obtained through Monte Carlo experiments procured by a special program (OPTAMA), where for several different scenarios (e.g. hospital acquired infections, secondary peritonitis, skin or soft tissue infections), the probability of attaining those figures were in the ranges of 85 - 95% and 90 - 89% respectively for the two regimes. In addition, two similar dosing regimes (3.375g and 4.5g every 6 hours) both had lower chances of reaching the 90% T>MIC threshold compared to the 50% threshold against hospital acquired pneumonia pathogens.The optimization of piperacillin-tazobactam drug efficiency has been covered by various studies, limiting the focus down to two types of infusions; continuous and intermittent. A comparison using the two administration methods under the same dosage regime of 13.5g per day highlighted no major differences when treating complex intra-abdominal infections. Furthermore, a follow-up analyzation of this trial deduced that both methods of administration lead to higher concentrations compared to the MIC of the pathogens that were used. Similar results are found in a study where a select number of β-lactam susceptible pathogens consisting of Enterococcus faecalis, Klebsiella pneumoniae and Citrobacter freundii were used to test a ~10g every 24 hour dosing interval for continuous infusion.Organisms with a piperacillin-tazobactam MIC values equal to 32 or less than 16ml/I lead to 50% T>MIC when extended-interval intermittent administrations under two different dosing intervals (8.1g and 6.75g every 12 hours) were used against them. The pharmacodynamic target attainments corresponding to pathogens with MIC values of 16 mg/I are found to reach 92% when a more traditional 4 hour dosing regime is utilized to administer at irregular intervals. One study using the Monte Carlo simulation produced contradicting results to the previous studies, deducing that inadequate pharmacodynamic targets were achieved (T>MIC > 50%) for similar ESBL-producing bacteria, applying to both continuous and high dosage intermittent infusion. Chemistry Derived from “the addition of a hydrophilic heterocyclic group to the α-amino group of ampicillin”, the structure consists of a thiazolidine ring conjoined to a β-lactam ring contained within several ring compounds. The addition of this substituent increases the compounds affinity to penicillin-binding protein PBP-3, improving activity against Gram-negative bacteria, and thus broadening its spectrum of activity. Susceptible β-lactamase producing bacteria such as Staphylococcus spp. or Haemophilus influenzae, the combination of tazobactam (which shares a similar structure to sulbactam, another β-lactamase inhibitor), and piperacillin significantly improves the stability of the drug against β-lactamases. == References ==
Dapagliflozin/metformin	Dapagliflozin/metformin, sold under the brand name Xigduo XR among others, is a fixed-dose combination anti-diabetic medication used as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes. It is a combination of dapagliflozin and metformin. Dapagliflozin/metformin was approved for use in the European Union in January 2014, and for use in the United States in February 2014. It is taken by mouth. Adverse effects To lessen the risk of developing ketoacidosis (a serious condition in which the body produces high levels of blood acids called ketones) after surgery, the FDA has approved changes to the prescribing information for SGLT2 inhibitor diabetes medicines to recommend they be stopped temporarily before scheduled surgery. Canagliflozin, dapagliflozin, and empagliflozin should each be stopped at least three days before, and ertugliflozin should be stopped at least four days before scheduled surgery.Symptoms of ketoacidosis include nausea, vomiting, abdominal pain, tiredness, and trouble breathing. References External links "Dapagliflozin mixture with metformin hydrochloride". Drug Information Portal. U.S. National Library of Medicine. "Dapagliflozin". MedlinePlus. "Metformin". MedlinePlus.
