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Anticholinergic drugs oxybutynin 2.5mg amex symptoms stomach cancer, of or prolonged buy cheap oxybutynin 2.5 mg line treatment low blood pressure, acute diarrhea may lead to serious fluid and which atropine is the prototype generic 5mg oxybutynin with amex symptoms 7dpiui, are infrequently used be- electrolyte depletion, especially in young children and older cause doses large enough to decrease intestinal motility and adults. Chronic diarrhea may cause malnutrition and anemia secretions cause intolerable adverse effects. The drugs are and is often characterized by remissions and exacerbations. Polycarbophil (eg, FiberCon) and psyllium preparations Antidiarrheal drugs include a variety of agents, most of (eg, Metamucil) are most often used as bulk-forming laxa- which are discussed in other chapters. They are occasionally used in diarrhea to decrease flu- ment of diarrhea, the drugs may be given to relieve the symp- (text continues on page 896) 894 SECTION 10 DRUGS AFFECTING THE DIGESTIVE SYSTEM Drugs at a Glance: Antidiarrheal Drugs Routes and Dosage Ranges Generic/Trade Name Characteristics Clinical Indications Adults Children Opiate-Related Drugs Paregoric Morphine is the active Symptomatic treatment of PO 5–10 mL 1–4 times PO 0. Recommended doses and short-term use do not produce euphoria, anal- gesia, or dependence. Difenoxin with atropine An active metabolite of Symptomatic treatment PO 2 mg initially, then Safety and effectiveness sulfate (Motofen) diphenoxylate of acute or chronic 1 mg after each loose not established for chil- Overdose may cause res- diarrhea stool or 1 mg q3–4h as dren <12 y piratory depression and needed; maximum coma. The atropine is added to discourage overdose and abuse for opioid effects. Contraindicated in chil- dren <2 y of age and clients who are allergic to the ingredients or have hepatic impair- ment. A Schedule IV drug Diphenoxylate with A derivative of meperidine Symptomatic treatment PO 5 mg (2 tablets or Liquid preparation (2. Contraindicated in severe liver disease, glaucoma, and children <2 y of age. A Schedule V drug (continued) CHAPTER 62 ANTIDIARRHEALS 895 Drugs at a Glance: Antidiarrheal Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Characteristics Clinical Indications Adults Children Loperamide (Imodium) A derivative of meperi- Symptomatic treatment PO 4 mg initially, then 2–5 y, 13–20 kg: PO 1 dine; decreases intesti- of acute or chronic 2 mg after each loose mg 3 times daily; nal motility diarrhea stool to a maximal daily 6–8 y, 20–30 kg: PO 2 mg As effective as diphenoxy- dose of 16 mg. For twice daily; late, with fewer adverse chronic diarrhea, 8–12 y, >30 kg: PO 2 mg effects in recom- dosage should be 3 times daily mended doses. High reduced to the lowest doses may produce effective amount (aver- morphine-like effects. Antibacterial Agents Ciprofloxacin (Cipro) A fluoroquinolone (See Diarrhea caused by sus- PO 500 mg q12h for Not recommended for use Chap. Colestipol (Colestid) Same as cholestyramine, Same as cholestyramine PO 15–30 g/d in 120– above 180 mL of water, in 2–4 divided doses be- fore or during meals and at bedtime (continued) 896 SECTION 10 DRUGS AFFECTING THE DIGESTIVE SYSTEM Drugs at a Glance: Antidiarrheal Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Characteristics Clinical Indications Adults Children Octreotide (Sandostatin) In GI tract, decreases se- Diarrhea associated with SC, IV 50 mcg 2–3 times Dosage not established cretions and motility carcinoid tumors, daily initially, then ad- HIV/AIDS, cancer justed according to re- chemotherapy or radia- sponse tion, or diarrhea unre- sponsive to other drugs Pancreatin or Pancreatic enzymes used Diarrhea and malabsorp- PO 1–3 tablets or cap- PO 1–3 tablets or cap- pancrelipase (Viokase, only for replacement tion due to deficiency sules or 1–2 packets of sules or 1–2 packets of Pancrease, Cotazym) of pancreatic enzymes powder with meals and powder with each meal snacks Psyllium preparations Absorbs water and de- Possibly effective for PO 1–2 tsp, 2 or 3 times (Metamucil) creases fluidity of symptomatic treatment daily, in 8 oz of fluid stools of diarrhea AIDS, acquired immunodeficiency syndrome; GI, gastrointestinal; HIV, human immunodeficiency virus. Severe or prolonged diarrhea (>2 to 3 days), to prevent and produce stools of gelatin-like consistency. They may severe fluid and electrolyte loss cause abdominal discomfort and bloating. In ileostomies or surgical excision of portions of the and bile salt–binding drugs. Antibacterial drugs are recom- ileum, to decrease fluidity and volume of stool mended for bacterial enteritis when diarrhea lasts longer than 5. HIV/AIDS-associated diarrhea 48 hours, when the patient passes 6 or more loose stools in 6. When specific causes of diarrhea have been determined 24 hours, when diarrhea is associated with fever, or when blood or pus is seen in the stools. Although effective in reduc- Contraindications to the use of antidiarrheal drugs include di- ing diarrhea due to Salmonella and E. In these circum- stances, antidiarrheal agents that slow peristalsis may aggra- vate and prolong diarrhea. Opiates (morphine, codeine) usually Indications for Use are contraindicated in chronic diarrhea because of possible opi- ate dependence. Difenoxin, diphenoxylate, and loperamide are Despite the limitations of drug therapy in prevention and contraindicated in children younger than 2 years of age. Most include tannins, substances with astringent prop- Diphenoxylate (Lomotil), 1 tablet after every bowel movement PRN, erties that reduce intestinal inflammation and secretions. You ing water over 1 to 2 teaspoons of leaves and drunk up to note she has already had 6 tablets during earlier shifts.

