Publications - Ebenstein, Llp - Intellectual Property Law, Imoper

Personal Jurisdiction and the Improper Service of Process

- Journal of Intellectual Property Law and Practice, January 19, 2011

Nuance Communications, Inc. v Abbyy Software House . No. 2010-1100, US Court of Appeals for the Federal Circuit, 2010 US App. LEXIS 23419, 12 November 2010 (Nuance II)

Abstract Under California’s Long-Arm Statute, a US District Court erroneously dismissed patent infringement claim against a Cyprus parent corporation and its Russian affiliate for lack of personal jurisdiction and improper service of process.

As emerging markets play a bigger role in the global economy, and corporate entities located in them continue to avail themselves of US markets, when and how such entities become subject to personal jurisdiction in US Courts for alleged patent infringement is a matter of increasing concern. In Nuance Communications, Inc. v Abbyy Software House, et al. . the US Court of Appeals for the Federal Circuit laid out in great detail how two of the defendants (Abbyy Software, a Republic of Cyprus corporation, and Russian Federation Abbyy Production) were improperly dismissed for lack of personal jurisdiction and improper service of process outside the Hague Convention by the US District Court for the Northern District of California.

Nuance Communications was the owner by assignment of six US patents related to methods and systems for performing optical character recognition.

In 2008 Nuance brought a patent infringement action in the Central District of California against Abbyy USA Software House (‘Abbyy USA’) and Lexmark. The case was transferred to the US District Court for the Northern District of California. Later that year Abbyy USA identified in discovery responses a Cyprus company, Abbyy Software, and a wholly-owned Russian subsidiary, Abbyy Production. Nuance filed an amended complaint, adding Abbyy Production and Abbyy Software as additional defendants and served documents requests on both entities.

In May 2009 a local process server in Moscow personally served a manager of Abbyy Production with the amended complaint, amended summons and standing orders of the court, as well as Russian translations of these documents, effecting personal service on Abbyy Production. In June 2009 the Abbyy defendants filed a motion to dismiss Abbyy Production and Abbyy Software for lack of personal jurisdiction, and to dismiss Abbyy Production for improper service of process. Abbyy Software did not object to service of process. The motion was supported with written declarations and previously unproduced documents. The Abbyy defendants also sought a protective order to preclude pending written discovery until the motion to dismiss was resolved.

In August 2009 the District Court issued an order in which it found:

service of process of Abbyy Software and Abbyy Production was improper pursuant to Fed. R. Civ. P. 4(h)(2), due to Nuance’s failure to follow the Hague Convention;

the plaintiff failed to meet its burden to establish a prima facie showing of general or specific jurisdiction over each defendant it sued; and

the defendants’ motion for a protective order was moot.

In particular, with respect to the jurisdictional issue, the District Court explained its rationale as follows:

“Here, because there is no showing that the Moving Defendants purposefully directed any specific activity at residents of California or within the forum state or that the plaintiffs’ claim arises out of or relates to those activities, the Court need not reach the issue whether the assertion of personal jurisdiction is reasonable and fair. Again, there is no controlling precedent or evidence sustaining the position that this Court should pierce the corporate veil between the United States defendant, Abbyy USA, and the foreign defendants. Based on the record, the Court finds that it cannot exercise personal jurisdiction over the Moving Defendants. Defendants Abbyy Software, Ltd. or Abbyy Production, LLC are dismissed as defendants.”

Nuance Commc’ns Inc. v Abbyy Software House . No. 08-02912, 2009 WL 2707390, at *3 (ND Cal. 25 Aug, 2009) (‘ Nuance I ’) (citation omitted).

Significantly, as the Federal Circuit observed, no evidentiary hearing was conducted by the District Court before it reached its decision, and Abbyy Production and Abbyy Software never responded to Nuance’s discovery requests.

Nuance filed a notice of appeal challenging the District Court’s determination that it cannot exercise personal jurisdiction over Abbyy Production and Abbyy Software, and that these companies were served in a legally insufficient manner.

On appeal, the Federal Circuit found:

the District Court erred when it declined to exercise jurisdiction over Abbyy Production and abused its discretion when it denied Nuance’s request for jurisdictional discovery;

the District Court erred when it dismissed the Abbyy defendants for improper service of process; and

the District Court’s decision was vacated and remanded for further proceedings consistent with the Federal Circuit’s opinion.

First, the Federal Circuit analysed the personal jurisdiction issues over Abbyy Production and Abbyy Software. In this regard, the Federal Circuit applied its own law (rather than the regional Ninth Circuit law) to determine if the District Court properly declined to exercise personal jurisdiction over an out-of-state accused patent infringer. This is a question of law that the Federal Circuit reviews without deference, with the underlying factual determinations reviewed under a clear error standard.

In particular, the Federal Circuit applied the California Long-Arm statute, which is coextensive with the due process requirements under US federal law, to determine whether the California District Court had personal jurisdiction over the Abbyy Defendants. The touchstone of this analysis was whether the defendant was consistent with due process ‘purposefully established “minimum contacts” in the forum State’ ( Nuance II at *10).

In this case, the issue was whether there was specific jurisdiction (rather than general jurisdiction) over the two defendants. In particular, under Federal Circuit law, specific jurisdiction exists under the following three-prong test:

whether the defendant purposefully directed activities at residents of the forum;

whether the claim arises out of or relates to those activities; and

whether assertion of personal jurisdiction is reasonable and fair.

Significantly, the Federal Circuit found troubling the failure of the District Court to allow for jurisdictional discovery and to hold a factual hearing on the subject. In such a situation, the Court noted that ‘[w]ithout discovery and a record on jurisdiction, this court must resolve all factual disputes in the plaintiff’s favor’ ( Id . at *11–12).

Personal jurisdiction over Abbyy Production

First, the Federal Circuit analysed whether Abbyy Production, the Russian Federation affiliate of Abbyy USA, was subject to personal jurisdiction, and found that it was.

Under the first prong, the Federal Circuit found, ‘Abbyy Production purposefully directed its activities at residents of California and therefore satisfies the first prong of the Akro test’ ( Id . at *16).

In particular, the Federal Circuit cited Nuance’s arguments regarding:

an article dated 11 February 2008 quoted the CEO’s stated goal of conquering the US market and noted that Abbyy’s FineReader software program allegedly controlled about thirty percent of the US market;

the importation of allegedly infringing products into California;

the extraction of royalty payments for the sale of those products; and

Abbyy Production’s agreement to provide assistance to Abbyy USA in selling, reproducing, and modifying the accused products in California.

The Federal Circuit also distinguished two cases cited by defendants, HollyAnne Corp. v TFT, Inc. . 199 F.3d 1304 (Fed. Cir. 1999) and Pieczenik v Dyax . 265 F.3d 1329 (Fed. Cir. 2001), both of which affirmed dismissals for lack of jurisdiction.

HollyAnne involved a single ‘offer to donate’ as being insufficient to confer personal jurisdiction. The Federal Circuit found it to be inapposite, ‘because Abbyy Production seeks to “conquer” the US market, not to donate its services, and its contacts with California are much more significant than the single interaction in HollyAnne ’ ( Nuance II at *14).

Pieczenik found an arrangement which ‘superficially resemble[d]’ the arrangement between the Abbyy defendants as insufficient to establish personal jurisdiction. In particular, Pieczenik found ‘that [an] agreement [between the defendant there and a New York company] did not confer personal jurisdiction because

the agreement was not negotiated or executed in New York;

there was no visit to New York in connection with the licensing;

the choice-of-law provision did not specify New York law;

the agreement did not require the defendant to send any goods into New York or provide any services in New York; and

the only payments were payments by the licensee in New York to the defendant in Massachusetts’ (Id. at *15).

The Federal Circuit distinguished Pieczenik . as applying a different standard under New York’s narrower long-arm statute, after an extensive factual hearing, which more importantly involved unrelated entities. The Federal Circuit found it significant that Abbyy Production and Abby USA not only had an agreement like in Pieczenik . but also had:

'an expressed desire to “win the whole US market” by issuing ABBYY’S FineReader software program in the United States’;

‘the admitted distribution of that software to Abbyy USA, a California entity’; and

‘[o]ver ninety-five percent of the profits resulting from the sale of that software flow to Abbyy Production’. (Id. at *16).

Under the second prong, the Federal Circuit found ‘that the claims arise out of or relate to the purposefully directed activities, because Nuance’s infringement claims relate to Abbyy Production’s importation of goods into California.’ ( Id .) The Federal Circuit rejected Abbyy Production’s argument that it ‘has no physical presence in California’:

“To the contrary, the record shows that Abbyy Production provided copies of the accused software products to Abbyy USA, a California entity. By operation of the Agreement, Abbyy Production retains ownership in the accused software even after that software enters California. Greater than ninety-five percent of the profits in California flow to Abbyy Production. Under these facts, Abbyy Production has sufficient presence in the forum for importation under 35 U. S.C. § 271(a). (Id. at *17).”

The Federal Circuit also found that ‘Abbyy Production also runs afoul of the Supreme Court’s and this court’s stream of commerce jurisprudence’ (Id. at *18). In particular, the Federal Circuit distinguished its Beverly Hills Fan Co. v. Royal Sovereign Corp. . 21 F.3d 1558 (Fed. Cir. 1994), precedent, as follows:

“Abbyy Production purposefully ships the accused software products into California through an established distribution channel, with the expectation that copies of those products will be sold in California. Unlike Beverly Hills Fan, which involved the more attenuated connection of an out-of-state distributor, Nuance brought suit in the same forum in which Abbyy Production’s distributor, Abbyy USA, is located. Moreover, under the Agreement, Abbyy Production has agreed to furnish Abbyy USA with new versions and updates of the Software, technical support, and oral and written consultations. The Supreme Court has endorsed precisely this sort of purposeful activity as reinforcing the proper exercise of jurisdiction. See Asahi ( Metal Indus. Co. v. Superior Ct. of Cal. ), 480 US (102), 112 (1987). [ Nuance II at *19–20 (citation omitted).]”

Significantly, the Federal Circuit emphasized that no more is required to establish specific jurisdiction than the non-US defendant making the accused products available for sale through an established distribution chain, and the cause of action for patent infringement is alleged to arise out of these activities.

With respect to the third prong, the Federal Circuit rejected the argument that assertion of jurisdiction over Abbyy Production would be unfair. The Federal Circuit distinguished Asahi . on the following grounds:

Abbyy Production was not merely an upstream provider like in Asahi, but instead established a distribution system with Abbyy USA that was intended to deliver products to the US market via a commonly owned California entity.

Abbyy Production knew the destination of its products, and its conduct and connections with the forum state were such that it should have reasonably anticipated being brought into court there.

Abbyy Production and Abbyy USA share the same counsel and operate under a consolidated Global Management Team.

In sum, the Federal Circuit found ‘[t]hese relationships should ameliorate any possible burden of litigating in California.’ ( Id . at *21).

Personal jurisdiction over Abbyy Software

The Federal Circuit separately analysed whether the California District Court had personal jurisdiction over Abbyy Software. While the Federal Circuit found evidence to establish a prima facie case of personal jurisdiction, it also recognized that the factual record was insufficient to make a proper determination. Thus the Federal Circuit found that the district court abused its discretion by dismissing Abbyy Software without jurisdictional discovery.

In particular, the Federal Circuit identified the following facts to support a conclusion that Abbyy Software was more than merely a holding company:

“Abbyy Software’s website portrays Abbyy as a single company with offices in many countries, including the United States. The CEO of Abbyy Software, who expressed a desire to return to the U. S. market, is both the founder of the Abbyy companies and the Chairman of Abbyy’s Global Management Team, which includes among its members the CEOs of Abbyy USA and Abbyy Production. Abbyy Software’s website lists multiple California entities as customers of the accused products, including Hewlett-Packard, Alameda County, and Los Angeles County. Abbyy Software’s website also promotes the sale of these products in California by providing the names and contact information for retail stores located in California as well as online stores that sell the FineReader product. ( Id . at *22–23).”

However, the record also included evidence making ‘uncertain’ the extent of Abbyy Software’s involvement:

“Abbyy Software does not directly sell products through its website or otherwise. The record does not show at this point that Abbyy Software receives revenue from the sale of the accused software. Abbyy Production, not Abbyy Software, appears to develop the accused software and import master copies of that software into California. While the Global Management Team and the statements in the Trade Secret Magazine article suggest that Abbyy Software exerts some control over its subsidiaries, the record is unclear about the degree to which Abbyy Software intentionally established distribution channels that it knew, or could have foreseen, terminated in California. ( Id . at *23–24).”

Because the Federal Circuit could not ‘determine that Abbyy Software purposefully availed itself of the privilege of conducting activities in California by some affirmative act or conduct, and that Nuance’s claims arise out of those activities,’ the Court remanded the case for further discovery. ( Id . at *24).

Service of process over Abbyy Production and Abbyy Software

The Federal Circuit found the District Court improperly found Nuance’s service of process over Abbyy Production and Abbyy Software to be insufficient under the Hague Convention.

With respect to Abbyy Production, Nuance served Abbyy Production personally in Moscow, but did not attempt to serve Abbyy Production under the Hague Convention. The record in the case indicates that Nuance could not serve Abbyy Production through the Russian Federated Authority under the Hague Convention. While the Federal Circuit expressly did not decide whether personal service is allowed under Russian law, it nonetheless found that on remand ‘the district court should therefore allow alternate service as it deems appropriate, including at least substitute service, pursuant to Rule 4(f)(3), of Abbyy Production by substitute service on Abbyy USA.’ ( Id . at *39).

With respect to Abbyy Software, the Federal Circuit found the District Court’s dismissal of Abbyy Software for lack of personal jurisdiction on its own motion to be clear error. First, the District Court erred in failing to provide Nuance with any opportunity to show its service of process was sufficient on Abbyy Software. Moreover, since Abbyy Software failed to raise this defence in their first motion under Rule 12(b), the defence was waived, and thus it was improper for the District Court to dismiss on this ground in any event.

Nuance II provides helpful guidelines to non-US entities whose products are sold in the US to determine whether they may be subject to jurisdiction in the US. It confirms the expansive reach of US courts in patent infringement actions over non-US entities that purposely seek to avail themselves of US markets. When establishing worldwide networks of related entities to manufacture and distribute products, entities that seek to avoid jurisdiction in the US should pay careful attention to the considerations outlined in Nuance II .

* Mr. Macedo is a Partner at Amster, Rothstein & Ebenstein LLP and author of The Corporate Insider’s Guide to U. S. Patent Practice . published by Oxford University Press. Mr. Macedo ’s practice specializes on intellectual property issues including litigating patent, trademark and other intellectual property disputes, prosecuting patents before the U. S. Patent and Trademark Office and other patent offices throughout the world, registering trademarks and service marks with the U. S. Patent and Trademark Office and other trademark offices throughout the world, and drafting and negotiating intellectual property agreements. He may be reached at [email protected].

Personal Jurisdiction and the Improper Service of Process

- Journal of Intellectual Property Law and Practice, January 19, 2011

Nuance Communications, Inc. v Abbyy Software House . No. 2010-1100, US Court of Appeals for the Federal Circuit, 2010 US App. LEXIS 23419, 12 November 2010 (Nuance II)

Abstract Under California’s Long-Arm Statute, a US District Court erroneously dismissed patent infringement claim against a Cyprus parent corporation and its Russian affiliate for lack of personal jurisdiction and improper service of process.

As emerging markets play a bigger role in the global economy, and corporate entities located in them continue to avail themselves of US markets, when and how such entities become subject to personal jurisdiction in US Courts for alleged patent infringement is a matter of increasing concern. In Nuance Communications, Inc. v Abbyy Software House, et al. . the US Court of Appeals for the Federal Circuit laid out in great detail how two of the defendants (Abbyy Software, a Republic of Cyprus corporation, and Russian Federation Abbyy Production) were improperly dismissed for lack of personal jurisdiction and improper service of process outside the Hague Convention by the US District Court for the Northern District of California.

Nuance Communications was the owner by assignment of six US patents related to methods and systems for performing optical character recognition.

In 2008 Nuance brought a patent infringement action in the Central District of California against Abbyy USA Software House (‘Abbyy USA’) and Lexmark. The case was transferred to the US District Court for the Northern District of California. Later that year Abbyy USA identified in discovery responses a Cyprus company, Abbyy Software, and a wholly-owned Russian subsidiary, Abbyy Production. Nuance filed an amended complaint, adding Abbyy Production and Abbyy Software as additional defendants and served documents requests on both entities.

In May 2009 a local process server in Moscow personally served a manager of Abbyy Production with the amended complaint, amended summons and standing orders of the court, as well as Russian translations of these documents, effecting personal service on Abbyy Production. In June 2009 the Abbyy defendants filed a motion to dismiss Abbyy Production and Abbyy Software for lack of personal jurisdiction, and to dismiss Abbyy Production for improper service of process. Abbyy Software did not object to service of process. The motion was supported with written declarations and previously unproduced documents. The Abbyy defendants also sought a protective order to preclude pending written discovery until the motion to dismiss was resolved.

In August 2009 the District Court issued an order in which it found:

service of process of Abbyy Software and Abbyy Production was improper pursuant to Fed. R. Civ. P. 4(h)(2), due to Nuance’s failure to follow the Hague Convention;

the plaintiff failed to meet its burden to establish a prima facie showing of general or specific jurisdiction over each defendant it sued; and

the defendants’ motion for a protective order was moot.

In particular, with respect to the jurisdictional issue, the District Court explained its rationale as follows:

“Here, because there is no showing that the Moving Defendants purposefully directed any specific activity at residents of California or within the forum state or that the plaintiffs’ claim arises out of or relates to those activities, the Court need not reach the issue whether the assertion of personal jurisdiction is reasonable and fair. Again, there is no controlling precedent or evidence sustaining the position that this Court should pierce the corporate veil between the United States defendant, Abbyy USA, and the foreign defendants. Based on the record, the Court finds that it cannot exercise personal jurisdiction over the Moving Defendants. Defendants Abbyy Software, Ltd. or Abbyy Production, LLC are dismissed as defendants.”

Nuance Commc’ns Inc. v Abbyy Software House . No. 08-02912, 2009 WL 2707390, at *3 (ND Cal. 25 Aug, 2009) (‘ Nuance I ’) (citation omitted).

Significantly, as the Federal Circuit observed, no evidentiary hearing was conducted by the District Court before it reached its decision, and Abbyy Production and Abbyy Software never responded to Nuance’s discovery requests.

Nuance filed a notice of appeal challenging the District Court’s determination that it cannot exercise personal jurisdiction over Abbyy Production and Abbyy Software, and that these companies were served in a legally insufficient manner.

On appeal, the Federal Circuit found:

the District Court erred when it declined to exercise jurisdiction over Abbyy Production and abused its discretion when it denied Nuance’s request for jurisdictional discovery;

the District Court erred when it dismissed the Abbyy defendants for improper service of process; and

the District Court’s decision was vacated and remanded for further proceedings consistent with the Federal Circuit’s opinion.

First, the Federal Circuit analysed the personal jurisdiction issues over Abbyy Production and Abbyy Software. In this regard, the Federal Circuit applied its own law (rather than the regional Ninth Circuit law) to determine if the District Court properly declined to exercise personal jurisdiction over an out-of-state accused patent infringer. This is a question of law that the Federal Circuit reviews without deference, with the underlying factual determinations reviewed under a clear error standard.

In particular, the Federal Circuit applied the California Long-Arm statute, which is coextensive with the due process requirements under US federal law, to determine whether the California District Court had personal jurisdiction over the Abbyy Defendants. The touchstone of this analysis was whether the defendant was consistent with due process ‘purposefully established “minimum contacts” in the forum State’ ( Nuance II at *10).

In this case, the issue was whether there was specific jurisdiction (rather than general jurisdiction) over the two defendants. In particular, under Federal Circuit law, specific jurisdiction exists under the following three-prong test:

whether the defendant purposefully directed activities at residents of the forum;

whether the claim arises out of or relates to those activities; and

whether assertion of personal jurisdiction is reasonable and fair.

Significantly, the Federal Circuit found troubling the failure of the District Court to allow for jurisdictional discovery and to hold a factual hearing on the subject. In such a situation, the Court noted that ‘[w]ithout discovery and a record on jurisdiction, this court must resolve all factual disputes in the plaintiff’s favor’ ( Id . at *11–12).

Personal jurisdiction over Abbyy Production

First, the Federal Circuit analysed whether Abbyy Production, the Russian Federation affiliate of Abbyy USA, was subject to personal jurisdiction, and found that it was.

Under the first prong, the Federal Circuit found, ‘Abbyy Production purposefully directed its activities at residents of California and therefore satisfies the first prong of the Akro test’ ( Id . at *16).

In particular, the Federal Circuit cited Nuance’s arguments regarding:

an article dated 11 February 2008 quoted the CEO’s stated goal of conquering the US market and noted that Abbyy’s FineReader software program allegedly controlled about thirty percent of the US market;

the importation of allegedly infringing products into California;

the extraction of royalty payments for the sale of those products; and

Abbyy Production’s agreement to provide assistance to Abbyy USA in selling, reproducing, and modifying the accused products in California.

The Federal Circuit also distinguished two cases cited by defendants, HollyAnne Corp. v TFT, Inc. . 199 F.3d 1304 (Fed. Cir. 1999) and Pieczenik v Dyax . 265 F.3d 1329 (Fed. Cir. 2001), both of which affirmed dismissals for lack of jurisdiction.

HollyAnne involved a single ‘offer to donate’ as being insufficient to confer personal jurisdiction. The Federal Circuit found it to be inapposite, ‘because Abbyy Production seeks to “conquer” the US market, not to donate its services, and its contacts with California are much more significant than the single interaction in HollyAnne ’ ( Nuance II at *14).

Pieczenik found an arrangement which ‘superficially resemble[d]’ the arrangement between the Abbyy defendants as insufficient to establish personal jurisdiction. In particular, Pieczenik found ‘that [an] agreement [between the defendant there and a New York company] did not confer personal jurisdiction because

the agreement was not negotiated or executed in New York;

there was no visit to New York in connection with the licensing;

the choice-of-law provision did not specify New York law;

the agreement did not require the defendant to send any goods into New York or provide any services in New York; and

the only payments were payments by the licensee in New York to the defendant in Massachusetts’ (Id. at *15).

The Federal Circuit distinguished Pieczenik . as applying a different standard under New York’s narrower long-arm statute, after an extensive factual hearing, which more importantly involved unrelated entities. The Federal Circuit found it significant that Abbyy Production and Abby USA not only had an agreement like in Pieczenik . but also had:

'an expressed desire to “win the whole US market” by issuing ABBYY’S FineReader software program in the United States’;

‘the admitted distribution of that software to Abbyy USA, a California entity’; and

‘[o]ver ninety-five percent of the profits resulting from the sale of that software flow to Abbyy Production’. (Id. at *16).

Under the second prong, the Federal Circuit found ‘that the claims arise out of or relate to the purposefully directed activities, because Nuance’s infringement claims relate to Abbyy Production’s importation of goods into California.’ ( Id .) The Federal Circuit rejected Abbyy Production’s argument that it ‘has no physical presence in California’:

“To the contrary, the record shows that Abbyy Production provided copies of the accused software products to Abbyy USA, a California entity. By operation of the Agreement, Abbyy Production retains ownership in the accused software even after that software enters California. Greater than ninety-five percent of the profits in California flow to Abbyy Production. Under these facts, Abbyy Production has sufficient presence in the forum for importation under 35 U. S.C. § 271(a). (Id. at *17).”

The Federal Circuit also found that ‘Abbyy Production also runs afoul of the Supreme Court’s and this court’s stream of commerce jurisprudence’ (Id. at *18). In particular, the Federal Circuit distinguished its Beverly Hills Fan Co. v. Royal Sovereign Corp. . 21 F.3d 1558 (Fed. Cir. 1994), precedent, as follows:

“Abbyy Production purposefully ships the accused software products into California through an established distribution channel, with the expectation that copies of those products will be sold in California. Unlike Beverly Hills Fan, which involved the more attenuated connection of an out-of-state distributor, Nuance brought suit in the same forum in which Abbyy Production’s distributor, Abbyy USA, is located. Moreover, under the Agreement, Abbyy Production has agreed to furnish Abbyy USA with new versions and updates of the Software, technical support, and oral and written consultations. The Supreme Court has endorsed precisely this sort of purposeful activity as reinforcing the proper exercise of jurisdiction. See Asahi ( Metal Indus. Co. v. Superior Ct. of Cal. ), 480 US (102), 112 (1987). [ Nuance II at *19–20 (citation omitted).]”

Significantly, the Federal Circuit emphasized that no more is required to establish specific jurisdiction than the non-US defendant making the accused products available for sale through an established distribution chain, and the cause of action for patent infringement is alleged to arise out of these activities.

With respect to the third prong, the Federal Circuit rejected the argument that assertion of jurisdiction over Abbyy Production would be unfair. The Federal Circuit distinguished Asahi . on the following grounds:

Abbyy Production was not merely an upstream provider like in Asahi, but instead established a distribution system with Abbyy USA that was intended to deliver products to the US market via a commonly owned California entity.

Abbyy Production knew the destination of its products, and its conduct and connections with the forum state were such that it should have reasonably anticipated being brought into court there.

Abbyy Production and Abbyy USA share the same counsel and operate under a consolidated Global Management Team.

In sum, the Federal Circuit found ‘[t]hese relationships should ameliorate any possible burden of litigating in California.’ ( Id . at *21).

Personal jurisdiction over Abbyy Software

The Federal Circuit separately analysed whether the California District Court had personal jurisdiction over Abbyy Software. While the Federal Circuit found evidence to establish a prima facie case of personal jurisdiction, it also recognized that the factual record was insufficient to make a proper determination. Thus the Federal Circuit found that the district court abused its discretion by dismissing Abbyy Software without jurisdictional discovery.

In particular, the Federal Circuit identified the following facts to support a conclusion that Abbyy Software was more than merely a holding company:

“Abbyy Software’s website portrays Abbyy as a single company with offices in many countries, including the United States. The CEO of Abbyy Software, who expressed a desire to return to the U. S. market, is both the founder of the Abbyy companies and the Chairman of Abbyy’s Global Management Team, which includes among its members the CEOs of Abbyy USA and Abbyy Production. Abbyy Software’s website lists multiple California entities as customers of the accused products, including Hewlett-Packard, Alameda County, and Los Angeles County. Abbyy Software’s website also promotes the sale of these products in California by providing the names and contact information for retail stores located in California as well as online stores that sell the FineReader product. ( Id . at *22–23).”

However, the record also included evidence making ‘uncertain’ the extent of Abbyy Software’s involvement:

“Abbyy Software does not directly sell products through its website or otherwise. The record does not show at this point that Abbyy Software receives revenue from the sale of the accused software. Abbyy Production, not Abbyy Software, appears to develop the accused software and import master copies of that software into California. While the Global Management Team and the statements in the Trade Secret Magazine article suggest that Abbyy Software exerts some control over its subsidiaries, the record is unclear about the degree to which Abbyy Software intentionally established distribution channels that it knew, or could have foreseen, terminated in California. ( Id . at *23–24).”

Because the Federal Circuit could not ‘determine that Abbyy Software purposefully availed itself of the privilege of conducting activities in California by some affirmative act or conduct, and that Nuance’s claims arise out of those activities,’ the Court remanded the case for further discovery. ( Id . at *24).

Service of process over Abbyy Production and Abbyy Software

The Federal Circuit found the District Court improperly found Nuance’s service of process over Abbyy Production and Abbyy Software to be insufficient under the Hague Convention.

With respect to Abbyy Production, Nuance served Abbyy Production personally in Moscow, but did not attempt to serve Abbyy Production under the Hague Convention. The record in the case indicates that Nuance could not serve Abbyy Production through the Russian Federated Authority under the Hague Convention. While the Federal Circuit expressly did not decide whether personal service is allowed under Russian law, it nonetheless found that on remand ‘the district court should therefore allow alternate service as it deems appropriate, including at least substitute service, pursuant to Rule 4(f)(3), of Abbyy Production by substitute service on Abbyy USA.’ ( Id . at *39).

With respect to Abbyy Software, the Federal Circuit found the District Court’s dismissal of Abbyy Software for lack of personal jurisdiction on its own motion to be clear error. First, the District Court erred in failing to provide Nuance with any opportunity to show its service of process was sufficient on Abbyy Software. Moreover, since Abbyy Software failed to raise this defence in their first motion under Rule 12(b), the defence was waived, and thus it was improper for the District Court to dismiss on this ground in any event.

Nuance II provides helpful guidelines to non-US entities whose products are sold in the US to determine whether they may be subject to jurisdiction in the US. It confirms the expansive reach of US courts in patent infringement actions over non-US entities that purposely seek to avail themselves of US markets. When establishing worldwide networks of related entities to manufacture and distribute products, entities that seek to avoid jurisdiction in the US should pay careful attention to the considerations outlined in Nuance II .

* Mr. Macedo is a Partner at Amster, Rothstein & Ebenstein LLP and author of The Corporate Insider’s Guide to U. S. Patent Practice . published by Oxford University Press. Mr. Macedo ’s practice specializes on intellectual property issues including litigating patent, trademark and other intellectual property disputes, prosecuting patents before the U. S. Patent and Trademark Office and other patent offices throughout the world, registering trademarks and service marks with the U. S. Patent and Trademark Office and other trademark offices throughout the world, and drafting and negotiating intellectual property agreements. He may be reached at [email protected].

Lisinopril Side Effects In Detail, Lizinopril

Lisinopril Side Effects

In Summary

Commonly reported side effects of lisinopril include: dizziness, hypotension, hyperkalemia, increased blood urea nitrogen, and increased serum creatinine. Other side effects include: headache. See below for a comprehensive list of adverse effects.

For the Consumer

Applies to lisinopril: oral tablet

In addition to its needed effects, some unwanted effects may be caused by lisinopril. In the event that any of these side effects do occur, they may require medical attention.

