Mark Corson

By L. Anog. Molloy College. 2018.

It is thus of no use during the progress of typhus generic 20 mg female cialis mastercard pregnancy 5th month, typhoid and other protracted fevers generic female cialis 20 mg on-line menstrual weight fluctuation. In such cases it causes nerve irritation and increased temperature discount 10 mg female cialis breast cancer 60 mile walk, especially if there is deficient secretion. When the fever is broken and there is a tendency toward a restoration of secretion, and the temperature is normal or subnormal, then this agent is a vitally important one. Here the bisulphate, being readily absorbed, Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 128 produces the happiest results. In intermittent fevers it is excellent practice to give the remedy in broken doses during the intermission. The absorption of the sulphate of quinine takes place so slowly that a period of between four and six hours is required, under favorable circumstances, to develop the full effect of the remedy. A dose of from three to five grains, given five hours before the expected paroxysm, will exercise its full influence upon the paroxysm when it should appear. If another dose of two and one-half grains be given two hours after the first dose, and a third dose of the same size be administered after another period of two hours, or one hour before the chill will occur, the effect of the agent will be uniformly continued during the time in which both the chill and the fever would have reached their highest point. The repetition of this course on the second and third days will usually be sufficient to overcome the most severe. It is well to adopt the same course on the seventh, fourteenth and twenty-first days following the attack. The following formula is of excellent service in those cases in which the liver and other glandular organs have been profoundly influenced by the disease, and where the nervous system shows considerable depression: Rx— Quiniae Sulphat, xl grains. When the paroxysms no longer appear, two or three grains of quinine may be given regularly every three hours during the day. In the treatment of congestive chill, and in malignant conditions of malarial origin, quinine is specific, but should be given in much larger doses, and usually with some direct stimulant and in conjunction with the use of external heat. It may be given in doses of twenty grains preceding the attack, or with stimulants during the attack. If a severe attack is fully anticipated, large doses should be repeated every two or three hours during the entire remission. It was once considered of Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 129 essential importance in the reduction of high temperatures, but the conditions and character of its action were so imperfectly understood that it often did harm, and caused an increase in the temperature instead of a reduction. As a restorative after pneumonia, where hepatization has been extensive, this agent is an important one. Two grains of the bisulphate of quinine, with one-fourth of a grain of ipecac, and perhaps the one-fourth of a grain of nux vomica, will rapidly improve the function of the nervous system and of the circulation, and as rapidly overcome the hepatization and other results of inflammatory action. The influence upon the stomach and intestinal canal, and thus upon the digestion and assimilation of food, is marked and immediate. Its influence is exercised to the best possible advantage when there is impaired or deficient nerve force. It is indicated as a restorative after prostrating disease, especially after continued and inflammatory fevers. It strengthens the action of the heart, improving the character of the circulation of every organ. It stimulates the liver and kidneys, and thus assists in the rapid elimination of the waste products of the disease. It stimulates the respiratory function, promoting oxygenation of the blood, thus assisting in the restoration of the character of that fluid. These results are accomplished largely through its profoundly stimulating influence upon the cerebral and spinal centers. It is milder in its effects upon the nerve centers and fully as efficacious in its tonic influence. It is combined to excellent advantage with hydrastine, nux vomica or the salts of iron. Or it may be given with strychnine or picrotoxin or ignatia with excellent results, and if liver complications exist, it may be combined with leptandrin, podophyllin or iris. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 130 In chronic congestion of the liver, or splenitis, quinine dissolved in the tincture of the chloride of iron, and combined with syrup of orange or simple elixir, produces satisfactory results. In the prostrating night sweats following malarial fever this agent, in the above combination, is a fine tonic, quickly overcoming the sweating and other results of the disease. Where paludal miasm is the cause of various indefinite disorders, or of general malaise, the phenomena occurring periodically, quinine should be given to anticipate the unpleasant symptoms. Dumb ague, hemicrania and severe general headaches, neuralgias of various kinds and asthmatic attacks occur from this cause and are satisfactorily treated with this remedy. It may be afterward given as a tonic, in combination with any other tonic agent which may be specifically indicated. Quinine has a direct power in inducing contraction of the parturient womb, especially if from inefficient strength the labor has been prolonged until the nervous force of the patient is well nigh exhausted. If fifteen grains be given in one dose, it may overcome all undesirable conditions at once and prove sufficient. It is a good remedy for this latter condition when it has occurred, acting also as a stimulant to the heart and nervous system. It is a dangerous remedy in large doses during pregnancy, as it may bring on premature labor. In amenorrhea, from cold it is useful and may be prescribed alternately with aconite, after a hot bath has started secretion from the skin. In sluggish ulcers and old sores, where there is no activity to the capillary circulation, it may be applied with good results. It was at one time extensively used as a throat wash in diphtheria, and to its antiseptic character is credited its beneficial influence upon whooping cough, having been much depended on for the cure of that disease. A douche made by dissolving six or eight grains in a pint of hot water will be found of service in chronic catarrh, with fetid discharge, and in hay fever.