Imiquimod	Imiquimod, sold under the brand name Aldara among others, is a medication that acts as an immune response modifier that is used to treat genital warts, superficial basal cell carcinoma, and actinic keratosis. Scientists at 3Ms pharmaceuticals division discovered the drug and 3M obtained the first FDA approval in 1997. As of 2015, imiquimod is generic and is available worldwide under many brands. Medical uses Imiquimod is a patient-applied cream prescribed to treat genital warts, Bowens disease (squamous cell carcinoma in situ), and, secondary to surgery, for basal cell carcinoma, as well as actinic keratosis.Imiquimod 5% cream is indicated for the topical treatment of: external genital and perianal warts (condylomata acuminata) in adults; small superficial basal-cell carcinomas (sBCCs) in adults; clinically typical, non-hyperkeratotic, non-hypertrophic actinic keratoses (AKs) on the face or scalp in immunocompetent adults when size or number of lesions limit the efficacy and / or acceptability of cryotherapy and other topical treatment options are contraindicated or less appropriate.Imiquimod 3.75% cream is indicated for the topical treatment of clinically typical, non-hyperkeratotic, non-hypertrophic, visible or palpable actinic keratosis of the full face or balding scalp in immunocompetent adults when other topical treatment options are contraindicated or less appropriate. Side effects Side effects include local inflammatory reactions, such as blisters, a burning sensation, skin redness, dry skin, itching, skin breakdown, skin crusting or scabbing, skin drainage, skin flaking or scaling, skin ulceration, sores, swelling, as well as systemic reactions, such as fever, "flu-like" symptoms, headache, and tiredness.People who have had an organ transplant and are taking immune-suppressing drugs should not use imiquimod. Mechanism of action Imiquimod yields profound antitumoral activity by acting on several immunological levels synergistically. Imiquimod stimulates the innate immune system by activating toll-like receptor 7 (TLR7), commonly involved in pathogen recognition. Cells activated by imiquimod via TLR-7 secrete cytokines (primarily interferon-α (IFN-α), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α)). There is evidence that imiquimod, when applied to skin, can lead to the activation of Langerhans cells, which subsequently migrate to local lymph nodes to activate the adaptive immune system. Other cell types activated by imiquimod include natural killer cells, macrophages and B-lymphocytes.Imiquimod exerts its effect by increasing levels of the opioid growth factor receptor (OGFr). In experiments, blocking OGFr function with siRNA technology resulted in loss of any antiproliferative effect of imiquimod. History Scientists at 3Ms pharmaceutical division discovered imiquimod as part of a program to discover inhibitors of herpes simplex virus replication based on a known adenine derivative.: 369–372 3M obtained the first FDA approval for it in 1997 as a treatment for external genital and perianal warts under the brand, "Aldara". In 2004, 3M obtained FDA approval to market imiquimod as a treatment for superficial basal cell carcinoma.In 2006, 3M sold its pharmaceutical business in the Americas to Graceway Pharmaceuticals, its European pharmaceutical business to Meda AB, and its pharmaceutical business in other territories to two private equity firms.Graceway declared bankruptcy in 2011, after the expiration of the patents on imiquimod, and its assets, including the rights to imiquimod branding and approvals in the Americas, were purchased by Medicis Pharmaceutical.Imiquimod 5% was approved for medical use in the European Union in September 1998. Imiquimod 3.75% was approved for medical use in the European Union in August 2012.As of 2015, imiquimod is generic and is available worldwide under many brands. Research One randomized double-blind Phase III clinical study found clearance of genital warts (an FDA-approved indication) improved from 9% with placebo to 24.9% with 3.75% imiquimod cream applied for up to eight weeks.Imiquimod has been tested for treatment of molluscum contagiosum. Two large randomized controlled trials, however, found no evidence of effectiveness of imiquimod in treating children with molluscum contagiosum, and concerning adverse effects were also noted. These disprove earlier anecdotal claims and smaller, less reliable studies.Imiquimod has also been tested for treatment of vulvar intraepithelial neoplasia, vaginal intraepithelial neoplasia, common warts (a 2012 Cochrane review found no randomized controlled trials), plantar warts, warts in people with suppressed immune systems, flat warts on face and neck, and warts under and around fingernails and toenails. As of 2014, insufficient evidence exists to recommend treatment of warts (other than genital warts) with imiquimod, due to the small size of and lack of controls in existing studies. References External links "Imiquimod". Drug Information Portal. U.S. National Library of Medicine. DermNet treatments/imiquimod
Hydrea	Hydrea may refer to: Hydra island A brand name for the medication hydroxycarbamide