Major Side Effects

You should check with your doctor immediately if any of these side effects occur when taking lisinopril:

More common:

Blurred vision

cloudy urine

confusion

decrease in urine output or decrease in urine-concentrating ability

dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position

sweating

unusual tiredness or weakness

Less common:

Abdominal or stomach pain

body aches or pain

chest pain

chills

common cold

cough

diarrhea

difficulty breathing

ear congestion

fever

headache

loss of voice

nasal congestion

nausea

runny nose

sneezing

sore throat

vomiting

Rare

Arm, back, or jaw pain

chest discomfort, tightness, or heaviness

fast or irregular heartbeat

general feeling of discomfort or illness

joint pain

loss of appetite

muscle aches and pains

shivering

trouble sleeping

Minor Side Effects

Some of the side effects that can occur with lisinopril may not need medical attention. As your body adjusts to the medicine during treatment these side effects may go away. Your health care professional may also be able to tell you about ways to reduce or prevent some of these side effects. If any of the following side effects continue, are bothersome or if you have any questions about them, check with your health care professional:

Less common:

Decreased interest in sexual intercourse

inability to have or keep an erection

lack or loss of strength

loss in sexual ability, desire, drive, or performance

rash

Rare

Acid or sour stomach

belching

burning, crawling, itching, numbness, prickling, "pins and needles", or tingling feelings

feeling of constant movement of self or surroundings

heartburn

indigestion

muscle cramps

sensation of spinning

stomach discomfort or upset

swelling

For Healthcare Professionals

Applies to lisinopril: oral solution, oral tablet

Cardiovascular

Hypotension is most likely in patients who are sodium and intravascular volume depleted. In large studies, patients have reported "heart pounding" and chest pain, although the relationship to lisinopril is questionable. [Ref ]

Very common (10% or more): Hypotension (11%) Common (1% to 10%): Chest pain, angina pectoris, orthostatic hypotension, palpitations Uncommon (0.1% to 1%): Angioneurotic edema, myocardial infarction or cerebrovascular accident, palpitations, tachycardia, Raynaud's phenomenon [Ref ]

Renal

Common (1% to 10%): Creatinine increased (10%) Very rare (less than 0.01%): Renal insufficiency [Ref ]

Nervous system

Very common (10% or more): Dizziness (19%) Common (1% to 10%): Headache, syncope Uncommon (0.1% to 1%): Paresthesias [Ref ]

Respiratory

A study has revealed a significantly higher incidence of discontinuation of angiotensin converting enzyme inhibitor therapy due to cough among black patients compared with nonblack patients (9.6% vs. 2.4%). [Ref ]

Common (1% to 10%): Creatinine increased (10%) Uncommon (0.1% to 1%): Rhinitis Very rare (less than 0.01%): Bronchospasm, sinusitis, allergic alveolitis/eosinophilic pneumonia [Ref ]

Metabolic

Common (1% to 10%): Hyperkalemia Frequency not reported: Gout, hypoglycemia in diabetic patients receiving ACE inhibitors when concurrently treated with oral antidiabetic agents or insulin [Ref ]

Gastrointestinal

Common (1% to 10%): Diarrhea, nausea, vomiting Frequency not reported: Pancreatitis, constipation, flatulence, dry mouth, taste disturbance [Ref ]

Hypersensitivity

Uncommon (0.1% to 1%): Angioedema [Ref ]

Dermatologic

Uncommon (0.1% to 1%): Rash, pruritus, erythema Rare (0.01% to 0.1%): Alopecia, urticaria, psoriasis, hypersensitivity/angioedema, angioneurotic edema of the face, extremities, lips, tongue, glottis, and/or larynx Very rare (less than 0.01%): Sweating, skin lesions, skin infections, pemphigus, toxic epidermal necrolysis, Stevens-Johnson Syndrome, erythema multiforme, cutaneous pseudolymphoma Frequency not reported: Photosensitivity, flushing, diaphoresis [Ref ]

Hematologic

Very rare (less than 0.01%): Bone marrow depression, hemolytic anemia, leukopenia/neutropenia, thrombocytopenia, decreases in hemoglobin, decreases in hematocrit [Ref ]

Psychiatric

Rare (0.01% to 0.1%): Memory impairment, confusion, somnolence, irritability, nervousness, hallucinations Very rare (less than 0.01%): Mania

Hepatic

Common (1% to 10%): Creatinine increased Very rare (less than 0.01%): Cholestatic jaundice that progresses to fulminant hepatic necrosis and sometimes death (discontinue of therapy if jaundice or markedly elevated hepatic serum enzymes develop)

Endocrine

Very rare (less than 0.01%): Diabetes, syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Other

Common (1% to 10%): Cough Frequency not reported: Fatigue, asthenia, orthostatic effects, tinnitus, olfactory disturbance

Genitourinary

Uncommon (0.1% to 1%): Impotence Rare (less than 0.1%): Gynecomastia Frequency not reported: Proteinuria

References

1. Cerner Multum, Inc. "UK Summary of Product Characteristics." O 0

2. Pharmaceutical Society of Australia "APPGuide online. Australian prescription products guide online. Available from: URL: http://www. appco. com. au/appguide/default. asp." ([2006]):

3. Cerner Multum, Inc. "Australian Product Information." O 0

4. "Product Information. Prinivil (lisinopril)." Merck & Co, Inc, West Point, PA.

Not all side effects for lisinopril may be reported. You should always consult a doctor or healthcare professional for medical advice. Side effects can be reported to the FDA here .

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Disclaimer: Every effort has been made to ensure that the information provided is accurate, up-to-date and complete, but no guarantee is made to that effect. In addition, the drug information contained herein may be time sensitive and should not be utilized as a reference resource beyond the date hereof. This material does not endorse drugs, diagnose patients, or recommend therapy. This information is a reference resource designed as supplement to, and not a substitute for, the expertise, skill. knowledge, and judgement of healthcare practitioners in patient care. The absence of a warning for a given drug or combination thereof in no way should be construed to indicate safety, effectiveness, or appropriateness for any given patient. Drugs. com does not assume any responsibility for any aspect of healthcare administered with the aid of materials provided. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the substances you are taking, check with your doctor, nurse, or pharmacist.

Drug Status

Tarka - Fda Prescribing Information, Side Effects And Uses, Tarka

Tarka

WARNING: FETAL TOXICITY

When pregnancy is detected, discontinue Tarka as soon as possible.

Drugs that act directly on the renin-angiotensin system can cause injury and death to the developing fetus (see WARNINGS: Fetal Toxicity ) .

Tarka Description

Tarka (trandolapril/verapamil hydrochloride ER) combines a slow release formulation of a calcium channel blocker, verapamil hydrochloride, and an immediate release formulation of an angiotensin converting enzyme inhibitor, trandolapril.

Verapamil Component

Verapamil hydrochloride is chemically described as benzeneacetonitrile, α[3-[[2-(3,4-dimethoxyphenyl)ethyl]methylamino]propyl]-3, 4-dimethoxy-α-(1-methylethyl) hydrochloride. Its empirical formula is C 27 H 38 N 2 O 4 HCl and its structural formula is:

Verapamil hydrochloride is an almost white crystalline powder, with a molecular weight of 491.08. It is soluble in water, chloroform, and methanol. It is practically free of odor, with a bitter taste.

Trandolapril Component

Trandolapril is the ethyl ester prodrug of a nonsulfhydryl angiotensin converting enzyme (ACE) inhibitor, trandolaprilat. It is chemically described as (2S,3aR,7aS)-1-[(S)-N-[(S)-1-Carboxy-3-phenylpropyl]alanyl] hexahydro-2-indolinecarboxylic acid, 1-ethyl ester. Its empirical formula is C 24 H 34 N 2 O 5 and its structural formula is:

Trandolapril is a white or almost white powder with a molecular weight of 430.54. It is soluble (>100 mg/mL) in chloroform, dichloromethane, and methanol.

Tarka tablets are formulated for oral administration, containing verapamil hydrochloride as a controlled release formulation and trandolapril as an immediate release formulation. The tablet strengths are trandolapril 2 mg/verapamil hydrochloride ER 180 mg, trandolapril 1 mg/verapamil hydrochloride ER 240 mg, trandolapril 2 mg/verapamil hydrochloride ER 240 mg, and trandolapril 4 mg/verapamil hydrochloride ER 240 mg. The tablets also contain the following ingredients: corn starch, dioctyl sodium sulfosuccinate, ethanol, hydroxypropyl cellulose, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, povidone, purified water, silicon dioxide, sodium alginate, sodium stearyl fumarate, synthetic iron oxides, talc, and titanium dioxide.

Tarka - Clinical Pharmacology

Verapamil hydrochloride and trandolapril have been used individually and in combination for the treatment of hypertension. For the four dosing strengths, the antihypertensive effect of the combination is approximately additive to the individual components.

Verapamil Component

Verapamil is a calcium channel blocker that exerts its pharmacologic effects by modulating the influx of ionic calcium across the cell membrane of the arterial smooth muscle as well as in conductile and contractile myocardial cells. Verapamil exerts antihypertensive effects by decreasing systemic vascular resistance, usually without orthostatic decreases in blood pressure or reflex tachycardia. During isometric or dynamic exercise, verapamil does not alter systolic cardiac function in patients with normal ventricular function. Verapamil does not alter total serum calcium levels.

Trandolapril Component

Trandolapril is de-esterified to its diacid metabolite, trandolaprilat. Both inhibit angiotensin-converting enzyme (ACE) in human subjects and in animals. Trandolaprilat is about 8 times more potent than trandolapril. ACE is a peptidyl dipeptidase that catalyzes the conversion of angiotensin I to the vasoconstrictor, angiotensin II. Angiotensin II also stimulates aldosterone secretion by the adrenal cortex.

Inhibition of ACE results in decreased plasma angiotensin II, which leads to decreased vasopressor activity and to decreased aldosterone secretion. The latter decrease may result in a small increase of serum potassium. In controlled clinical trials, treatment with Tarka resulted in mean increases in potassium of 0.1 mEq/L (see PRECAUTIONS ). Removal of angiotensin II negative feedback on renin secretion leads to increased plasma renin activity (PRA).

ACE is identical to kininase II, an enzyme that degrades bradykinin. Whether increased levels of bradykinin, a potent vasodepressor peptide, play a role in the therapeutic effect of Tarka remains to be elucidated.

While the mechanism through which trandolapril lowers blood pressure is believed to be primarily suppression of the renin-angiotensin-aldosterone system, trandolapril has an antihypertensive effect even in patients with low renin hypertension. Trandolapril is an effective antihypertensive in all races studied. Both black patients (usually a predominantly low renin group) and non-black patients respond to 2 to 4 mg of trandolapril.

Pharmacokinetics and Metabolism

Following a single oral dose of Tarka in healthy subjects, peak plasma concentrations are reached within 0.5-2 hours for trandolapril and within 4-15 hours for verapamil. Peak plasma concentrations of the active desmethyl metabolite of verapamil, norverapamil, are reached within 5-15 hours. Cleavage of the ester group converts trandolapril to its active diacid metabolite, trandolaprilat, which reaches peak plasma concentrations within 2-12 hours. The pharmacokinetics of trandolapril and trandolaprilat are not altered when trandolapril is administered in combination with verapamil, compared to monotherapy.

The AUC and C max for both verapamil and norverapamil are increased when 240 mg of controlled release verapamil is administered concomitantly with 4 mg trandolapril. The increase in C max is 54 and 30% and the AUC is increased by 65 and 32% for verapamil and norverapamil, respectively. Administration of Tarka 4/240 (4 mg trandolapril and 240 mg verapamil hydrochloride ER) with a high-fat meal does not alter the bioavailability of trandolapril whereas verapamil peak concentrations and area under the curve (AUC) decrease 37% and 28%, respectively. Food thus decreases verapamil bioavailability and the time to peak plasma concentration for both verapamil and norverapamil are delayed by approximately 7 hours. Both optical isomers of verapamil are similarly affected.

The elimination half life of trandolapril is about 6 hours. At steady state, the effective half-life of trandolaprilat is 22.5 hours. Like all ACE inhibitors, trandolaprilat also has a prolonged terminal elimination phase, involving a small fraction of administered drug, probably representing binding to plasma and tissue ACE.

The terminal half-life of verapamil is 6-11 hours. Steady-state plasma concentrations of the two components are achieved after about a week of once-daily dosing of Tarka. At steady-state, plasma concentrations of verapamil and trandolaprilat are up to two-fold higher than those observed after a single oral Tarka dose.

The pharmacokinetics of verapamil and trandolaprilat are significantly different in the elderly (≥65 years) than in younger subjects. The bioavailability of verapamil and norverapamil are increased by 87% and 77%, respectively, and that of trandolapril by approximately 35% in the elderly. AUCs are approximately 80% and 35% higher, respectively.

With the immediate release formulation, more than 90% of the orally administered dose is absorbed with peak plasma concentrations of verapamil observed 1 to 2 hours after dosing. A delayed rate but similar extent of absorption is observed for the sustained release formulation when compared to the immediate release formulation. Because of the rapid biotransformation of verapamil during its first pass through the portal circulation, absolute bioavailability ranges from 20% to 35%. A nonlinear correlation exists between verapamil dose and plasma concentrations.

In early dose titration with verapamil, a relationship exists between plasma concentrations of verapamil and prolongation of the PR interval. However, during chronic administration, this relationship may disappear. No relationship has been established between the plasma concentration of verapamil and reduction in blood pressure.

In healthy subjects, orally administered verapamil undergoes extensive metabolism in the liver. Twelve metabolites have been identified in plasma; all except norverapamil are present in trace amounts only. Approximately 70% of an administered dose is excreted as metabolites in the urine and 16% or more in the feces within 5 days. Urinary excretion of unchanged drug is about 3% to 4% of the dose. Verapamil is approximately 90% bound to plasma proteins.

In patients with hepatic insufficiency, verapamil clearance is decreased about 30% and the elimination half-life is prolonged up to 14 to 16 hours (see PRECAUTIONS ). In patients with liver dysfunction, a dosage adjustment may be required. In the elderly (≥65 years), verapamil clearance is reduced resulting in increases in elimination half-life.

Following oral administration of trandolapril, the absolute bioavailability of trandolapril is approximately 10% as trandolapril and 70% as trandolaprilat. Plasma concentrations of trandolaprilat but not trandolapril increase in proportion with dose. Plasma concentrations of trandolaprilat decline in a triphasic manner. The more prolonged terminal elimination phase probably represents a small fraction of dose saturably bound to ACE.

After an oral radiolabeled dose of trandolapril, excretion of trandolapril and metabolites account for 33% of the dose in the urine and about 66% in the feces. Less than 1% of the dose is excreted in the urine as unchanged drug. Serum protein binding of trandolapril is about 80%, and is independent of concentration. Binding of trandolaprilat is concentration-dependent, varying from 65% at 1000 ng/mL to 94% at 0.1 ng/mL, indicating saturation of binding with increasing concentration.

Compared to normal subjects, the plasma concentrations of trandolapril and trandolaprilat are approximately 2-fold greater and renal clearance is reduced by about 85% in patients with creatinine clearance below 30 mL/min and in patients on hemodialysis. Dosage adjustment is recommended in renally impaired patients (see DOSAGE AND ADMINISTRATION ).

Following oral administration in patients with mild to moderate alcoholic cirrhosis, plasma concentrations of trandolapril and trandolaprilat were, respectively, 9-fold and 2-fold greater than in normal subjects, but inhibition of ACE activity was not affected. Lower doses should be considered in patients with hepatic insufficiency (see DOSAGE AND ADMINISTRATION ).

Pharmacodynamics

Verapamil does not interfere with ACE inhibition by trandolapril. Trandolapril does not alter the effect of verapamil on intra-cardiac conduction.

Verapamil dilates the main coronary arteries and coronary arterioles, both in normal and ischemic regions, and is a potent inhibitor of coronary artery spasm. This property increases myocardial oxygen delivery in patients with coronary artery spasm, and is responsible for the effectiveness of verapamil in vasospastic (Prinzmetal's or variant) as well as unstable angina at rest.

Verapamil regularly reduces the total systemic resistance (afterload) by dilating peripheral arterioles. By decreasing the influx of calcium, verapamil prolongs the effective refractory period within the AV node and slows AV conduction in a rate-related manner.

Normal sinus rhythm is usually not affected, but in patients with sick sinus syndrome, verapamil may interfere with sinus node impulse generation and may induce sinus arrest or sinoatrial block. Atrioventricular block can occur in patients without preexisting conduction defects (see WARNINGS ).

Verapamil does not alter the normal atrial action potential or intraventricular conduction time, but depresses amplitude, velocity of depolarization and conduction in depressed atrial fibers. Verapamil may shorten the antegrade effective refractory period of accessory bypass tracts. Acceleration of ventricular rate and/or ventricular fibrillation has been reported in patients with atrial flutter or atrial fibrillation and a coexisting accessory AV pathway following administration of verapamil (see WARNINGS ).

Hemodynamics and Myocardial Metabolism: Verapamil reduces afterload and myocardial contractility. Improved left ventricular diastolic function in patients with idiopathic hypertrophic subaortic stenosis (IHSS) and those with coronary heart disease has also been observed with verapamil therapy. In most patients, including those with organic cardiac disease, the negative inotropic action of verapamil is countered by a reduction of afterload and cardiac index is usually not reduced. However, in patients with severe left ventricular dysfunction (e. g. pulmonary wedge pressure about 20 mmHg or ejection fraction less than 30%), or in patients taking beta-adrenergic blocking agents or other cardio-depressant drugs, deterioration of ventricular function may occur (see PRECAUTIONS - Drug Interactions ).

Pulmonary Function: Verapamil does not induce bronchoconstriction and hence, does not impair ventilatory function.

After a single 2 mg dose of trandolapril, inhibition of ACE activity reaches a maximum (70-85%) at 4 hours with about 10% decline at 24 hours. Eight days after dosing, ACE inhibition is still 40%.

Four placebo-controlled dose response studies were conducted using once daily oral dosing of trandolapril in doses from 0.25 to 16 mg per day in 827 black and non-black patients with mild to moderate hypertension. The minimal effective once daily dose was 1.0 mg in non-black patients and 2.0 mg in black patients. Further decreases in trough supine diastolic blood pressure were obtained in non-black patients with higher doses, and no further response was seen with doses above 4 mg (up to 16 mg). The antihypertensive effect diminished somewhat at the end of the dosing interval.

During chronic therapy, the maximum reduction in blood pressure with any dose is achieved within one week. Following 6 weeks of monotherapy in placebo-controlled trials in patients with mild to moderate hypertension, once daily doses of 2 to 4 mg lowered supine or standing systolic/diastolic blood pressure 24 hours after dosing by an average 7-10/4-5 mmHg below placebo responses in non-black patients. Once daily doses of 2 to 4 mg lowered blood pressures 4-6/3-4 mmHg below placebo responses in black patients.

Clinical Studies

In controlled clinical trials, once daily doses of Tarka, trandolapril 4 mg/verapamil HCl ER 240 mg or trandolapril 2 mg/verapamil HCl ER 180 mg, decreased placebo-corrected seated pressure (systolic/diastolic) 24 hours after dosing by about 7-12/6-8 mmHg. Each of the components of Tarka added to the antihypertensive effect. Treatment effects were consistent across age groups (<65, ≥65 years), and gender (male, female).

Blood pressure reductions were significantly greater for the Tarka 4/240 combination than for either of the components used alone.

The antihypertensive effects of Tarka have continued during therapy for at least 1 year.

Indications and Usage for Tarka

Tarka is indicated for the treatment of hypertension.

This fixed combination drug is not indicated for the initial therapy of hypertension (see DOSAGE AND ADMINISTRATION ).

In using Tarka, consideration should be given to the fact that an angiotensin converting enzyme inhibitor, captopril, has caused agranulocytosis, particularly in patients with renal impairment or collagen vascular disease, and that available data are insufficient to show that trandolapril does not have similar risk (see WARNINGS - Neutropenia/Agranulocytosis ).

Contraindications

Tarka is contraindicated in patients who are hypersensitive to any ACE inhibitor or verapamil.

Because of the verapamil component, Tarka is contraindicated in:

Severe left ventricular dysfunction (see WARNINGS ).

Hypotension (systolic pressure less than 90 mmHg) or cardiogenic shock.

Sick sinus syndrome (except in patients with a functioning artificial ventricular pacemaker).

Second - or third-degree AV block (except in patients with a functioning artificial ventricular pacemaker).

Patients with atrial flutter or atrial fibrillation and an accessory bypass tract (e. g. Wolff-Parkinson-White, Lown-Ganong-Levine syndromes) (see WARNINGS ).

Because of the trandolapril component, Tarka is contraindicated in patients with a history of angioedema related to previous treatment with an angiotensin converting enzyme (ACE) inhibitor.

Do not co-administer aliskiren with Tarka in patients with diabetes (see PRECAUTIONS, Drug Interactions ).

Warnings

Heart Failure

Verapamil has a negative inotropic effect which, in most patients, is compensated by its afterload reduction (decreased systemic vascular resistance) properties without a net impairment of ventricular performance. In clinical experience with 4,954 patients, 87 (1.8%) developed congestive heart failure or pulmonary edema. Verapamil should be avoided in patients with severe left ventricular dysfunction (e. g. ejection fraction less than 30%, pulmonary wedge pressure above 20 mmHg, or severe symptoms of cardiac failure) and in patients with any degree of ventricular dysfunction if they are receiving a beta adrenergic blocker (see PRECAUTIONS - Drug Interactions ). Patients with milder ventricular dysfunction should, if possible, be controlled with optimum doses of digitalis and/or diuretics before verapamil treatment (Note interactions with digoxin under: PRECAUTIONS ).

Trandolapril, as an ACE inhibitor, may cause excessive hypotension in patients with congestive heart failure (see WARNINGS - Hypotension ).

Hypotension

Occasionally, the pharmacologic action of verapamil may produce a decrease in blood pressure below normal levels which may result in dizziness or symptomatic hypotension.

Trandolapril can cause symptomatic hypotension. Like other ACE inhibitors, trandolapril has only rarely been associated with symptomatic hypotension in uncomplicated hypertensive patients. Symptomatic hypotension is most likely to occur in patients who are salt - or volume-depleted as a result of prolonged treatment with diuretics, dietary salt restriction, dialysis, diarrhea, or vomiting. Volume and/or salt depletion should be corrected before initiating treatment with trandolapril (see PRECAUTIONS - Drug Interactions and ADVERSE REACTIONS ).

In controlled studies, hypotension was observed in 0.6% of patients receiving any combination of trandolapril and verapamil HCl ER.

In patients with concomitant congestive heart failure, with or without associated renal insufficiency, ACE inhibitor therapy may cause excessive hypotension, which may be associated with oliguria or azotemia, and, rarely, with acute renal failure and death (see DOSAGE AND ADMINISTRATION ).

If symptomatic hypotension occurs, the patient should be placed in the supine position and, if necessary, normal saline may be administered intravenously. A transient hypotensive response is not a contraindication to further doses; however, lower doses of verapamil HCl ER and/or trandolapril or reduced concomitant diuretic therapy should be considered.

Elevated Liver Enzymes/Hepatic Failure

Elevations of transaminases with and without concomitant elevations in alkaline phosphatase and bilirubin have been reported. Such elevations have sometimes been transient and may disappear even in the face of continued verapamil treatment. Several cases of hepatocellular injury related to verapamil have been proven by rechallenge; half of these had clinical symptoms (malaise, fever, and/or right upper quadrant pain) in addition to elevations of SGOT, SGPT, and alkaline phosphatase.

ACE inhibitors rarely have been associated with a syndrome of cholestatic jaundice, fulminant hepatic necrosis, and death. The mechanism of this syndrome is not understood. Patients receiving ACE inhibitors who develop jaundice should discontinue the ACE inhibitor and receive appropriate medical follow-up.

Liver abnormalities were noted in 3.2% of patients taking any of several combinations of trandolapril/verapamil doses. Periodic monitoring of liver function in patients taking Tarka is therefore prudent.

Accessory Bypass Tract (Wolff-Parkinson-White or Lown-Ganong-Levine Syndromes)

Some patients with paroxysmal and/or chronic atrial fibrillation or atrial flutter and a coexisting accessory AV pathway have developed increased antegrade conduction across the accessory pathway bypassing the AV node, producing a very rapid ventricular response or ventricular fibrillation after receiving intravenous verapamil (or digitalis). Although a risk of this occurring with oral verapamil has not been established, such patients receiving oral verapamil may be at risk and its use in these patients is contraindicated (see CONTRAINDICATIONS ).

Treatment is usually DC-cardioversion. Cardioversion has been used safely and effectively after oral verapamil.

Atrioventricular Block

The effect of verapamil on AV conduction and the SA node may lead to asymptomatic first-degree AV block and transient bradycardia, sometimes accompanied by nodal escape rhythms. PR interval prolongation is correlated with verapamil plasma concentrations, especially during the early titration phases of therapy. Higher degrees of AV block, however, were infrequently (0.8%) observed. Marked first-degree block or progressive development to second - or third-degree AV block requires a reduction in dosage or, in rare instances, discontinuation of verapamil HCl and institution of appropriate therapy depending upon the clinical situation.

Patients with Hypertrophic Cardiomyopathy (IHSS)

In 120 patients with hypertrophic cardiomyopathy (most of them refractory or intolerant to propranolol) who received therapy with verapamil at doses up to 720 mg/day, a variety of serious adverse effects were seen. Three patients died in pulmonary edema; all had severe left ventricular outflow obstruction and a past history of left ventricular dysfunction. Eight other patients had pulmonary edema and/or severe hypotension; abnormally high (over 20 mmHg) capillary wedge pressure and a marked left ventricular outflow obstruction were present in most of these patients. Sinus bradycardia occurred in 11% of the patients, second-degree AV block in 4% and sinus arrest in 2%. It must be appreciated that this group of patients had a serious disease with a high mortality rate. Most adverse effects responded well to dose reduction and only rarely did verapamil have to be discontinued.

Anaphylactoid and Possibly Related Reactions

Presumably because angiotensin-converting enzyme inhibitors affect the metabolism of eicosanoids and polypeptides, including endogenous bradykinin, patients receiving ACE inhibitors, including trandolapril may be subject to a variety of adverse reactions, some of them serious.

Angioedema of the face, extremities, lips, tongue, glottis, and larynx has been reported in patients treated with ACE inhibitors including trandolapril. Symptoms suggestive of angioedema or facial edema occurred in 0.13% of trandolapril-treated patients. Two of the four cases were life-threatening and resolved without treatment or with medication (corticosteroids). Angioedema associated with laryngeal edema can be fatal. If laryngeal stridor or angioedema of the face, tongue or glottis occurs, treatment with Tarka should be discontinued immediately, the patient treated in accordance with accepted medical care and carefully observed until the swelling disappears. In instances where swelling is confined to the face and lips, the condition generally resolves without treatment; antihistamines may be useful in relieving symptoms. Where there is involvement of the tongue, glottis, or larynx, likely to cause airway obstruction, emergency therapy, including but not limited to subcutaneous epinephrine solution 1:1,000 (0.3 to 0.5 mL) should be promptly administered (see PRECAUTIONS and ADVERSE REACTIONS ).

Patients receiving coadministration of an ACE inhibitor with an mTOR (mammalian target of rapamycin) inhibitor (e. g. temsirolimus, sirolimus, everolimus) may be at increased risk for angioedema.

Anaphylactoid Reactions During Desensitization

Two patients undergoing desensitizing treatment with hymenoptera venom while receiving ACE inhibitors sustained life-threatening anaphylactoid reactions. In the same patients, these reactions did not occur when ACE inhibitors were temporarily withheld, but they reappeared when the ACE inhibitors were inadvertently readministered.

Anaphylactoid Reactions During Membrane Exposure

Anaphylactoid reactions have been reported in patients dialyzed with high-flux membranes and treated concomitantly with an ACE inhibitor. Anaphylactoid reactions have also been reported in patients undergoing low-density lipoprotein apheresis with dextran sulfate absorption.

Neutropenia/Agranulocytosis

Another ACE inhibitor, captopril, has been shown to cause agranulocytosis and bone marrow depression rarely in patients with uncomplicated hypertension, but more frequently in patients with renal impairment, especially if they also have a collagen-vascular disease such as systemic lupus erythematosus or scleroderma. Available data from clinical trials of trandolapril or Tarka are insufficient to show that trandolapril does not cause agranulocytosis at similar rates. As with other ACE inhibitors, periodic monitoring of white blood cell counts in patients with collagen-vascular disease and/or renal disease should be considered.

Fetal Toxicity

Pregnancy Category D

Use of drugs that act on the renin-angiotensin system during the second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. Resulting oligohydramnios can be associated with fetal lung hypoplasia and skeletal deformations. Potential neonatal adverse effects include skull hypoplasia, anuria, hypotension, renal failure, and death. When pregnancy is detected, discontinue Tarka as soon as possible. These adverse outcomes are usually associated with use of these drugs in the second and third trimester of pregnancy. Most epidemiologic studies examining fetal abnormalities after exposure to antihypertensive use in the first trimester have not distinguished drugs affecting the renin-angiotensin system from other antihypertensive agents. Appropriate management of maternal hypertension during pregnancy is important to optimize outcomes for both mother and fetus.

In the unusual case that there is no appropriate alternative to therapy with drugs affecting the renin-angiotensin system for a particular patient, apprise the mother of the potential risk to the fetus. Perform serial ultrasound examinations to assess the intra-amniotic environment. If oligohydramnios is observed, discontinue Tarka, unless it is considered lifesaving for the mother. Fetal testing may be appropriate, based on the week of pregnancy. Patients and physicians should be aware, however, that oligohydramnios may not appear until after the fetus has sustained irreversible injury. Closely observe infants with histories of in utero exposure to Tarka for hypotension, oliguria, and hyperkalemia (see PRECAUTIONS - Pediatric Use ).

Doses of 0.8 mg/kg/day (9.4 mg/m2/day) in rabbits, 1000 mg/kg/day (7000 mg/m2/day) in rats, and 25 mg/kg/day (295 mg/m2/day) in cynomolgus monkeys did not produce teratogenic effects. These doses represent 10 and 3 times (rabbits), 1250 and 2564 times (rats), and 312 and 108 times (monkeys) the maximum projected human dose of 4 mg based on body-weight and body-surface-area, respectively assuming a 50 kg woman.

