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By U. Silvio. Mansfield University. 2019.

Popular Depression Medications – A Helpful Guide to Antidepressant Drugs Page 5 Popular Depression Medications Depression is an illness that involves the body buy proscar with a mastercard, mood purchase proscar uk, and thoughts order proscar 5mg mastercard, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. The signs and symptoms of depression include loss of interest in activities that were once interesting or enjoyable. The principal types of depression are major depression, dysthymia, and bipolar disease (also called manic-depressive or manic depression disease). You can also find additional depression related articles in MedicineNet’s depression area: http://www. For more detailed information, go to the Internet link provided next to each medication. The depression medications (which includes antidepressant drugs) here are listed alphabetically by generic name, with brand names in parentheses. Generic and branded depression related medications may differ in the amount of drug they contain, the absorption of the drug into the body, and the distribution of the drug throughout the body. In some patients with depression, abnormal levels of brain chemicals called neurotransmitters may relate to the depression. Amitriptyline elevates mood by raising the level of neurotransmitters in brain tissue. Amitriptyline is also a sedative that is useful for depressed patients with insomnia, restlessness, and nervousness. The neurotransmitters that are released by nerves are taken up again by the nerves that release them for reuse (referred to as reuptake). Many experts believe that depression is caused by an imbalance among the amounts of neurotransmitters that are released. It works by inhibiting the reuptake of the neurotransmitters dopamine, serotonin, and norepinephrine, resulting in more of these chemicals being available to transmit messages to other nerves. Unlike the most commonly prescribed antianxiety medications of the benzodiazepine class (e. Neurotransmitters manufactured and released by nerves attach to adjacent nerves and alter their activities. Thus, neurotransmitters can be thought of as the communication system of the brain. Many experts believe that an imbalance among neurotransmitters is the cause of depression. Citalopram works by preventing the uptake of one neurotransmitter, serotonin, by nerve cells after it has been released. Such uptake is an important mechanism for removing released neurotransmitters and terminating their actions on adjacent nerves. The reduced uptake caused by citalopram results in more free serotonin in the brain to stimulate nerve cells. Popular Depression Medications – A Helpful Guide to Antidepressant Drugs Page 7 desipramine (brand name: Norpramin) A medication that is used to treat depression, defined as an all-pervasive sense of sadness and gloom. In some patients with depression, abnormal levels of neurotransmitters in the brain (chemicals that the nerves use to communicate with each other) may be responsible for the depression. Desipramine elevates mood and relieves depression by raising the levels of neurotransmitters in the brain. It works by affecting neurotransmitters in the brain, the chemical messengers that nerves use to communicate with one another. Neurotransmitters are made and released by nerves and then travel to other nearby nerves where they attach to receptors on the nerves. Some neurotransmitters that are released do not bind to receptors and are taken up by the nerves that produced them. Escitalopram prevents the reuptake of one neurotransmitter, serotonin, by nerves, an action which results in more serotonin in the brain to attach to receptors. Many experts believe that an imbalance in these neurotransmitters is the cause of depression. Fluoxetine is used in the treatment of depression and obsessive-compulsive disorders. Fluoxetine is believed to work by inhibiting the release of or affecting the action of serotonin. Popular Depression Medications – A Helpful Guide to Antidepressant Drugs Page 8 fluvoxamine (brand name: Luvox) A medication used to treat depression (antidepressant) that affects the chemicals within the brain that serve as messengers between the nerve cells. Fluvoxamine works by inhibiting the uptake by the nerve cells of a neurotransmitter, serotonin, an action which results in more serotonin in the brain. It also has been used in the management of obsessive-compulsive disorder, obesity, bulimia, schizophrenia, and panic disorder. In patients with depression, abnormal levels of chemicals in the brain (called neurotransmitters) may be the cause of their depression. These neurotransmitters are what the nerves in the brain use to communicate with each other. Imipramine elevates mood by raising the level of neurotransmitters in brain tissue. Imipramine is useful in depressed patients with insomnia, restlessness, and nervousness. Lithium is a positively charged element or particle that is similar to sodium and potassium. It interferes at several places inside cells and on the cell surface with other positively charged atoms such as sodium, potassium, calcium, and magnesium which are important in many cellular functions. Lithium interferes with the synthesis and reuptake of chemical messengers by which nerves communicate