Propylthiouracil	Propylthiouracil (PTU) is a medication used to treat hyperthyroidism. This includes hyperthyroidism due to Graves disease and toxic multinodular goiter. In a thyrotoxic crisis it is generally more effective than methimazole. Otherwise it is typically only used when methimazole, surgery, and radioactive iodine is not possible. It is taken by mouth.Common side effects include itchiness, hair loss, parotid swelling, vomiting, muscle pains, numbness, and headache. Other severe side effects include liver problems and low blood cell counts. Use during pregnancy may harm the baby. Propylthiouracil is in the antithyroid family of medications. It works by decreasing the amount of thyroid hormone produced by the thyroid gland and blocking the conversion of thyroxine (T4) to triiodothyronine (T3).Propylthiouracil came into medical use in the 1940s. It is on the World Health Organizations List of Essential Medicines. Side effects Propylthiouracil is generally well tolerated, with side effects occurring in one of every 100 patients. The most common side effects are related to the skin and include rash, itching, hives, abnormal hair loss, and skin pigmentation. Other common side effects are swelling, nausea, vomiting, heartburn, loss of taste, joint or muscle aches, numbness and headache, allergic reactions, and hair whitening.Its notable side effects include a risk of agranulocytosis and aplastic anemia. On 3 June 2009, the FDA published an alert "notifying healthcare professionals of the risk of serious liver injury, including liver failure and death, with the use of propylthiouracil." As a result, propylthiouracil is no longer recommended in non-pregnant adults and in children as the front line antithyroid medication.One possible side effect is agranulocytosis, a decrease of white blood cells in the blood. Symptoms and signs of agranulocytosis include infectious lesions of the throat, the gastrointestinal tract, and skin with an overall feeling of illness and fever. A decrease in blood platelets (thrombocytopenia) also may occur. Since platelets are important for the clotting of blood, thrombocytopenia may lead to problems with excessive bleeding. Side effects are suspected and the drug is sometimes discontinued if the patient complains of recurrent episodes of sore throat. Another life-threatening side effect is sudden, severe, fulminant liver failure resulting in death or the need for a liver transplantation, which occurs in up to 1 in 10,000 people taking propylthiouracil. Unlike agranulocytosis which most commonly occurs in the first three months of therapy, this side effect may occur at any time during treatment. Pregnancy Propylthiouracil is classified as Drug Class D in pregnancy. Class D signifies there is positive evidence of human fetal risk. The maternal benefit may outweigh fetal risk in life-threatening situations. PTU is preferred over methimazole (which is also a class D) only in the first trimester of pregnancy and in women who may become pregnant because of the increased risk of teratogenicity of methimazole during critical organogenesis. In the second and third trimester, this risk is diminished and methimazole is preferred to avoid the risk of liver complications from PTU in the mother.The primary effect on the fetus from transplacental passage of PTU is the production of a mild hypothyroidism when the drug is used close to term. This usually resolves within a few days without treatment. The hypothyroid state may be observed as a goiter in the newborn, and is the result of increased levels of fetal pituitary thyrotropin. The incidence of fetal goiter after PTU treatment in reported cases is approximately 12%. Mechanism of action Thyroid PTU inhibits the enzyme thyroperoxidase, which normally acts in thyroid hormone synthesis by oxidizing the anion iodide (I−) to iodine (I0), facilitating iodines addition to tyrosine residues on the hormone precursor thyroglobulin. This is one of the essential steps in the formation of thyroxine (T4).PTU does not inhibit the action of the sodium-dependent iodide transporter located on follicular cells basolateral membranes. Inhibition of this step requires competitive inhibitors, such as perchlorate and thiocyanate. T3/T4 target tissues PTU also acts by inhibiting the enzyme 5-deiodinase (tetraiodothyronine 5 deiodinase), which converts T4 to the more active form T3. (This is in contrast to methimazole, which shares propylthiouracils central mechanism, but not its peripheral one.) It is important to recognize that these enzymes only work on the conjugated tyrosine molecules of T3 and T4: a completely different enzyme family is responsible for the deiodinase activity of iodized single tyrosine molecules within the thyroid follicular cells. For information on that enzyme family, see Iodotyrosine deiodinase. Pharmacokinetics The administration is oral, with peak serum concentrations occurring in one hour, and actively concentrated to the thyroid gland. Depending on several patient variables, however, euthyroid status may not be achieved until 2–4 months after treatment initiation. Of note, the drug is approximately 70% protein-bound and significantly ionized at normal physiologic pH, while the antithyroid agent methimazole is substantially less protein bound. However, both are equally transferred across the placenta.The plasma half-life is one hour and is not altered appreciably by the thyroid status of the patient. Due to the concentration in the thyroid, however, dosing intervals may last 8 hours or longer. Less than 10% of the drug is excreted unchanged, with the remaining fraction undergoing extensive hepatic metabolism via glucuronidation. Chemical synthesis Propylthiouracil can be prepared from ethyl 3-oxohexanoate and thiourea. Role in taste Propylthiouracil, together with phenylthiocarbamide (PTC), are known to have bitter taste. However, it seems the propensity for tasting these compounds is genetically based and the bitter taste is likely to be engendered by the thiocyanate moiety, also present in PTC. History It was approved by the United States Food and Drug Administration in 1947. References External links "Propylthiouracil". Drug Information Portal. U.S. National Library of Medicine.