Trandolapril in doses of 0.8 mg/kg/day in rabbits, 100.0 mg/kg/day in rats, and 25 mg/kg/day in cynomolgus monkeys (10, 1250, and 312 times the maximum projected human dose, respectively, assuming a 50 kg woman) did not produce teratogenic effects.

Precautions

Use in Patients with Impaired Hepatic Function

Tarka has not been evaluated in subjects with impaired hepatic function.

Since verapamil is highly metabolized by the liver, it should be administered cautiously to patients with impaired hepatic function. Severe liver dysfunction prolongs the elimination half-life of immediate release verapamil to about 14 to 16 hours; hence, approximately 30% of the dose given to patients with normal liver function should be administered to these patients.

Careful monitoring for abnormal prolongation of the PR interval or other signs of excessive pharmacologic effects (see OVERDOSAGE ) should be carried out.

Trandolapril and trandolaprilat concentrations increase in patients with impaired liver function.

Use in Patients with Impaired Renal Function

Tarka has not been evaluated in patients with impaired renal function.

About 70% of an administered dose of verapamil is excreted as metabolites in the urine. Verapamil is not removed by hemodialysis. Until further data are available, verapamil should be administered cautiously to patients with impaired renal function. These patients should be carefully monitored for abnormal prolongation of the PR interval or other signs of overdosage (see OVERDOSAGE ).

As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function may be anticipated in susceptible individuals. In patients with severe heart failure whose renal function may depend on the activity of the renin-angiotensin-aldosterone system, treatment with ACE inhibitors, including trandolapril, may be associated with oliguria and/or progressive azotemia and rarely with acute renal failure and/or death.

In hypertensive patients with unilateral or bilateral renal artery stenosis, increases in blood urea nitrogen and serum creatinine have been observed in some patients following ACE inhibitor therapy. These increases were almost always reversible upon discontinuation of the ACE inhibitor and/or diuretic therapy. In such patients, renal function should be monitored during the first few weeks of therapy.

Some hypertensive patients with no apparent pre-existing renal vascular disease have developed increases in blood urea and serum creatinine, usually minor and transient, especially when ACE inhibitors have been given concomitantly with a diuretic. This is more likely to occur in patients with pre-existing renal impairment. Dosage reduction and/or discontinuation of any diuretic and/or the ACE inhibitor may be required.

Evaluation of hypertensive patients should always include assessment of renal function (see DOSAGE AND ADMINISTRATION ).

Use in Patients with Attenuated (Decreased) Neuromuscular Transmission

It has been reported that verapamil decreases neuromuscular transmission in patients with Duchenne's muscular dystrophy, and that verapamil prolongs recovery from the neuromuscular blocking agent vecuronium. It may be necessary to decrease the dosage of verapamil when it is administered to patients with attenuated neuromuscular transmission (see PRECAUTIONS - Surgery/Anesthesia ).

Hyperkalemia and Potassium-sparing Diuretics

In clinical trials, hyperkalemia (serum potassium > 6.00 mEq/L) occurred in approximately 0.4 percent of hypertensive patients receiving trandolapril and in 0.8% of patients receiving a dose of trandolapril (0.5-8 mg) in combination with a dose of verapamil SR (120-240 mg). In most cases, elevated serum potassium levels were isolated values, which resolved despite continued therapy. None of these patients were discontinued from the trials because of hyperkalemia. Risk factors for the development of hyperkalemia include renal insufficiency, diabetes mellitus, and the concomitant use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salt substitutes, which should be used cautiously, if at all, with trandolapril (see PRECAUTIONS - Drug Interactions ).

Cough

Presumably due to the inhibition of the degradation of endogenous bradykinin, persistent nonproductive cough has been reported with all ACE inhibitors, always resolving after discontinuation of therapy. ACE inhibitor-induced cough should be considered in the differential diagnosis of cough. In controlled trials of trandolapril, cough was present in 2% of trandolapril patients and 0% of patients given placebo. There was no evidence of a relationship to dose.

Surgery/anesthesia

In patients undergoing major surgery or during anesthesia with agents that produce hypotension, trandolapril will block angiotensin II formation secondary to compensatory renin release. If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion (see PRECAUTIONS - Use in Patients with Attenuated (Decreased) Neuromuscular Transmission ).

Drug Interactions

In vitro metabolic studies indicate that verapamil is metabolized by cytochrome P450 including CYP3A4, CYP1A2, CYP2C8, CYP2C9 and CYP2C18. Verapamil has been shown to be an inhibitor of CYP3A4 enzymes and P-glycoprotein (P-gp).

Clinically significant interactions have been reported with inhibitors of CYP3A4 (e. g. erythromycin, ritonavir) causing elevation of plasma levels of verapamil while inducers of CYP3A4 (e. g. rifampin) have caused a lowering of plasma levels of verapamil. Therefore, patients receiving inhibitors or inducers of the cytochrome P450 system should be monitored for drug interactions.

Clinical use of verapamil in digitalized patients has shown the combination to be well tolerated if digoxin doses are properly adjusted. Chronic verapamil treatment can increase serum digoxin levels by 50 to 75% during the first week of therapy, and this can result in digoxin toxicity. In patients with hepatic cirrhosis, the influence of verapamil on digoxin kinetics is magnified. Verapamil may reduce total body clearance and extrarenal clearance of digitoxin by 27% and 29%, respectively. Maintenance digoxin doses should be reduced when verapamil is administered, and the patient should be carefully monitored to avoid over - or under-digitalization. Whenever overdigitalization is suspected, the daily dose of digoxin should be reduced or temporarily discontinued. Upon discontinuation of any verapamil-containing regime including Tarka (trandolapril/verapamil hydrochloride ER), the patient should be reassessed to avoid underdigitalization. No clinically significant pharmacokinetic interaction has been found between trandolapril (or its metabolites) and digoxin.

Increased sensitivity to the effects of lithium (neurotoxicity) has been reported during concomitant verapamil-lithium therapy with either no change or an increase in serum lithium levels. Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients receiving concomitant lithium and ACE inhibitor therapy. Tarka and lithium should be coadministered with caution, and frequent monitoring of serum lithium levels is recommended. If a diuretic is also used, the risk of lithium toxicity may be increased.

Hypotension, bradyarrhythmias, and lactic acidosis have been observed in patients receiving concurrent clarithromycin.

Hypotension, bradyarrhythmias, and lactic acidosis have been observed in patients receiving concurrent erythromycin ethylsuccinate.

The interaction between cimetidine and chronically administered verapamil has not been studied. Variable results on clearance have been obtained in acute studies of healthy volunteers; clearance of verapamil was either reduced or unchanged. No clinically significant pharmacokinetic interaction has been found between trandolapril (or its metabolites) and cimetidine.

Disopyramide Phosphate

Data on possible interactions between verapamil and disopyramide phosphate are not available. Therefore, disopyramide should not be administered within 48 hours before or 24 hours after verapamil administration.

Flecainide

A study of healthy volunteers showed that the concomitant administration of flecainide and verapamil may have additive effects on myocardial contractility, AV conduction, and repolarization. Concomitant therapy with flecainide and verapamil may result in additive negative inotropic effect and prolongation of atrioventricular conduction.

Quinidine

In a small number of patients with hypertrophic cardiomyopathy (IHSS), concomitant use of verapamil and quinidine resulted in significant hypotension. Until further data are obtained, combined therapy of verapamil and quinidine in patients with hypertrophic cardiomyopathy should probably be avoided.

The electrophysiological effects of quinidine and verapamil on AV conduction were studied in 8 patients. Verapamil significantly counteracted the effects of quinidine on AV conduction. There has been a report of increased quinidine levels during verapamil therapy.

Concomitant use of Tarka with other antihypertensive agents including diuretics, vasodilators, beta-adrenergic blockers, and alpha-antagonists may result in additive hypotensive effects. There are reports that verapamil may result in higher concentrations of the alpha-agonists prazosin and terazosin.

Dual Blockade of the Renin-Angiotensin System (RAS)

Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy. Most patients receiving the combination of two RAS inhibitors do not obtain any additional benefit compared to monotherapy. In general, avoid combined use of RAS inhibitors. Closely monitor blood pressure, renal function and electrolytes in patients on Tarka and other agents that affect the RAS.

Do not co-administer aliskiren with Tarka in patients with diabetes. Avoid use of aliskiren with Tarka in patients with renal impairment (GFR <60 ml/min).

Concomitant therapy with beta-adrenergic blockers and verapamil may result in additive negative effects on heart rate, atrioventricular conduction, and/or cardiac contractility. Drug interaction studies have indicated that the maximum concentrations of metoprolol and propanolol are increased after the administration of verapamil. The use of verapamil in combination with a beta-adrenergic blocker should be used only with caution, and close monitoring.

Asymptomatic bradycardia (36 beats/min) with a wandering atrial pacemaker has been observed in a patient receiving concomitant timolol (a beta-adrenergic blocker) eyedrops and oral verapamil.

Concomitant Diuretic Therapy

As with other ACE inhibitors, patients on diuretics, especially those on recently instituted diuretic therapy, may occasionally experience an excessive reduction of blood pressure after initiation of therapy with Tarka. The possibility of exacerbation of hypotensive effects with Tarka may be minimized by either discontinuing the diuretic or cautiously increasing salt intake prior to initiation of treatment with Tarka. If it is not possible to discontinue the diuretic, the starting dose of Tarka should be reduced (see DOSAGE AND ADMINISTRATION ). No clinically significant pharmacokinetic interaction has been found between trandolapril (or its metabolites) and furosemide.

Agents Increasing Serum Potassium

Trandolapril can attenuate potassium loss caused by thiazide diuretics and increase serum potassium when used alone. Use of potassium-sparing diuretics (spironolactone, triamterene, or amiloride), potassium supplements, or potassium-containing salt substitutes concomitantly with ACE inhibitors can increase the risk of hyperkalemia. If concomitant use of such agents is indicated, they should be used with caution and with appropriate monitoring of serum potassium (see PRECAUTIONS ).

HMG-CoA Reductase Inhibitors (“Statins”)

The use of HMG-CoA reductase inhibitors that are CYP3A4 substrates in combination with verapamil has been associated with reports of myopathy/rhabdomyolysis.

Co-administration of multiple doses of 10 mg of verapamil with 80 mg simvastatin resulted in exposure to simvastatin 2.5-fold that following simvastatin alone. Limit the dose of simvastatin in patients on verapamil to 10 mg daily. Limit the daily dose of lovastatin to 40 mg. Lower starting and maintenance doses of other CYP3A4 substrates (e. g. atorvastatin) may be required as verapamil may increase the plasma concentration of these drugs.

Non-Steroidal Anti-Inflammatory Agents including Selective Cyclooxygenase-2 Inhibitors (COX-2 Inhibitors)

In patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, co-administration of NSAIDs, including selective COX-2 inhibitors, with ACE inhibitors, including trandolapril, may result in deterioration of renal function, including possible acute renal failure. These effects are usually reversible. Monitor renal function periodically in patients receiving trandolapril and NSAID therapy.

The antihypertensive effect of ACE inhibitors, including trandolapril may be attenuated by NSAIDs.

Verapamil has been given concomitantly with short - and long-acting nitrates without any undesirable drug interactions. The pharmacologic profile of both drugs and the clinical experience suggest beneficial interactions.

Verapamil may increase carbamazepine concentrations during combined therapy. This may produce carbamazepine side effects such as diplopia, headache, ataxia, or dizziness.

Therapy with rifampin may markedly reduce oral verapamil bioavailability. There have been reports that erythromycin and telithromycin may increase concentrations of verapamil.

Phenobarbital therapy may increase verapamil clearance.

Verapamil therapy may increase serum levels of cyclosporin, sirolimus and tacrolimus.

Verapamil therapy may inhibit the clearance and increase the plasma levels of theophylline.

Due to metabolism via the CYP enzyme system, there have been reports that verapamil may increase the concentrations of buspirone, midazolam, almotriptan and imipramine.

Colchicine is a substrate for both CYP3A and the efflux transporter, P-gp. Verapamil is known to inhibit CYP3A and P-gp. When verapamil and colchicine are administered together, the potential inhibition of P-gp and/or CYP3A by verapamil may lead to increased exposure to colchicine (see PRECAUTIONS - Drug Interactions ).

Concentrations of verapamil may be increased by the concomitant administration of protease inhibitors such as ritonavir, and reduced by the concomitant administration of sulfinpyrazone, or St John’s Wort.

Concentrations of doxorubicin may be increased by the administration of verapamil.

There have been reports that verapamil may elevate the concentrations of the oral anti-diabetic glyburide.

Animal experiments have shown that inhalation anesthetics depress cardiovascular activity by decreasing the inward movement of calcium ions. When used concomitantly, inhalation anesthetics and calcium antagonists, such as verapamil, should be titrated carefully to avoid excessive cardiovascular depression.

Neuromuscular Blocking Agents

Clinical data and animal studies suggest that verapamil may potentiate the activity of neuromuscular blocking agents (curare-like and depolarizing). It may be necessary to decrease the dose of verapamil and/or the dose of the neuromuscular blocking agent when the drugs are used concomitantly.

Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor therapy including Tarka.

Other (Trandolapril Component)

No clinically significant pharmacokinetic interaction has been found between trandolapril (or its metabolites) and nifedipine.

The anticoagulant effect of warfarin was not significantly changed by trandolapril.

Mammalian Target of Rapamycin (mTOR) Inhibitors

Patients taking concomitant mTOR inhibitor (e. g. temsirolimus, sirolimus, everolimus) therapy may be at increased risk for angioedema (see WARNINGS - Angioedema ).

The concomitant use of ACE inhibitors such as trandolapril with antidiabetic medications (insulin or oral hypoglycemic agents) may result in increased blood glucose lowering effects.

Carcinogenesis, Mutagenesis, Impairment of Fertility

An 18-month toxicity study in rats, at a low multiple (6 fold) of the maximum recommended human dose, and not the maximum tolerated dose, did not suggest a tumorigenic potential. There was no evidence of a carcinogenic potential of verapamil administered in the diet of rats for two years at doses of 10, 35, and 120 mg/kg per day or approximately 1x, 3.5x, and 12x, respectively, the maximum recommended human daily dose (480 mg per day or 9.6 mg/kg/day).

Verapamil was not mutagenic in the Ames test in 5 test strains at 3 mg per plate, with or without metabolic activation.

Studies in female rats at daily dietary doses up to 5.5 times (55 mg/kg/day) the maximum recommended human dose did not show impaired fertility. Effects on male fertility have not been determined.

Long-term studies were conducted with oral trandolapril administered by gavage to mice (78 weeks) and rats (104 and 106 weeks). No evidence of carcinogenic potential was seen in mice dosed up to 25 mg/kg/day (85 mg/m 2 /day) or rats dosed up to 8 mg/kg/day (60 mg/m 2 /day). These doses are 313 and 32 times (mice), and 100 and 23 times (rats) the maximum recommended human daily dose (MRHDD) of 4 mg based on body-weight and body-surface-area, respectively assuming a 50 kg individual. The genotoxic potential of trandolapril was evaluated in the microbial mutagenicity (Ames) test, the point mutation and chromosome aberration assays in Chinese hamster V79 cells, and the micronucleus test in mice. There was no evidence of mutagenic or clastogenic potential in these in vitro and in vivo assays.

Reproduction studies in rats did not show any impairment of fertility at doses up to 100 mg/kg/day (710 mg/m 2 /day) of trandolapril, or 1250 and 260 times the MRHDD on the basis of body-weight and body-surface-area, respectively.

Pregnancy

Female patients of childbearing age should be told about the consequences of exposure to Tarka during pregnancy. Discuss treatment options with women planning to become pregnant. Patients should be asked to report pregnancies to their physicians as soon as possible.

Nursing Mothers

Verapamil is excreted in human milk. Radiolabeled trandolapril or its metabolites are secreted in rat milk. Tarka should not be administered to nursing mothers.

Geriatric Use

In placebo-controlled studies, where 23% of patients receiving Tarka were 65 years and older, and 2.4% were 75 years and older, no overall differences in effectiveness or safety were observed between these patients and younger patients. However, greater sensitivity of some older individual patients cannot be ruled out.

Pediatric Use

Neonates with a history of in utero exposure to Tarka:

If oliguria or hypotension occurs, direct attention toward support of blood pressure and renal perfusion. Exchange transfusions or dialysis may be required as a means of reversing hypotension and/or substituting for disordered renal function.

The safety and effectiveness of Tarka in children below the age of 18 have not been established.

Animal Pharmacology and/or Animal Toxicology

In chronic animal toxicology studies, verapamil caused lenticular and/or suture line changes at 30 mg/kg/day or greater and frank cataracts at 62.5 mg/kg/day or greater in the beagle dog but not the rat. Development of cataracts due to verapamil has not been reported in man.

Adverse Reactions

Tarka has been evaluated in over 1,957 subjects and patients. Of these, 541 patients, including 23% elderly patients, participated in U. S. controlled clinical trials, and 251 were studied in foreign controlled clinical trials. In clinical trials with Tarka, no adverse experiences peculiar to this combination drug have been observed. Adverse experiences that have occurred have been limited to those that have been previously reported with verapamil or trandolapril. Tarka has been evaluated for long-term safety in 272 patients treated for 1 year or more. Adverse experiences were usually mild and transient.

Discontinuation of therapy because of adverse events in U. S. placebo-controlled hypertension studies was required in 2.6% and 1.9% of patients treated with Tarka and placebo, respectively.

Adverse experiences occurring in 1% or more of the 541 patients in placebo-controlled hypertension trials who were treated with a range of trandolapril (0.5-8 mg) and verapamil (120-240 mg) combinations are shown below.

ADVERSE EVENTS OCCURRING in ≥ 1% of Tarka PATIENTS IN U. S. PLACEBO-CONTROLLED TRIALS

Tarka (N = 541) % Incidence (% Discontinuance)

PLACEBO (N = 206) % Incidence (% Discontinuance)

* Also includes increase in SGPT, SGOT, Alkaline Phosphatase + Incidence of adverse events is higher in Placebo group than Tarka patients

Other clinical adverse experiences possibly, probably, or definitely related to drug treatment occurring in 0.3% or more of patients treated with trandolapril/verapamil combinations with or without concomitant diuretic in controlled or uncontrolled trials (N = 990) and less frequent, clinically significant events (in italics) include the following:

Cardiovascular

Angina, AV block second degree, bundle branch block, edema, flushing, hypotension, myocardial infarction. palpitations, premature ventricular contractions, nonspecific ST-T changes, near syncope, tachycardia.

Central Nervous System

Drowsiness, hypesthesia, insomnia, loss of balance, paresthesia, vertigo.

Dermatologic

Emotional, Mental, Sexual States

Anxiety, impotence, abnormal mentation.

Eye, Ear, Nose, Throat

Epistaxis, tinnitus, upper respiratory tract infection, blurred vision.

Gastrointestinal

Diarrhea, dyspepsia, dry mouth, nausea.

General Body Function

Chest pain, malaise, weakness.

Genitourinary

Endometriosis, hematuria, nocturia, polyuria, proteinuria.

Hemopoietic

Decreased leukocytes, decreased neutrophils.

Musculoskeletal System

Arthralgias/myalgias, gout (increased uric acid).

Pulmonary

Angioedema

Angioedema has been reported in 3 (0.15%) patients receiving Tarka in U. S. and foreign studies (N = 1,957). Angioedema associated with laryngeal edema may be fatal. If angioedema of the face, extremities, lips, tongue, glottis, and/or larynx occurs, treatment with Tarka should be discontinued and appropriate therapy instituted immediately (see WARNINGS ).

Hypotension

(See WARNINGS ). In hypertensive patients, hypotension occurred in 0.6% and near syncope occurred in 0.1%. Hypotension or syncope was a cause for discontinuation of therapy in 0.4% of hypertensive patients.

Treatment of Acute Cardiovascular Adverse Reactions

The frequency of cardiovascular adverse reactions which require therapy is rare, hence, experience with their treatment is limited. Whenever severe hypotension or complete AV block occur following oral administration of Tarka (verapamil component), the appropriate emergency measures should be applied immediately, e. g. intravenously administered isoproterenol HCl, levarterenol bitartrate, atropine (all in the usual doses), or calcium gluconate (10% solution). In patients with hypertrophic cardiomyopathy (IHSS), alpha-adrenergic agents (phenylephrine, metaraminol bitartrate or methoxamine) should be used to maintain blood pressure, and isoproterenol and levarterenol should be avoided. If further support is necessary, inotropic agents (dopamine or dobutamine) may be administered. Actual treatment and dosage should depend on the severity and the clinical situation and the judgment and experience of the treating physician.

Other

Other adverse experiences (in addition to those in table and listed above) that have been reported with the individual components are listed below.

(See WARNINGS ). CHF/pulmonary edema, AV block 3°, atrioventricular dissociation, claudication, purpura (vasculitis), syncope.

Gingival hyperplasia. Reversible, (upon discontinuation of verapamil) nonobstructive, paralytic ileus has been infrequently reported in association with the use of verapamil.

Hemic and Lymphatic

Ecchymosis or bruising.

Cerebrovascular accident, confusion, psychotic symptoms, shakiness, somnolence.

Exanthema, hair loss, hyperkeratosis, maculae, sweating, urticaria, Stevens-Johnson syndrome, erythema multiform.

Gynecomastia, galactorrhea/hyperprolactinemia, increased urination, spotty menstruation.

Emotional, Mental, Sexual States

Clinical Laboratory Test Findings

(See WARNINGS ). Low white blood cells, low neutrophils, low lymphocytes, low platelets.

Hyperkalemia (see PRECAUTIONS ), hyponatremia.

Renal Function Tests

Increases in creatinine and blood urea nitrogen levels occurred in 1.1 percent and 0.3 percent, respectively, of patients receiving Tarka with or without hydrochlorothiazide therapy. None of these increases required discontinuation of treatment. Increases in these laboratory values are more likely to occur in patients with renal insufficiency or those pretreated with a diuretic and, based on experience with other ACE inhibitors, would be expected to be especially likely in patients with renal artery stenosis (see PRECAUTIONS and WARNINGS ).

Liver Function Tests

Elevations of liver enzymes (SGOT, SGPT, LDH, and alkaline phosphatase) and/or serum bilirubin occurred. Discontinuation for elevated liver enzymes occurred in 0.9 percent of patients (see WARNINGS ).

Post Marketing Experience

There has been a single postmarketing report of paralysis (tetraparesis) associated with the combined use of verapamil and colchicine. This may have been caused by colchicine crossing the blood-brain barrier due to CYP3A4 and P-gp inhibition by verapamil. Combined use of verapamil and colchicine is not recommended (see PRECAUTIONS - Drug Interactions ).

Overdosage

No specific information is available on the treatment of overdosage with Tarka.

Verapamil Component

Overdose with verapamil may lead to pronounced hypotension, bradycardia, and conduction system abnormalities (e. g. junctional rhythm with AV dissociation and high degree AV block, including asystole). Other symptoms secondary to hypoperfusion (e. g. metabolic acidosis, hyperglycemia, hyperkalemia, renal dysfunction, and convulsions) may be evident.

Treat all verapamil overdoses as serious and maintain observation for at least 48 hours, preferably under continuous hospital care. Delayed pharmacodynamic consequences may occur with the sustained release formulation. Verapamil is known to decrease gastrointestinal transit time. In cases of overdose, tablets of ISOPTIN SR have occasionally been reported to form concretions within the stomach or intestines. These concretions have not been visible on plain radiographs of the abdomen, and no medical means of gastrointestinal emptying is of proven efficacy in removing them. Endoscopy might reasonably be considered in cases of overdose when symptoms are unusually prolonged. Verapamil cannot be removed by hemodialysis.

Treatment of overdosage should be supportive. Beta adrenergic stimulation or parenteral administration of calcium solutions may increase calcium ion flux across the slow channel, and have been used effectively in treatment of deliberate overdosage with verapamil. The following measures may be considered:

Bradycardia and Conduction System Abnormalities

Atropine, isoproterenol, and cardiac pacing.

Intravenous fluids, vasopressors (e. g. dopamine, dobutamine), calcium solutions (e. g. 10% calcium chloride solution).

Inotropic agents (e. g. isoproterenol, dopamine, dobutamine), diuretics. Asystole should be handled by the usual measures including cardiopulmonary resuscitation.

Trandolapril Component

The oral LD 50 of trandolapril in mice was 4875 mg/kg in males and 3990 mg/kg in females. In rats, an oral dose of 5000 mg/kg caused low mortality (1 male out of 5; 0 females). In dogs, an oral dose of 1000 mg/kg did not cause mortality and abnormal clinical signs were not observed.

In humans, the most likely clinical manifestation would be symptoms attributable to severe hypotension. Laboratory determinations of serum levels of trandolapril and its metabolites are not widely available, and such determinations have, in any event, no established role in the management of trandolapril overdose. No data are available to suggest that physiological maneuvers (e. g. maneuvers to change pH of the urine) might accelerate elimination of trandolapril and its metabolites. It is not known if trandolapril or trandolaprilat can be usefully removed from the body by hemodialysis.

Angiotensin II could presumably serve as a specific antagonist antidote in the setting of trandolapril overdose, but angiotensin II is essentially unavailable outside of scattered research facilities. Because the hypotensive effect of trandolapril is achieved through vasodilation and effective hypovolemia, it is reasonable to treat trandolapril overdose by infusion of normal saline solution.

Tarka Dosage and Administration

The recommended usual dosage range of trandolapril for hypertension is 1 to 4 mg per day administered in a single dose or two divided doses. The recommended usual dosage range of Isoptin-SR for hypertension is 120 to 480 mg per day administered in a single dose or two divided doses.

The hazards (see WARNINGS ) of trandolapril are generally independent of dose; those of verapamil are a mixture of dose-dependent phenomena (primarily dizziness, AV block, constipation) and dose-independent phenomena, the former much more common than the latter. Therapy with any combination of trandolapril and verapamil will thus be associated with both sets of dose-independent hazards. The dose-dependent side effects of verapamil have not been shown to be decreased by the addition of trandolapril nor vice versa.

Rarely, the dose-independent hazards of trandolapril are serious. To minimize dose-independent hazards, it is usually appropriate to begin therapy with Tarka only after a patient has either (a) failed to achieve the desired antihypertensive effect with one or the other monotherapy at its respective maximally recommended dose and shortest dosing interval, or (b) the dose of one or the other monotherapy cannot be increased further because of dose-limiting side effects.

Clinical trials with Tarka have explored only once-a-day doses. The antihypertensive effect and or adverse effects of adding 4 mg of trandolapril once-a-day to a dose of 240 mg Isoptin-SR administered twice-a-day has not been studied, nor have the effects of adding as little of 180 mg Isoptin-SR to 2 mg trandolapril administered twice-a-day been evaluated. Over the dose range of Isoptin-SR 120 to 240 mg once-a-day and trandolapril 0.5 to 8 mg once-a-day, the effects of the combination increase with increasing doses of either component.

Replacement Therapy

For convenience, patients receiving trandolapril (up to 8 mg) and verapamil (up to 240 mg) in separate tablets, administered once-a-day, may instead wish to receive tablets of Tarka containing the same component doses.

Tarka should be administered with food.

How is Tarka Supplied

Tarka 2/180 mg tablets are supplied as pink, oval, film-coated tablets containing 2 mg trandolapril in an immediate release form and 180 mg verapamil hydrochloride in a sustained release form. The tablet is debossed with a triangle and 182 on one side and plain on the other side.

NDC 0074-3287-13 - bottles of 100

Tarka 1/240 mg tablets are supplied as white, oval, film-coated tablets containing 1 mg trandolapril in an immediate release form and 240 mg verapamil hydrochloride in a sustained release form. The tablet is debossed with a triangle and 241 on one side and plain on the other side.

NDC 0074-3288-13 - bottles of 100

Tarka 2/240 mg tablets are supplied as gold, oval, film-coated tablets containing 2 mg trandolapril in an immediate release form and 240 mg verapamil hydrochloride in a sustained release form. The tablet is debossed with a triangle and 242 on one side and plain on the other side.

NDC 0074-3289-13 - bottles of 100

Tarka 4/240 mg tablets are supplied as reddish-brown, oval, film-coated tablets containing 4 mg trandolapril in an immediate release form and 240 mg verapamil hydrochloride in a sustained release form. The tablet is debossed with a triangle and 244 on one side and plain on the other side.

NDC 0074-3290-13 - bottles of 100

Dispense in well-closed container with safety closure.

Storage

Store at 15°-25°C (59°-77°F) see USP.

North Chicago, IL 60064, U. S.A.

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A: Brexivel is a perfect remedy in struggle against pain or inflammation caused by arthritis.

Q: What are Brexivel side effects?

A: Brexivel has its common side effects such as: mild heartburn, stomach pain, diarrhea, costiveness, gas, migraine, nervousness, blurred vision, ringing in your ears, bloating, dyspepsia, lightheadedness. But in case of rejection of Brexivel components you can experience more serious side effects: weakness, shortness of breath, slurred speech, problems with vision or balance, black, bloody, coughing up blood or vomit that looks like coffee grounds, rapid weight gain, problems with urination, nausea, stomach pain, decreased appetite, dark urine, clay-colored stools, yellowing of the skin or eyes, high temperature, migraine, bruising, severe tingling, numbness, pain, muscle weakness, neck stiffness, chills, increased sensitivity to light, convulsions, chest pain, low fever, symptoms of allergy (difficulties with breathing, swelling, skin rash or hives), tarry stools, sore throat. Possibility of side effects appearing depends on health status and, of course, on your right following Brexivel prescriptions.

Q: What are generic and brand names of Brexivel?

A: Generic name of Brexivel is Piroxicam. Brand name of Brexivel is Brexivel.

Q: Is it possible to drink alcohol?

A: No, it is forbidden to drink alcohol.

Q: In what way does Brexivel operate?

A: Brexivel effectiveness is in reducing hormones that cause inflammation and pain in the body. It is nonsteroidal anti-inflammatory drug (NSAIDs).

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Vioridon, Vioridon

Baclofen

Click for further information on drug naming conventions and International Nonproprietary Names .