This schedule allows rest periods so that adverse effects are decreased while anti- Corticosteroids are commonly used in the treatment of inflammatory effects continue oxybutynin 2.5 mg visa treatment 02 binh. ADT seems to be as effective as more frequent ad- asthma attacks or status asthmaticus unrelieved by an in- ministration in most clients with bronchial asthma buy oxybutynin pills in toronto medicine 027 pill, haled beta-adrenergic bronchodilator order oxybutynin line medicine search, high doses of sys- ulcerative colitis, and other conditions for which temic corticosteroids are given orally or IV along with the long-term corticosteroid therapy is prescribed. Although CHAPTER 24 CORTICOSTEROIDS 347 these high doses suppress the HPA axis, the suppression Primary central nervous system (CNS) lymphomas. For- only lasts for 1 to 3 days and other serious adverse effects merly considered rare tumors of older adults, these are avoided. Thus, systemic corticosteroids are used in short tumors are being diagnosed more often in younger courses as needed and not for long-term treatment. They are usually associated with chronic immuno- who regularly use inhaled corticosteroids also need high suppression from immunosuppressant drugs or from ac- doses of systemic drugs during acute attacks because quired immunodeficiency syndrome (AIDS). As soon as acute symptoms sub- these lymphomas are very sensitive to corticosteroids side, dosage should be tapered to the lowest effective main- and therapy is indicated once the diagnosis is established. Corticosteroid therapy may be useful in In chronic asthma, inhaled corticosteroids are drugs of first both supportive and definitive treatment of brain and choice. This recommendation evolved from increased knowl- spinal cord tumors; neurologic signs and symptoms often edge about the importance of inflammation in the patho- improve dramatically within 24 to 48 hours. Cortico- physiology of asthma and the development of aerosol steroids help to relieve symptoms by controlling edema corticosteroids that are effective with minimal adverse effects. Some clients can be tapered off general, inhaled corticosteroids can replace oral drugs when corticosteroids after surgical or radiation therapy; others daily dosage of the oral agent has been tapered to 10 to 15 mg require continued therapy to manage neurologic symp- of prednisone or the equivalent dosage of other agents. Adverse effects of long-term corticosteroid therapy a client is being switched from an oral to an inhaled cortico- may include mental changes ranging from mild agitation steroid, the inhaled drug should be started during tapering of the to psychosis and steroid myopathy (muscle weakness oral drug, approximately 1 or 2 weeks before discontinuing or and atrophy), which may be confused with tumor pro- reaching the lowest anticipated dose of the oral drug. Mental symptoms usually improve if drug client requires a systemic corticosteroid, coadministration of dosage is reduced and resolve if the drug is discontinued; an aerosol allows smaller doses of the systemic corticosteroid. Although the inhaled drugs can cause suppression of the HPA Chemotherapy-induced emesis. Corticosteroids have strong axis and adrenocortical function, especially at higher doses, antiemetic effects; the mechanism is unknown. They perform this of choice for chemotherapy with cisplatin, which is a important function by increasing the number and responsive- strongly emetic drug. Research studies indicate increased respon- siveness to beta-adrenergic bronchodilators within 2 hours Corticosteroids are more helpful in acute exacerbations than and increased numbers of beta receptors within 4 hours of cor- in stable disease. For a client with inadequate relief from a bronchodilator, a trial of Cancer a corticosteroid (eg, prednisone 20 to 40 mg each morning for 5 to 7 days) may be justified. Treatment should be continued Corticosteroids are commonly used in the treatment of lym- only if there is significant improvement. In tions, the lowest effective dose is needed to minimize adverse these disorders, corticosteroids inhibit cell reproduction and drug effects. In addition to their anticancer Inhaled corticosteroids can also be tried. They produce effects in hematologic malignancies, corticosteroids are ben- minimal adverse effects, but their effectiveness in COPD has eficial in treatment of several signs and symptoms that often not been clearly demonstrated. With severe disease, clients often require hospitaliza- and other disorders. Clients tend to feel better when taking tion, IV fluids for hydration, and parenteral corticosteroids