Anthrax vaccines	Anthrax vaccines are vaccines to prevent the livestock and human disease anthrax, caused by the bacterium Bacillus anthracis.They have had a prominent place in the history of medicine, from Pasteurs pioneering 19th-century work with cattle (the first effective bacterial vaccine and the second effective vaccine ever) to the controversial late 20th century use of a modern product to protect American troops against the use of anthrax in biological warfare. Human anthrax vaccines were developed by the Soviet Union in the late 1930s and in the US and UK in the 1950s. The current vaccine approved by the U.S. Food and Drug Administration (FDA) was formulated in the 1960s. Currently administered human anthrax vaccines include acellular (USA, UK) and live spore (Russia) varieties. All currently used anthrax vaccines show considerable local and general reactogenicity (erythema, induration, soreness, fever) and serious adverse reactions occur in about 1% of recipients. New third-generation vaccines being researched include recombinant live vaccines and recombinant sub-unit vaccines. Pasteurs vaccine In the 1870s, the French chemist Louis Pasteur (1822–1895) applied his previous method of immunising chickens against chicken cholera to anthrax, which affected cattle, and thereby aroused widespread interest in combating other diseases with the same approach. In May 1881, Pasteur performed a famous public experiment at Pouilly-le-Fort to demonstrate his concept of vaccination. He prepared two groups of 25 sheep, one goat and several cows. The animals of one group were twice injected, with an interval of 15 days, with an anthrax vaccine prepared by Pasteur; a control group was left unvaccinated. Thirty days after the first injection, both groups were injected with a culture of live anthrax bacteria. All the animals in the non-vaccinated group died, while all of the animals in the vaccinated group survived. The public reception was sensational. Pasteur publicly claimed he had made the anthrax vaccine by exposing the bacilli to oxygen. His laboratory notebooks, now in the Bibliothèque Nationale in Paris, in fact show Pasteur used the method of rival Jean-Joseph-Henri Toussaint (1847–1890), a Toulouse veterinary surgeon, to create the anthrax vaccine. This method used the oxidizing agent potassium dichromate. Pasteurs oxygen method did eventually produce a vaccine but only after he had been awarded a patent on the production of an anthrax vaccine. The notion of a weak form of a disease causing immunity to the virulent version was not new; this had been known for a long time for smallpox. Inoculation with smallpox (variolation) was known to result in far less scarring, and greatly reduced mortality, in comparison with the naturally acquired disease. The English physician Edward Jenner (1749–1823) had also discovered (1796) the process of vaccination by using cowpox to give cross-immunity to smallpox and by Pasteurs time this had generally replaced the use of actual smallpox material in inoculation. The difference between smallpox vaccination and anthrax or chicken cholera vaccination was that the weakened form of the latter two disease organisms had been "generated artificially", so a naturally weak form of the disease organism did not need to be found. This discovery revolutionized work in infectious diseases and Pasteur gave these artificially weakened diseases the generic name "vaccines", in honor of Jenners groundbreaking discovery. In 1885, Pasteur produced his celebrated first vaccine for rabies by growing the virus in rabbits and then weakening it by drying the affected nerve tissue. In 1995, the centennial of Pasteurs death, The New York Times ran an article titled "Pasteurs Deception". After having thoroughly read Pasteurs lab notes, the science historian Gerald L. Geison declared Pasteur had given a misleading account of the preparation of the anthrax vaccine used in the experiment at Pouilly-le-Fort. The same year, Max Perutz published a vigorous defense of Pasteur in The New York Review of Books. Sternes vaccine The Austrian-South African immunologist Max Sterne (1905–1997) developed an attenuated live animal vaccine in 1935 that is still employed and derivatives of his strain account for almost all veterinary anthrax vaccines used in the world today. Beginning in 1934 at the Onderstepoort Veterinary Research Institute, north of Pretoria, he prepared an attenuated anthrax vaccine, using the method developed by Pasteur. A persistent problem with Pasteurs vaccine was achieving the correct balance between virulence and immunogenicity during preparation. This notoriously difficult procedure regularly produced casualties among vaccinated animals. With