Important Notice: The Drugs. com international database is in BETA release. This means it is still under development and may contain inaccuracies. It is not intended as a substitute for the expertise and judgement of your physician, pharmacist or other healthcare professional. It should not be construed to indicate that the use of any medication in any country is safe, appropriate or effective for you. Consult with your healthcare professional before taking any medication.

Acyclovir Medlineplus Drug Information, Aciclovin

Acyclovir

Acyclovir is used to decrease pain and speed the healing of sores or blisters in people who have varicella (chickenpox)), herpes zoster (shingles; a rash that can occur in people who have had chickenpox in the past), and first-time or repeat outbreaks of genital herpes (a herpes virus infection that causes sores to form around the genitals and rectum from time to time). Acyclovir is also sometimes used to prevent outbreaks of genital herpes in people who are infected with the virus. Acyclovir is in a class of antiviral medications called synthetic nucleoside analogues. It works by stopping the spread of the herpes virus in the body. Acyclovir will not cure genital herpes and may not stop the spread of genital herpes to other people.

How should this medicine be used?

Acyclovir comes as a tablet, a capsule, and a suspension (liquid) to take by mouth. It is usually taken with or without food two to five times a day for 5 to 10 days, starting as soon as possible after your symptoms begin. When acyclovir is used to prevent outbreaks of genital herpes, it is usually taken two to five times a day for up to 12 months. Take acyclovir at around the same times every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take acyclovir exactly as directed. Do not take more or less of it or take it more often or for a longer time than prescribed by your doctor.

Shake the liquid well before each use to mix the medication evenly.

Your symptoms should improve during your treatment with acyclovir. Call your doctor if your symptoms do not improve or if they get worse.

Take acyclovir until you finish the prescription, even if you feel better. If you stop taking acyclovir too soon or skip doses, your infection may not be completely treated or may become more difficult to treat.

Other uses for this medicine

Acyclovir is also sometimes used to treat eczema herpeticum (a skin infection caused by the herpes virus) to treat and prevent herpes infections of the skin, eyes, nose, and mouth in patients with human immunodeficiency virus (HIV), and to treat oral hairy leukoplakia (condition that causes hairy white or gray-colored patches on the tongue or inside of the cheek).

This medication may be prescribed for other uses; ask your doctor or pharmacist for more information.

What special precautions should I follow?

Before taking acyclovir,

tell your doctor and pharmacist if you are allergic to acyclovir, valacyclovir (Valtrex), any other medications, or any of the ingredients in acyclovir. Ask your pharmacist for a list of the ingredients.

tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention any of the following: amphotericin B (Fungizone); aminoglycoside antibiotics such as amikacin (Amikin), gentamicin (Garamycin), kanamycin (Kantrex), neomycin (Nes-RX, Neo-Fradin), paramomycin (Humatin), streptomycin, and tobramycin (Tobi, Nebcin); aspirin and other nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn); cyclosporine (Neoral, Sandimmune); medications to treat HIV or AIDS such as zidovudine (Retrovir, AZT); pentamidine (NebuPent); probenecid (Benemid); sulfonamides such as sulfamethoxazole and trimethoprim (Bactrim); tacrolimus (Prograf); and vancomycin. Many other medications may also interact with acyclovir, so be sure to tell your doctor about all the medications you are taking, even those that do not appear on this list. Your doctor may need to change the doses of your medications or monitor you carefully for side effects.

tell your doctor if there is a possibility you may be dehydrated from a recent illness or activity, or if you have or have ever had problems with your immune system; human immunodeficiency virus infection (HIV); acquired immunodeficiency syndrome (AIDS); or kidney disease.

tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking acyclovir, call your doctor.

if you are taking acyclovir to treat genital herpes, you should know that genital herpes can be spread through sexual contact even if you don't have blisters or other symptoms and possibly even if you are taking acyclovir. Talk to your doctor about ways to stop the spread of genital herpes and about whether your partner(s) should receive treatment.

What special dietary instructions should I follow?

Drink plenty of fluids while you are taking acyclovir.

What should I do if I forget a dose?

Take the missed dose as soon as you remember it and take any remaining doses for that day at evenly spaced intervals. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.

What side effects can this medication cause?

Acyclovir may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

upset stomach

vomiting

diarrhea

dizziness

tiredness

agitation

pain, especially in the joints

hair loss

changes in vision

Some side effects can be serious. If you experience any of the following symptoms, call your doctor immediately:

hives

rash or blisters

itching

difficulty breathing or swallowing

swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs

hoarseness

fast heartbeat

weakness

pale skin

difficulty sleeping

fever, sore throat, chills, cough, and other signs of infection

unusual bruising or bleeding

blood in the urine

stomach pain or cramps

bloody diarrhea

decreased urination

headache

hallucinations (seeing things or hearing voices that do not exist)

confusion

aggressive behavior

difficulty speaking

numbness, burning, or tingling in the arms or legs

temporary inability to move parts of your body

shaking of a part of your body that you cannot control

seizures

loss of consciousness

Acyclovir may cause other side effects. Call your doctor if you have any unusual problems while you are taking this medication.

If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online (http://www. fda. gov/Safety/MedWatch ) or by phone (1-800-332-1088).

What should I know about storage and disposal of this medication?

Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication.

In case of emergency/overdose

In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911.

Symptoms of overdose may include:

agitation

seizures

extreme tiredness

loss of consciousness

swelling of the hands, feet, ankles, or lower legs

decreased urination

What other information should I know?

Keep all appointments with your doctor and the laboratory. Your doctor may order certain lab tests to check your response to acyclovir.

Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription.

It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.

Brand names

Salofalk Gastro-Resistant Prolonged-Release Granules - Patient Information Leaflet (Pil), Colitofalk

Salofalk 1.5g gastro-resistant prolonged-release granules

The Patient Information Leaflet (PIL) is the leaflet included in the pack with a medicine. It is written for patients and gives information about taking or using a medicine. It is possible that the leaflet in your medicine pack may differ from this version because it may have been updated since your medicine was packaged.

Please click on the link to the left to view the PIL in PDF format.

Text only version for the visually impaired Below is a text only representation of the Patient Information leaflet. The original may contain images or tables and can be viewed in PDF format using the link to the left. This PIL may be available from the RNIB in large print, Braille or audio CD. For further information please call the RNIB Medicine Leaflet line on 0800 198 5000. The product code(s) for this leaflet is/are: PL 08637/0016.

Salofalk 1.5g gastro-resistant prolonged-release granules

Package leaflet: Information for the user

Salofalk 1.5g gastro-resistant prolonged-release granules

Read all of this leaflet carefully before you start taking this medicine because it contains important information for you.

Keep this leaflet. You may need to read it again.

If you have any further questions, ask your doctor or pharmacist.

This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.

What is in this leaflet:

1. What Salofalk 1.5g granules are and what they are used for 2. What you need to know before you take Salofalk 1.5g granules 3. How to take Salofalk 1.5g granules 4. Possible side effects 5. How to store Salofalk 1.5g granules 6. Contents of the pack and other information

1. What Salofalk 1.5g granules are and what they are used for

Salofalk granules contain the active substance mesalazine, an anti-inflammatory agent used to treat inflammatory bowel disease.

Salofalk 1.5g granules are used for:

the treatment of acute episodes and prevention of further episodes (recurrence) of an inflammatory disease of the large intestine (colon), known by doctors as ulcerative colitis.

2. What you need to know before you take Salofalk 1.5g granules

Do not take Salofalk granules

If you are allergic to mesalazine, salicylic acid, to salicylates such as Aspirin or to any of the other ingredients of this medicine (listed in section 6)

If you have a serious liver or kidney disease

Warnings and precautions

Talk to your doctor before taking Salofalk 1.5g granules

If you have a history of problems with your lungs, particularly if you suffer from bronchial asthma

If you have a history of allergy to sulphasalazine . a substance related to mesalazine

If you suffer with problems of your liver

If you suffer with problems of your kidney

During treatment your doctor may want to keep you under close medical supervision, and you may need to have regular blood and urine tests.

Other medicines and Salofalk granules

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines. In particular

Azathioprine, 6-mercaptopurine or thioguanine (medicines used to treat immune disorders)

Certain agents that inhibit blood clotting (medicines for thrombosis or to thin your blood, e. g. warfarin)

Lactulose (medicine used to treat constipation) or other preparations that can change the acidity of your stools

Please tell your doctor or pharmacist, if you are taking or have recently taken any other medicines, including medicines obtained without a prescription. It may still be all right for you to use Salofalk granules and your doctor will be able to decide, what is suitable for you.

Pregnancy and breastfeeding

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine.

You should only use Salofalk granules during pregnancy if your doctor tells you to.

You should also only use Salofalk granules during breastfeeding if your doctor tells you to, as this medicine may pass into breast milk.

Driving and using machines

Salofalk granules have no or negligible influence on the ability to drive or use machines.

Salofalk 1.5g granules contain aspartame and sucrose

This medicine contains the sweetening agent aspartame. Aspartame is a source of phenylalanine and may be harmful if you suffer from phenylketonuria . One sachet of Salofalk 1.5g granules contains the equivalent of 1.68 mg phenylalanine.

One sachet contains 0.06 mg sucrose. If you have been told by your doctor that you have an intolerance to some sugars, contact your doctor before taking this medicinal product.

3. How to take Salofalk 1.5g granules

Always take Salofalk granules exactly as your doctor has told you. Check with your doctor or pharmacist if you are not sure.

Method of administration

Salofalk granules are for oral use only.

Salofalk granules should not be chewed . You should take the Salofalk granules by placing the granules directly on the tongue and then swallowing them with plenty of liquid without chewing.

Adults and the elderly

Unless otherwise prescribed by your doctor, the normal dosage for the treatment of acute episodes of ulcerative colitis is:

1-2 sachets of Salofalk 1.5g granules once daily preferably in the morning (equivalent to 1.5-3g mesalazine per day) depending on the clinical requirements in the individual case.

To prevent a relapse of ulcerative colitis

The normal dosage to prevent further episodes of ulcerative colitis is:

1 sachet of Salofalk 500mg granules three times daily (equivalent to 1.5g mesalazine per day).

If upon the decision of your doctor you are at increased risk for recurrence, the dosage for prevention of further episodes of ulcerative colitis is:

2 sachets of Salofalk 1.5g granules once daily preferably in the morning (equivalent to 3g mesalazine per day).

Use in children

There is only limited documentation for an effect in children (age 6-18 years).

Children 6 years of age and older

Please ask your doctor about the precise dosage of Salofalk granules for your child.

In acute episodes: to be determined individually, starting with 30-50 mg mesalazine per kg body weight per day that should be given once daily preferably in the morning or in divided doses. The maximum dose is 75 mg mesalazine per kg body weight per day. The total dose should not exceed the maximum adult dose.

It is generally recommended that half the adult dose should be given to children up to a body weight of 40 kg; and the normal adult dose to those above 40 kg.

Due to their high content in active substance, Salofalk 1.5g granules are not suitable for children weighing less than 40 kg. Please use Salofalk 500mg granules or 1000mg instead.

Duration of treatment

Your doctor will decide how long you need to continue the treatment with this medicine. This will depend on your condition. To obtain the maximum benefit from this medicine, you should use Salofalk granules regularly and consistently both during the acute episode of inflammation and also as long-term treatment, as directed.

If you think your Salofalk granules are too strong or too weak, talk to your doctor.

If you take more Salofalk granules than you should

Contact a doctor if you are in doubt, so he or she can decide what to do.

If you use too much Salofalk granules on one occasion, just take your next dose as prescribed.

Do not use a smaller amount.

If you forget to take Salofalk granules

Do not take a double dose to make up for a forgotten dose.

If you stop taking Salofalk granules

Do not stop taking this product until you have talked to your doctor.

If you have any further questions on the use of this product, ask your doctor or pharmacist.

4. Possible side effects

Like all medicines, Salofalk granules can cause side effects, although not everybody gets them.

All medicines can cause allergic reactions although serious allergic reactions are very rare. If you get any of the following symptoms after taking this medicine, you should contact your doctor immediately:

If you experience a marked reduction of your general health, especially if accompanied by fever, and/or a sore throat and mouth, stop using these granules and contact your doctor immediately. These symptoms can, very rarely, be due to a fall in the number of white cells in your blood (a condition called agranulocytosis), which may make you more prone to developing a serious infection.

A blood test can confirm whether your symptoms are due to an effect of this medicine on your blood.

The following side effects have also been reported by patients using mesalazine:

Rare side effects (may affect up to 1 in 1,000 patients):

Abdominal pain, diarrhoea, wind (flatulence), nausea and vomiting

Headache, dizziness

Chest pain, breathlessness or swollen limbs because of an effect on your heart

Very rare side effects (may affect up to 1 in 10,000 patients):

Changes in kidney function, sometimes with swollen limbs or flank pain

Severe abdominal pain because of acute inflammation of the pancreas

Fever, sore throat or malaise because of blood count changes

Shortness of breath, cough, wheezing, lung shadow on x-ray due to allergic and/or inflammatory lung conditions

Severe diarrhoea and abdominal pain because of an allergic reaction to this medicine within the bowel

Skin rash or inflammation

Muscle and joint pain

Jaundice or abdominal pain because of liver and bile flow disorders

Hair loss and the development of baldness

Numbness and tingling in the hands and feet (peripheral neuropathy)

Reversible decrease in semen production

Reporting of side effects

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly as follows:

Republic of Ireland:

HPRA Pharmacovigilance Earlsfort Terrace IRL - Dublin 2

Tel:+353 1 6764971

Fax:+353 1 6762517

Dr. Falk Pharma UK Ltd

Forced Nudity Story Archive Entry Page, Nudep

Forced Nudity Story Archive For Adults Only!

The fictional stories in this archive are intended for the entertainment of adults only. They depict forced nudity, spanking, embarrassment, humiliation, and often, the non-consensual sexual and other physical abuse of preteen and young teen children, mostly boys, but including girls. Some stories may be very intense and may tend toward the extreme. All material on this site is legal in the country from where it's p osted and hosted T he behaviors depicted in these stories, but not the stories themselves, are likely in real life to be illegal. The stories describe activities that may be considered by society to be abusive, harmful, unacceptable or undesirable. The various authors of these stories neither advocate, condone nor engage in any such real life illegal behavior. These stories, as is all fiction, are fantasy and not reality. The authors do recognize the difference between the two. This site contains copyrighted text stories only, there are no videos, photographs, drawings, or other visual images of any kind available on this site.

I've read the above statements, am of legal age to view and read this material, don't object to the subject matter, have permission from my spouse, boss, girlfriend, boyfriend, next door neighbor, or whoever else has supervisory responsibility for me, and want it now! enter

This site copyright ? 2000-2011, all rights reserved. Distribution of the stories contained on this site is subject to the copyright restrictions contained in each individual story. Some material on this site, including but not limited to stories, graphics and site design elements may be the work of authors other than Cassie. All such material is used with the permission of the author, who retains copyright.

Ryzen Homes, Sanford Maine Modular Homes Builder, Panelized Homes, Timber Frame, Ryzen

About Ryzen Homes

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Karin Kurosaki - Bleach Wiki, Karin

Karin Kurosaki

Contents

Appearance

Karin has dark grey eyes and black hair that is straight and cropped to hang around her face, just above her shoulders. More often than not, she wears sportswear, with alternative shirts and trainers, giving her a tomboy appearance. Her eyes are large and dark and she sometimes wears a red cap upon her head and often carries a soccer ball.

Seventeen months later, Karin wears her hair in a short ponytail. She typically wears her school uniform, a blue and white sailor fuku. [6]

Personality

Karin often assaults her father when he acts like an idiot.

Compared to her soft-spoken twin sister, Yuzu, Karin is a more authoritative and out-spoken person. Karin's tough exterior results from her mother's death; because she could not be useful around the house like Yuzu, she resolved never to cry so that she would not burden her family with her personal troubles. [7] As a result, Karin is the more hardened and least emotional between the two, resulting in her not being affected by most events that would more or less bring tears to Yuzu's eyes. Despite these obvious differences, both girls remain close. She is concerned for her brother when Ichigo appears stressed or when he disappears for long periods of time. During these times, despite her own worries, Karin will reassure her sister, being there for her. [8]

Karin is a sensible person but is not above kicking her father in the head when she thinks he's acting unreasonable. Despite this, Karin is still helpful around the clinic, as she and Yuzu help out their father as nurses when they can. [9] Despite being able to see them as clearly as Ichigo can, Karin initially claims that she believes spirits do not exist, which she says is the same as them not actually existing. In spite of her attitude about spirits, Karin is willing to use her's and Ichigo's ability to see them to earn a little cash. [10]

History

Karin as a baby with her family.

When Ichigo was four, Karin, along with her fraternal twin sister Yuzu. was born to Isshin and Masaki Kurosaki. When she was young, Karin cried a lot, much like her sister. [4] When she was five years old, Masaki died, leaving all three of her children motherless. [11] Both of her daughters decided then that they had to mature much faster than usual, with Yuzu deciding to take over the housework and looking after the family. However, Karin felt useless compared to her sister and decided that her way of contributing would be to never cause her family to worry about her and therefore stopped crying all together even when she was injured or upset. Karin thus went for many years without shedding a tear. [4]

Plot

Agent of the Shinigami arc

Karin caught by Fishbone D.

When Ichigo arrives home and argues with Isshin, Karin comments to Yuzu that she should just leave their father and brother to their squabbling while requesting more food at the table and making fun of Ichigo's powers to see ghosts. She claims she does not care nor believe in ghosts despite being able to see them, much to the dismay of the Plus present in the room at that time. Isshin complains about how Ichigo never tells him about his problems, prompting Karin to tell him it's because he has no communication skills. This prompts Isshin to ask a poster on the wall of Masaki what he should do, as all of his children seem to be rather cold towards him, to which Karin responds by telling him that he should start by taking the poster down. [12]

Karin struggles up the stairs to warn Ichigo about Fishbone D. a Hollow who has attacked the house, injured Isshin and captured Yuzu. She tells Ichigo to get away quickly before falling unconscious. [13] She, along with the rest of her family, except Ichigo, have their memories wiped of these events. Instead, they believe that a truck hit their house that night while they were all asleep. Karin acts rather annoyed that they "let the criminal get away." [14]

Several days later, the Kurosaki Clinic is busy following a car crash. Karin helps transport some patients around. [15] However, when Yasutora Sado is carried into the clinic, she notices the parakeet he was carrying, which had the soul of a young boy inside it. The parakeet unintentionally begins to transmit its memories into Karin. [16] Next morning, Yuzu tells Ichigo that Karin isn't feeling well and can't come to breakfast, to which Ichigo comments that it's rather rare for her to feel unwell. [17] The memories transmitted turn out to be the cause of Karin's sudden pains, and she ends up vomiting in the middle of the school day. Finally unable to take it, she tells Yuzu that she'll be leaving early. [18]

Karin unusually upset and in pain over Yuichi Shibata .

Instead of going home though, Karin goes to Ichigo, and ends up collapsing right in front of him, prompting Rukia to order him to bring her home while she chases after Chad, as Ichigo would have to focus on protecting her more. As Ichigo takes her home, she wearily tells him about the strongest transmitted memory: Yuichi Shibata. the boy inside the parakeet, saw his mother being murdered right in front of him. Weeping, Karin begs Ichigo to save Yuichi and send him to "the other side" to reunite him with his mother. [19] Ichigo says that it was the first time he had seen her cry since their mother had died, and vows to stop her from crying any more. [7] She is promptly put to bed in order to rest while Ichigo deals with the Hollow who is attacking Rukia. When Yuichi is finally sent to Soul Society. Karin thanks Ichigo in her sleep. [20] The next day, Yuzu sees what appears to be Ichigo jumping on the school wall and calls out to him. At first, Karin dismisses the idea, but then sees Kon in Ichigo's body jumping to a seemingly impossible height, and is shocked. Stopping Yuzu from calling out to him, Karin tells her sister it can't be him and that they shouldn't say anything about it. As another student appears, having seen Ichigo, Karin makes the girl deny that she saw what happened. [21] Later on, Karin overhears some boys who claim Ichigo broke their video game. Believing he wouldn't do such a thing, Karin dismisses the idea that he was there and states it had to be someone else. [22]

Karin suppressed by an invisible Grand Fisher .

The entire Kurosaki family prepares for their yearly tradition of visiting their mother's grave on June 17th. [23] Karin is annoyed when Isshin declares he has complete control over who gets what job during the trip, but gets happier when she is declared Staff Director. On the way to the grave, Karin runs ahead of Yuzu while saying the hill they're climbing isn't too hard to climb, to which Isshin begins to try to encourage Yuzu, but Karin eventually kicks Isshin down to the bottom of the hill when his "encouragement" begins to really annoy her. [24] When she sees Rukia Kuchiki waving at Ichigo and watching her brother get flustered by her sudden appearance, she assumes that there is something going on between them, saying that he's at that age, and tells Yuzu to leave them alone. [25]

At the grave, Karin talks with her mother in her mind, telling her that the whole family is doing alright, although in Isshin's case she's disgusted at this fact. [26] Next, she chides Yuzu for crying by their mother's grave, telling her to stop crying so much every year. [27] They hear Isshin blowing the whistle for them to return; however, Karin then notices a ghost of a girl standing on the cliff, and goes over to her to talk to her, but suddenly the girl turns and comments that a girl like her who can see and hear her will be very tasty. [28] Karin is able to see the true form of Grand Fisher and is horrified by it, but she is unable to defend herself and is struck down by the Hollow. She tries to stop Yuzu from approaching, but both end up captured by Grand Fisher. The Hollow begins to eat Yuzu, but Ichigo attacks Grand Fisher, freeing them. [29] The two are left by Ichigo safely out of the way of the battle. [30] Shortly afterward, Karin and Yuzu are brought home by Kon in Ichigo's body, who tells her he found them asleep, and tells her to rest. Karin recalls what happened with Grand Fisher and Ichigo saving her, though, and wonders what part of that was a dream. [31]

Karin is not impressed at all by "Ghost Bust," Don Kanonji's show, noting that Yuzu and Isshin are fascinated by it because Yuzu can't see ghosts, whereas she and Ichigo can see them, and so they don't find the show very interesting. Ichigo realizes that this was the reason she was the first to see the Hollow, and wonders if she can see Shinigami as well. [32] The entire Kurosaki family attends the live broadcast of "Ghost Bust" in Karakura Town. [33] Along with Ichigo, Rukia and Chad, Karin hears the spirit bound to the abandoned hospital where the show is being filmed, and is frightened by it to the point where she mutters that she shouldn't have come, although she denies having said anything when asked by Isshin. As she continues to hear the screams, she feels sick and wonders where Ichigo went. [34] When Kanonji attempts to "free" the spirit, the screams frighten Karin, and she doubles over in shock and fear. [35] Shortly afterward, Ichigo begins to battle the spirit-turned Hollow, and Karin spots him doing this, almost unable to believe her eyes. [36] Ichigo jumps into the hospital by breaking a window, and Isshin makes sure Karin and Yuzu weren't hurt by the glass. Yuzu asks Karin if they should look for Ichigo, but Karin is still confused over what she saw. [37]

Yuzu's scream of excitement when Don Kanonji appears at the Kurosaki clinic catches Karin's attention, and she looks out the window to see what's the matter, but instead sees Ichigo and Rukia running to find another Hollow. [38] Several days later, when Uryu Ishida scatters Hollow Bait across Karakura Town in a challenge with Ichigo, Karin is one of the people who notices the strange change in atmosphere which precedes the appearance of a massive wave of Hollows. [39] Her friends notice the sudden drop in Karin's performance in soccer, and Karin decides to leave because she finds herself unable to concentrate. However, at that moment, Chad appears in the lot she was playing in, and a Hollow follows him in. [40] Chad gets Karin out of the way of the Hollow's attack, and is surprised Karin can see it. Fortunately, Karin warns him about the Hollow before it crushes them both, and guides him away from the monster's attacks, acting as his eyes when she realizes he cannot see it. Chad protests, concerned about her safety, but Karin insists as she wants to know their connection with Ichigo. Chad strikes the Hollow, but is then injured greatly by the following blow. When Karin's friends come to see how she's doing, she tells them to leave, afraid the Hollow will attack them. Hoping to draw it away from them, Karin flees the scene. [41]

Karin witnesses Chad beating the Hollow with his newfound power, wondering what it is and realizes that he's now able to see the Hollow. The exhausted Chad falls after defeating the Hollow and Karin runs over to see if he's alright. She is annoyed that Chad is only concerned about her safety, noting that he's similar to Ichigo in that respect. Deciding to get Isshin to see him, Karin runs off. [42] However, Urahara takes Chad away before she comes back. [43] When the two arrive and do not see Chad, Isshin assumes Karin just wanted some time with him, prompting Karin to punch him in the face. She then continues to wonder where Chad went. [44]

Karin attends a fireworks festival with the rest of the Kurosaki family, although when they find Ichigo, Yuzu and Karin are very loud and act out of character, due to apparently drinking fruit juice that was diluted with wine. After the festival, both Yuzu and Karin, fast asleep, are carried home by Ichigo, much to his annoyance and not helped by the fact that Isshin makes a rather perverted joke. [45] Ichigo leaves for Soul Society while Karin is asleep. [46]

Soul Society arc

Karin spots a flying Hollow which she has been seeing lately, wondering what it is. [47] She then decides to follow it since she has nothing better to do, wondering where it is going. [48] However, the Hollow is suddenly destroyed by Don Kanonji. [49] As he introduces himself to her, she wonders why he came to Karakura Town when Ichigo is away. [50] He explains to her what the flying creature was and asks her to join Karakura Superheroes in order to protect the town from Hollows. [51] Although she isn't enthusiastic about that idea, [51] she changes her mind when Kanonji bids her to take the role of Karakura Red . [52] However, she has to share her title with Jinta Hanakari. [53] Along with Ururu Tsumugiya. they are able to defeat a number of Hollows, much to the chagrin of Zennosuke Kurumadani. Rukia's official replacement. [54]

Bount arc (anime only)

Note: Events occurring in this arc are only in the anime and do not constitute canon material .

Click "show" to read the arc plot. 

Karin notices Ichigo 's distraction and improved physique.

When Ichigo and Isshin are fighting upstairs, Yuzu calls them down for breakfast and Karin wonders what they're doing now. As they're eating, Yuzu asks Isshin for an explanation as to what happened to his face and Isshin simply turns around saying nothing happened. Karin then asks Ichigo if he's been working out lately since he's built up a few muscles lately. Ichigo changes the subject though and asks Yuzu and Karin if they've been doing their homework. Yuzu states that she got it done in hardly any time at all and then Karin states that Don Kanonji has been coming over a lot, saying that Ichigo is now his pupil. Ichigo begins to get worried and tells them that Kanonji doesn't know what he's talking about. All of a sudden Isshin gets up from his chair and kicks Ichigo in the face, sending him backwards. Isshin mocks Ichigo for not being able to react fast enough and the two of them begin fighting. Yuzu then tells them to stop fighting at the table. Later, after Ichigo returns home from school, Karin greets him and Yuzu tells him he's just in time for dinner. However, Isshin immediately begins fighting with Ichigo again, telling him he's late. Yuzu tries to stop this but Karin tells her to leave them alone and to think of it as a bonding experience for the two of them. [55]

Arrancar arc

Karin informed Ichigo that she knows he is a Shinigami.

Karin later reveals that she does, in fact, know that her brother is a Shinigami. When he leaves his body as a Shinigami, she grabs onto his arm in order to try and prevent Ichigo from confronting Ulquiorra Cifer and Yammy Llargo. the first Arrancar that arrive in Karakura Town. However, she fails and Ichigo leaves anyway. [56] As Rukia Kuchiki convinces Yuzu and Isshin to stay at their house, Karin is looking at her suspiciously. [57] Ichigo soon leaves for the Visored training ground without a word, causing Yuzu to cry over his disappearance. Karin tells her he will come back for sure, but gets annoyed with her moaning and Isshin's buffoonery. [58]

Karin enrages Hitsugaya by calling him a school student.

She also encounters Toshiro Hitsugaya while he is stationed in the World of the Living. Upon seeing his talent in soccer, she manages to convince him to join her team and help them win the match. After their victory, she realizes that he too is a Shinigami after he saves her from a large Hollow and easily purifies it. She tries to find out where her missing brother is but Hitsugaya reveals that he is also in the dark with regards to Ichigo’s Visored training. Despite this, he reassures her that Ichigo will be alright. [59]

The twins want to eat with their brother.

Ichigo stays away for a month and both Karin and Yuzu miss him greatly during that time. When he returns, wounded, he is put to bed to rest as Rukia watches over him. Yuzu wants to eat her dinner in Ichigo's bedroom but Karin reminds her that their brother needs to rest and the two bicker over it. Rukia overhears them and, when she opens the door, Yuzu asks if they can eat their dinner with Ichigo. Rukia lets them do so, stating that Ichigo would like that and the two fall asleep on the floor after finishing their meal, staying there all night. [60]

Beast Swords arc (anime only)

Note: Events occurring in this arc are only in the anime and do not constitute canon material.

Click "show" to read the arc plot. 

Karin meets Zabimaru.

While in a shop, Karin spots a strange humanoid spirit trying to eat onigiri without paying for them. After she stops the spirit, it disappears. Karin later finds it again in town and, seeing that the spirit is alone, she tries to befriend him. After learning that the spirit's name is Zabimaru. Yuzu (who cannot see the spirit) suggests Zabimaru comes back to their house for food since he is clearly hungry. There, Zabimaru continues to act bratty, saying he enjoys being by himself, to which Karin says he is being foolish to think it is better to be alone. [61]

Zabimaru carries Karin.