with each other (neurotransmitters). In addition, lithium increases the production of white blood cells in the bone marrow. Lithium’s effects usually begin within one week of starting treatment, and the full effect is seen by 2 to 3 weeks. Popular Depression Medications – A Helpful Guide to Antidepressant Drugs Page 9 mirtazapine (brand name: Remeron) A medication used to treat depression (antidepressant) in the same class as maprotiline (Ludiomil). Although the precise mechanism of action of this class of antidepressants is not known, they increase the amount of noradrenaline and serotonin in the brain. Noradrenaline and serotonin are neurotransmitters, chemicals that nerves use to communicate with each other. The neurotransmitters that are released by nerves are taken up again by the nerves that release them for reuse. Nefazodone works by inhibiting the uptake by nerves of serotonin and norepinephrine, two neurotransmitters, an action which results in more serotonin and norepinephrine to transmit messages to other nerves. It is chemically related to another antidepressant, trazodone (Desyrel), and shares its actions. In some patients with depression, abnormal levels of brain neurotransmitters (chemicals that the nerve cells use to communicate with each other) may be responsible for the depression.

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Similarly purchase proscar in united states online, methamphetamine trafficking is prima- a) North America rily intra-regional order proscar 5mg otc, with flows from Mexico into the United States buy generic proscar 5 mg on line, as well as locally produced methampheta- North America continues to be the world’s largest drug mine being trafficked domestically in the United States. Substantial amounts of cannabis are grown in all North The largest seizures in North America are reported for American countries and important exports are directed cannabis, followed by cocaine and the amphetamines. Cannabis resin seizures accounted for less than laboratories worldwide (though mostly ‘kitchen labs’) 1% of the total, showing that hashish does not play a are dismantled in North America, notably in the United significant role in North America. Significant amounts of methamphetamine con- While cocaine seizures declined markedly between 2005 tinue to be shipped across the border from Mexico to and 2009 (-43%), reflecting the overall decline of the the United States. Asian groups with links to China and South- East Asian countries are mainly involved in the ecstasy Illicit drug use production. The highest levels of illicit drug use are related to the Production of opiates in North America only takes place consumption of cannabis, mainly cannabis herb. The region accounts for about one fifth Trafficking of global cannabis users, far above its share of the global Trafficking of drugs continues to be primarily directed population (around 7%). Trafficking of drugs out of the cannabis use increased again in 2009 in the United region to other destinations exists, but is limited. In 2009, prescription The relative importance of North America is larger opioid misuse in Canada was reported at 0. The national – still has the highest prevalence rate of any subregion, household survey found prescription opioid prevalence far above the global average (0. Significant Drug-related deaths declines in cocaine use were also reported from Canada North America seems to experience a large proportion in recent years, with the annual prevalence rate falling of drug-related deaths (45,100 deaths) and the highest from 2. The United States saw an estimated amphetamines and a similar proportion uses ecstasy. Use ing to a drug-related mortality rate of 182 deaths per of amphetamine-type stimulants showed a downward one million inhabitants aged 15-64. The increase was mainly related to the ids have been steadily increasing from 4,000 in 2001 to ‘recovery’ of methamphetamine, rising from 0. These high levels are mainly due to and the Caribbean widespread non-medical use of prescription opioids, South America continues to be primarily a subregion which rose between 2002 and 2006, before falling until known for large-scale cocaine production and traffick- 2008 and rising again in 2009. North America has, in general, a significant problem Production when it comes to the non-medical use of prescription Notable illicit drug production continues to take place drugs. Colombia, Peru and the drugs (‘psychotherapeutics’) has ranked for some years Plurinational State of Bolivia are responsible for close to second after cannabis, with an annual prevalence of 100% of global coca leaf production, the raw material 6. Department of Justice, Drug Enforcement Administration, National Drug Intelligence Centre, National Prescription Drug Threat number of those who initiated their drug use with can- Assessment 2009,and National Drug Threat Assessment 2010. Cocaine manufacture in clan- ecstasy are still mainly from Europe towards South destine laboratories also takes place, to a large extent, in America, though these appear to be declining as they the Andean countries. In contrast, cocaine ica and the Caribbean have significant levels of cannabis seizures, for which the countries of South America, Cen- production, notably of cannabis herb. In 2009, 70% of tral America and the Caribbean accounted