Some authorities say the drug’s apparent hallucinogenic qualities are caused instead by its abil- ity to lower heart rate enough to produce oxygen starvation in the optic nerves cheap 10 mg female cialis free shipping women's health issues globally, causing a person to “see stars best 20mg female cialis menstruation 1700s. Studies have found that levels of the substance are often elevated in the urine of schizophrenics female cialis 10 mg overnight delivery breast cancer headbands, in some types of autistic indi- viduals, and in depressed persons but rarely in psychologically normal people. Although cause and effect is by no means established, a study found higher bufotenine levels in urine of paranoid persons convicted of violent crimes than in urine from nonparanoid violent offenders. Additional scientific information may be found in: “Deaths Associated with a Purported Aphrodisiac—New York City, February 1993– May 1995. This pain reliever is produced from thebaine and is both longer last- ing than morphine and 25 to 50 times stronger. Buprenorphine is given to persons suffering from conditions causing great discomfort, such as cancer, pancreatitis, and surgery. Experimental use of the drug to treat depression and schizophrenia has had promising results. Typical unwanted effects are sedation, nausea, constipation, dizziness, sweating, and low blood pressure. The drug can interfere with skills needed to operate a car or other dangerous machinery; volunteers in one experiment still had trouble eight hours after a dose. A medical case report tells of a heart attack after someone inhaled powder from a pul- verized oral buprenorphine tablet. Heart trouble has also been noted when the drug is used medically, but in a therapeutic context, such difficulty is very unusual. Long-term administration of the drug in mice can change their blood composition, including a drastic decline in the number of white blood cells, but these changes clear up after administration of buprenorphine stops. Although the drug produces sensations likened to those of morphine, when this book was written, buprenorphine was a Schedule V con- trolled substance, a classification reserved for drugs with the lowest addictive potential. Research conducted on behalf of the National Institute on Drug Abuse and published in 2001 found no illicit buprenorphine use in the United States but described the drug as having appeal to street markets. Such a mar- ket may develop; in an experiment testing opiate users’ ability to detect dif- ferences among drugs, the volunteers misidentified buprenorphine as heroin. People can become addicted to buprenorphine; one study found no differ- ence other than age between buprenorphine addicts and heroin addicts, sug- gesting the two drugs appeal to the same kinds of people. Given that finding, it is unsurprising that buprenorphine’s experimental use as an alternative to methadone has been successful in switching heroin addicts to buprenorphine. Various studies note that buprenorphine may create euphoria, an effect that is normally considered a drawback if a drug is used for treating addiction. Indeed, an experiment indicated that buprenorphine increases pleasurable effects from cocaine. After a certain point, buprenorphine’s effects no longer increase as much when dosage size increases; this characteristic may deter addicts from taking too much buprenorphine and thereby make it a relatively safe substitute for heroin. An experiment demonstrated that persons lacking dependence with opiates could receive 70 times the normal medical dose of buprenorphine without harm, a safety factor of significance in addiction treatment programs, particularly since dependent persons (such as those in addiction treatment) normally can withstand even higher opiate doses than nondependent persons can. A statistical analysis of drug abuser fatalities in France concluded that the death rate from buprenorphine is far less than the rate from methadone. Another advantage to buprenorphine is that maintenance doses can be given less often than with methadone. Still another advantage is that, unlike most opiates, buprenorphine can provoke withdrawal symptoms when taken with another opiate. Thus addicts may be deterred from continuing to take heroin or other opiates while using buprenorphine. Some addicts, however, are able to take both heroin and buprenorphine simultaneously. Tolerance does not necessarily develop with long-term use, although evi- dence of tolerance