While trying to entertain Zabimaru, the spirit starts to take a liking to them. After Karin and Yuzu fall asleep, Ichigo returns home and finds Zabimaru. When Karin awakes, she sees Zabimaru arguing with Ichigo. Zabimaru then turns his attention to Karin, saying he's angry Karin brought him to her house and runs away. Karin quickly runs after him. She finds him fighting a Toju. The Toju, realizing that he could not defeat Zabimaru directly, chooses to use Karin as a hostage. Renji arrives and Zabimaru defeats the Toju. Zabimaru then brings Karin back to Ichigo and asks him not to tell Karin about Zabimaru. Upon awakening at her home, Karin asks Ichigo where Zabimaru went. As Ichigo pretends not to know, Karin realizes that Zabimaru is fine. [61]

Fake Karakura Town arc

When Ichigo confronts Aizen once again, he closes his eyes and remarks that Karin and Yuzu are all right at their house, presumably sensing their Reiatsu. [62]

Gotei 13 Invading Army arc (anime only)

Note: Events occurring in this arc are only in the anime and do not constitute canon material.

Click "show" to read the arc plot. 

Karin welcomes Nozomi to the household.

Ichigo introduces Yuzu, Karin and Isshin to Nozomi Kujo. saying that Rukia is the only relative she has left following the break up of her family. Yuzu pleads with Isshin to allow Nozomi to stay with them, which Isshin agrees to. Karin comments that she has seen this before. Karin tells Nozomi that they are a loud family, but that she should not let that bother her. Isshin, Karin and Yuzu leave to do some shopping. Later, Orihime prepares a meal and presents it to the household. When Nozomi states that it is delicious, Karin invites Orihime to come back later to make dinner. At dinner, Yuzu and Karin watch Kon, in Ichigo's body, eating Orihime's cooking with the others. Noticing Kon's behavior, Karin comments that Ichigo is going through late onset adolescence. [63]

The Lost Substitute Shinigami arc

Karin buys supplies from Kisuke Urahara .

Over the 17 months following Ichigo's loss of his spiritual powers, Karin's have grown stronger. Though she acts as if it is a pain, she does not ask Ichigo about it, and deals with it herself. [64] She frequently visits the Urahara Shop. [65]

Karin visits Kisuke Urahara. who sells her various goods for repelling spirits and Hollows. When she asks if Kisuke is sure that he does not want money from her that day, he insists that it is fine as he owes Ichigo a lot. Kisuke then asks Karin how Ichigo is and how she feels. Karin comments that it is fine even if his Shinigami powers do not return, saying that Ichigo has always been fighting and protecting, and now it is her turn to protect Ichigo. Then leaves the store. On her way out, Kisuke asks her to let him know if something were to happen and that he will prepare something. Karin thanks him and leaves. [66]

At the Kurosaki Clinic, Karin asks Yuzu where Ichigo is as they have dinner. Yuzu tells her that he is upstairs and when she had called him, he had told her that he would eat later. Karin then calls teenage boys gross and perverts. Yuzu scolds her for saying such things during dinner, denying that Ichigo is like that. Karin relents, but says that she should let go of her delusions about Ichigo, saying that he is not an anime character. Yuzu denies she thought of him like that and storms off, telling Karin that it is her turn to clean up. As she wonders if Ichigo had been cold to Yuzu again, she decides to make him console her later. However, Ichigo rushes passed her and leaves. [67] Karin waits for Ichigo to come home late one night, revealing that he has arrived home late for the last two nights while telling Yuzu to go to bed. Both girls argue for a bit until he comes home. Happy that he is back, they bid him goodnight before going to bed. [68]

Karin and Yuzu try to stop Ichigo from attacking Tsukishima.

As Ichigo arrives home to find Shukuro Tsukishima in his house, Karin, under his influence, says that Tsukishima dropped in without a word and has not changed at all. Tsukishima asks if he is being too much trouble but Karin tells him he's not at all. When Ichigo grabs Tsukishima, she is shocked and tries to get her brother to let him go, saying he is hurting him. Ichigo asks Tsukishima what he has done and Tsukishima tells Karin and Yuzu that it is okay and Ichigo is probably just angry he stayed so late. [69] As Ichigo and Kugo Ginjo enter Tsukishima's mansion, they are greeted by Karin and other friends of Ichigo. Karin, along with everyone else, tells Ichigo that Tsukishima is not angry and then tells Ichigo he should apologize. [70] Some time later, following Kugo's defeat and Tsukishima's death, she returns to normal, alongside Ichigo's friends and the rest of his family. [71]

The Thousand-Year Blood War arc

Karin is having a meal when she hears Ichigo kicking Asguiaro out of the window. [72]

Later, when Yuzu calls her for lunch, she states she needs to beat the boss on the video game she's playing. Yuzu tells her she needs to stop, which Karin acknowledges. [73]

When the Soul King 's death causes an earthquake in Karakura Town, Yuzu grabs Karin and spills her drink. Karin tells her that everything is okay and helps her clean up while commenting that the earthquake is going on for a long time. [74]

Ten years later, Karin and Yuzu bring snacks and drinks for a get-together with Rukia's family, and they happily greet Rukia. Karin then races to the television to see Sado's upcoming boxing match, and tells Ichigo to hurry along as well. They find out that Ichigo and Orihime's son Kazui Kurosaki is probably in Yuzu's room, which she is fine with, and Karin asks her if Kazui gets a free pass like Ichigo. [75]

Powers & Abilities

Spiritual Awareness . Karin is able to see spirits very clearly, including Pluses. Hollows and Shinigami. [76] [77] [78]

Spiritual Power . Toshiro Hitsugaya mentions that Karin has high spiritual power for a Human, as she is able to see him. After Ichigo lost his powers, Karin's powers have gotten stronger and she now has hi spec spiritual medium disposition. [79]

Enhanced Strength . As demonstrated, her kicks were strong enough to hurt weak Hollows. [80]

Keen Aim . Karin is also talented at soccer which would strengthen her physical power. She defeats weak Hollows by kicking a soccer ball at them, which she calls her "Karin-Style Annihilation Shoot" (??????????, Karin-ryu Zetsumei Shuto ). [80]

Quotes

(To Yuzu Kurosaki about ghosts) " Whether you can see them or not, as long as you don't believe, it's the same as them not existing." [81]

(To Kisuke Urahara ) " From now on, it's my turn to protect my brother." [82]

References

^ 1.0 1.1 Bleach Official Character Book Souls, page 37

^ Bleach manga; Chapter 19, page 17

^ 3.0 3.1 Bleach Official Character Book 2 MASKED, page 65

^ 4.0 4.1 4.2 Bleach manga; Chapter 8, page 6

^ Bleach manga; Chapter 424, page 6

^ Bleach manga; Chapter 424, page 8

^ 7.0 7.1 Bleach manga; Chapter 9, page 6

^ Bleach manga; Chapter 434, pages 1-4

^ Bleach manga; Chapter 7, page 17

^ Bleach manga; Chapter 1, page 10

^ Bleach manga; Chapter 19, pages 13-15

^ Bleach manga; Chapter 1, pages 10-12

^ Bleach manga; Chapter 1, page 26-32

^ Bleach manga; Chapter 2, page 5

^ Bleach manga; Chapter 7, page 17

^ Bleach manga; Chapter 7, page 20

^ Bleach manga; Chapter 8, page 1

^ Bleach manga; Chapter 8, pages 7-9

^ Bleach manga; Chapter 8, pages 17-20

^ Bleach manga; Chapter 12, page 21

^ Bleach manga; Chapter 15, pages 14-16

^ Bleach manga; Chapter 16, page 4

^ Bleach manga; Chapter 17, page 18

^ Bleach manga; Chapter 18, pages 6-7

^ Bleach manga; Chapter 18, page 9

^ Bleach manga; Chapter 19, page 1

^ Bleach manga; Chapter 19, page 17

^ Bleach manga; Chapter 19, pages 18-19

^ Bleach manga; Chapter 20, pages 14-20

^ Bleach manga; Chapter 21, page 4

^ Bleach manga; Chapter 21, pages 16-18

^ Bleach manga; Chapter 27, pages 8-9

^ Bleach manga; Chapter 27, page 15

^ Bleach manga; Chapter 28, pages 8-9

^ Bleach manga; Chapter 29, pages 5-6

^ Bleach manga; Chapter 30, page 19

^ Bleach manga; Chapter 31, page 6

^ Bleach manga; Chapter 33, pages 17-18

^ Bleach manga; Chapter 37, page 20

^ Bleach manga; Chapter 38, pages 17-20

^ Bleach manga; Chapter 39, pages 4-16

^ Bleach manga; Chapter 40, pages 6-15

^ Bleach manga; Chapter 43, page 19

^ Bleach manga; Chapter 44, pages 2-3

^ Bleach manga; Chapter 68, pages 8-18

^ Bleach manga; Chapter 69, page 11

^ Bleach manga, Volume 10, the sketch between Chapters 81 & 82

^ Bleach manga, Volume 10, the sketch between Chapters 82 & 83

^ Bleach manga, Volume 10, the sketch between Chapters 83 & 84

^ Bleach manga, Volume 10, the sketch between Chapters 84 & 85

^ 51.0 51.1 Bleach manga, Volume 10, the sketch between Chapters 85 & 86

^ Bleach manga, Volume 10, the sketch between Chapters 86 & 87

^ Bleach manga, Volume 10, the sketch between Chapters 87 & 88

^ Bleach manga; Chapter 88.5

^ Bleach anime; Episode 64

^ Bleach manga; Chapter 190, pages 14-15

^ Bleach manga; Chapter 199, page 2

^ Bleach manga; Chapter 217, pages 1-2

^ Bleach anime; Episode 132

^ Bleach manga; Chapter 237, pages 9-14

^ 61.0 61.1 Bleach anime; Episode 258

^ Bleach manga; Chapter 417, page 5

^ Bleach anime; Episode 330

^ Bleach manga; Chapter 424, pages 10-11

^ Bleach manga; Chapter 428, page 22

^ Bleach manga; Chapter 428, pages 17-21

^ Bleach manga; Chapter 430, pages 5-7

^ Bleach manga; Chapter 434, pages 1-4

^ Bleach manga; Chapter 453, pages 1-4

^ Bleach manga; Chapter 455, pages 6-9

^ Bleach manga; Chapter 479, page 14

^ Bleach manga; Chapter 482, page 2

^ Bleach manga; Chapter 545 pages 1-2

^ Bleach manga; Chapter 615 pages 1-2

^ Bleach manga; Chapter 686, pages 7 & 9

^ Bleach manga; Chapter 1, page 10

^ Bleach manga; Chapter 18, pages 18-19

^ Bleach manga; Chapter 22, page 17

^ Bleach manga; Chapter 424, page 10

^ 80.0 80.1 Bleach manga; Volume 10, Omake chapter 88.5, page 4

^ Bleach manga; Chapter 1, page 11

^ Bleach manga; Chapter 426, page 23

Navigation

Naprosyn - Woman S Health, Apranax

Common use Naproxen sodium belongs to a class of non-steroidal anti-inflammatory drugs (NSAIDs). This medication is used to reduce intense pain, inflammation and stiffness caused by conditions like osteoarthritis, rheumatoid arthritis, psoriatic arthritis, etc. It can be also applied in other cases.

Dosage and direction Take Naprosyn by mouth with a glass of water, with or without food. Avoid cutting, crushing or chewing this medicine. Do not take the medicine more often than it is prescribed. Do not give up taking it except on the advice of your doctor. It may need time for the medicine to help. Consult your doctor concerning proper dose for you.

Precautions Before taking Naprosyn tell your doctor or chemist if you are allergic to it; or if you have other allergies. Naproxen, like other NSAIDs, can inhibit the excretion of sodium and lithium. Be cautious when using this drug along with lithium supplements. Avoid drinking alcohol and smoking while being treated with this medication. Aged people can be more sensitive to side effects of the medicine. During pregnancy this treatment should be used only when strongly necessary. As this medicament can be absorbed by skin, women who are pregnant or may become pregnant should not manipulate this medicine.

Contraindications Naprosyn should not be used by patients with sodium-sensitive hypertension as well as by patients having demonstrated a reaction of hypersensitivity to it.

Possible side effect The most common side effects are dry mouth, dizziness, irritability, sedation, insomnia, urinary retention, etc. A very serious allergic reaction rarely occurs. Many people using this medicine do not have serious side effects. Turn to your doctor or pharmacist for more details. In case you notice the effects not listed here, contact your doctor or pharmacist.

Drug interaction Tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use before using this medication. Naprosyn can interact with: * NSAIDs of the salicylate family (Aspirin) * anticoagulants. Turn to your doctor or pharmacist for more details.

Missed dose If you have missed your dose, take it as soon as you remember. If you see that it is near the time for the next dose, skip the missed dose and resume your usual dosing schedule. Do not take your dose twice.

Overdose If you think you have used too much of this medicine, seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Storage Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store your drugs in the bathroom. Keep all drugs away from reach of children and pets.

We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

Avessa 250 Inhaler ( Ranbaxy ) - Buy Avessa 250 Inhaler Online At Best Price In India, Avessa

AVESSA 250 INHALER

What is Fluticasone for:

This medication is a synthetic glucocorticoid, prescribed for preventing asthma and chronic obstructive pulmonary disease. It reduces inflammatory reactions in the airways. Topical: Topical preparation is used for certain types of skin conditions such as allergic reactions, eczema and psoriasis.

How does Fluticasone work:

Fluticasone stops or lowers irritation and swelling. It lowers or stops the bodys reaction to the allergen.

How should Fluticasone be used:

Asthma - Adult - Dose is based on asthma severity. The recommended dose is 1 inhalation twice daily. The maximum recommended dosage is 50050 twice daily. Chronic Obstructive Pulmonary Disease - The recommended dose is 1 inhalation (25050) twice daily. Skin Inflammation: Cream, Lotion, and Ointment - Apply as directed by your physician. It comes as an aerosol to inhale by mouth. It also comes as a cream, lotion and ointment to apply over the affected area.

Common side effects of Fluticasone :

What do I do if I miss a dose

Take a missed dose as soon as you think about it. If it is close to the time for your next dose, skip the missed dose and go back to your normal time. Do not take 2 doses at the same time or extra doses. Do not change the dose or stop this drug. Talk with the doctor.

What precautions should I take when taking Fluticasone :

If you have an allergy to fluticasone or any other part of this drug. If you have an allergy to formaldehyde. Tell your doctor if you are allergic to any drugs. Make sure to tell about the allergy and what signs you had. This includes telling about rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs. If you have a skin infection.

When do I need to seek medical help

If you think there was an overdose, call your local poison control center or ER right away. Signs of a very bad reaction to the drug. These include wheezing; chest tightness; fever; itching; bad cough; blue or gray skin color; seizures; or swelling of face, lips, tongue, or throat. Very bad skin irritation. Any rash. Side effect or health problem is not better or you are feeling worse.

Can I take Fluticasone with other medicines:

Sometimes drugs are not safe when you take them with certain other drugs and food. - Taking them together can cause bad side effects. - Be sure to talk to your doctor about all the drugs you take.

Are there any food restrictions

How do I store Fluticasone :

Store it in controlled room temperature (4 and 30°C), and in an airtight container.

Pregnancy Category

Category C. Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Therapeutic Classification

Antiasthmatic & COPD Preparations, Nasal Decongestants & Other Nasal Preparations, Topical Corticosteroids

This medication is a synthetic glucocorticoid, prescribed for preventing asthma and chronic obstructive pulmonary disease. It reduces inflammatory reactions in the airways. Topical: Topical preparation is used for certain types of skin conditions such as allergic reactions, eczema and psoriasis.

What is Formoterol for:

This medication is a long-acting bronchodilator, prescribed for asthma and Chronic Obstructive Pulmonary Disorder (COPD). It widens air passage and helps in easy breathing.

How does Formoterol work:

Formoterol works in the airways to calm the muscles and help the flow of oxygen.

How should Formoterol be used:

Adult: PO - Acute bronchospasm; Reversible airways obstruction - 80 mcg twice daily. Inhalation - Acute bronchospasm; Reversible airways obstruction - as inhalation cap: 12 mcg twice daily, up to 24 mcg twice daily in severe cases. As dry powder inhaler: 6 or 12 mcg 1-2 timesday, up to 24 mcg twice daily in sever cases. As metered doses from aerosol inhaler: 12 or 24 mcg twice daily. As nebuliser: 20 mcg twice daily. Prevention of exercise-induced bronchospasm 6 or 12 mcg at least 15 minutes before exercise. Additional doses may be given 12 hour later. It comes as a powder-filled capsule to inhale by mouth using a special inhaler.

What do I do if I miss a dose

Take a missed dose as soon as you think about it. If it is close to the time for your next dose, skip the missed dose and go back to your normal time. Do not take 2 doses at the same time or extra doses. Many times this drug is taken on an as needed basis for asthma caused by working out. Do not take more often than every 12 hours unless told to do so by your doctor.

What precautions should I take when taking Formoterol :

If you have an allergy to formoterol or any other part of this drug. Tell your doctor if you are allergic to any drugs. Make sure to tell about the allergy and what signs you had. This includes telling about rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs. If you are allergic to milk, talk with the doctor. If you are not using other asthma drugs. This drug must be used with a long-term asthma-control drug like a breathed in steroid. If you are having a breathing attack.

When do I need to seek medical help

If you think there was an overdose, call your local poison control center or ER right away. Signs of a very bad reaction to the drug. These include wheezing; chest tightness; fever; itching; bad cough; blue or gray skin color; seizures; or swelling of face, lips, tongue, or throat. If you are not able to get the breathing attack under control. Get help right away. Peak flow measurement low. Use of short-acting puffer (inhaler) more often. Chest pain or pressure or a fast heartbeat. Trouble breathing. Very nervous and excitable. Any rash. Side effect or health problem is not better or you are feeling worse.

Can I take Formoterol with other medicines:

Sometimes drugs are not safe when you take them with certain other drugs and food. - Taking them together can cause bad side effects. - Be sure to talk to your doctor about all the drugs you take.

Are there any food restrictions

How do I store Formoterol :

Store it at room temperature and away from excess heat and moisture. Keep away from children.

Pregnancy Category

Category C. Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Therapeutic Classification

Antiasthmatic & COPD Preparations

This medication is a long-acting bronchodilator, prescribed for asthma and Chronic Obstructive Pulmonary Disorder (COPD). It widens air passage and helps in easy breathing.

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Cardizem (Lacerol)

Cardizem is used for treating supraventricular tachycardia, a rhythm disturbance of the heart. It is also used for controlling heart rate response to other rhythm disturbances, specifically, atrial fibrillation and flutter. Cardizem is a calcium channel blocker. It works by slowing the electrical conduction in the heart, slowing heart rate, and/or normalizing heart rhythm.

Use Cardizem as directed by your doctor.

Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.

Your doctor may occasionally change your dose to make sure you get the best results from this medication.

Take Cardizem with a full glass of water. Swallow the pill whole. It is specially made to release medicine slowly in the body. Breaking or opening the pill would cause too much of the drug to be released at one time.

It is important to use Cardizem regularly to get the most benefit. Get your prescription refilled before you run out of medicine completely.

Do not stop taking this medication without first talking to your doctor. If you stop taking Cardizem suddenly, your condition may become worse.

If you are being treated for high blood pressure, keep using this medication even if you feel fine.

If you miss a dose of Cardizem, use it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not use 2 doses at once.

Ask your health care provider any questions you may have about how to use Cardizem.

Store Cardizem at room temperature away from moisture and heat. Keep Cardizem out of the reach of children and away from pets.

Active Ingredient: Diltiazem.

Do NOT use Cardizem if:

you are allergic to any ingredient in Cardizem

you have sick sinus syndrome or have second - or third-degree heart block and do not have a pacemaker, or very low blood pressure

you have atrial fibrillation or flutter and a pre-excitation syndrome (extra conduction pathway in the heart), such as Wolff-Parkinson-White syndrome (WPW) or Lown-Ganong-Levine syndrome (LGL)

you are receiving injectable beta-blockers (eg, metoprolol) or erythromycin.

Contact your doctor or health care provider right away if any of these apply to you.

Some medical conditions may interact with Cardizem. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:

if you are pregnant, planning to become pregnant, or are breast-feeding

if you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplement

if you have allergies to medicines, foods, or other substances

if you have heart failure or have had a recent heart attack with lung congestion, heart block, low blood pressure, a very slow heart rate, or abnormal heart rhythm

if you have kidney or liver disease.

Some medicines may interact with Cardizem. Tell your health care provider if you are taking any other medicines, especially any of the following:

Cimetidine or protease inhibitors (eg, indinavir) because they may increase the actions and side effects of Cardizem

Rifampin because it may decrease the effectiveness of Cardizem

Amiodarone, cisapride, digoxin, erythromycin, protease inhibitors (eg, indinavir), quinidine, tricyclic antidepressants (eg, desipramine), theophylline, or general anesthetics because toxic effects on the heart may occur

Benzodiazepines (eg, midazolam), beta-blockers (eg, metoprolol), buspirone, carbamazepine, cilostazol, corticosteroids (eg, prednisone), cyclosporine, HMG-CoA reductase inhibitors (eg, atorvastatin), macrolide immunomodulators (eg, tacrolimus) because the risk of their side effects, some potentially life-threatening, may be increased by Cardizem.

This may not be a complete list of all interactions that may occur. Ask your health care provider if Cardizem may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine.

Important safety information:

Cardizem may cause dizziness. These effects may be worse if you take it with alcohol or certain medicines. Use Cardizem with caution. Do not drive or perform other possible unsafe tasks until you know how you react to it.

Cardizem may cause dizziness, lightheadedness, or fainting; alcohol, hot weather, exercise, or fever may increase these effects. To prevent them, sit up or stand slowly, especially in the morning. Sit or lie down at the first sign of any of these effects.

Cardizem may cause you to become sunburned more easily. Avoid the sun, sunlamps, or tanning booths until you know how you react to Cardizem. Use a sunscreen or wear protective clothing if you must be outside for more than a short time.

Tell your doctor or dentist that you take Cardizem before you receive any medical or dental care, emergency care, or surgery.

Lab tests, including electrocardiogram (ECG), heart rate, and blood pressure monitoring, may be performed while you use Cardizem. These tests may be used to monitor your condition or check for side effects. Be sure to keep all doctor and lab appointments.

Use Cardizem with caution in the elderly; they may be more sensitive to its effects.

Cardizem should not be used in children; safety and effectiveness in children have not been confirmed.

Pregnancy and breast-feeding: If you become pregnant, contact your doctor. You will need to discuss the benefits and risks of using Cardizem while you are pregnant. Cardizem is found in breast milk. Do not breastfeed while taking Cardizem.

All medicines may cause side effects, but many people have no, or minor, side effects.

Check with your doctor if any of these most common side effects persist or become bothersome:

Constipation; dizziness; facial flushing; headache; weakness.

Seek medical attention right away if any of these severe side effects occur:

Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); hallucinations; irregular heartbeat; swelling of the feet or hands; symptoms of liver problems (eg, yellowing of the skin or eyes, dark urine, pale stools); tender, bleeding, or swollen gums.

This is not a complete list of all side effects that may occur. If you have questions about side effects, contact your health care provider.

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Baxicin (Noroxin) Description

Baxicin medication belongs to a class of drugs called quinolone antibiotics. Baxicin works by stopping the growth of bacteria.

Baxicin should not be used for colds, flu, other virus infections, sore throats or other minor infections, or to prevent infections.

Baxicin is also known as Norfloxacin, Norfloxacine, Apo-Norflox, Norflohexal, Roxin, Utinor.

Generic name of Baxicin is Norfloxacin.

Brand name of Baxicin is Baxicin.

Baxicin (Noroxin) Dosage

Baxicin is available in:

400mg Standard Dosage

Take Baxicin orally with a full glass of water.

Take Baxicin usually twice a day, at least 1 hour before or at least 2 hours after a meal or dairy products (e. g. milk, yogurt).

Take Baxicin 2 hours before or 2 hours after taking any products containing magnesium, aluminum or calcium.

The dosage of tablets depends on the disease and its prescribed treatment.

If you want to achieve most effective results do not stop taking Baxicin suddenly.

Baxicin (Noroxin) Missing of dose

Do not take double dose. If you miss a dose you should take it as soon as you remember about your missing. If it is the time for the next dose you should continue your regular dosing schedule.

Baxicin (Noroxin) Overdose

If you overdose Baxicin and you don't feel good you should visit your doctor or health care provider immediately.

Baxicin (Noroxin) Storage

Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F) away from moisture and heat. Keep bottle closed tightly. Throw away any unused medicine after the expiration date. Keep out of the reach of children.

Baxicin (Noroxin) Side effects

Baxicin has its side effects. The most common are:

seizures

mental changes (including rare thoughts of suicide)

persistent sore throat

fever

vision changes

hearing loss

change in amount or appearance of urine

yellowing of the eyes or skin

fainting

fast, slow, or irregular heartbeat

easy bruising or bleeding

numbness, tingling of arms or legs

persistent diarrhea

abdominal or stomach pain or cramping

blood or mucus in your stool

Less common but more serious side effects during taking Baxicin: allergy reactions (urticaria, breathing difficulties, rash, and eruption).

Side effects manifestations are not only depend on medicine you are taking but also depend on your health state and on the other factors.

Baxicin (Noroxin) Contra-indications

Do not take Baxicin if you are allergic to Baxicin components or to quinolone antibiotics such as ciprofloxacin, gatifloxacin, gemifloxacin, levofloxacin, lomefloxacin, moxifloxacin or ofloxacin.

Baxicin should not be used for colds, flu, other virus infections, sore throats or other minor infections, or to prevent infections.

Be careful if you are pregnant, planning to become pregnant, or are breast-feeding.

Be careful if you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplement.

Be careful if you have seizures, brain disorders (e. g. cerebral arteriosclerosis, tumor, increased intracranial pressure), muscle disease/weakness (e. g. myasthenia gravis), heart problems (e. g. cardiomyopathy, slow heart rate, torsades de pointes, QTc interval prolongation), kidney disease, mineral imbalance (e. g. low potassium or magnesium), history of tendonitis/tendon problems.

When you take Baxicin you should drink plenty of fluids.

Avoid alcohol and beverages containing caffeine (coffee, tea, colas), do not eat large amounts of chocolate.

Avoid prolonged sun exposure, tanning booths or sunlamps. Use a sunscreen and wear protective clothing when outdoors.

It can be dangerous to stop Baxicin taking suddenly.

Baxicin (Noroxin) Frequently asked questions

Q: What is Baxicin?

A: Baxicin medication belongs to a class of drugs called quinolone antibiotics.

Q: What is Baxicin used for?

A: Baxicin is used to treat a variety of bacterial infections.

Q: How does Baxicin work?

A: Baxicin works by stopping the growth of bacteria.

Q: What is the generic name of Baxicin?

A: Generic name is Norfloxacin.

Q: What should I do in case of dose missing?

A: In case of dose missing you should take your tablet as soon as possible. Do not take double dosage. And if it is right time for the next dosage you should continue your regular schedule of Baxicin taking.

Q: Why should I not use Baxicin?

A: Do not use Baxicin if you have allergy to it or its components.

Q: Can Baxicin cause allergic reaction?

A: Yes, it can. Be careful. Symptoms of allergic reactions to Baxicin: rash, itching, swelling, severe dizziness, trouble breathing.

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Nitro-Dur patch is used for:

Preventing chronic chest pain caused by heart disease. It also may be used for other conditions as determined by your doctor.

Nitro-Dur patch is a nitrate. It works by relaxing (widening) blood vessels. Chest pain occurs when the heart needs more oxygen than it can get. Relaxing blood vessels allows blood to flow more easily. This reduces the heart's workload and the amount of oxygen needed by the heart.

Do NOT use Nitro-Dur patch if:

you are allergic to any ingredient in Nitro-Dur patch

you are allergic to the adhesive that makes the patch stick to your skin

you have increased pressure in or severe injury to the head

you have severe anemia

you are taking avanafil, riociguat, sildenafil, tadalafil, or vardenafil

Contact your doctor or health care provider right away if any of these apply to you.

Before using Nitro-Dur patch:

Some medical conditions may interact with Nitro-Dur patch. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:

if you are pregnant, planning to become pregnant, or are breast-feeding

if you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplement

if you have allergies to medicines, foods, or other substances

if you drink alcoholic beverages

if you have a history of other heart problems (eg, heart failure, enlarged heart, heart attack), overactive thyroid, stroke or other bleeding in the brain, or recent head injury

if you have anemia, low blood pressure, dehydration, or low blood volume

if you will be having a certain heart procedure (cardioversion)

Some MEDICINES MAY INTERACT with Nitro-Dur patch. Tell your health care provider if you are taking any other medicines, especially any of the following:

Avanafil, beta-blockers (eg, propranolol), calcium channel blockers (eg, diltiazem), diuretics (eg, furosemide, hydrochlorothiazide), medicines for high blood pressure, phenothiazines (eg, thioridazine), riociguat, sildenafil, tadalafil, or vardenafil because the risk of low blood pressure and dizziness on standing may be increased

Salicylates (eg, aspirin) because they may increase the risk of Nitro-Dur patch's side effects

Alteplase because the effectiveness of Nitro-Dur patch may be decreased

This may not be a complete list of all interactions that may occur. Ask your health care provider if Nitro-Dur patch may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine.

How to use Nitro-Dur patch:

Use Nitro-Dur patch as directed by your doctor. Check the label on the medicine for exact dosing instructions.

An extra patient leaflet is available with Nitro-Dur patch. Talk to your pharmacist if you have questions about this information.

Nitro-Dur patch is for external use only.

Apply the patch at the same time every day.

Wash your hands thoroughly before and after applying the patch.

Apply the patch to a non-hairy area of the chest, inner side of the upper arm, back, or shoulder.

Clean and completely dry the skin before applying the patch. If necessary, hair should be removed by clipping or lightly shaving.

Remove the patch from the package. Apply with a firm pressure to the skin. To avoid skin irritation, change the treatment site daily. Do not apply to irritated or damaged skin.

If the patch becomes loose, remove it and apply a new patch at a different site.

After removing the used patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and away from pets.

This patch should only be worn for up to 12 to 14 hours a day, or as directed by your doctor, so that you will have a 10 to 12 hour "nitrate-free" period each day. Do not use more of Nitro-Dur patch than prescribed. It is important to have a "nitrate-free" period of time each day for Nitro-Dur patch to continue to work well and to decrease the risk of physical dependence.

If you miss a dose of Nitro-Dur patch, use it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not use 2 doses at once.