corticosteroids, although the basic disease process may be until symptoms subside. The capsule dissolves steroid therapy of cancer and associated symptoms: in the small intestine and acts locally before being absorbed 348 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM into the bloodstream and transported to the liver for metabo- plication, including aerosols for oral or nasal inhalation, lism. It has fewer adverse effects than systemic corticosteroids, formulations for topical application to the skin, eyes, but is also less effective and more expensive. With ulcerative colitis, corticosteroids are usually used • Use ADT, which involves titrating the daily dose to the when aminosalicylates (eg, mesalamine) are not effective or lowest effective maintenance level, then giving a double when symptoms are more severe. If not effective, oral prednisone 20 to 60 mg daily may be given until symptoms subside. In clients with severe disease, oral prednisone may be required Use in Children initially.

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Think of your affinity for bread buy oxybutynin in india rust treatment, sweets generic oxybutynin 2.5mg without prescription medicine evolution, and other 24 THE ULTIMATE NEW YORK BODY PLAN TLFeBOOK carbohydrates the same way you would an addiction to drugs buy oxybutynin 2.5mg mastercard medicine in motion, alcohol, or nicotine. You can kick any addictive habit with a firm, strong commitment and a high dose of motivation. As your body gets into top shape, the soreness and fatigue will give way to a deep reservoir of energy and confidence. So think of it as a boot camp, a temporary hurdle that leads to living fit and healthy for the rest of your life. It was an exotic, but equally physically strenuous version of this program. The clients who accompanied me on the trip trained throughout the day—doing yoga, car- diovascular exercise, and strength training, among other things. By the end of the trip, however, instead of craving pasta and biscotti, we were reaching for the protein and fresh grilled vegetables. We had trained, disciplined, and honed our bodies in such a way that polluting them with junk food (even Italian junk food) seemed sinful. Although these mental toughness exercises will not sculpt your legs, butt, and tummy, they will help you to stick with the Ultimate Body Plan without cheating or backsliding. Just as importantly, these exercises will help you maintain your body makeover and translate the positive effects and bene- fits well beyond the two-week period and into your everyday life. The mental, physical, and spiritual all work in concert to bring about real, meaningful, and lasting changes. Without a solid approach to carry you beyond the first two weeks, how can anyone expect you to maintain your inspirational results? ULTIMATE MOTIVATION 25 TLFeBOOK STEP 1 FIND YOUR TRUE SOURCE OF MOTIVATION Incentive, inspiration, drive, enthusiasm, impetus, stimulus, spur, impulse, and driving force are just some of the synonyms I found when I looked up the word motivation in the dictionary. One of the prerequisites to successfully completing any challenge is motivation. Without it, any challenge, including this one, will ultimately become too daunting to see to completion. We all need to find that special something that takes us beyond the ordinary. The trick is to find and identify a challenge—something that evokes pas- sion and meaning in your life. It is important to identify whether you are moti- vated for a cause, such as getting ready for a high school reunion or your wedding, or whether you are self-motivated and interested mostly in self- betterment. I caution you, however, against setting your sights on a particu- lar number on the scale. Each pound of muscle you build burns an additional 35 to 50 calories a day just to maintain itself. So even if your weight remains stable on the scale, exchanging a few pounds of fat for a few pounds of muscle will result in a slimmer, firmer, sexier body! Over the course of the two weeks, you will be transforming your body into a more efficient fat-burning machine. Of course, you may initially have decided to tackle the two-week Ultimate Body Plan because you wanted to look great in a swimsuit or stun your high 26 THE ULTIMATE NEW YORK BODY PLAN TLFeBOOK school buddies at your next reunion. To uncover the true source of your moti- vation, however, look a little deeper. The pride found from looking great in a swimsuit pales in comparison to the pride and confidence gained from suc- cessfully completing the program without cheating or backsliding. Then, just imagine how confident and successful you can become when you maintain your results. To find the true source of your motivation, contemplate the following questions: 1 Why am I taking this makeover challenge? Those last two questions may seem out of left field to you at this point. I found myself get- ting caught up in a New York moment—not very pretty—when a homeless person stopped me and asked me if I had any spare change. In that split sec- ond I realized that this was all happening for a reason. I reached into my wal- let, and the smallest dollar denomination I had was $20.