exists among buprenorphine addicts. Animals that are dosed on buprenorphine develop little or no dependence, a finding duplicated in a study of heroin addicts receiving maintenance doses of buprenorphine. Experiments show, however, that when buprenorphine addicts receive a drug that counteracts opiate actions, subjects experience classic symptoms of with- drawal from opiate dependence: yawning, muscle ache, and general uneasi- ness. An experiment showed that buprenorphine further ac- celerates pulse rates that are already raised by cocaine. Another human study and a monkey experiment found no significant interaction between cocaine and buprenorphine, but still another primate study showed buprenorphine as boosting cocaine effects. Researchers operating a rat study concluded that bu- prenorphine boosts cocaine actions, but mice studies found that buprenor- phine diminished some cocaine effects; such varying results from different animal species indicate the difficulty of applying those results to humans. A human experiment showed that blood flow damage in the brain caused by cocaine can improve after taking buprenorphine. People using buprenorphine have suffered collapse of breathing and blood Buprenorphine 65 circulation when also taking diazepam. Evidence exists that the drug may promote bleeding under the skin when taken with the anti–blood clot medicine phen- procoumon. Another possible drug interaction involves nicotine; people using bu- prenorphine tend to increase their tobacco cigarette consumption. Buprenor- phine should be used with particular carefulness if a person suffers from enlarged prostrate, urination difficulty, alcoholism, thyroid gland deficiency, or adrenal gland deficiency. Pregnant rats receiving 1,000 times the normal human dose have had difficulty when giving birth. Early pregnancy failure and fetal deaths occurred when rats received 10 to 100 times the normal human dose, but not if they had 1,000 times the standard dose.

The use of morphine in patients who are intoxicated with alcohol is especially dangerous and even small doses can be fatal when there is a high concentration in the blood (15) order female cialis 10 mg overnight delivery menopause bleeding. However purchase female cialis 10mg free shipping menstrual 7 days late, age cheap 20 mg female cialis overnight delivery womens health and surgery center, gender, and other risk factors do not account for the strong age and gender patterns observed among victims of overdose. There is evidence that systemic diseases particularly pulmonary and hepatic disorders may be more prevalent in users who are at greater risk of overdose. There is no effective role for opiate mediation in ethanol intake as well as any ethanol sweet-fluid intake interactions (60). Both ethanol and opioids are metabolized in part by the hepatic mixed enzyme oxidative system. When both drugs are used together, slower disposal rates and possibly higher toxicity may arise. Ethanol may affect some opiate receptors and possibly change the brain tis- sue endogenous opiate peptide levels in some loci. Mixed alcohol and opiate abusers did poorly in standard alcohol abstinence treatment compared to matched alcoholics without opiate abuse histories (61). It has been found that rifampin was found to reduce morphine’s analgesic effects, probably due to the induction of its metabolism (62). Opioids and Opiates 137 fluvoxamine (and fluoxetine to a less extent) may cause an important increase in serum methadone concentrations (64). In patients unable to maintain effective methadone blood level throughout the dosing interval, fluvoxamine can help increase the methadone blood level and alleviate opiate withdrawal symptoms (65). The inhibition of differ- ent clusters of the cytochrome P450 system is involved in these interactions. Quinidine-induced inhibition of codeine O-demethylation is ethnically dependent with the reduction being greater in Caucasians (67). Ciprofloxacin may inhibit cytochrome P450 3A4 up to 65%, thus elevat- ing methadone levels significantly (68). The clearance of intravenous morphine (1 mg) was increased by 75%, oral morphine (10 mg) by 120% in six young women taking an oral contraceptive (70). This implies that the dosage of morphine will need to be virtually doubled to achieve the same degree of analgesia. Urinary morphine concentration will then be greater in patients taking oral contraceptives. In a study, the administration of ammonium chloride and sodium carbonate over 3 