Ask your health care provider any questions you may have about how to use Nitro-Dur patch.

Important safety information:

Tell your doctor or dentist that you take Nitro-Dur patch before you receive any medical or dental care, emergency care, or surgery.

Nitro-Dur patch may cause dizziness, light-headedness, or blurred vision. These effects may be worse if you take it with alcohol or certain medicines. Use Nitro-Dur patch with caution. Do not drive or perform other possibly unsafe tasks until you know how you react to it.

Check with your doctor before you drink alcohol while you are taking Nitro-Dur patch. Drinking alcohol may increase the risk of low blood pressure with Nitro-Dur patch.

Nitro-Dur patch may cause dizziness, light-headedness, or fainting; alcohol, hot weather, exercise, or fever may increase these effects. To prevent them, sit up or stand slowly, especially in the morning. Sit or lie down at the first sign of any of these effects.

Contact your doctor right away if you develop slow heartbeat or new or worsening chest pain after you take Nitro-Dur patch.

Nitro-Dur patch may give you daily headaches. This should become less noticeable with time. Do not change how you use Nitro-Dur patch to avoid these headaches. Talk with your doctor for ways to lessen this side effect.

Your skin may be red or feel warm after you take the patch off. This is normal. If these effects persist, call your doctor.

Other dosage forms of Nitro-Dur patch (eg, sublingual, or under the tongue, tablets) may not work as well while you are taking Nitro-Dur patch.

Nitro-Dur patch takes about 1 to 2 hours to start working and should not be used for a sudden chest pain attack.

You may need to check your blood pressure often while using Nitro-Dur patch. Talk with your doctor.

Use Nitro-Dur patch with caution in the ELDERLY; they may be more sensitive to its effects.

PREGNANCY and BREAST-FEEDING: If you become pregnant, contact your doctor. You will need to discuss the benefits and risks of using Nitro-Dur patch while you are pregnant. It is not known if this medicine is found in breast milk. If you are or will be breast-feeding while you are using Nitro-Dur patch, check with your doctor. Discuss any possible risks to your baby.

When used for long periods of time without a break, Nitro-Dur patch may not work as well. This is known as TOLERANCE. Increasing the dose is not effective in managing tolerance to Nitro-Dur patch. Tolerance to other nitrates or nitrites may also occur. Be sure to have a "nitrate-free" period of time each day to help prevent this tolerance. Talk with your doctor if Nitro-Dur patch stops working well. Do not take more than prescribed.

Some people who use Nitro-Dur patch for a long time without a break may develop a physical need to continue taking it. This is known as physical DEPENDENCE. If you use Nitro-Dur patch without a break and then suddenly stop using it, you may get WITHDRAWAL symptoms. These may include chest pain, heart attack, or possibly sudden death. Be sure to have a "nitrate-free" period of time each day; this may help prevent dependence and withdrawal problems.

Possible side effects of Nitro-Dur patch:

All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome:

Dizziness or light-headedness; headache; irritation at site of patch.

Seek medical attention right away if any of these SEVERE side effects occur:

Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); blurred vision; dry mouth; fainting; fast or irregular heartbeat; flushing; heavy sweating; pale skin; restlessness; severe or persistent dizziness or headache; severe or persistent nausea or vomiting; severe skin irritation; unusual tiredness or weakness.

This is not a complete list of all side effects that may occur. If you have questions about side effects, contact your health care provider. Call your doctor for medical advice about side effects. To report side effects to the appropriate agency, please read the Guide to Reporting Problems to FDA .

If OVERDOSE is suspected:

Contact 1-800-222-1222 (the American Association of Poison Control Centers), your local poison control center. or emergency room immediately.

Proper storage of Nitro-Dur patch:

Store Nitro-Dur patch at room temperature. Store away from heat, moisture, and light. Do not store in the bathroom. Keep Nitro-Dur patch out of the reach of children and away from pets.

General information:

If you have any questions about Nitro-Dur patch, please talk with your doctor, pharmacist, or other health care provider.

Nitro-Dur patch is to be used only by the patient for whom it is prescribed. Do not share it with other people.

If your symptoms do not improve or if they become worse, check with your doctor.

Check with your pharmacist about how to dispose of unused medicine.

This information should not be used to decide whether or not to take Nitro-Dur patch or any other medicine. Only your health care provider has the knowledge and training to decide which medicines are right for you. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about Nitro-Dur patch. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to Nitro-Dur patch. This information is not specific medical advice and does not replace information you receive from your health care provider. You must talk with your health care provider for complete information about the risks and benefits of using Nitro-Dur patch.

Review Date: August 8, 2016

Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only your health care provider has the knowledge and training to decide which medicines are right for you. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from your health care provider. You must talk with your healthcare provider for complete information about the risks and benefits of using this medicine.

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Diclofenac is used to treat pain or inflammation caused by arthritis or ankylosing spondylitis. Diclofenac may also be used for purposes other than those listed in this medication guide.

Use Diclofenac as directed by your doctor.

Take Diclofenac by mouth with or without food. Ask your health care provider any questions you may have about how to use Diclofenac.

Drug Class and Mechanism

Diclofenac is in a group of drugs called nonsteroidal anti-inflammatory drugs (NSAIDs). Diclofenac works by reducing hormones that cause inflammation and pain in the body.

If you miss a dose of Diclofenac, use it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not use 2 doses at once.

Store Diclofenac at room temperature between 68 and 77 degrees F (20 and 25 degrees C) in a tightly closed container. Brief periods at temperatures of 59 to 86 degrees F (15 to 30 degrees C) are permitted. Store away from heat, moisture, and light. Do not store in the bathroom. Keep Diclofenac out of the reach of children and away from pets.

Do not use Diclofenac if:

you are allergic to any ingredient in Diclofenac; you have had a severe allergic reaction (e. g. severe rash, hives, breathing difficulties, dizziness) to another NSAID (e. g. ibuprofen, naproxen, celecoxib) or aspirin. Contact your doctor or health care provider right away if any of these apply to you.

Important : Diclofenac may cause dizziness or blurred vision. These effects may be worse if you take it with alcohol or certain medicines. Use Diclofenac with caution. Do not drive or perform other possibly unsafe tasks until you know how you react to it. Before you start any new medicine, check the label to see if it has Doroxan or another nonsteroidal anti-inflammatory drug (NSAID) medicine in it too. If it does or if you are not sure, check with your doctor or pharmacist. Diclofenac should not be used in children; safety and effectiveness in children have not been confirmed. Pregnancy and breast-feeding: If you become pregnant, contact your doctor. You will need to discuss the benefits and risks of using Diclofenac while you are pregnant. It is not known if Diclofenac is found in breast milk. Do not breast-feed while using Diclofenac.

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Atenolol is prescribed to patients who are suffering from any of the following medical conditions: - Anginapectoris; - High Blood pressure; - Prevention of future heart attacks (especially after the patient has already experienced at least one); - Prevention of migraines;

Atenolol is prescribed in the treatment of high blood pressure. It combines a beta-blocker drug and a diuretic. Atenolol can be prescribed alone or in combination with other high blood pressure medications. Atenolol, the beta blocker, decreases the force and rate of heart contractions. Chlorthalidone, the diuretic, helps your body produce and eliminate more urine, which helps in lowering blood pressure.

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Atenolol side effects that you should report to your health care professional or doctor as soon as possible: - Bradycardia; - Bronchospasm; - Cold Extremities; - Diarrhea, Nausea, Constipation, Vomiting and so on; - Disturbed sleep; - Dizziness; - Fatigue; - Heart Failure; - Rash;

Atenolol side effects that you should report to your health care professional or doctor as soon as possible: - Slow Heartbeat; - Nausea; - Fatigue; - Dizziness;

Other Brand Names

In some countries Atenolol may also be known as: - Ablok; - Adenamin; - Angipress; - Anselol; - Apo-Atenol; - Arcablock; - Ate Lich; - Atebeta; - Ateblocor; - Atecard; - Atel; - Atenblock; - Ateneo; - Atenet; - Atenobal; - Atenobene; - Atenoblock; - Atenodan; - Atenogamma; - Atenolab; - Atenolan; - Atenopress; - Atenor; - Atenorm; - Atenotop; - Atenovit; - Atenuol; - Atepress; - Azectol; - Betacar; - Betasyn; - Biotenor; - Cardioblock; - Catenol; - Corotenol; - Corpaz; - Ditenol; - Docateno; - Fabotenol; - Felobits; - Grifotenol; - Ilaten; - Labotensil; - Myocord; - Neotenol; - Novo-Atenol; - Nu-Atenol; - Plenacor; - Prenormine; - Sifnolol; - Telvodin; - Tenoblock; - Tenoprin; - Tenormin; - Tenormine; - Tensig; - Tensilol; - Tozolden; - Uniloc; - Vericordin;

Dosage.

Dosage is always individualized.

The usual starting dosage is 1 Atenolol 50 tablet taken once a day. Your doctor may increase the dosage to 1 Atenolol 100 tablet taken once a day. Your doctor may gradually add other high blood pressure medications.

Your doctor will adjust your dosage if your kidney function is impaired.

The safety and effectiveness of Atenolol have not been established in children.

Maxeran Drug Information, Professional, Maxartan

Maxeran

Generic Name: Metoclopramide VA CLASSIFICATION Primary: AU300 Secondary: GA609

Commonly used brand name(s): Apo-Metoclop; Maxeran; Metoclopramide Intensol; Octamide; PMS-Metoclopramide; Reglan.

Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).

Dopaminergic blocking agent—

gastrointestinal emptying (delayed) adjunct—

Note: Bracketed information in the Indications section refers to uses that are not included in U. S. product labeling. Accepted

Radiography, gastrointestinal, adjunct and Intubation, intestinal—Metoclopramide injection is indicated to facilitate intestinal intubation in adults and children, and to stimulate gastric emptying and intestinal transit of barium in cases where delayed emptying interferes with radiological examinations of stomach or small intestine.

Gastroparesis (treatment) 1 —Metoclopramide is indicated for the relief of symptoms of acute and recurrent diabetic gastroparesis.

Nausea and vomiting, cancer chemotherapy–induced (prophylaxis) —Metoclopramide injection is indicated in high doses for the prevention of nausea and vomiting associated with emetogenic cancer chemotherapy. —Some clinicians may prefer ondansetron to high-dose metoclopramide for prophylaxis of cancer chemotherapy–induced nausea and vomiting because ondansetron is less toxic, and in some studies, has been proven more effective than high-dose metoclopramide .

Nausea and vomiting, postoperative (prophylaxis)—Metoclopramide is indicated for the prophylaxis of postoperative nausea and vomiting in cases where nasogastric suction is undesirable.

Reflux, gastroesophageal (treatment) 1 —Oral metoclopramide is indicated in adults for the symptomatic short-term treatment of heartburn and reflux esophagitis due to delayed gastric emptying. [In infants, it is used in the treatment of chronic vomiting and recurrent bronchopulmonary manifestations associated with gastroesophageal reflux.]

[Nausea and vomiting, postoperative, drug-related (treatment)]—Metoclopramide is used in the treatment of drug-related postoperative nausea and vomiting.

[Gastric emptying, slow (treatment)] or [Gastric stasis, in preterm infants (treatment)] —Metoclopramide is used for correcting the slow gastric emptying in postvagotomy stasis, in idiopathic stasis, and in various collagen diseases such as scleroderma. In addition, it is used for persistent functional feeding intolerance and gastric stasis in preterm infants.

[Pneumonitis, aspiration (prophylaxis) ] 1 —Metoclopramide is used prior to general anesthesia to promote gastric emptying and reduce the risk of aspiration, especially in emergency surgery, cesarean sections, or delivery.

[Headache, vascular (treatment adjunct) ] 1 —Metoclopramide is used to counteract the gastric stasis and nausea associated with migraine, and to promote the absorption of orally administered analgesics given in the treatment of migraine.

—[Metoclopramide has been used in the treatment of lactation deficiency; however, it has generally been replaced by more effective medications.]

1 Not included in Canadian product labeling.

pKa— 0.6 and 9.3 Mechanism of action/Effect:

Dopaminergic blocking agents—Gastrointestinal emptying (delayed) adjunct; peristaltic stimulant: Exact mechanism of action is unknown; however, it is believed that metoclopramide inhibits gastric smooth muscle relaxation produced by dopamine, thus enhancing cholinergic responses of the gastrointestinal smooth muscle. Accelerates intestinal transit and gastric emptying by preventing relaxation of gastric body and increasing the phasic activity of antrum. At the same time, this action is accompanied by relaxation of the upper small intestine, resulting in an improved coordination between the body and antrum of the stomach and the upper small intestine. Decreases reflux into the esophagus by increasing the resting pressure of the lower esophageal sphincter and improves acid clearance from the esophagus by increasing amplitude of esophageal peristaltic contractions.

Antiemetic—Dopamine antagonist action raises the threshold of activity in the chemoreceptor trigger zone and decreases the input from afferent visceral nerves. High doses of metoclopramide have been found to antagonize 5-hydroxytryptamine (5-HT) receptors in the peripheral nervous system in animals.

Metoclopramide stimulates prolactin secretion and causes a transient increase in circulating aldosterone levels, which may be associated with transient fluid retention. Absorption:

Intramuscular—10 to 15 minutes.

Intravenous—1 to 3 minutes.

Oral—30 to 60 minutes. Time to peak serum concentrations

1 to 2 hours after a single oral dose. Duration of action:

1 to 2 hours. Elimination: Renal; approximately 85% of an oral dose appears in the urine within 72 hours as unchanged drug and sulfate and glucuronide conjugates.

Precautions to Consider Cross-sensitivity and/or related problems

Patients sensitive to procaine and procainamide may be sensitive to this medication also. Mutagenicity/Tumorigenicity

An Ames mutagenicity test performed on metoclopramide was negative.

Dopaminergic blocking medications produce an elevation in prolactin concentrations, which persists during long-term administration. Tissue culture experiments indicate that approximately one third of human breast cancers are prolactin-dependent in vitro . a factor of potential importance if the prescription of these medications is contemplated in a patient with a previously detected breast cancer. Although disturbances such as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported, the clinical significance of elevated serum prolactin concentrations is unknown for most patients. An increase in mammary neoplasms has been found in rodents after long-term administration of dopaminergic blocking medications. However, neither clinical studies nor epidemiologic studies conducted to date have shown an association between long-term administration of these medications and mammary tumorigenesis; the available evidence is considered too limited to be conclusive at this time. Pregnancy/Reproduction Fertility— Studies in rats, mice, and rabbits at doses from 12 to 250 times the human dose have shown that metoclopramide does not impair fertility.

Pregnancy— Extensive studies in humans have not been done.

Studies in animals have not shown that metoclopramide causes adverse effects in the fetus.

FDA Pregnancy Category B. Breast-feeding

Problems in humans have not been documented; however, risk-benefit must be considered since metoclopramide is distributed into breast milk. Pediatrics

Extrapyramidal effects, especially dystonic reactions, of metoclopramide are more likely to occur in children shortly after initiation of therapy, and usually with doses higher than 0.5 mg per kg of body weight (mg/kg) per day. Methemoglobinemia has been reported in premature and full-term neonates receiving metoclopramide intramuscularly at a dose of 1 to 2 mg/kg a day for 3 days or more.

Extrapyramidal effects, especially parkinsonism and tardive dyskinesia, of metoclopramide are more likely to occur in elderly patients following usual or high doses over a long period of time. Drug interactions and/or related problems The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive ( » = major clinical significance):

Note: Only specific interactions between metoclopramide and other oral medications have been identified in this monograph. However, because of increased gastrointestinal motility and decreased gastric emptying time caused by metoclopramide, absorption of oral medications from the stomach may be decreased, while absorption from the small intestine may be enhanced. Combinations containing any of the following medications, depending on the amount present, may also interact with this medication.

» Alcohol (concurrent use may increase the central nervous system [CNS] depressant effects of either alcohol or metoclopramide; concurrent use also may accelerate gastric emptying of alcohol, thus possibly increasing its rate and extent of absorption from the small intestine )

Anticholinergics or other medications with anticholinergic activity (see Appendix II ) or Opioid-containing medications (concurrent use may antagonize the effects of metoclopramide on gastrointestinal motility )

Apomorphine (prior administration of metoclopramide may decrease the emetic response to apomorphine; also, concurrent use may potentiate the CNS depressant effects of either apomorphine or metoclopramide)

Bromocriptine (metoclopramide may increase serum prolactin concentrations and interfere with effects of bromocriptine; dosage adjustment of bromocriptine may be necessary )

Cimetidine (concurrent use may decrease the effect of cimetidine due to decreased absorption )

» CNS depression–producing medications, other (see Appendix II ) (concurrent use may increase the sedative effects of either these medications or metoclopramide )

Cyclosporine (the decrease in gastric emptying time caused by metoclopramide may increase the bioavailability of cyclosporine; monitoring of cyclosporine concentrations may be necessary )

Digoxin (concurrent use may decrease absorption of digoxin from stomach; dosage adjustment of digoxin may be necessary )

Extrapyramidal reaction–causing medications (see Appendix II ) (concurrent use with metoclopramide may increase the frequency and severity of extrapyramidal effects)

Hepatotoxic medications (see Appendix II ) (concurrent use with metoclopramide may increase the risk of hepatotoxicity )

Levodopa (metoclopramide has been reported to decrease the effectiveness of levodopa with concurrent use )

Mexiletine (concurrent use with metoclopramide may accelerate absorption of mexiletine )

Monoamine oxidase (MAO) inhibitors, including furazolidine and procarbazine (metoclopramide releases catecholamines in patients with essential hypertension and should be used cautiously in patients receiving MAO inhibitors )

Pergolide (dopamine antagonists such as metoclopramide may decrease the effectiveness of pergolide )

Succinylcholine (metoclopramide has been reported to prolong succinylcholine block; dosage reduction of succinylcholine may be necessary with concurrent use )

Laboratory value alterations The following have been selected on the basis of their potential clinical significance (possible effect in parentheses where appropriate)—not necessarily inclusive ( » = major clinical significance):

With diagnostic test results Gonadorelin test (concurrent use with metoclopramide may blunt the response to gonadorelin by increasing serum prolactin concentrations)

Hepatic function test (results may be altered )

With physiology/laboratory test values Aldosterone and Prolactin, serum (concentrations may be increased )

Medical considerations/Contraindications The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive ( » = major clinical significance).

Except under special circumstances, this medication should not be used when the following medical problems exist: » Epilepsy (severity and frequency of seizures or extrapyramidal effects may be increased )

» Gastrointestinal hemorrhage, mechanical obstruction, or perforation (stimulation of gastrointestinal motility may aggravate condition )

Risk-benefit should be considered when the following medical problems exist Asthma (administration of metoclopramide may increase risk of bronchospasm )

Depression, mental (condition may be exacerbated )

Hypertension (administration of intravenous metoclopramide may worsen condition due to release of catecholamines )

Parkinson's disease (symptoms may be exacerbated )

» Renal failure, severe, chronic (risk of extrapyramidal effects may be increased; reduced dosage is recommended )

Sensitivity to metoclopramide, procaine, or procainamide

Note: Methemoglobinemia has been reported in premature and full-term neonates receiving metoclopramide at a dose of 1 to 4 mg per kg of body weight (mg/kg) a day for 1 to 3 days or more.

The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive: Those indicating need for medical attention Incidence rare Agranulocytosis (chills; fever; sore throat; general feeling of tiredness or weakness) cardiovascular effects, specifically hypotension (dizziness or fainting), hypertension (dizziness; severe or continuing headaches; increase in blood pressure), tachycardia (fast or irregular heartbeat) extrapyramidal effects, dystonic (muscle spasms of face, neck, and back; tic-like or twitching movements; twisting movements of body; inability to move eyes; weakness of arms and legs) extrapyramidal effects, parkinsonian (difficulty in speaking or swallowing; loss of balance control; mask-like face; shuffling walk; stiffness of arms or legs; trembling and shaking of hands and fingers) tardive dyskinesia (lip smacking or puckering; puffing of cheeks; rapid or worm-like movements of tongue; uncontrolled chewing movements; uncontrolled movements of arms and legs) —usually occurs after at least one year of continuous treatment and may persist after discontinuation of metoclopramide Note: Extrapyramidal effects may occur at therapeutic doses in any age group. However, they occur more frequently in children and young adults, and at the higher doses used in prophylaxis of vomiting due to cancer chemotherapy. Dystonic reactions may start within minutes after start of intravenous therapy and disappear within 24 hours after discontinuation of metoclopramide. Onset of parkinsonian symptoms may vary from a few weeks to several months after initiation of therapy; symptoms are reversible upon discontinuation of metoclopramide.

With high doses Agitation (unusual nervousness, restlessness, or irritability) panic-like sensation restless legs syndrome (aching or discomfort in lower legs or sensation of crawling in legs) Note: These effects may occur within minutes of receiving high doses of metoclopramide and may last for 2 to 24 hours.

Overdose For specific information on the agents used in the management of metoclopramide overdose, see: • Diphenhydramine in Antihistamines (Systemic) monograph; and/or • Methylene Blue (Systemic) monograph. For more information on the management of overdose or unintentional ingestion, contact a Poison Control Center (see Poison Control Center Listing ). Clinical effects of overdose Symptoms are self-limiting and usually disappear within 24 hours.

The following have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive: Confusion drowsiness, severe extrapyramidal effects, severe seizures

To decrease absorption: Dialysis is not likely to be an effective method of drug removal in overdose situations; hemodialysis and continuous ambulatory peritoneal dialysis do not remove significant amounts of metoclopramide.

Specific treatment: Anticholinergic or antiparkinson drugs or antihistamines with anticholinergic properties (50 mg of diphenhydramine administered intramuscularly in adults and 1 mg per kg of body weight [mg/kg] intramuscularly or intravenously in infants and children ) to help in controlling the extrapyramidal reactions.

Methylene blue (1 to 2 mg/kg of a 1% solution injected intravenously over a 5-minute period) is used to reverse methemoglobinemia resulting from metoclopramide administration in premature and full-term infants.

Supportive care: Patients in whom intentional overdose is confirmed or suspected should be referred for psychiatric consultation.

Patient Consultation As an aid to patient consultation, refer to Advice for the Patient, Metoclopramide (Systemic) .

In providing consultation, consider emphasizing the following selected information ( » = major clinical significance): Before using this medication » Conditions affecting use, especially: Sensitivity to metoclopramide, procaine, or procainamide

Breast-feeding—Distributed into breast milk

Use in children—Extrapyramidal effects more likely; increased risk of methemoglobinemia in premature and full-term infants

Use in the elderly—Extrapyramidal effects more likely Other medications, especially alcohol and CNS depressants Other medical problems, especially epilepsy; gastrointestinal bleeding, mechanical obstruction, or perforation; pheochromocytoma; or severe renal function impairment Proper use of this medication » Taking 30 minutes before meals and at bedtime (for oral dosage forms)

» Not taking more medication than the amount prescribed

» Proper administration of metoclopramide oral solution (concentrate): Mix with liquid or semi-solid food, such as water, juices, soda or soda-like beverages, applesauce, and puddings

» Proper dosing Missed dose: Using as soon as possible; not using if almost time for next dose

» Proper storage Precautions while using this medication » Avoiding use of alcohol or other CNS depressants

» Caution if drowsiness occurs

Side/adverse effects Signs of potential side effects, especially agranulocytosis, cardiovascular effects, extrapyramidal effects, and tardive dyskinesia

General Dosing Information In patients with severe renal function impairment (i. e. creatinine clearance < 40 mL per minute), the normally prescribed dose should be reduced by 50%, since adverse effects are more likely to be exacerbated. For parenteral dosage forms only Intravenous injections of metoclopramide should be made slowly over a 1- to 2-minute period, since a transient but intense feeling of anxiety and restlessness followed by drowsiness may occur with rapid administration.

Intravenous infusion should be made slowly over a period of not less than 15 minutes. Metoclopramide injection may be diluted for intravenous infusion with 50 mL of 5% dextrose in water, sodium chloride injection, 5% dextrose in 0.45% sodium chloride, Ringer's injection, or lactated Ringer's injection.

For treatment of adverse effects and/or overdose Recommended treatment for metoclopramide's adverse effects and/or overdose includes:

• Anticholinergic or antiparkinson drugs or antihistamines with anticholinergic properties (50 mg of diphenhydramine administered intramuscularly in adults and 1 mg per kg of body weight [mg/kg] intramuscularly or intravenously in infants and children ) to help in controlling the extrapyramidal reactions. • Methylene blue (1 to 2 mg/kg of a 1% solution injected intravenously over a 5-minute period) is used to reverse methemoglobinemia resulting from metoclopramide administration in premature and full-term infants.

Oral Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U. S. product labeling.

The dosing and strengths of the dosage forms available are expressed in terms of metoclopramide base. METOCLOPRAMIDE ORAL SOLUTION USP Usual adult and adolescent dose Treatment of diabetic gastroparesis 1 Oral, 10 mg (base) thirty minutes before symptoms are likely to occur or before each meal and at bedtime, up to four times a day.

Note: In the initial treatment of diabetic gastroparesis, the parenteral route of administration is recommended if severe symptoms are present. Therapy may begin at 10 mg (base) administered intramuscularly or intravenously three or four times a day, the dose adjusted as needed.

Treatment of gastroesophageal reflux 1 Oral, 10 to 15 mg (base) thirty minutes before symptoms are likely to occur or before each meal and at bedtime, up to four times a day.

Note: Intermittent symptoms may be treated by taking 20 mg of metoclopramide prior to the provoking situation.

[Treatment of hiccups] 1 Oral, 10 to 20 mg (base) four times a day for seven days. An initial dose of 10 mg intramuscularly may be given if necessary.

Note: In patients with renal function impairment whose creatinine clearance is less than 40 mL per minute, initial dosage should be reduced by approximately one half .

Usual adult and adolescent prescribing limits 500 mcg (0.5 mg) per kg of body weight per day. Usual pediatric dose Gastrointestinal emptying (delayed) adjunct or Peristaltic stimulant Oral, 0.1 to 0.2 mg per kg of body weight per dose, given thirty minutes before meals and at bedtime.

Strength(s) usually available U. S.—

5 mg (base) per 5 mL (Rx) [ Reglan ][Generic]

5 mg (base) per 5 mL (Rx) [ Maxeran ] [ Reglan ] Packaging and storage: Store between 20 and 25 °C (68 and 77 °F), in a tight container, unless otherwise specified by manufacturer. Protect from light. Protect from freezing. Auxiliary labeling: • May cause drowsiness. • Avoid alcoholic beverages.

10 mg (base) per 1 mL (Rx) [ Metoclopramide Intensol (calibrated dropper enclosed) (sodium benzoate) (sorbitol)]

Canada— Not commercially available. Packaging and storage: Store between 15 and 30 °C (59 and 86 °F), in a tight container, unless otherwise specified by manufacturer. Protect from light. Protect from freezing. Preparation of dosage form: Each dose should be mixed with liquid or semi-solid food such as water, juices, soda or soda-like beverages, applesauce, or puddings . Auxiliary labeling: • Dilute before use. • May cause drowsiness. • Avoid alcoholic beverages.

5 mg (Rx) [ Reglan (scored)][Generic]

10 mg (Rx) [ Octamide ] [ Reglan (scored)][Generic]

5 mg (Rx) [ Apo-Metoclop ] [ Maxeran ] [ PMS-Metoclopramide ] [ Reglan ]

10 mg (Rx) [ Apo-Metoclop ] [ Maxeran (scored)] [ PMS-Metoclopramide ] [ Reglan ] Packaging and storage: Store between 20 and 25 °C (68 and 77 °F), unless otherwise specified by manufacturer. Store in a tight, light-resistant container. Auxiliary labeling: • May cause drowsiness. • Avoid alcoholic beverages.

Parenteral Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U. S. product labeling. METOCLOPRAMIDE INJECTION USP Usual adult and adolescent dose Gastrointestinal emptying (delayed) adjunct or Peristaltic stimulant Intravenous, 10 mg as a single dose.

[Treatment of hiccups] 1 Intramuscular, 10 mg initially, followed by oral metoclopramide at a dose of 10 to 20 mg four times a day for seven days.

Antiemetic: For prevention of cancer chemotherapy–induced emesis Intravenous infusion, 2 mg per kg of body weight, administered thirty minutes before cisplatin or other highly emetogenic chemotherapeutic agent; may be repeated as needed every two or three hours.

Note: For prevention of emesis induced by chemotherapeutic agents with low emetic potential—Intravenous infusion, 1 mg per kg of body weight.

Continuous intravenous infusion, 3 mg per kg of body weight before chemotherapy, followed by 0.5 mg per kg of body weight per hour for eight hours.

Antiemetic: For prevention of postoperative emesis Intramuscular, 10 to 20 mg near the end of surgery.

Usual pediatric dose Antiemetic—For prevention of cancer chemotherapy–induced emesis or Gastrointestinal emptying (delayed) adjunct or Peristaltic stimulant Intravenous, 1 mg per kg of body weight as a single dose. May be repeated one time after sixty minutes.

Note: To reduce the chance of increased adverse reactions, dosages should not exceed 2 mg per kg of body weight. Some clinicians recommend concurrent therapy with diphenhydramine at an intravenous dose of 1 mg per kg of body weight 15 minutes prior to metoclopramide infusion to limit side effects that may occur with doses of less than 2 mg per kg of body weight.

Strength(s) usually available U. S.—

5 mg per mL (Rx) [ Reglan ][Generic]

5 mg per mL (Rx) [ Reglan ] Packaging and storage: Store between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Protect from light (if injection does not contain an antioxidant). Preparation of dosage form: Doses of Metoclopramide Injection USP in excess of 10 mg may be mixed with 50 mL of 0.9% sodium chloride injection, 5% dextrose injection, 5% dextrose in 0.45% sodium chloride injection, Ringer's injection, or lactated Ringer's injection. Stability: Unused portion should be discarded.

Dilutions of metoclopramide injection may be stored for up to 48 hours after preparation if protected from light, or 24 hours if not protected from light.