for 74% of global cannabis plant seizures, an indirect indicator of the world total, showed an increase by 27% over the cannabis eradication, occurred in this subregion. Increasing interdiction efforts by the quarters of these seizures took place in South America. Andean countries (notably Colombia) as well as Cannabis production seems to be - in most countries - improvements in international cooperation – and thus primarily for domestic use. Opium production in South more ‘upstream’ interdictions – have been responsible America is almost negligible at the global level. Illicit drug use Trafficking Surveys suggest that about 5% of all cannabis users worldwide are found in South America, the Caribbean Trafficking flows are primarily directed out of the and Central America, slightly less than the region’s share cocaine-producing countries in the Andean region of the global population. Nonetheless, cannabis is the towards North America, either directly to Mexico and most widely consumed illicit substance in the region. The prevalence of cocaine use in South America, Central America and the Caribbean is clearly above the global Cannabis trafficking flows are mainly intra-regional. In % of global 2005 2006 2007 2008 2009 total in 2009 Cannabis herb 509,265 1,065,673 1,009,470 857,534 619,786 10% Coca leaf 3,195,757 3,318,645 4,698,820 4,883,732 3,517,918 100% Cocaine 429,740 400,266 427,685 523,040 541,070 74% Amphetamines 140 87 519 41 189 0. Cocaine continues to be • In East Europe, notably in the Russian Federation the main problem drug in South America, Central and Ukraine, there is domestic production of opium America and the Caribbean, accounting for some 50% or poppy straw for local consumption purposes of all drug-related treatment demand in the region. Overall opioid use is far more Most cannabis seizures are related to cannabis resin in prevalent (some 0. The most prevalent prescriptions drugs in the region Cannabis resin found on the European market origi- seem to be prescription opioids. While cannabis resin sei- non-medical use of prescription opioids has been reported zures declined over the 2005-2009 period, those of by Costa Rica, Brazil and Chile. High levels of con- Despite the increasing importance of cannabis herb, sumption have been reported for 2009, in particular overall cannabis seizures declined by 19% between 2005 from Argentina, Brazil and, to a lesser extent, Chile. Cocaine is trafficked to Europe mainly by sea, though in Drug-related deaths terms of reported seizure cases, deliveries by air are Countries in South America, including the Caribbean higher. Countries consistently strong increases in trafficking over the 1998-2006 period rank cocaine first as the primary cause of death, which – cocaine seizures declined massively over this period is in accordance with high prevalence of cocaine use and (-53%). This partially reflects improved cooperation the dominance of cocaine in treatment demand. The countries of West Illicit drug production in Europe is mainly linked to and Central Europe accounted for 97% of all European cannabis, amphetamines and ecstasy. In addition to direct shipments from South America, shipments via Africa, notably West • Cannabis production in Europe is believed to be increasing, mostly in indoor settings. Twenty-nine Africa, gained strongly in importance over the 2004- European countries reported domestic cultivation of 2007 period, before decreasing over the 2007-2009 cannabis herb in 2008. Though the Iberian peninsula, followed by the Netherlands and Belgium, continue to be main entry • In the past, ecstasy-group substances used to be points for cocaine shipments into Europe, there have manufactured predominantly in West Europe. Te also been reports of shipping cocaine to the Balkan Netherlands and Belgium are still the main sources for ecstasy in Europe. However, manufacture has shifted region (by container or air freight) for final destinations away from the region and only a few laboratories were in the European Union. Heroin seizures made in Europe accounted for 38% of • Most amphetamine seized in Europe is manufactured, the world total in 2009. Heroin seizures are mostly con- in order of importance, in the Netherlands, Poland centrated in South-East Europe (63% of all heroin sei- and Belgium. While Methamphetamine production and consumption are, heroin seizures in West and Central Europe remained however, still the exception in Europe. Europe’s share in global ecstasy seizures Cocaine use is still concentrated in West and Central declined from 90% in 1996 to 18% in 2009. Cocaine prevalence rates in West and Central Europe accounted for 24% of global amphetamine sei- Europe doubled between 1998 and 2006 but remained zures in 2009. More than 80% of all European amphetamine seizures in 2009 took place in The next most prevalent substance is ecstasy (0. Methamphetamine use is ecstasy’ and as a ‘date rape drug,’ increased four-fold in mainly limited to the Czech Republic, though some Europe over the 2005-2009 period. European seizures consumption also occurs in neighbouring Slovakia, some accounted for almost 80% of the world total. Illicit drug use In contrast to other regions, non-medical use of pre- scription drugs has not been regarded as a major prob- The most prevalent drug in Europe is cannabis, showing 32 lem in Europe so far.