little help from colleagues, Sterne performed small-scale experiments which isolated the "Sterne strain" (34F2) of anthrax which became, and remains today, the basis of most of the improved livestock anthrax vaccines throughout the world. Russian anthrax vaccines Anthrax vaccines were developed in the Soviet Union in the 1930s and available for use in humans by 1940. A live attenuated, unencapsulated spore vaccine became widely used for humans. It was given either by scarification or subcutaneously and its developers claimed that it was reasonably well tolerated and showed some degree of protective efficacy against cutaneous anthrax in clinical field trials. The efficacy of the live Russian vaccine was reported to have been greater than that of either of the killed British or US anthrax vaccines (AVP and AVA, respectively) during the 1970s and 80s. Today both Russia and China use live attenuated strains for their human vaccines. These vaccines may be given by aerosol, scarification, or subcutaneous injection. A Georgian/Russian live anthrax spore vaccine (called STI) was based on spores from the Sterne strain of B. anthracis. It was given in a two-dose schedule, but serious side-effects restricted its use to healthy adults. It was reportedly manufactured at the George Eliava Institute of Bacteriophage, Microbiology and Virology in Tbilisi, Georgia, until 1991. British anthrax vaccines British biochemist Harry Smith (1921–2011), working for the UK bio-weapons program at Porton Down, discovered the three anthrax toxins in 1948. This discovery was the basis of the next generation of antigenic anthrax vaccines and for modern antitoxins to anthrax. The widely used British anthrax vaccine—sometimes called Anthrax Vaccine Precipitated (AVP) to distinguish it from the similar AVA (see below)—became available for human use in 1954. This was a cell-free vaccine in distinction to the live-cell Pasteur-style vaccine previously used for veterinary purposes. It is now manufactured by Porton Biopharma Ltd, a Company owned by the UK Department of Health. AVP is administered at primovaccination in three doses with a booster dose after six months. The active ingredient is a sterile filtrate of an alum-precipitated anthrax antigen from the Sterne strain in a solution for injection. The other ingredients are aluminium potassium sulphate, sodium chloride and purified water. The preservative is thiomersal (0.005%). The vaccine is given by intramuscular injection and the primary course of four single injections (3 injections 3 weeks apart, followed by a 6-month dose) is followed by a single booster dose given once a year. During the Gulf War (1990–1991), UK military personnel were given AVP concomitantly with the pertussis vaccine as an adjuvant to improve overall immune response and efficacy. American anthrax vaccines The United States undertook basic research directed at producing a new anthrax vaccine during the 1950s and 60s. The product known as Anthrax Vaccine Adsorbed (AVA)—trade name BioThrax—was licensed in 1970 by the U.S. National Institutes of Health (NIH) and in 1972 the Food and Drug Administration (FDA) took over responsibility for vaccine licensure and oversight. AVA is produced from culture filtrates of an avirulent, nonencapsulated mutant of the B. anthracis Vollum strain known as V770-NP1-R. No living organisms are present in the vaccine which results in protective immunity after 3 to 6 doses. AVA remains the only FDA-licensed human anthrax vaccine in the United States and is produced by Emergent BioSolutions, formerly known as BioPort Corporation in Lansing, Michigan. The principal purchasers of the vaccine in the United States are the Department of Defense and Department of Health and Human Services. Ten million doses of AVA have been purchased for the U.S. Strategic National Stockpile for use in the event of a mass bioterrorist anthrax attack. In 1997, the Clinton administration initiated the Anthrax Vaccine Immunization Program (AVIP), under which active U.S. service personnel were to be immunized with the vaccine. Controversy ensued since vaccination was mandatory and GAO published reports that questioned the safety and efficacy of AVA, causing sometimes serious side effects. A Congressional report also questioned the safety and efficacy of the vaccine and challenged the legality of mandatory inoculations. Mandatory vaccinations were halted in 2004 by a formal legal injunction which made numerous substantive challenges regarding the vaccine and its safety. After reviewing extensive scientific evidence, the FDA determined in 2005 that AVA is safe and effective as licensed for the prevention of anthrax, regardless of the route of exposure. In 2006, the Defense