Dilutions of metoclopramide and 0.9% sodium chloride may be stored frozen for up to 4 weeks after preparation. Incompatibilities: Metoclopramide injection is incompatible with calcium gluconate, cephalothin sodium . chloramphenicol sodium . cisplatin, erythromycin lactobionate, furosemide, methotrexate, penicillin G potassium, and sodium bicarbonate .

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Kolodzik P, Eilers M. Hiccups (singultus): Review and approach to management. Ann Emerg Med 1991; 10(5): 565-73.

AHFS, 1991.

Goodman & Gilman's Pharmacologic basis of therapeutics, 1990: 928-9.

Fozard J, Mobarok A. Blockade of neuronal tryptamine receptors by metoclopramide. Eur J Pharmacol 1978; 49: 109-12.

Panel consensus, 1991 revision cycle.

Panelist comment, 1991 revision cycle.

Marty M, Pouillart P, Scholl S, Droz J, Azab M, Brion N, et al. Comparison of the 5-hydroxytryptamine (serotonin) antagonist ondansetron (GR38032F) with high-dose metoclopramide in the control of cisplatin-induced emesis. N Eng J Med 1990; 322: 816-21.

Panelist comment, 1991 revision cycle.

Howrie D, Felix C, Wollman M, Juhl R, Blatt J. Metoclopramide as an emetic agent in pediatric oncology patients. DICP 1986; 20: 122-4.

DeMulder P, Seynaeve C, Vermorken J, van Liessum P, Mols-Jevdevic S, Allman E, et al. Ann Int Med 1990; 113(11): 834-9.

Panelist comment, 1991 revision cycle.

Panelist comment, 1991 revision cycle.

Trissel's Handbook on Injectable Drugs, 1988, 5th Edition.

Hyman P, Abrams C, Dubois A. Gastric emptying in infants: response to metoclopramide depends on the underlying condition. J Pediatr Gastroenterol Nutr 1988; 7(2): 181-4.

Medical Toxicology, Diagnosis and Treatment of Human Poisonings, Elsevier Science Publishing Co, 1988.

Panel comment, 1991 revision cycle.

Parkes J, DeBono A, Marsden C. Bromocriptine in Parkinsonism: long-term treatment, dose response, and comparison with levodopa. J Neurol Neurosurg Psychiatry 1976; 39(11): 1101-8.

Panelist ballot, 1991 revision cycle.

Panelist comment, 1991 revision cycle.

Maxeran product monograph (Nordic Laboratories—Canada), Rev 10/20/92, Rec 3/27/97.

Metaclopramide package insert (Watson Laboratories—U. S.), Rev 3/10/95, Rec 8/27/96.

Reglan package insert (A. H. Robins—U. S.), Rev 2/94, Rec 5/10/96.

pms-Metoclopramide product monograph (Pharmascience—Canada), Rev 12/30/96, Rec 3/19/97.

Metoclopramide Oral Solution USP and Intensol package inserts (Roxane—U. S.), Rev. 1/95, Rec 7/98.

Aciclovir - Anti Viral, Acilomin

Common use Aciclovir is an antiviral drug, it is a synthetic ingredient with a similar molecular structure to purine nucleoside. Aciclovir is used to treat viral infections such as cold sores, to stop the growth of Herpes simplex virus, Varicella zoster virus (caused by chickenpox and shingles), Epstein Barr Virus (caused by glandular fever), and to a lesser extent Cytomegalovirus (CMV). It is also useful in preventing genital herpes and in preventing viral infections occurring in those with a lowered immune system. This medication may also help reduce the time when pain remains after the sores heal. In addition, in people with a weakened immune system, Aciclovir can decrease the risk of the virus spreading to other parts of the body and causing serious infections.

Dosage and direction

Take this medication by mouth with or without food, usually 2 to 5 times a day as directed by your doctor. Take this medicine by mouth with a glass of water. Take your medicine at regular intervals. Do not take your medicine more often than directed. Take all of your medicine as directed even if you think your are better. If you are using the liquid form of this medication, shake the bottle well before each dose. Carefully measure the dose using a special measuring device/spoon. Do not use a household spoon because you may not get the correct dose. Dosage is based on your medical condition and response to treatment. In children, dosage is also based on weight.

You should talk with your healthcare provider prior to taking Aciclovir if you have kidney disease, including kidney failure (renal failure), any allergies, including allergies to food, dyes, or preservatives. Let your healthcare provider know if you are pregnant or thinking of becoming pregnant, breastfeeding. Make sure to tell your healthcare provider about all medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. The medication passes through breast milk. Therefore, if you are breastfeeding or plan to start, discuss this with your healthcare provider prior to taking the drug.

Aciclovir Injection is contraindicated for patients who develop hypersensitivity to Acilomin or valaciclovir.

Possible side effects Side effects are potentially serious and you should report to your doctor or health care professional as soon as possible. These include, but are not limited to: allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue, chest pain, confusion, hallucinations, tremor, dark urine, increased sensitivity to the sun, redness, blistering, peeling or loosening of the skin (including inside the mouth), seizures, trouble passing urine or change in the amount of urine, unusual bleeding or bruising, or pinpoint red spots on the skin, unusually weak or tired, yellowing of the eyes or skin. Side effects that usually do not require medical attention: diarrhea, fever, headache, nausea, vomiting stomach upset. In this way report to your doctor or health care professional if they continue or are bothersome.

Drug interactions There are negative interactions that can occur when Aciclovir is combined with any of the drugs listed above. Phenytoin (Fosphenytoin) and Aciclovir: it may decrease the level of phenytoin in your blood, perhaps making it less effective. Your healthcare provider may need to measure the level of phenytoin in your blood (using a blood test) and adjust your dose as necessary. Probenecid can increase the level of Aciclovir in your blood, increasing your risk of acyclovir side effects. Your healthcare provider may need to decrease your acyclovir dosage to prevent this interaction from occurring. Acyclovir can increase the level of Tenofovir in your blood, potentially increasing your risk of side effects. Your healthcare provider may need to lower your tenofovir dosage to prevent drug interactions.

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

Seek emergency medical attention if you think you have used too much of this medicine. Overdose symptoms may include seizure (convulsions), hallucinations, and urinating less than usual or not at all.

Store at controlled room temperature of 15°C to 25°C (59°F to 77°F). Keep this medicine out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Disclaimer We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information on the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

Fluoxetine Oral Uses, Side Effects, Interactions, Pictures, Warnings - Dosing, Flutine

fluoxetine

GENERIC NAME(S): FLUOXETINE HCL

Warnings

Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially people younger than 25) who take antidepressants for any condition may experience worsening depression. other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for people younger than 25), even if treatment is not for a mental/mood condition.

Tell the doctor right away if you notice worsening depression /other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety. panic attacks. trouble sleeping. irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Uses

This medication may improve your mood, sleep. appetite, and energy level and may help restore your interest in daily living. It may decrease fear, anxiety. unwanted thoughts, and the number of panic attacks. It may also reduce the urge to perform repeated tasks (compulsions such as hand-washing, counting, and checking) that interfere with daily living. Fluoxetine may lessen premenstrual symptoms such as irritability, increased appetite, and depression. It may decrease binging and purging behaviors in bulimia .

OTHER USES: This section contains uses of this drug that are not listed in the approved professional labeling for the drug but that may be prescribed by your health care professional. Use this drug for a condition that is listed in this section only if it has been so prescribed by your health care professional.

How to use fluoxetine

Read the Medication Guide provided by your pharmacist before you start using fluoxetine and each time you get a refill. If you have any questions, ask your doctor or pharmacist.

Take this medication by mouth as directed by your doctor, usually once daily in the morning. If you are taking this medication twice a day, your doctor may direct you to take it in the morning and at noon.

If you are taking fluoxetine for premenstrual problems, your doctor may direct you to take it every day of the month or just for the 2 weeks before your period through the first full day of your period. To help you remember, mark your calendar.

If you are using the liquid form of this medication, measure the dose carefully using a special measuring device/spoon. Do not use a household spoon because you may not get the correct dose.

The dosage is based on your medical condition and response to treatment. To reduce your risk of side effects, your doctor may direct you to start this medication at a low dose and gradually increase your dose. Follow your doctor's instructions carefully. Take this medication regularly to get the most benefit from it. To help you remember, take it at the same time each day.

It is important to continue taking this medication as prescribed even if you feel well. Do not stop taking this medication without first consulting your doctor. Some conditions may become worse when the drug is abruptly stopped. Your dose may need to be gradually decreased.

You should see some improvement in 1 to 2 weeks. It may take 4 to 5 weeks before you feel the full benefit.

Tell your doctor if your condition does not improve or if it worsens.

Side Effects

See also Warning section.

Nausea. drowsiness, dizziness. anxiety, trouble sleeping, loss of appetite, tiredness, sweating. or yawning may occur. If any of these effects persist or worsen, tell your doctor promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor right away if any of these unlikely but serious side effects occur: unusual or severe mental/mood changes (such as agitation, unusual high energy/excitement, thoughts of suicide), easy bruising/bleeding, muscle weakness /spasm, shakiness (tremor), decreased interest in sex. changes in sexual ability, unusual weight loss. large pupils.

Get medical help right away if you have any very serious side effects, including: bloody/black/tarry stools, vomit that looks like coffee grounds, fast/irregular heartbeat. fainting. seizures. change in amount of urine, eye pain /swelling/redness, vision changes (such as seeing rainbows around lights at night, blurred vision ).

If you have diabetes. fluoxetine may affect your blood sugar levels. Monitor your blood sugar regularly and share the results with your doctor. Your doctor may need to adjust your medication, diet, and exercise when you start or stop fluoxetine.

This medication may increase serotonin and rarely cause a very serious condition called serotonin syndrome/toxicity. The risk increases if you are also taking other drugs that increase serotonin, so tell your doctor or pharmacist of all the drugs you take (see Drug Interactions section). Get medical help right away if you develop some of the following symptoms: fast heartbeat, hallucinations, loss of coordination, severe dizziness, severe nausea/vomiting/diarrhea, twitching muscles, unexplained fever, unusual agitation/restlessness.

Rarely, males may have a painful or prolonged erection lasting 4 or more hours. If this occurs, stop using this drug and get medical help right away, or permanent problems could occur.

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www. fda. gov/medwatch.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Precautions

Before taking fluoxetine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: personal or family history of bipolar/manic-depressive disorder, personal or family history of suicide attempts, liver problems, diabetes, low sodium in the blood (such as may occur while taking "water pills" - diuretics), severe loss of body water (dehydration), seizures, stomach/intestinal ulcers, personal or family history of glaucoma (angle-closure type).

This drug may make you dizzy or drowsy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Avoid alcoholic beverages.

Fluoxetine may cause a condition that affects the heart rhythm (QT prolongation). QT prolongation can rarely cause serious (rarely fatal) fast/irregular heartbeat and other symptoms (such as severe dizziness, fainting) that need medical attention right away.

The risk of QT prolongation may be increased if you have certain medical conditions or are taking other drugs that may cause QT prolongation. Before using fluoxetine, tell your doctor or pharmacist of all the drugs you take and if you have any of the following conditions: certain heart problems (heart failure, slow heartbeat, QT prolongation in the EKG), family history of certain heart problems (QT prolongation in the EKG, sudden cardiac death).

Low levels of potassium or magnesium in the blood may also increase your risk of QT prolongation. This risk may increase if you use certain drugs (such as diuretics/"water pills") or if you have conditions such as severe sweating, diarrhea, or vomiting. Talk to your doctor about using this medication safely.

The liquid form of this medication contains alcohol. Caution is advised if you have diabetes, alcohol dependence, or liver disease. Some medications (such as metronidazole, disulfiram) can cause a serious reaction when combined with alcohol. Ask your doctor or pharmacist about using this product safely.

Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).

Older adults may be more sensitive to the side effects of this drug, especially bleeding and QT prolongation (see above). Older adults may also be more likely to develop low sodium in the blood, especially if they are taking "water pills" (diuretics).

During pregnancy, this medication should be used only when clearly needed. It may harm an unborn baby. Also, babies born to mothers who have used this drug during the last 3 months of pregnancy may rarely develop withdrawal symptoms such as feeding/breathing difficulties, seizures, muscle stiffness, or constant crying. If you notice any of these symptoms in your newborn, tell the doctor promptly.

Since untreated mental/mood problems (such as depression, panic attacks, obsessive compulsive disorder) can be a serious condition, do not stop taking this medication unless directed by your doctor. If you are planning pregnancy, become pregnant, or think you may be pregnant, immediately discuss the benefits and risks of using this medication during pregnancy with your doctor.

This drug may pass into breast milk and could have undesirable effects on a nursing infant. Consult your doctor before breast-feeding.

Interactions

Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

Fluoxetine can stay in your body for many weeks after your last dose and may interact with many other medications. Before using any medication, tell your doctor or pharmacist if you have taken fluoxetine in the previous 5 weeks.

Some products that may interact with this drug include: drugs removed from your body by certain liver enzymes including carbamazepine, vinblastine, antiarrhythmics such as propafenone/flecainide, tricyclic antidepressants such as desipramine/imipramine, other drugs that can cause bleeding/bruising including antiplatelet drugs such as clopidogrel, NSAIDs such as ibuprofen, "blood thinners" such as warfarin.

Taking MAO inhibitors with his medication may cause a serious (possibly fatal) drug interaction. Avoid taking MAO inhibitors (isocarboxazid, linezolid, methylene blue, moclobemide, phenelzine, procarbazine, rasagiline, selegiline, tranylcypromine) during treatment with this medication. Most MAO inhibitors should also not be taken for 2 weeks before and at least 5 weeks after treatment with this medication. Ask your doctor when to start or stop taking this medication.

Many drugs besides fluoxetine may affect the heart rhythm (QT prolongation), including pimozide and thioridazine, among others.

Aspirin can increase the risk of bleeding when used with this medication. However, if your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually at dosages of 81-325 milligrams a day), you should continue taking it unless your doctor instructs you otherwise.

The risk of serotonin syndrome/toxicity increases if you are also taking other drugs that increase serotonin. Examples include street drugs such as MDMA/"ecstasy," St. John's wort, certain antidepressants (including other SSRIs such as citalopram/paroxetine, SNRIs such as duloxetine/venlafaxine), tryptophan, among others. The risk of serotonin syndrome/toxicity may be more likely when you start or increase the dose of these drugs.

Tell your doctor or pharmacist if you are taking other products that cause drowsiness including alcohol, antihistamines (such as cetirizine, diphenhydramine), drugs for sleep or anxiety (such as alprazolam, diazepam, zolpidem), muscle relaxants, and narcotic pain relievers (such as codeine). Check the labels on all your medicines (such as allergy or cough-and-cold products) because they may contain ingredients that cause drowsiness. Ask your pharmacist about using those products safely.

This medication may interfere with certain medical/laboratory tests (including brain scan for Parkinson's disease), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.

Overdose

If overdose is suspected, contact a poison control center or emergency room right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: severe dizziness, fainting.

Notes

Do not share this medication with others.

Keep all regular medical and psychiatric appointments.

Missed Dose

If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Storage

Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

Information last revised October 2015. Copyright(c) 2015 First Databank, Inc.

Images

Invasive Species Aquatic Species - Giant Reed (Arundo Donax), Donaz

Review of Giant Reed ( Arundo donax ) (PDF | 34 KB) Alabama Invasive Plant Council .

Invasive Plants of California's Wildlands - Arundo donax California Invasive Plant Council. Bossard, C. C. J. M. Randall, and M. C. Hoshovsky (Editors). 2000. Invasive Plants of California's Wildlands. University of California Press. Berkeley, CA .

Fact Sheet: Phragmites (Apr 2016; PDF | 1.2 MB) Alberta Invasive Species Council (Canada). See also: Fact Sheets for more information about individual invasive species, including those listed as "Prohibited Noxious" and "Noxious" under the Alberta Weed Control Act.

Pacific Island Ecosystems at Risk (PIER) - Arundo donax USDA. FS. Institute of Pacific Islands Forestry.

Texas Invasives Database - Arundo donax TexasInvasives. org.

Invasive Species Compendium - Arundo donax CAB International.

Plantwise Technical Factsheet - Giant Reed ( Arundo dona x) CABI. Plantwise Knowledge Bank.

Global Invasive Species Database - Arundo donax (grass) IUCN. Species Survival Commission. Invasive Species Specialist Group.

U. S. National Plant Germplasm System - Arundo donax USDA. ARS. National Genetic Resources Program. GRIN-Global.

Fire Effects Information System (FEIS) - Arundo donax USDA. FS. Rocky Mountain Research Station. Fire Sciences Laboratory.

Weeds in Australia - Giant Reed ( Arundo donax ) Australian Government. Department of the Environment and Energy .

Noxious Weed Species - Giant Reed Colorado Department of Agriculture. Conservation Services Division. Noxious Weed Program.

Giant Reed, Arundo donax (Poaceae) University of California, Riverside. Center for Invasive Species Research .

Giant Reed University of California, Santa Barbara. Riparian Invasion Research Laboratory .

AQUAPLANT - Giant Reed Texas A&M University. AgriLife Extension Service. Department of Wildlife and Fisheries Sciences .

Arundo donax (Giant Reed) East African Network for Taxonomy .

Plants of Hawaii - Arundo donax (Jan 2003; PDF | 21 KB) Hawaiian Ecosystems at Risk.

Review of Giant Reed ( Arundo donax ) (PDF | 34 KB) Alabama Invasive Plant Council .

Invasive Plants of California's Wildlands - Arundo donax California Invasive Plant Council. Bossard, C. C. J. M. Randall, and M. C. Hoshovsky (Editors). 2000. Invasive Plants of California's Wildlands. University of California Press. Berkeley, CA .

Fact Sheet: Phragmites (Apr 2016; PDF | 1.2 MB) Alberta Invasive Species Council (Canada). See also: Fact Sheets for more information about individual invasive species, including those listed as "Prohibited Noxious" and "Noxious" under the Alberta Weed Control Act.

Pacific Island Ecosystems at Risk (PIER) - Arundo donax USDA. FS. Institute of Pacific Islands Forestry.

Texas Invasives Database - Arundo donax TexasInvasives. org.

Invasive Species Compendium - Arundo donax CAB International.

Plantwise Technical Factsheet - Giant Reed ( Arundo dona x) CABI. Plantwise Knowledge Bank.

Global Invasive Species Database - Arundo donax (grass) IUCN. Species Survival Commission. Invasive Species Specialist Group.

U. S. National Plant Germplasm System - Arundo donax USDA. ARS. National Genetic Resources Program. GRIN-Global.

Fire Effects Information System (FEIS) - Arundo donax USDA. FS. Rocky Mountain Research Station. Fire Sciences Laboratory.

Weeds in Australia - Giant Reed ( Arundo donax ) Australian Government. Department of the Environment and Energy .

Noxious Weed Species - Giant Reed Colorado Department of Agriculture. Conservation Services Division. Noxious Weed Program.

Giant Reed, Arundo donax (Poaceae) University of California, Riverside. Center for Invasive Species Research .

Giant Reed University of California, Santa Barbara. Riparian Invasion Research Laboratory .

AQUAPLANT - Giant Reed Texas A&M University. AgriLife Extension Service. Department of Wildlife and Fisheries Sciences .

Arundo donax (Giant Reed) East African Network for Taxonomy .

Plants of Hawaii - Arundo donax (Jan 2003; PDF | 21 KB) Hawaiian Ecosystems at Risk.

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Die Level spielen in der Therapie des Mammakarzinoms eine Rolle. Weitere Lymphabflusse bestehen uber Nodi lymphatici intercostales und Nodi lymphatici mediastinales posteriores sowie Nodi lymphatici supraclaviculares. Die Brustdruse wird innerviert durch die Rr.

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Diese Mundung, der au?ere Muttermund, ist bei Nulliparae grubchenformig. Ventral ist der Uterus bis zur Korpus-Zervix-Grenze von Peritoneum bedeckt, das hier auf die Harnblase umschlagt und die Excavatio vesicouterina bildet.

Articulos de interes:

Logastric Indication, Action Of Logastric, Interactions, Logastric

Logastric [in more detail]

Logastric Mechanism Of Action:

Logastric is a proton pump inhibitor that suppresses gastric acid secretion by specific inhibition of the H + /K + - ATPase in the gastric parietal cell. By acting specifically on the proton pump, omeprazole blocks the final step in acid production, thus reducing gastric acidity.

Logastric Drug Interactions:

Alprazolam Logastric increases the effect of benzodiazepine Diazepam Logastric increases the effect of benzodiazepine Clonazepam Logastric increases the effect of benzodiazepine Clorazepate Logastric increases the effect of benzodiazepine Chlordiazepoxide Logastric increases the effect of benzodiazepine Estazolam Logastric increases the effect of benzodiazepine Flurazepam Logastric increases the effect of benzodiazepine Halazepam Logastric increases the effect of benzodiazepine Ketazolam Logastric increases the effect of benzodiazepine Midazolam Logastric increases the effect of benzodiazepine Prazepam Logastric increases the effect of benzodiazepine Quazepam Logastric increases the effect of benzodiazepine Triazolam Logastric increases the effect of benzodiazepine Mephenytoin Logastric increases the effect of hydantoin Phenytoin Logastric increases the effect of hydantoin Fosphenytoin Logastric increases the effect of hydantoin Ethotoin Logastric increases the effect of hydantoin Voriconazole Voriconazole increases the effect and toxicity of omeprazole St. John's Wort St. John's Wort decreases the levels/effects of omeprazole Methotrexate Logastric increases the levels of methotrexate Cilostazol Logastric increases the effect of cilostazol Atazanavir This gastric pH modifier decreases the levels/effects of atazanavir Cyclosporine Logastric increases the effect and toxicity of cyclosporine Dasatinib Possible decreased levels of dasatinib Enoxacin The agent decreases the absorption of enoxacin Indinavir Logastric decreases the absorption of indinavir Itraconazole The proton pump inhibitor decreases the absorption of the imidazole Ketoconazole The proton pump inhibitor decreases the absorption of the imidazole Disopyramide The beta-blocker increases toxicity of disopyramide

Food Interactions:

Avoid alcohol. Take 30-60 minutes before meals.

Logastric Chemical Formula:

Appeton - Health For Life, Apeton

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Ranitidine - Xpharm The Comprehensive Pharmacology Reference, Ranimerck

Ranitidine

Nomenclature

Name of the Clinical Form

Related Names Source: EMTREE

Aciloc; Acloral; Aducin; AH-19065; Alquen; Antagon; Antagonin; Antak; Alter-H 2 ; Alvidina; Anistal; Antanidina; Apozan; Apoprin; Artonil; Ausran; Avintac; Azantac; Azuranit; Baroxal; Cauteridol; Coralen; Credaxol; d 14951; Danitin; Denulcer; Digestosan; Dinaxin; EINECS266-332-5; Esofex; Fagus; Galidrin; Gastran; Gastrec; Gastridina; Gastrolav; Gastrulcer; Gasyran; Histac; Histak; HSDB 3925; Indigestion Relief; Inside; Iqfadina; Katalem; Kuracid; Label; Lake; Logat; Lumaren; Melfax; Meticel; Microdit; Microtid; Neugal; Noctone; Novo-Ranidine; Nu-Rantit; Pep-Rani; Peptic Relief; Ppetab; Pertifar; Quantor; Quardin; Radan; Radine; Radyn; Ran; Ran H2; Ranacid; Ranaps; Ranepal; Rani; Rani 2; Raniben; Raniberi; Ranibeta; Ranibloc; Ranic; Ranicodan; Ranicur; Ranicux; Ranidil; Ranidin; Ranidine; Ranidura; Ranidura T; Ranifarma; Ranifur; Ranigast; Ranihexal; Ranikur; Ranil; Ranilonga; Ranimed; Ranimerck; Ranimex; Rani-nerton; Raniplex; Raniprotect; Rani-Q; Ranisan; Ranisen; Ranitic; Ranitidina; Ranitidine; Ranitidine hydrochloride; Ranitidinum; Ranitil; Ranitine; Ranivel; Ranix; Ranixal; Ran Lich; Ranoxyl; Rantec; Ranteen; Ranuber; Ranulin; Ranzil; Rantag; Ratic; Ratica; Raudil; Redacid; Regalil; Rubiulcer; Serranit; Serviradine; Simetac; Sinhcloran; Sirani; Sostril; Stacer; Suronit; Syntidine; Tanidina; Taural; Terposen; Toriol; Trigger; Ulcaid; Ulcecur; Ulcedin; Ulceran; Ulcerol; Ulcex; Ulcidine; Ulcirex; Ulcolind Rani; Ulcoren; Ulcocur; Ulkodin; Ulsal; Ulsavin; Ultidine; Ultran; Xanidine; Zadine; Zaedoc; Zanidex; Zanidin; Zanamet; Zantab; Zantac; Zantac 75; Zantic; Zantidon; Zendhin; Zerandin; Zidac; Zinetac; Zoran; Zylium; Zantac (trade); aciloc; ah 19065; ah19065; antagonin; azantac; baroxal; coralen; d14951; gastran; histac; lumaren; n [2 [[5 [(dimethylamino)methyl]furfuryl]thio]ethyl] n' methyl 2 nitro 1,1 ethenediamine; ranidil; ranidura; ranigast; raniplex; ranisan; ranitidin; ranitidine hydrochloride; ranitine; ranuber; retamin; sostril; toriol; ulceran; ulcocur; ulsal; ultidine; zantac; zantac 75; zantic; zinetac

N-[2-[[[-5-[(Dimethylamino)methyl]-2-furanyl]methyl]thio]ethyl]-N'-methyl-2-nitro-1,1-ethenediaminehydrochloride; n [2 [[5 [(dimethylamino)methyl]furfuryl]thio]ethyl] n' methyl2 nitro 1,1 ethenediamine; NN-Dimethyl-5-[2-(1-methylamino-2-nitrovinylamino)ethylthiomethyl]furfurylamine

Copyright © 2007 Elsevier Inc. All rights reserved.

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Copyright © 2016 Elsevier B. V. or its licensors or contributors. ScienceDirect ® is a registered trademark of Elsevier B. V.

Cipro Oral Uses, Side Effects, Interactions, Pictures, Warnings - Dosing, Ciprol

Cipro

Warnings

This medication may rarely cause tendon damage (such as tendonitis. tendon rupture) during or after treatment. Your risk for tendon problems is greater if you are over 60 years of age, if you are taking corticosteroids (such as prednisone ), or if you have a kidney. heart. or lung transplant. Stop exercising. rest, and get medical help right away if you develop joint/muscle/tendon pain or swelling.

Ciprofloxacin should not be used by patients with myasthenia gravis. It may cause the condition to become worse. Get medical help right away if you develop muscle weakness or trouble breathing .

Uses

This medication is used to treat a variety of bacterial infections. Ciprofloxacin belongs to a class of drugs called quinolone antibiotics. It works by stopping the growth of bacteria.

This antibiotic treats only bacterial infections. It will not work for virus infections (such as common cold. flu ). Unnecessary use or misuse of any antibiotic can lead to its decreased effectiveness.

How to use Cipro

Read the Medication Guide and, if available, the Patient Information Leaflet provided by your pharmacist before you start taking ciprofloxacin and each time you get a refill. If you have any questions, ask your doctor or pharmacist.

Take this medication by mouth with or without food as directed by your doctor, usually twice a day in the morning and evening.

The tablet may have a bitter taste if you split, chew, or crush it before taking it. The manufacturer recommends swallowing the tablet whole for this reason.

The dosage and length of treatment is based on your medical condition and response to treatment. Drink plenty of fluids while taking this medication unless your doctor tells you otherwise.

Take this medication at least 2 hours before or 6 hours after taking other products that may bind to it, decreasing its effectiveness. Ask your pharmacist about the other products you take. Some examples include: quinapril. sevelamer. sucralfate, vitamins/minerals (including iron and zinc supplements ), and products containing magnesium. aluminum, or calcium (such as antacids, didanosine solution, calcium supplements ).

Calcium - rich foods, including dairy products (such as milk, yogurt) or calcium-enriched juice, can also decrease the effect of this medication. Take this medication at least 2 hours before or 6 hours after eating calcium-rich foods, unless you are eating these foods as part of a larger meal that contains other (non-calcium-rich) foods. These other foods decrease the calcium binding effect.

Ask your doctor or pharmacist about safely using nutritional supplements /replacements with this medication.

Antibiotics work best when the amount of medicine in your body is kept at a constant level. Therefore, take this drug at evenly spaced intervals.

Continue to take this medication until the full prescribed amount is finished, even if symptoms disappear after a few days. Stopping the medication too early may result in a return of the infection.

Tell your doctor if your condition persists or worsens.

Side Effects

See also Warning section.

Nausea. diarrhea. dizziness. lightheadedness, headache. and trouble sleeping may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor right away if you have any serious side effects, including: skin that sunburns more easily (sun sensitivity), unusual bruising/bleeding, signs of a new infection (such as new/persistent fever. persistent sore throat ), signs of kidney problems (such as change in the amount of urine, red/pink urine), signs of liver problems (such as unusual tiredness, stomach /abdominal pain. persistent nausea/vomiting. yellowing eyes /skin, dark urine).

Get medical help right away if you have any very serious side effects, including: severe/persistent headache. vision changes, shaking (tremors), seizures. severe dizziness, fainting. fast/irregular heartbeat. mental/mood changes (such as anxiety. confusion, hallucinations. depression. rare thoughts of suicide ).

Rarely, this medication may cause serious, possibly permanent, nerve problems (peripheral neuropathy). Stop taking ciprofloxacin and tell your doctor right away if you have any of the following symptoms: pain/numbness/burning/tingling/weakness in your arms, hands, legs, or feet, changes in how you sense touch/pain/temperature/vibration/body position.

This medication may rarely cause a severe intestinal condition (Clostridium difficile-associated diarrhea) due to a type of resistant bacteria. This condition may occur during treatment or weeks to months after treatment has stopped. Tell your doctor right away if you develop: persistent diarrhea, abdominal or stomach pain/cramping, blood/mucus in your stool.

Do not use anti-diarrhea products or narcotic pain medications if you have any of these symptoms because these products may make them worse.