d each resulted in a mean methadone elimination half- 138 Moallem, Balali-Mood, and Balali-Mood life of 19. It was shown that haemodynamic changes induced by propofol may have an important influence on the pharmacokinetics of alfentanil (76). In 30 normal subjects, it was found that quinalbarbitone and morphine depressed ventilation when given alone. However, a combination of quinalbarbitone and morphine resulted in a much greater and more prolonged depression. Other respiratory depressant drugs such as narcotics, opiates, and analgesics can also have additive effects (77). In one study, it was found that fen- tanyl and alfentanil pretreatment have also reduced the dose of thiopental required for anesthesia induction (78). Also, the simultaneous administration of morphine and phenothiazines can result in significant hypotension (15). Alprazolam mediated analgesic effects, most probably via a µ opiate mechanism of action (79). For instance, sertaline increases the plasma methadone concentration significantly in depressed patients on methadone (80). Several lines of evidence suggest that benzodiazepines and methadone may have synergistic interactions and that opiate sedation or respiratory depression could be increased. In a study, meperidine and chlorpromazine com- pared to meperidine and placebo resulted in significantly increased lethargy and hypo- tension (81). Opiate abusers use amphetamines to in- crease the effects obtained from poor quality heroin (82). Braida and coworkers demonstrated that cannabinoids produce reward in conditioned place preference tests and interconnection of opioid and cannabinoid systems (83). Muscle Relaxants Patients recovering from relaxant anaesthesia are especially vulnerable to the respiratory depressant effects of morphine. Respiratory acidosis, secondary to acute hypercapnia, can result in reactivation of the long-acting relaxant on the completion of anesthesia, resulting in further depression of respiration. The combination of muscle relaxant and morphine could result in a rapidly progressing respiratory crisis (15). Adrenergic Drugs Agmatin (an endogenous polyamine metabolite formed by the carboxylation of L-arginine) potentiates antinociception of morphine via an alpha2 adrenergic receptor- mediated mechanism. This combination may be an effective therapeutic strategy for the medical treatment of pain (92). Yohimbine (an alpha2 antagonist) tends to limit opiate antinociception and the additive potential of µ and delta opioid agonists (93). Clonidine (4 and 10 µg/kg) in cats had a differential degree of inhibition in the order of analgesia, much greater than hypotension, greater than bradycardia. Fur- thermore, pain suppression of clonidine appeared to be independent of vasodepression and cardio inhibition (94). When administered with pentazocine, clonidine caused a statistically signif- icant increase in pentazocine analgesia (95).

This is despite many police forces giving warnings and cautions for low-level possession of cannabis rather than proceeding with prosecution order female cialis 20 mg on line women's health magazine uk back issues. Because of these complexities drug dependence is classified somewhat on the basis of the effects produced or nature of the dependence- producing compound order female cialis 20 mg overnight delivery women's health center of oregon. On repeated use tolerance may develop leading to an increase in the dose of drug required to produce the required effect buy female cialis 10mg on line menstrual 2 days late. Physical dependence is not produced by all drugs of abuse and is most pronounced after use of depressant drugs such as alcohol or heroin. If a drug usage is halted withdrawal or abstinence occurs, the symptoms of which can be psychological (i. To avoid withdrawal symptoms drug administration is continued and a cycle is set up (see Table 23. It contains morphine and codeine, both effective and widely used analgesics, along with heroin which can be made from morphine and in its pure form is a white powder. Today street heroin usually comes as an off-white or brown powder whereas for medical use it is usually tablets or an injectable liquid. A number of synthetic opioids are also manufactured for medical use and all have similar effects. Methadone, a drug which is often prescribed as a substitute drug in the treatment of heroin addiction, is a weaker but long-lasting orally effective opioid and is usually prescribed as a syrup. Opioids prescribed for medical