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Effect of nitazoxanide on morbidity and mortality in Zambian children with cryptosporidiosis: a randomised controlled trial purchase proscar 5 mg without a prescription. Nitazoxanide in the treatment of acquired immune deficiency syndrome-related cryptosporidiosis: results of the United States compassionate use program in 365 patients order discount proscar on-line. Evaluation of an animal model system for cryptosporidiosis: therapeutic efficacy of paromomycin and hyperimmune bovine colostrum-immunoglobulin discount proscar 5 mg fast delivery. Paromomycin: no more effective than placebo for treatment of cryptosporidiosis in patients with advanced human immunodeficiency virus infection. They are ubiquitous organisms and are likely zoonotic and/or waterborne in origin. The microsporidia reported as pathogens in humans include Encephalitozoon cuniculi, Encephalitozoon hellem, Encephalitozoon (syn Septata) intestinalis, Enterocytozoon bieneusi, Trachipleistophora hominis, Trachipleistophora anthropophthera, Pleistophora species, P. Nosema, Vittaforma, and Microsporidium are associated with stromal keratitis following trauma in immunocompetent hosts. Diagnosis Effective morphologic demonstration of microsporidia by light microscopy can be accomplished with staining methods that produce differential contrast between the spores of the microsporidia and the cells and debris in clinical samples such as stool. In addition, because of the small size of the spores (1–5 mm), magnification up to 1,000 times is required for visualization. Chromotrope 2R and the fluorescent brighteners calcofluor white and Uvitex 2B are useful as selective stains for microsporidia in stool and other body fluids. If stool examination is negative and microsporidiosis is suspected, a small bowel biopsy may be useful. No specific chemoprophylactic regimens are known to be effective in preventing microsporidiosis. One report indicated that treatment with nitazoxanide might resolve chronic diarrhea caused by E. Albendazole, a benzimidazole that binds to β-tubulin, has activity against many species of microsporidia, but it is not effective against Enterocytozoon infections or V. Albendazole is only recommended for initial therapy of intestinal and disseminated microsporidiosis caused by microsporidia other than E. Although clearance of microsporidia from the eye can be demonstrated, the organism often is still present systemically and can be detected in urine or in nasal smears. Oral fumagillin has been associated with thrombocytopenia, which is reversible on stopping the drug. In rats and rabbits, albendazole is embryotoxic and teratogenic at exposure levels less than that estimated with therapeutic human dosing. There are no adequate and well- controlled studies of albendazole exposure in early human pregnancy. A recent randomized trial in which albendazole was used for second-trimester treatment of soil-transmitted helminth infections found no evidence of teratogenicity or other adverse pregnancy effects. Systemic fumagillin has been associated with increased resorption and growth retardation in rats. Furazolidone is not teratogenic in animal studies, but human data are limited to a case series that found no association between first-trimester use of furazolidone and birth defects in 132 exposed pregnancies. Loperamide is poorly absorbed and has not been associated with birth defects in animal studies. However, a recent study identified an increased risk of congenital malformations, and specifically hypospadias, among 683 women with exposure to loperamide early in pregnancy. For Intestinal and Disseminated (Not Ocular) Infection Caused by Microsporidia Other Than E. Comparative evaluation of five diagnostic methods for demonstrating microsporidia in stool and intestinal biopsy specimens. Microsporidia: emerging advances in