Department announced the reinstatement of mandatory anthrax vaccinations for more than 200,000 troops and defense contractors. The vaccinations are required for most U.S. military units and civilian contractors assigned to homeland bioterrorism defense or deployed in Iraq, Afghanistan or South Korea. Investigational anthrax vaccines A number of experimental anthrax vaccines are undergoing pre-clinical testing, notably the Bacillus anthracis protective antigen—known as PA (see Anthrax toxin—combined with various adjuvants such as aluminum hydroxide (Alhydrogel), saponin QS-21, and monophosphoryl lipid A (MPL) in squalene/lecithin/Tween 80 emulsion (SLT). One dose of each formulation has provided significant protection (> 90%) against inhalational anthrax in rhesus macaques. Omer-2 trial: Beginning in 1998 and running for eight years, a secret Israeli project known as Omer-2 tested an Israeli investigational anthrax vaccine on 716 volunteers of the Israel Defense Forces. The vaccine—given under a seven-dose schedule—was developed by the Nes Tziona Biological Institute. A group of study volunteers complained of multi-symptom illnesses allegedly associated with the vaccine and petitioned for disability benefits to the Defense Ministry, but were denied. In February 2009, a petition from the volunteers to disclose a report about Omer-2 was filed with the Israels High Court against the Defense Ministry, the Israel Institute for Biological Research at Nes Tziona, the director, Avigdor Shafferman, and the IDF Medical Corps. Release of the information was requested to support further action to provide disability compensation for the volunteers. In 2014 it was announced that the Israeli government would pay $6 million compensation to the 716 soldiers who participated in the Omer-2 trial. In 2012, B. anthracis isolate H9401 was obtained from a Korean patient with gastrointestinal anthrax. The goal of the Republic of Korea is to use this strain as a challenge strain to develop a recombinant vaccine against anthrax. References Further reading Donegan S, Bellamy R, Gamble CL (2009). Donegan S (ed.). "Vaccines for preventing anthrax". Cochrane Database Syst Rev (2): CD006403. doi:10.1002/14651858.CD006403.pub2. PMC 6532564. PMID 19370633. Ramsay M, ed. (2017). "Chapter 13: Anthrax". Immunisation against infectious disease. Public Health England. Turnbull, P.C.B. (1991), "Anthrax Vaccines: Past, Present, and Future", Vaccine, 533–9.
Magnesium gluconate	Magnesium gluconate is a compound with formula MgC12H22O14. It is the magnesium salt of gluconic acid. According to one study, magnesium gluconate showed the highest level of bioavailability of any magnesium salt which implies its viability as a supplement, although of the 10 salts studied, all increased magnesium levels significantly. This study did not include magnesium glycinate, which is one of the most bioavailable forms of magnesium.It has E number "E580". Use in medicine There are data on the pharmacological properties of magnesium gluconate. Gluconic acid is the initial substrate for the reactions of pentose phosphate path of oxidation of glucose, so it was suggested that it may affect the energy metabolism of mitochondria. In Ukraine, magnesium gluconate, together with potassium gluconate in the drug Rhythmocor is used to treat heart disease. Pilot studies have shown efficacy in various cardiac arrhythmia. Whether these effects are from the influence of gluconic acid on the metabolism of the heart or from the influence of magnesium and potassium on osmotic pressure is unknown. == References ==
Telmisartan/hydrochlorothiazide	Telmisartan/hydrochlorothiazide, sold under the brand name Micardis HCT among others, is a fixed-dose combination medication used to treat high blood pressure. It is a combination of telmisartan an angiotensin II receptor antagonist with hydrochlorothiazide a diuretic. It may be used if telmisartan by itself is not sufficient. It is taken by mouth.Common side effects include dizziness, upper respiratory tract infections, nausea, diarrhea, and tiredness. Severe side effects may include kidney problems, electrolyte problems, and allergic reactions. Use during pregnancy may harm the baby. Telmisartan works by blocking the effects of angiotensin II while hydrochlorothiazide works by decreasing the kidneys ability to retain water.The combination was approved for medical use in the United States in November 2000, and in the European Union in April 2002. The combination is on the World Health Organizations List of Essential Medicines. It is available as a generic medication. References External links "Hydrochlorothiazide mixture with telmisartan". Drug Information Portal. U.S. National Library of Medicine.