use may be used for non-medical reasons, especially by heroin users who cannot otherwise get hold of heroin. The sudden influx of smokable heroin in the 1980s caused a dramatic increase in use, because it was no longer necessary to inject the drug in order to obtain its effects. Despite new initiatives to try to reduce heroin use it has continued to increase and there is concern about the wider availability and use of cheap heroin among young people, particularly in deprived areas. Likewise, removal of dealers from the street appears to simply allow others to move in to supply the constant demand. The idea is to gradually reduce the dose of methadone until the person is able to come off drugs without suffering withdrawal symptoms. The problem is that many users seem to quickly go back on heroin so that some doctors prescribe methadone on a maintenance basis, not reducing the dosage until the person feels ready to give up, a process that can be lengthy. One school of thought would claim that this approach simply keeps people dependent on a different drug. The opposite view is that methadone keeps people away from the dangerous street market in heroin, with the associated risks of crime and overdose. Unfortunately, many users obtain methadone legally and then sell it to buy street heroin. These schemes seem to be very effective although it has been claimed that they encourage injecting. Another issue is heroin- related crime, especially theft, burglary and forgery, as a dependent user will need about £50 a day to pay for the drug. The cost to the community is unknown but some police forces have estimated that up to one-third of crime relates to drug use. Legal Heroin and other opiates are controlled under the Misuse of Drugs Act making it illegal to possess them or to supply them to other people without a prescription. The desired effect on the street is not the analgesia that is the reason for their medical use but the feeling of warmth, reduction in anxiety and detachment. The effects of both smoked and obviously injected heroin are rapid and then last several hours but this varies with how much is taken and the route of application. Mental anguish is removed and hence the use of the drug as a means of escape from social and other pressures becomes clearer. With high doses of heroin a marked sedation takes over and people can fall asleep. Excessive doses can lead to severe sedation and vomiting Ð the combination can be lethal. This is further compounded by the fact that opioids can depress the respiratory centre and with non-medical use the most common form of death is from respiratory failure. With regular use tolerance develops as does psychological and physical dependence. The withdrawal syndrome leads to unpleasant flu-like symptoms which may include aches, tremor, sweating, chills and muscular spasms. While many people do successfully give up long-term heroin use, coming off and staying off heroin can be very difficult. Fatal overdoses can happen, especially when users take their initial dose after a break during which tolerance has faded, or when opiate use is combined with use of other drugs such as alcohol, tranquillisers or other opiates. Many regular heroin users will use other opiates or depressant drugs when they cannot get hold of heroin. If is often difficult to know exactly what is being taken because the purity of street heroin varies and it is often mixed with adulterants. Regular injectors may suffer a wide range of health problems including chronic constipation, damaged veins, heart and lung disorders. Opiates produce more discreet inhibitory effects since they bind to and activate inhibitory opioid receptors which, due to their restricted distribution, cause less widespread effects than those of the barbiturates and alcohol. It is a white powder, but as a street drug, it is a liquid absorbed into paper sheets. The sheets are cut into tiny squares like postage stamps or transfers and often have pictures or designs on. The chemist, Albert Hofmann, was the first to take the drug in 1943 when he, supposedly inadvertently, took it on a Friday evening Ð he then reported the dreamlike state caused by the drug with a vivid description of the visual changes and other perceptual effects of the drug. The effects vary greatly depending on dose level, how the user feels and the situation they are in. Users often report visual effects such as intensified colours, distorted shapes and sizes and move- ment in stationary objects.