understanding the basic biology of these unique organisms. Improved light-microscopical detection of microsporidia spores in stool and duodenal aspirates. Clinical significance of enteric protozoa in the immunosuppressed human population. Eradication of cryptosporidia and microsporidia following successful antiretroviral therapy. Modification of the clinical course of intestinal microsporidiosis in acquired immunodeficiency syndrome patients by immune status and anti-human immunodeficiency virus therapy. Analysis of the beta-tubulin genes from Enterocytozoon bieneusi isolates from a human and rhesus macaque. Analysis of the beta-tubulin gene from Vittaforma corneae suggests benzimidazole resistance. Efficacy of ivermectin and albendazole alone and in combination for treatment of soil-transmitted helminths in pregnancy and adverse events: a randomized open label controlled intervention trial in Masindi district, western Uganda. Usually within 2 to 12 weeks after infection, the immune response limits multiplication of tubercle bacilli. A significant disadvantage of the 9-month regimen is that the majority of patients do not complete all 9 months of therapy. Increased clinical monitoring is not recommended, but should be based on clinical judgment. If the serum aminotransferase level increases greater than five times the upper limit of normal without symptoms or greater than three times the upper limit of normal with symptoms (or greater than two times the upper limit of normal among patients with baseline abnormal transaminases), chemoprophylaxis should be stopped. Factors that increase the risk of clinical hepatitis include daily alcohol consumption, underlying liver disease, and concurrent treatment with other hepatotoxic drugs. Patients should be reminded at each visit about potential adverse effects (unexplained anorexia, nausea, vomiting, dark urine, icterus, rash, persistent paresthesia of the hands and feet, persistent fatigue, weakness or fever lasting 3 or more days, abdominal tenderness, easy bruising or bleeding, and arthralgia) and told to immediately stop isoniazid and return to the clinic for an assessment should any of these occur. The majority of patients have disease limited to the lungs, and common chest radiographic manifestations are upper lobe infiltrates with or without cavitation. If a sensitive broth culture technique is used, the sensitivity of sputum culture is quite high. With progressive immunodeficiency, granulomas become poorly formed or can be completely absent. The yield of mycobacterial urine and blood cultures depends on the clinical setting; among patients with advanced immunodeficiency, the yield of culture from these two readily-available body fluids can be relatively high68,72 and may allow definitive diagnosis and be a source of an isolate for drug-susceptibility testing. In a 2014 meta-analysis, the sensitivity for detection of rifampin resistance was 95% (95% confidence interval 90%–97%) and specificity was 98% (95% confidence interval 97%–99%). Two recent analyses showed that treatment failure was more common among patients whose isolates had phenotypic susceptibility but mutations in the rpoB gene compared to patients whose isolates had normal rpoB gene sequences. Ethambutol can be discontinued when susceptibility to isoniazid and rifampin has been confirmed. Regimens that included once- or twice-weekly dosing during the continuation phase of therapy were also associated with increased risks of treatment failure or relapse with acquired rifamycin resistance. Although drug-drug interaction studies suggest that thrice-weekly and daily rifampin dosing is associated with similar levels of cytochrome P450 enzyme induction when dosed with raltegravir,120 whether there is a difference between daily and thrice- weekly dosing during the continuation phase of therapy has not been adequately studied in randomized trials.