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I mean no disrespect and do not mean to trivialize this natural fact of life trusted 2.5 mg oxybutynin medications 1, but having worked with woman of all ages for 16 years purchase online oxybutynin medications japan, I have seen my clients rise above and conquer this monthly occurrence buy oxybutynin medicine glossary. ULTIMATE SUCCESS Name: Kenny Sylvester Residence: New York, New York Occupation: Managing director of the Red Eye Grille Weight Lost: 10 pounds Other Accomplishments: Shrunk his waist by 2 1/ inches and gained an 2 inch in his chest. Comments: As a restaurant manager, Kenny is surrounded by bad food choices. By the end of the program, however, he was looking pretty spiffy in his suits. Now that my health seemed to be suffering as a result, I decided to get serious about exercising and healthful eating. THE ULTIMATE BODY 14-DAY PLAN 185 TLFeBOOK Although the program was certainly challenging, it was easier than I expected. I am so used to eating on the run and grabbing any type of junk food that will stop the hunger. While on the program, for the first time in many years, I ate nutritious foods every day. By the end of the day, you will have successfully com- pleted the two-week Ultimate New York Body Plan. During the past 13 days, you have displayed an inordinate amount of willpower, strength, and confidence. This program will set you apart, enrich and empower your life like nothing before has done. Embracing wellness as a lifelong partner is the ulti- mate goal and the invaluable prize. This might mean getting out and taking a brisk walk around the block to clear your head. My father embraced this philosophy and instilled this empow- ering belief in me. I want you to go forward and meet every challenge with a strong, positive response. ULTIMATE SUCCESS Name: Heidi Klum Residence: New York, New York Occupation: Supermodel, Supermom Accomplishments: Heidi started working out again just four weeks after giving birth to her beautiful daughter. With safe, carefully focused, and cus- tom-tailored sessions, we were able to get Heidi looking and feeling amaz- ingly beautiful in just two weeks. I gained about 30 pounds during my preg- nancy, but mostly around the stomach; my arms, legs, and face stayed pretty much my usual size. At the same time, I am a model, and I was scheduled to do my first photo shoot for my clothing line just a couple of months after having the baby. I definitely saw results very quickly, even with the amount that I did do. I went to a fitting for a gor- geous dress to wear to the CFDA Awards event just five weeks after giv- ing birth. By the time the event rolled around a week later, I was already smaller, and the dress had to be taken in at the last fitting. I really do want to be energized and healthy so I can keep up with my daughter as she gets a little older and starts running around. I think everyone should just come up with their own motivations for wanting to do the program and get in shape. The maintenance chapter will prove an invaluable tool that will be continually referred to. As I said at the outset, teaching you how to maintain your dramatic results is one of the things that is so often missing from other makeover programs. Mastering this skill will help you guarantee long-time success and a life-long transformation. We worked hard not only to eliminate alcohol, bread, carbs, dairy products, extra sweets, and fruit, but also to design delicious meals. ULTIMATE BODY PLAN RECIPES SCRAMBLED EGG WHITES WITH SHIITAKE MUSHROOMS AND TURKEY BACON At the Madison Square Club, plain scrambled egg whites will never do. TLFeBOOK 2 strips turkey bacon 1 tablespoon water 1 shiitake mushroom cap, Freshly ground black pepper to taste cut into julienne strips Garnish: 1/ teaspoon chopped 4 3 egg whites fresh parsley Heat a 9-inch nonstick skillet over medium heat and coat with nonfat, veg- etable cooking spray. Sauté the two strips of turkey bacon until cooked through and crispy— approximately 1 to 2 minutes for each side.