Nefazodone	Nefazodone, sold formerly under the brand names Serzone, Dutonin, and Nefadar among others, is an atypical antidepressant which was first marketed by Bristol-Myers Squibb (BMS) in 1994 but has since largely been discontinued. BMS withdrew it from the market by 2004 due to decreasing sales due to the rare incidence of severe liver damage and the onset of generic competition. The incidence of severe liver damage is approximately 1 in every 250,000 to 300,000 patient-years. Generic versions were introduced in 2003.Nefazodone is a phenylpiperazine compound and is related to trazodone. It has been described as a serotonin antagonist and reuptake inhibitor (SARI) due to its combined actions as a potent serotonin 5-HT2A receptor and 5-HT2C receptor antagonist and weak serotonin–norepinephrine–dopamine reuptake inhibitor (SNDRI). Medical uses Nefazodone is used to treat major depressive disorder, aggressive behavior, anxiety, and panic disorder. Available forms Nefazodone is available as 50 mg, 100 mg, 150 mg, 200 mg, and 250 mg tablets for oral ingestion. Contraindications Side effects Nefazodone can cause severe liver damage, leading to a need for liver transplant, and death. The incidence of severe liver damage is approximately 1 in every 250,000 to 300,000 patient-years. By the time that it started to be withdrawn in 2003, nefazodone had been associated with at least 53 cases of liver injury, with 11 deaths, in the United States, and 51 cases of liver toxicity, with 2 cases of liver transplantation, in Canada. In a Canadian study which found 32 cases in 2002, it was noted that databases like that used in the study tended to include only a small proportion of suspected drug reactions.Protocols are that nefazodone should not be used in patients who have a pre-existing liver condition. Prior to treatment liver enzymes should be tested to make sure there is not an underlying liver condition. If serum AST or serum ALT levels are more than 3 times the upper limit of normal (ULN) should be permanently withdrawn from the drug. Regular enzyme labs should be done every 6 months. Due to liver issues Nefazodone should not be a first line treatment. Common and mild side effects of nefazodone reported in clinical trials more often than placebo include dry mouth (25%), sleepiness (25%), nausea (22%), dizziness (17%), blurred vision (16%), weakness (11%), lightheadedness (10%), confusion (7%), and orthostatic hypotension (5%). Rare and serious adverse reactions may include allergic reactions, fainting, painful/prolonged erection, and jaundice.Nefazodone is not especially associated with increased appetite and weight gain. Interactions Nefazodone is a potent inhibitor of CYP3A4, and may interact adversely with many commonly used medications that are metabolized by CYP3A4. Pharmacology Pharmacodynamics Nefazodone acts primarily as a potent antagonist of the serotonin 5-HT2A receptor and to a lesser extent of the serotonin 5-HT2C receptor. It also has high affinity for the α1-adrenergic receptor and serotonin 5-HT1A receptor, and relatively lower affinity for the α2-adrenergic receptor and dopamine D2 receptor. Nefazodone has low but significant affinity for the serotonin, norepinephrine, and dopamine transporters as well, and therefore acts as a weak serotonin-norepinephrine-dopamine reuptake inhibitor (SNDRI). It has low but potentially significant affinity for the histamine H1 receptor, where it is an antagonist, and hence may have some antihistamine activity. Nefazodone has negligible activity at muscarinic acetylcholine receptors, and accordingly, has no anticholinergic effects. Pharmacokinetics The bioavailability of nefazodone is low and variable, about 20%. Its plasma protein binding is approximately 99%, but it is bound loosely.Nefazodone is metabolized in the liver, with the main enzyme involved thought to be CYP3A4. The drug has at least four active metabolites, which include hydroxynefazodone, para-hydroxynefazodone, triazoledione, and meta-chlorophenylpiperazine. Nefazodone has a short elimination half-life of about 2 to 4 hours. Its metabolite hydroxynefazodone similarly has an elimination half-life of about 1.5 to 4 hours, whereas the elimination half-lives of triazoledione and mCPP are longer at around 18 hours and 4 to 8 hours, respectively. Due to its long elimination half-life, triazole is the major metabolite and predominates in the circulation during nefazodone treatment, with plasma levels that are 4 to 10 times higher than those