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It is highly recommended that a luer lock syringe is used for all bolus injections and flushes to avoid possible leakage buy cheap proscar on-line. Hold wings of the cannula firmly and remove introducer (needle) by pulling back in a smooth single movement generic proscar 5mg on line. Notes: Check site 4 hourly (daily in community setting) for erythema cheap proscar 5mg visa, pain or swelling. If the cannula is being used to deliver a subcutaneous infusion remove the bung and attach an anti-siphon extension set (e. McKinley 100-172S) If the cannula is being used to deliver subcutaneous bolus injections remove the bung and cap 6. Such use can be supported by experience in clinical practice and accepted reference sources such as The Oxford Textbook of Palliative Medicine or the Palliative Care Formulary. The licensing process regulates the activities of pharmaceutical companies and not the prescribing practice of a qualified prescriber. If you have any queries or concerns please see contact details documented in Appendix 1. Drug Administration Table All of the drugs below are commonly given by subcutaneous bolus or infusion in palliative care patients regardless of their licensed routes of administration Note: If administering cyclizine or haloperidol ensure line is flushed before and after use with water for injection. The medication is administered into the fatty tissue under the skin and is absorbed systemically. A significant advantage of subcutaneous infusion over other drug delivery methods is that plasma levels of a drug are much more stable, and appropriate symptom control can be achieved without the toxic effects of the peaks and troughs resulting from episodic drug administration. It can give relief of multiple symptoms including pain, nausea and vomiting, restlessness, confusion and excess respiratory secretions. The entire administration set should be replaced if a new mixture of drugs is used. The rationale behind this preference is: • Less likely to cause site reactions • Insertion is less traumatic • Needle stick injury is reduced • Less expensive • Can remain in situ longer than other devices. Other considerations Resite cannula if there are local reactions – use a new administration set each time. Reassess patient’s symptoms Medication being administered is Check that infusion is running Request medical or palliative care not controlling or managing – e. Due to subcutaneous Check that drugs are reconstituted medication in correct diluent and in appropriate volume. The correct dose relieves pain Twitching or plucking at the air without adverse side effects. If the patient is in pain and not currently on a modified or slow release opioid, e. If the patient is on a fentanyl patch, refer to the fentanyl patch algorithm, or consult the palliative care pharmacist or another member of the palliative care team for advice. The patient should have oral breakthrough medication prescribed as this may be required until the modified release dose reaches a therapeutic level. This can be found on the attached charts or by consulting a pharmacist or palliative care specialist, or by contacting Medicines Information (contact numbers listed in Appendix 1). Information is also available from the following resources: • The Oxford Textbook of Palliative Medicine • Palliative Care Formulary • The Syringe Driver -continuous subcutaneous infusions in palliative care 14 5. Compatibility and stability of drugs ‘Instability’ or ‘incompatibility’ refers to chemical reactions that occur when diluting or mixing drugs, resulting in the formation of different chemicals that can be therapeutically inactive or possibly toxic to the patient. Sometimes there are visible signs of incompatibility such as cloudiness, change in colour or the appearance of crystals. If in doubt, contact the palliative care pharmacist or another member of the palliative care team. Factors that affect stability include light, heat, pH, time and volume of diluent. If an untoward incident occurs with a licensed product in an approved clinical situation, depending on the circumstances, any liability arising subsequently may in part or whole be transferred to the license holder. Due to licensing restrictions, it is common in palliative care to use licensed medicines for an unlicensed indication, by an unlicensed route or in an unlicensed dose. In this case the manufacturer is unlikely to be found liable if the patient is harmed. The prescriber and the clinical pharmacist assume responsibility for ensuring appropriate use of medication and patient safety. Nursing staff who administer ‘off-label’ medications also have a duty of care to the patient. Two or more Drugs When two or more drugs are mixed in a syringe the diluent is usually water for injection. If