Since the lungs govern the defensive exterior oxybutynin 5mg lowest price medicine qid, these wind evils inhibit the diffu- sion and depuration of the lung qi which then inhibits the descen- sion and depuration of water fluids buy 2.5mg oxybutynin fast delivery medications ranitidine. Some mention also needs to be made of the heart and its role in enuresis buy oxybutynin 5mg overnight delivery symptoms 8 months pregnant. The heart spirit is nothing other than an accumulation of the heart qi nourished and enriched by blood and kidney essence. Further, this heart qi mainly comes from the clear qi upborne by the spleen. Therefore, because of inherent spleen vacuity in chil- dren, there tends to be an inherent heart qi and blood vacuity which is compounded by the inherent kidney vacuity we talked 42 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine about above. When the spirit is quiet and tranquil, heart fire or yang moves downward to the kid- neys to transform cold water. But, when the spirit is disquieted, it tends to stir frenetically and counterflow upward. Hence, heart fire and kidney water fail to interact, and this may also lead to the kidney qi failing to secure and astringe and control urination. In this case, kidney vacuity is the proximate cause of enuresis, but a disquieted heart spirit is a complicating or even causative factor. Before moving on to the Chinese medical treatment of enuresis, I would also like to explain why deep sleep is such a common part of pediatric enuresis. We wake when the clear yang qi is upborne to the heart which allows the spirit to flow freely to and through the sensory orifices to connect with the outside world. We go to sleep when this clear yang qi retreats and descends to the inner and lower parts of the body away from the heart. The clear yang qi is a by-product of water and foods transformed by the spleen and catalyzed by the kidneys, and we have seen that the spleen and kidneys are inherently vacuous and weak in chil- dren. In addition, when the yang qi arises to the heart, it must penetrate any phlegm, dampness, and turbidity before it can flow freely to and through the orifices, and infants and children typical- ly have more phlegm, dampness, and turbidity than adults do. Thus the abnormal deep sleep of the pediatric enuresis patient is typically some combination of spleen-kidney vacuity complicated by phlegm, dampness, and turbidity. Therefore, pattern discrimination is the absolute prerequisite for treating enuresis with TCM. In gener- al, the patterns of enuresis can be divided into vacuity and reple- tion patterns, with vacuity patterns being the far more important in pediatric bed-wetting. Kidney qi vacuity and spleen-lung qi vacu- ity are the two main vacuity patterns of enuresis, and these two patterns often complicate each other. Further, kidney qi vacuity may also be complicated by either yin or yang vacuity. Kidney qi insufficiency Note: Kidney qi insufficiency specifically refers to an insufficien- cy of the kidney qi not securing. Because it is a fundamental statement of fact that the kidneys do not become exuberant till puberty and are not firm and mature until the early 20s, an element of kidney qi vacuity is endemic to infants and young children. Signs & symptoms: Nocturnal enuresis one or more times per night, deep sleep, not easy to wake when called, devitalized essence spirit, a normal tongue with white fur, and a forceless pulse Treatment principles: the treatment principles for kidney qi insufficiency without concomitant yin or yang vacuity are to sup- plement the kidneys and secure the essence 44 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Guiding formula: Jin Suo Gu Jing Wan (Golden Lock Secure the Essence Pills) Sha Yuan Zi (Semen Astragali Complanati), 3-10g Qian Shi (Semen Euryalis), 3-10g Lian Zi (Semen Nelumbinis), 6-15g Lian Xu (Stamen Nelumbinis), 3-10g calcined Mu Li (Concha Ostreae), 3-15g Long Gu (Os Draconis), 3-15g Method of administration: This formula is available as ready-made pills for children old enough to swallow them. It is also possible to grind up these pills, mix them with some warm water and a little sugar, and administer them by spoon. For very young children or for those the pre- vious two methods of administration do not work, one can make a decoction out of bulk-dispensed medicinals and then administer the resulting strained medicinal liquid with an eye-dropper. In this latter case, one can use the above dosages for making such a decoction, choosing either the high or low dose depending on the age and weight of the child. This formula may be made out of desiccated extracts, mixed with water and a little sugar, and administered by spoon or eyedropper. Additions & subtractions: If one is administering this formula as a decoction, one can add 3-6 grams of Jin Ying Zi (Fructus Rosae Laevigatae) in order to increase its ability to secure and astringe. If there is a spleen-kidney qi vacuity, one can add 6-18 grams of Huang Qi (Radix Astragali) and 3-15 grams of Dang Shen (Radix Codonopsitis) to fortify the spleen and boost the qi.

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