In general buy discount female cialis 20mg menstrual undergarments, lowering the blood pressure with antihypertensive agents discount 10mg female cialis with amex menstrual cycle 8 years old, weight loss buy female cialis 20mg lowest price womens health upenn, or dietary sodium restriction decreases cardiac mass in patients with left ventricular hypertrophy. Regression is largely absent with direct vasodilators (such as hydralazine or minoxidil) despite adequate blood pressure control. Diazoxide Diazoxide, in comparison to nitroprusside and nitroglycerin, is an arteriolar vaso- dilator that has little effect on the venous circulation. Diazoxide is also longer acting and, in the currently recommended doses, requires less monitoring than nitroprusside, since the peak effect is seen within 15 min and lasts for 4–24 h. A beta-blocker such as propranolol or labetalol is usually given concurrently to block reflex activation of the sympathetic nervous system. This protection, however, is not complete, and it is recommended that diazoxide not be used in patients with angina pectoris, myocardial infarction, pulmo- nary edema, or a dissecting aortic aneurysm. Diazoxide can also cause marked fluid retention and a diuretic may need to be added if edema or otherwise unexplained weight gain is noted. Decreased binding in uremia or the nephrotic syndrome results in increased free drug in the circu- lation and increased response. Dose adjustment according to creatinine clearance: (a) >50 mL/min: normal dose; (b) 20–50 mL/min: two-thirds of normal dose; (c) <20 mL/ min: one-half to two-thirds normal dose. Adverse effects include marked edema (which may require high doses of loop diuretics) and hirsutism. Medical therapy for insulinoma should be considered in the patient whose insulin- oma was missed during pancreatic exploration, who is not a candidate for or refuses surgery, or who has metastatic insulinoma. The therapeutic choices to prevent sympto- matic hypoglycemia include diazoxide, verapamil, phenytoin, and the somatostatin ana- log octreotide. Diazoxide (which must be given in divided doses of up to 1200 mg/d) is the most effective drug for controlling hypoglycemia. However, its use is often limited by marked edema (which may require high doses of loop diuretics) and hirsutism. Calcium Channel Blockers Calcium channel blockers are widely used in the treatment of hypertension, angina pectoris, cardiac arrhythmias, and other disorders and the longer-acting preparations have been prescribed with increasing frequency since 1989. Types of Calcium Channel Blockers The calcium channel blockers currently available are divided into two major cate- gories based upon their predominant physiologic effects: the dihydropyridines, which preferentially block the L-type calcium channels; and verapamil and diltiazem. The L- type calcium channels are responsible for myocardial contractility and vascular smooth muscle contractility; they also affect conducting and pacemaker cells. They can be further divided into three cate- gories based upon half-life and effect on contractility: 1. Side Effects The side effects that may be seen with the calcium channel blockers vary with the agent that is used. The potent vasodilators can, in 10–20% of patients, lead to one or more of the following: headache, dizziness or lightheadedness, flushing, and periph- eral edema. The peripheral edema, which is infrequent with verapamil, is related to redistribution of fluid from the vascular space into the interstitium, possibly induced by vasodilation, which allows more of the systemic pressure to be transmitted to the capillary circulation. In one study of 12 healthy subjects, for example, a single dose of nifedipine increased the foot volume despite also increasing sodium excretion. The major adverse effect with verap- amil is constipation, which can occur in over 25% of patients. Cardiovascular Drugs 243 patients who are taking beta-blockers or who have severe left ventricular systolic dys- function, sick sinus syndrome, and second- or third-degree atrioventricular block. The dihydropyridines have less cardiac depressant activity in vivo for two reasons: (a) the doses employed are limited by the peripheral vasodilation; as a result, plasma levels sufficient to impair contractility and atrioventricular conduction are not achieved; and (b) acute vasodilation leads to a reflex increase in sympathetic activity that can counteract the direct effect of calcium channel blockade. Anticonvulsants (such as phenytoin, phenobarbital, and carbamazepine) induce both the intestinal and hepatic form of this isoenzyme. Induction increases the first- pass metabolism of isradipine and decreases its bioavailability. On the other hand, keto- conazole, erythromycin, clarithromycin, cimetidine, grapefruit juice, and other calcium channel blockers can inhibit cytochrome P450 3A. The calcium channel blocker effect is greatest with verapamil, which can slow metabolism of substrates for this isoenzyme by up to 50%. Diltiazem is less potent and other dihydropyridines (such as nicardipine and nisoldipine) appear to have negligible effects. Cytochrome inhibition diminishes first-pass metabolism and increases (as much as twofold) the bioavailability of isra- dipine. Elimination of absorbed isradipine is also reduced, and the combined effect cause dramatic increases in the plasma level and activity of this drug. As a result, its coadministration with other drugs that are metabolized by this isoenzyme (such as terfenadine and quinidine) can lead to a clinically important interaction and careful monitoring is important. Induction of this enzyme increases the first-pass effect of felodipine and decreases its bioavailability. In comparison, inhibitors of this isoenzyme lead to an increase in plasma drug levels. The clinical significance of the change in felodipine metabolism with more usual amounts of grapefruit juice ingestion is uncertain. The net effect may be a dramatic elevation in the plasma felodipine concen- tration and in drug activity. Elimination of absorbed nicardipine is also reduced, and the combined effect cause dramatic increases in the plasma level and activity of this drug.