compatibility/stability data is available for an alternative diluent then that diluent should be used 18 8. Morphine: Drug combinations for subcutaneous infusion that are stable for 24 hours • These are not clinical doses to prescribe. Use the minimum effective dose and titrate according to response • Monitor closely for visible signs of incompatibility such as the solution becoming cloudy, changing colour or the appearance of crystals Drug Combination Maximum concentrations of two drug combinations that are physically stable 17ml in 20ml syringe 22ml in 30ml syringe Morphine Sulphate 300mg Cyclizine 150mg Morphine Sulphate 300mg Glycopyrronium bromide 1200micrograms Morphine Sulphate 400mg Haloperidol 10mg Morphine Sulphate 300mg Hyoscine butylbromide 120mg Morphine Sulphate 450mg Hyoscine hydrobromide 1200micrograms Morphine Sulphate 300mg Levomepromazine 100mg Morphine Sulphate 120mg 160mg Metoclopramide 60mg 80mg Morphine Sulphate 300mg 380mg Midazolam 30mg 40mg Morphine Sulphate 400mg 500mg Octreotide 400micrograms 500micrograms 19 Drug Combination Maximum concentrations of three drug combinations that are physically stable 17ml in 20ml syringe 22ml in 30ml syringe Morphine Sulphate 40mg Cyclizine 100mg Haloperidol 2. Diamorphine: Drug combinations for subcutaneous infusion that are stable for 24 hours • These are not clinical doses to prescribe. Use the minimum effective dose and titrate according to response • Monitor closely for visible signs of incompatibility such as the solution becoming cloudy, changing colour or the appearance of crystals Drug Combination Maximum concentrations of two drug combinations that are physically stable 17ml in 20ml syringe 22ml in 30ml syringe Diamorphine 340mg Cyclizine 150mg Diamorphine 425mg Glycopyrronium bromide 1200micrograms Diamorphine 800mg Haloperidol 10mg Diamorphine 1200mg Hyoscine butylbromide 120mg Diamorphine 1200mg Hyoscine hydrobromide 1200micrograms Diamorphine 90mg Ketorolac 30mg Diamorphine 850mg Levomepromazine 100mg Diamorphine 2550mg 3300mg Metoclopramide 85mg 110mg Diamorphine 560mg 720mg Midazolam 80mg 100mg Diamorphine 425mg Octreotide 900 micrograms 21 Drug Combination Maximum concentrations of three drug combinations that are physically stable 17ml in 20ml syringe 22ml in 30ml syringe Diamorphine 340mg Cyclizine 150mg Haloperidol 10mg Diamorphine 800mg 1000mg Haloperidol 7. Oxycodone: Drug combinations for subcutaneous infusion that are stable for 24 hours • These are not clinical doses to prescribe. Use the minimum effective dose and titrate according to response • Monitor closely for visible signs of incompatibility such as the solution becoming cloudy, changing colour or the appearance of crystals Drug Combination Maximum concentrations of two drug combinations that are physically stable 17ml in 20ml syringe 22ml in 30ml syringe Oxycodone Do not mix - Do not mix - Cyclizine Incompatible Incompatible Oxycodone 140mg Haloperidol 10mg Oxycodone 140mg 180mg Hyoscine butylbromide 40mg 50mg Oxycodone 130mg Hyoscine hydrobromide 1200micrograms Oxycodone 85mg Ketorolac 30mg Oxycodone 120mg Levomepromazine 100mg Oxycodone 80mg 100mg Metoclopramide 40mg 50mg Oxycodone 80mg 100mg Midazolam 40mg 50mg Oxycodone 80mg 100mg Octreotide 400micrograms 500micrograms 23 Drug Combination Maximum concentrations of three drug combinations that are physically stable 17ml in 20ml syringe 22ml in 30ml syringe Oxycodone 80mg 100mg Haloperidol 2. Drug Conversions Converting to Diamorphine or Morphine Diamorphine and Morphine are the opioids of choice for moderate to severe pain. Diamorphine is particularly suitable for use in a syringe pump because it is highly soluble in small volumes. To convert from oral morphine to subcutaneous diamorphine: The total 24-hour dose of oral morphine should be divided by 3. To convert from oral morphine to subcutaneous morphine: The total 24-hour dose of oral morphine should be divided by 2. Total 24 hours oral morphine dose: 120 mg + 120 mg + 40 mg + 40 mg + 40mg = 360 mg. Breakthrough analgesia Breakthrough analgesia should still be prescribed subcutaneously when a th continuous infusion is in use. If the dose is difficult to calculate, round up or down to the nearest easy dose to achieve. Caution: Breakthrough analgesia given for movement related pain or incident pain in a patient whose background pain is satisfactorily controlled should not normally be added into the regular 24hour dose as toxicity may ensue. Also inhibits IgE synthesis, attenuates mucous secretion and eicosanoid generation, up-regulates beta-receptors, promotes vasoconstriction, suppresses inflammatory cell influx, and prevents / controls inflammation. Require 4-6 weeks of around-the-clock use for full effect; often misperceived as “rescuers” for acute attacks.

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