of nefazodone itself. Conversely, hydroxynefazodone levels are about 40% of those of nefazodone at steady state. Plasma levels of mCPP are very low at about 7% of those of nefazodone; hence, mCPP is only a minor metabolite. mCPP is thought to be formed from nefazodone specifically by CYP2D6.The ratios of brain-to-plasma concentrations of mCPP to nefazodone are 47:1 in mice and 10:1 in rats, suggesting that brain exposure to mCPP may be much higher than plasma exposure. Conversely, hydroxynefazodone levels in the brain are 10% of those in plasma in rats. As such, in spite of its relatively low plasma concentrations, brain exposure to mCPP may be substantial, whereas that of hydroxynefazodone may be minimal. Chemistry Nefazodone is a phenylpiperazine; it is an alpha-phenoxyl derivative of etoperidone which in turn was a derivative of trazodone. History Nefazodone was discovered by scientists at Bristol-Myers Squibb (BMS) who were seeking to improve on trazodone by reducing its sedating qualities.BMS obtained marketing approvals worldwide for nefazodone in 1994. It was marketed in the US under the brand name Serzone and in Europe under the brand name Dutonin.In 2002 the FDA obligated BMS to add a black box warning about potential fatal liver toxicity to the drug label. Worldwide sales in 2002 were $409 million.In 2003 Public Citizen filed a citizen petition asking the FDA to withdraw the marketing authorization in the US, and in early 2004 the organization sued the FDA to attempt to force withdrawal of the drug. The FDA issued a response to the petition in June 2004 and filed a motion to dismiss, and Public Citizen withdrew the suit.Generic versions were introduced in the US in 2003 and Health Canada withdrew the marketing authorization that year.Sales of nefazodone were about $100 million in 2003. By that time it was also being marketed under the additional brand names Serzonil, Nefadar, and Rulivan.In April 2004, BMS announced that it was going to discontinue the sale of Serzone in the US in June 2004 and said that this was due to declining sales. By that time BMS had already withdrawn the drug from the market in Europe, Australia, New Zealand and Canada.As of 2012 generic nefazodone was available in the US.In August 2020, Teva Pharmaceuticals placed nefazodone in shortage due to a shortage of a raw ingredient. On December 20, 2021, Nefazodone was again made available in all strengths. Society and culture Generic names Nefazodone is the generic name of the drug and its INN and BAN, while néfazodone is its DCF and nefazodone hydrochloride is its USAN and USP. Brand names Nefazodone has been marketed under a number of brand names including Dutonin (AT, ES, IE, UK), Menfazona (ES), Nefadar (CH, DE, NO, SE), Nefazodone BMS (AT), Nefazodone Hydrochloride Teva (US), Reseril (IT), Rulivan (ES), and Serzone (AU, CA, US). Research The use of nefazodone to prevent migraine has been studied, due to its antagonistic effects on the 5-HT2A and 5-HT2C receptors. References External links Media related to Nefazodone at Wikimedia Commons
Rimexolone	Rimexolone is a glucocorticoid steroid used to treat inflammation in the eye. It is marketed as a 1% eye drop suspension under the trade name Vexol by Alcon Laboratories, but was discontinued in the US and other countries. Medical uses Rimexolone is used to treat inflammation after eye surgery, to treat anterior uveitis, conjunctivitis and keratitis. Contraindications The substance is contraindicated in herpes simplex and most other viral eye infections, as well as mycobacterial, fungal and amoebal eye infections because it only reduces the inflammation but does not act against such microorganisms. Side effects The most common adverse effects are blurred vision, tearing and other kinds of eye discomfort. Eye pain, eye oedema, headache, increased intraocular pressure and other side effects are seen in less than 1% of patients. Pharmacology Pharmacodynamics As a glucocorticoid, rimexolone acts as an agonist of the glucocorticoid receptor. Pharmacokinetics A small amount of rimexolone is absorbed into the systemic circulation. On hourly treatment with the eye drops for a week, blood serum concentrations peaked at 150 pg/ml on average, with many patients remaining below the detection threshold of 80 pg/ml. The elimination half-life from the circulation is estimated at one to two hours; the substance is mainly (over 80%) excreted via the faeces. == References ==

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