Use of this medication for prolonged or repeated periods may result in oral thrush or a new yeast infection. Contact your doctor if you notice white patches in your mouth, a change in vaginal discharge, or other new symptoms.

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www. fda. gov/medwatch.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Precautions

Before taking ciprofloxacin, tell your doctor or pharmacist if you are allergic to it; or to other quinolone antibiotics such as norfloxacin, gemifloxacin, levofloxacin, moxifloxacin, or ofloxacin; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: diabetes, heart problems (such as recent heart attack), joint/tendon problems (such as tendonitis, bursitis), kidney disease, liver disease, myasthenia gravis, nerve problems (such as peripheral neuropathy), seizures, conditions that increase your risk of seizures (such as brain/head injury, brain tumors, cerebral atherosclerosis).

Ciprofloxacin may cause a condition that affects the heart rhythm (QT prolongation). QT prolongation can rarely cause serious (rarely fatal) fast/irregular heartbeat and other symptoms (such as severe dizziness, fainting) that need medical attention right away.

The risk of QT prolongation may be increased if you have certain medical conditions or are taking other drugs that may cause QT prolongation. Before using ciprofloxacin, tell your doctor or pharmacist of all the drugs you take and if you have any of the following conditions: certain heart problems (heart failure, slow heartbeat, QT prolongation in the EKG), family history of certain heart problems (QT prolongation in the EKG, sudden cardiac death).

Low levels of potassium or magnesium in the blood may also increase your risk of QT prolongation. This risk may increase if you use certain drugs (such as diuretics/"water pills") or if you have conditions such as severe sweating, diarrhea, or vomiting. Talk to your doctor about using ciprofloxacin safely.

This medication may rarely cause serious changes in blood sugar levels, especially if you have diabetes. Watch for symptoms of high blood sugar including increased thirst and urination. Ciprofloxacin may increase the blood sugar-lowering effects of the medication glyburide. Also watch for symptoms of low blood sugar such as sudden sweating, shaking, fast heartbeat, hunger, blurred vision, dizziness, or tingling hands/feet. Check your blood sugar regularly as directed by your doctor and report any changes. If you experience symptoms of low blood sugar, you may raise your blood sugar by using glucose tablets/gel or eating a quick source of sugar such as table sugar, honey, or candy, or drinking fruit juice or non-diet soda. Tell your doctor right away about the reaction and the use of this product. To help prevent low blood sugar, eat meals on a regular schedule, and do not skip meals. Your doctor may need to switch you to another antibiotic or adjust your diabetes medications if any reaction occurs.

This drug may make you dizzy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Limit alcoholic beverages.

This medication may make you more sensitive to the sun. Avoid prolonged sun exposure, tanning booths, and sunlamps. Use a sunscreen and wear protective clothing when outdoors. Other medications (such as tretinoin-mequinol) may increase your sun sensitivity. Ask your doctor or pharmacist for more details.

Ciprofloxacin may cause live bacterial vaccines (such as typhoid vaccine) not to work as well. Therefore, do not have any immunizations/vaccinations while using this medication without the consent of your doctor.

Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).

Children may be more sensitive to the side effects of this drug, especially joint/tendon problems.

Older adults may be more sensitive to the side effects of this drug, especially tendon problems (especially if they are also taking corticosteroids such as prednisone or hydrocortisone) and QT prolongation (see above).

During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.

This medication passes into breast milk. Consult your doctor before breast-feeding.

Interactions

See also How to Use and Precautions sections.

Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

Some products that may interact with this drug include: "blood thinners" (such as acenocoumarol, warfarin), strontium.

Many drugs besides ciprofloxacin may affect the heart rhythm (QT prolongation), including amiodarone, dofetilide, quinidine, procainamide, sotalol, among others.

This medication can slow down the removal of other medications from your body, which may affect how they work. Examples of affected drugs include duloxetine, pirfenidone, tasimelteon, tizanidine, among others.

Avoid drinking large amounts of beverages containing caffeine (coffee, tea, colas), eating large amounts of chocolate, or taking over-the-counter products that contain caffeine. This drug may increase and/or prolong the effects of caffeine.

Although most antibiotics are unlikely to affect hormonal birth control such as pills, patch, or ring, a few antibiotics (such as rifampin, rifabutin) can decrease their effectiveness. This could result in pregnancy. If you use hormonal birth control, ask your doctor or pharmacist for more details.

Overdose

If overdose is suspected, contact a poison control center or emergency room right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

Notes

Do not share this medication with others.

This medication has been prescribed for your current condition only. Do not use it later for another infection unless your doctor directs you to do so. A different medication may be necessary in that case.

Laboratory and/or medical tests (such as kidney function, blood counts, cultures) should be performed periodically to monitor your progress or to check for side effects. Consult your doctor for more details.

Do not change brands of this medication without checking with your doctor or pharmacist. Not all brands have the same effects.

Missed Dose

If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Storage

Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

Information last revised May 2016. Copyright(c) 2016 First Databank, Inc.

Images

Selected from data included with permission and copyrighted by First Databank, Inc. This copyrighted material has been downloaded from a licensed data provider and is not for distribution, expect as may be authorized by the applicable terms of use.

CONDITIONS OF USE: The information in this database is intended to supplement, not substitute for, the expertise and judgment of healthcare professionals. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for you or anyone else. A healthcare professional should be consulted before taking any drug, changing any diet or commencing or discontinuing any course of treatment.

Top Picks

ADHD Drug Side Effects

Drug Overdose

Cocktail (Official Trailer), Cotalil

Это видео недоступно.

Cocktail (Official Trailer) | Saif Ali Khan, Deepika Padukone & Diana Penty

Опубликовано: 20 мая 2012 г.

Download all the "Cocktail" uncut Best Movie Scenes and songs here = http://tzeros. co/Xs75At? Cocktail

Illuminati Films & Eros International presents Cocktail. Catch the exclusive Theatrical Trailer of the most awaited film Cocktail, starring Saif Ali Khan, Deepika Padukone & Diana Penty.

Film – Cocktail Music – Pritam Actor – Saif Ali Khan, Deepika Padukone, Diana Penty, Dimple Kapadia Produced by – Saif Ali Khan, Dinesh Vijan Directed by - Homi Adajania

Cocktail is releasing on 13th July 2012.

Категория

V-Gan-50 Injection Uses, Side Effects, Interactions, Pictures, Warnings - Dosing, V-Gan

V-Gan-50 injection

GENERIC NAME(S): PROMETHAZINE HCL

Warnings

Promethazine should not be used in children younger than 2 years because it may cause serious (possibly fatal) slow/shallow breathing. When using this medication in children 2 years and older, use the lowest effective dosage and avoid other drugs that affect breathing. Get medical help right away if slow/shallow breathing occurs.

In children, drugs for nausea should only be used in cases of prolonged vomiting of a known cause. Avoid use of promethazine in children with liver disease (including possible Reye's syndrome ).

This medication can cause severe tissue damage, possibly requiring surgery. Tell your health care professional right away if you have burning, pain, redness, swelling, or numbness at or near the injection site. If this occurs, the injection should be stopped and the injection site checked.

It is preferred that this medication be given by injection into a muscle. There may be an increased risk of side effects if this medication is given by injection into a vein. This medication must not be given by injection under the skin .

Uses

Promethazine is used to prevent and treat nausea and vomiting related to certain conditions (such as before/after surgery, motion sickness). It is also used with other medication to treat severe allergic reactions (anaphylaxis ) and reactions to blood products. It may also be used to treat milder allergic reactions when you cannot take promethazine by mouth. It may also be used to help you feel sleepy/relaxed before and after surgery, during other procedures, or during labor and delivery. It may also be used to help certain narcotic pain relievers (such as meperidine ) work better.

Promethazine is an antihistamine and works by blocking a certain natural substance (histamine ) that your body makes during an allergic reaction. Its other effects (such as anti-nausea, calming, pain relief) may work by affecting other natural substances (such as acetylcholine) and by acting directly on certain parts of the brain .

This drug is not approved for use in children younger than 2 years due to an increased risk of side effects (such as slow/shallow breathing). See also Warning section.

How to use V-Gan-50 injection

See also Warning section.

It is best to inject this medication deep into a muscle. It may also be given by injection slowly into a large vein by a health care professional. Do not inject this medication under the skin or into an artery. For nausea and vomiting, use this medication as directed by your doctor, usually every 4 hours as needed. If you have any questions about the proper use of this medication, ask your doctor or pharmacist.

If you are using this medication at home, learn all preparation and usage instructions from your health care professional. Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. Learn how to store and discard medical supplies safely.

The dosage and how often you receive this medication are based on your age, medical condition, and response to treatment. In children, the dosage may also be based on weight. Do not increase your dose or use this medication more often or for longer than prescribed. Your condition will not improve any faster, and your risk of side effects will increase.

Tell your doctor if you do not get better or if you get worse.

Side Effects

See also Warning section.

Drowsiness, dizziness. constipation. blurred vision. or dry mouth may occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly.

To relieve dry mouth. suck (sugarless) hard candy or ice chips, chew (sugarless) gum, drink water, or use a saliva substitute.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor right away if you have any side effects, including: signs of infection (such as sore throat that doesn't go away, fever, chills), loss of coordination, fainting. confusion, slow heartbeat, shaking (tremor), unusual/uncontrolled movements (such as fixed upward stare, neck twisting, tongue movements), mental/mood changes (such as hallucinations. nervousness, irritability, restlessness, confusion), trouble urinating, easy bleeding/bruising, severe stomach /abdominal pain. yellowing of eyes /skin.

Get medical help right away if you have any very serious side effects, including: slow/shallow breathing, seizures .

This medication may rarely cause a very serious condition called neuroleptic malignant syndrome (NMS). Get medical help right away if you have any of the following symptoms: fever, muscle stiffness/pain/tenderness/weakness. severe tiredness, severe confusion, sweating. fast/irregular heartbeat. dark urine, signs of kidney problems (such as change in the amount of urine).

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash. itching /swelling (especially of the face/tongue /throat), severe dizziness, trouble breathing .

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www. fda. gov/medwatch.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Precautions

See also Warning section.

Before using promethazine, tell your doctor or pharmacist if you are allergic to it; or to any other phenothiazines (such as prochlorperazine ); or if you have any other allergies. This product may contain inactive ingredients (such as sulfites including sodium metabisulfite), which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: breathing problems (such as asthma, chronic obstructive pulmonary disease - COPD, sleep apnea), blood/immune system problems (such as bone marrow depression), high pressure in the eye (glaucoma), heart disease (such as angina, irregular heartbeat), high or low blood pressure. liver disease, certain brain disorders (such as neuroleptic malignant syndrome, Reye's syndrome, seizures), stomach/intestinal problems (such as blockage, ulcer), trouble urinating (for example, due to enlarged prostate).

This drug may make you dizzy or drowsy or cause blurred vision. Do not drive, use machinery, or do any activity that requires alertness or clear vision until you are sure you can perform such activities safely. Avoid alcoholic beverages. Children should be supervised during bicycle riding and other possibly hazardous activities to avoid injury.

Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).

Promethazine may make you more sensitive to the sun. Avoid prolonged sun exposure, tanning booths, and sunlamps. Use a sunscreen and wear protective clothing when outdoors.

This medication may make you sweat less, making you more likely to get heat stroke. Avoid doing things that may cause you to overheat, such as hard work or exercise in hot weather, or using hot tubs. When the weather is hot, drink a lot of fluids and dress lightly. If you overheat, quickly look for a place to cool down and rest. Get medical help right away if you have a fever that does not go away, mental/mood changes, headache, or dizziness.

Older adults may be more sensitive to the side effects of this drug, especially drowsiness, confusion, constipation, or trouble urinating. Drowsiness and confusion can increase the risk of falling.

Children may be more sensitive to the side effects of this drug, especially slowed breathing (see also Warning section). This drug can often cause excitement in young children instead of drowsiness. Special care should be taken when using this medication in children who have lost a lot of fluid (dehydration), those who have a family history of sudden infant death syndrome (SIDS), and those who are hard to wake up from sleep.

During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.

It is unknown if promethazine passes into breast milk. It may have undesirable effects on a nursing infant. Consult your doctor before breast-feeding.

Interactions

Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

Some products that may interact with this drug include: antihistamines applied to the skin (such as diphenhydramine cream, ointment, spray), metoclopramide.

The risk of serious side effects (such as slow/shallow breathing, severe drowsiness/dizziness) may be increased if this medication is used with other products that may also affect breathing or cause drowsiness. Tell your doctor or pharmacist if you are taking other products such as alcohol, antihistamines (such as cetirizine, diphenhydramine), drugs for sleep or anxiety (such as alprazolam, diazepam, zolpidem), muscle relaxants (such as carisoprodol, cyclobenzaprine), and other narcotic pain relievers (such as codeine, hydrocodone).

Check the labels on all your medicines (such as allergy or cough-and-cold products) because they may contain ingredients that cause drowsiness. Ask your pharmacist about using those products safely.

This medication may interfere with certain laboratory tests (including some pregnancy tests, blood sugar tests), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.

Overdose

If overdose is suspected, contact a poison control center or emergency room right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: severe drowsiness/dizziness, fainting, slow/shallow breathing, seizures, muscle stiffness/twitching, widened pupils. In children, mental/mood changes (such as restlessness, irritability, hallucinations) may occur before drowsiness.

Notes

Do not share this medication with others.

Missed Dose

If you are using this medication on a regular schedule and you miss a dose, use it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Use your next dose at the regular time. Do not double the dose to catch up.

Storage

Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

Information last revised October 2015. Copyright(c) 2015 First Databank, Inc.

Images

No data available at this time.

Selected from data included with permission and copyrighted by First Databank, Inc. This copyrighted material has been downloaded from a licensed data provider and is not for distribution, expect as may be authorized by the applicable terms of use.

CONDITIONS OF USE: The information in this database is intended to supplement, not substitute for, the expertise and judgment of healthcare professionals. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for you or anyone else. A healthcare professional should be consulted before taking any drug, changing any diet or commencing or discontinuing any course of treatment.

Top Picks

ADHD Drug Side Effects

Drug Overdose

Maxpro - Vms, Maxpro

Description

Video Management System Honeywell’s MAXPRO® VMS (Video Management System) controls multiple sources of video subsystems in a facility to collect, manage and present video in a clear and concise manner. MAXPRO® VMS intelligently determines the capabilities of each subsystem across various sites, allowing video management of any analogue or digital video device through a unified configuration and viewer. The subsystems can be analogue matrix switches or digital/network video recorders allowing any analogue or digital input to be viewed on analogue or digital monitors. Users can benefit from using traditional analogue systems and IP-network systems at the same time to ensure maximum use of their initial investments. The subsystems can range from Honeywell and 3rd party matrix switchers and Honeywell and 3rd party DVR/NVR’s.

Control of the MAXPRO VMS can be with a traditional joystick controller, keyboard mouse or even through a 3rd party interface. MAXPRO VMS has an extremely powerful rules engine allowing customisation of the system to respond and control in the best possible manner for the application. MAXPRO VMS is highly scalable so users can easily expand their video surveillance network as required. Using an open architecture framework, MAXPRO VMS is able to integrate with existing video infrastructures and a multitude of third-party recorders and devices available now and in the future. Additionally, MAXPRO® VMS includes integration with Honeywell’s Pro-Watch® security management system, Active Alert® and People Counter video analytics, and other Honeywell products and solutions. The feature-rich user interface of MAXPRO® VMS truly offers a unified management platform across many disparate systems to further embody Honeywell’s concept of ‘Learn One, Know them All.’

Market Opportunities MAXPRO® VMS is ideal for facilities requiring at-risk critical infrastructure protection such as airports, seaports, large multi-site commercial buildings, casinos, and other high-profile facilities. It is the perfect client-server video management solution for locations requiring the use of both digital and analogue technologies.

Features

Feature-rich and user-friendly interface to view video from numerous different recorders from a single point

Role-based operator privileges

Redundant server configuration increases system reliability

Operators can log on using their local language and the built-in messaging system allows operators to share video scenes via instant messages

Auto-discovery of cameras connected to MAXPRO NVR, Rapid Eye™, Fusion, IP Engine and Enterprise recorders

User-defined macros to execute common operations

An extremely powerful macro programming language is available to fully customise actions based on events

Surrounding cameras mode with presets, makes following subjects of interest simple and efficient

Incident management mode allows creating a single clip with multiple cameras at different times that can be played back sequentially or simultaneously through a salvo layout

Remote monitor mode allows sharing and controlling a remote monitor while still viewing locally

Control any monitor, whether analogue or digital, from a single workstation or joystick keyboard. Allows the system to be used as a true analogue and digital matrix.

Ability to investigate events and alarms by simultaneously viewing alarm video at various stages. For every alarm, users can view the video captured during pre-alarm, on-alarm, post-alarm, and also view live video from the camera which triggered the alarm

Enriched video viewing experience through the intuitive video rendering engine that optimises CPU utilisation by altering the video frame rate

Search and find video through event view or timeline. Preview search allows viewing a snapshot at various times to quickly narrow the scene of interest.

Commentable bookmarks allow for easily returning to scenes of interest

VMS in VMS feature allows parent/child topology of numerous MAXPRO VMS systems, discover, view video and receive events from other MAXPRO VMS systems

Description

Video Management System Honeywell’s MAXPRO® VMS (Video Management System) controls multiple sources of video subsystems in a facility to collect, manage and present video in a clear and concise manner. MAXPRO® VMS intelligently determines the capabilities of each subsystem across various sites, allowing video management of any analogue or digital video device through a unified configuration and viewer. The subsystems can be analogue matrix switches or digital/network video recorders allowing any analogue or digital input to be viewed on analogue or digital monitors. Users can benefit from using traditional analogue systems and IP-network systems at the same time to ensure maximum use of their initial investments. The subsystems can range from Honeywell and 3rd party matrix switchers and Honeywell and 3rd party DVR/NVR’s.

Control of the MAXPRO VMS can be with a traditional joystick controller, keyboard mouse or even through a 3rd party interface. MAXPRO VMS has an extremely powerful rules engine allowing customisation of the system to respond and control in the best possible manner for the application. MAXPRO VMS is highly scalable so users can easily expand their video surveillance network as required. Using an open architecture framework, MAXPRO VMS is able to integrate with existing video infrastructures and a multitude of third-party recorders and devices available now and in the future. Additionally, MAXPRO® VMS includes integration with Honeywell’s Pro-Watch® security management system, Active Alert® and People Counter video analytics, and other Honeywell products and solutions. The feature-rich user interface of MAXPRO® VMS truly offers a unified management platform across many disparate systems to further embody Honeywell’s concept of ‘Learn One, Know them All.’

Market Opportunities MAXPRO® VMS is ideal for facilities requiring at-risk critical infrastructure protection such as airports, seaports, large multi-site commercial buildings, casinos, and other high-profile facilities. It is the perfect client-server video management solution for locations requiring the use of both digital and analogue technologies.

Features

Feature-rich and user-friendly interface to view video from numerous different recorders from a single point

Role-based operator privileges

Redundant server configuration increases system reliability

Operators can log on using their local language and the built-in messaging system allows operators to share video scenes via instant messages

Auto-discovery of cameras connected to MAXPRO NVR, Rapid Eye™, Fusion, IP Engine and Enterprise recorders

User-defined macros to execute common operations

An extremely powerful macro programming language is available to fully customise actions based on events

Surrounding cameras mode with presets, makes following subjects of interest simple and efficient

Incident management mode allows creating a single clip with multiple cameras at different times that can be played back sequentially or simultaneously through a salvo layout

Remote monitor mode allows sharing and controlling a remote monitor while still viewing locally

Control any monitor, whether analogue or digital, from a single workstation or joystick keyboard. Allows the system to be used as a true analogue and digital matrix.

Ability to investigate events and alarms by simultaneously viewing alarm video at various stages. For every alarm, users can view the video captured during pre-alarm, on-alarm, post-alarm, and also view live video from the camera which triggered the alarm

Enriched video viewing experience through the intuitive video rendering engine that optimises CPU utilisation by altering the video frame rate

Search and find video through event view or timeline. Preview search allows viewing a snapshot at various times to quickly narrow the scene of interest.

Commentable bookmarks allow for easily returning to scenes of interest

VMS in VMS feature allows parent/child topology of numerous MAXPRO VMS systems, discover, view video and receive events from other MAXPRO VMS systems

Kilnits, Kilnits

Kilnits

Important Notice: The Drugs. com international database is in BETA release. This means it is still under development and may contain inaccuracies. It is not intended as a substitute for the expertise and judgement of your physician, pharmacist or other healthcare professional. It should not be construed to indicate that the use of any medication in any country is safe, appropriate or effective for you. Consult with your healthcare professional before taking any medication.

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Capozide - Side Effects, Uses, Dosage, Overdose, Pregnancy, Alcohol, Captozid

Capozide

Updated: August 21, 2015

Capozide is a prescription medication used to treat high blood pressure. It is a single product containing 2 medications: captopril and hydrochlorothiazide. Captopril belongs to a group of drugs called angiotensin-converting enzyme (ACE) inhibitors. Captopril works by blocking the ACE enzyme, which helps blood vessels to relax and lowers blood pressure. Hydrochlorothiazide belongs to a group of drugs called thiazide diuretics, which work by stopping reabsorption of salt into your body. This prevents fluid from building up in the body.

This medication comes in tablet form and is typically given once daily with or without food.

Common side effects of Capozide include rash, loss of taste, and headache.

Capozide may also cause dizziness. Do not drive or operate heavy machinery until you know how Capozide affects you.

This brand is no longer available, but the generic, captopril and hydrochlorothiazide. is available.

Patient Ratings for Capozide

How was your experience with Capozide?

Capozide Cautionary Labels

Uses of Capozide

Capozide is a prescription medication used to treat high blood pressure.

This medication may be prescribed for other uses. Ask your doctor or pharmacist for more information.

Serious side effects have been reported with Capozide. See the "Capozide Precautions" section.

Common side effects of Capozide include the following:

skin reactions such as rash, itching, and sensitivity to the sun

loss of taste

low blood pressure (especially upon standing)

fast heart beat

chest pain

a noticeably rapid, strong, or irregular heartbeat (palpitation)

cough

dizziness

feeling like your surroundings are spinning or moving (vertigo)

an eating disorder associated with low body weight (anorexia)

nausea or vomiting

cramping

diarrhea or constipation

headache

This is not a complete list of Capozide side effects. Ask your doctor or pharmacist for more information.

Tell your doctor if you have any side effect that bothers you or that does not go away.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

Capozide Interactions

Tell your doctor about all the medicines you take including prescription and non-prescription medicines, vitamins, and herbal supplements. Especially tell your doctor if you take:

certain medicines that lower blood pressure such as diuretics like furosemide (Lasix ), hydrochlorothiazide (Microzide. HCTZ), spironolactone (Aldactone ), and triamterene (trade name Dyrenium), or vasodilators like doxazosin (Cardura ), prazosin (Minipress ), terazosin (Hytrin ), clonidine (Catapres), hydralazine (Bidil, Hydra­Zide), and minoxidil

potassium products including potassium chloride (K-Dur, Klor-Con, Micro-K), potassium citrate (Urocit-K, Polycitra-K), potassium gluconate, potassium phosphate (Neutra-Phos-K, K-Phos)

salt substitutes that contain potassium

anticoagulant (blood thinner) medications such as warfarin (Coumadin, Jantoven), heparin, enoxaparin (Lovenox), fondaparinux (Arixtra), rivaroxaban (Xarelto ), and apixaban (Eliquis)

gout medications such as allopurinol (Aloprim, Lopurin, Zyloprim), febuxostat (Uloric), probenecid (Benemid), and sulfinpyrazone (Anturane)

a group of pain medicines called narcotics such as oxycodone (Roxicodone, Oxycontin, Oxecta)

barbiturates such as amobarbital (Amytal), butalbital (Fioricet, Fiorinal), phenobarbital (Luminal) and others

substances that raise blood pressure (pressor amines) such as norepinephrine (Levophed)

medicines that relax skeletal muscles such as cyclobenzaprine (Flexeril) and carisoprodol (Soma)

cholestyramine (Questran) and colestipol (Colestid)

nonsteroidal anti-inflammatory medications such as ibuprofen (Motrin, Nuprin) or naproxen (Aleve) and salicylates

amphotericin B

corticosteroids such as prednisone, hydrocortisone (Cortef), and dexamethasone (Decadron, Dexone, Hexadrol)

lithium (Eskalith, Lithobid)

calcium salts

digoxin (Digox, Lanoxin) and digitoxin (Crystodigin)

diazoxide (Proglycem, Hyperstat)

monoamine oxidase inhibitors such as tranylcypromine (Parnate), phenelzine (Nardil), selegiline (Eldepryl. Zelapar ), isocarboxazid (Marplan), and rasagiline (Azilect)

methenamine (Hiprex)

Do not drink alcohol while taking this medication.

This is not a complete list of Capozide drug interactions. Ask your doctor or pharmacist for more information.

Capozide Precautions

Serious side effects have been reported with Capozide or its ingredients including the following:

protein in your urine (proteinuria)

lowered white blood cell count (neutropenia/agranulocytosis) increasing the risk of infections

low red blood cell count (anemia)

low amount of platelets in the blood which causes bleeding into the tissues, bruising, and slow blood clotting after injury (thrombocytopenia)

deficiency of all three cellular components of the blood (red cells, white cells, and platelets) called pancytopenia

angioedema (a severe allergic reaction). Tell your healthcare provider right away if you have signs or symptoms of angioedema, which include the following:

swelling of face, eyes, lips, tongue, larynx and extremities

difficulty in swallowing or breathing

hoarseness (having difficulty making sounds when trying to speak)

liver, pancreas, and kidney damage

inflammation of a saliva gland (sialadenitis)

allergic reactions. Tell your healthcare provider right away if you have some or all of the following symptoms:

swelling of the face, limbs, lips, tongue, throat

difficulty breathing

stomach (abdominal) pain (intestinal angioedema) with or without nausea or vomiting

excessive low blood pressure

harm to an unborn baby (fetal toxicity). Do not take Capozide if you are pregnant or will become pregnant.

an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue (systemic lupus erythematosus)

imbalances in the levels of salts and fluids in your body (electrolyte and fluid imbalance). Tell your healthcare provider right away if you have some or all of the following symptoms:

dry mouth

thirst

weakness

drowsiness

restlessness

muscle pains or cramps

low blood pressure

low output of urine

fast heart rate

nausea

vomiting

Capozide can cause dizziness. Do not drive or operate heavy machinery until you know how Capozide affects you.

Do not take Capozide if you:

are allergic to Capozide or to any of its ingredients, other sulfonamide-derived drugs, or other ACE inhibitors

kidneys are unable to produce urine (anuric)

history of a type of swelling that affects deeper layers in your skin, often around your eyes and lips (angioedema) with other ACE inhibitors

Capozide Food Interactions

Medications can interact with certain foods. In some cases, this may be harmful and your doctor may advise you to avoid certain foods. In the case of Capozide, salt substitutes containing potassium should be avoided.

How Can I Overcome My Fear Of Flying, Reisetabletten

How can I overcome my fear of flying?

Overcoming a fear of flying takes a lot of courage and practice. But it is possible with appropriate treatment. I never flew until I was almost 30 years old, and getting over my own fear of flying was one of the most difficult achievements of my life.

If you can successfully identify the triggers that produce your anxiety, you've taken the first step. It's important to note that fear of flying is not a single phobia. Most people who fear flying are claustrophobic, or frightened of being locked in the plane and unable to choose when to get off.

A phobia is an intense fear that is out of proportion to the danger, which is particularly relevant to fears of flying. Most “flight phobics” agree that flying is safe, yet frightening. They have a hard time reconciling their fear with safety statistics. Although we know our phobias are not logical, we cannot reason ourselves out of one.

Understanding Triggers

Our fears of flying have triggers, which are thoughts, images, sensations, and memories to which we have become sensitized. A person who is sensitized to certain bodily feelings might fear turbulence or normal take-off and landing. And someone who fears heights might become terrified thinking about flying many miles above the ground.

The list of triggers is long: turbulence, take-off, landings, terrorism, crashes, social anxieties, or being too far from home. Some people fear fire, illness spread through the air system, using the toilets, or violence on a plane. Others have a “bad feeling” about their flight, afraid that their anxieties will somehow predict a catastrophe.

Behind the Phobias and Fear

The common denominator for more than 90 percent of flight phobics is the fear that they will become overwhelmed with anxiety during the flight.

Usually people experience an unexpected panic while flying, and then they fear the terrifying symptoms will return during their next flight. These panics typically emerge between the ages of 17 to 34, around the time of a significant life change such as a birth, death, marriage, divorce, or graduation. That is why people with flying phobias often wonder why they had once been able to fly so comfortably. Very few fears of flying originate with a traumatic flight.

Fear of flying is quite common, but almost 20 percent of the population report that their fear interferes with their work and social lives. It’s not uncommon for fearful fliers to avoid vacations and job promotions. Experts divide fear of flying into three main groups; which one do you belong to?

Those who don’t fly or haven’t flown for more than five years despite the opportunity to do so.

Those who fly only when absolutely necessary with extreme terror.

Those who fly when required, but with anxiety.

Elements of Successful Treatment

The “active ingredient” for overcoming phobias is exposure to feared triggers. It’s important to note that avoidance keeps your phobia alive and intense.

With fear of flying, there is a huge component of anticipatory anxiety, or the fear experienced in anticipation of taking a flight. Any successful treatment will help fearful fliers manage anticipatory anxiety (because many people avoid planning flights, or they just cancel them) as well as during a flight.

Newer treatments for fear of flying involve traditional methods of cognitive-behavioral therapy, or CBT , tailored to flying. Therapy includes techniques for managing anxiety, such as diaphragmatic breathing, to use while on the flight. People who are sensitized to bodily sensations during take-off, landing, or turbulence are desensitized to these triggers.

Education helps calm anxiety, too: how a plane flies, facts about turbulence, and the meaning of the various sounds and bumps during a normal flight. Virtual reality programs, during which fearful fliers are exposed to computer simulations of flight triggers, are also helpful. So, too, are flight simulators that are ordinarily used to teach private pilots how to fly small planes. (These are sometimes located near airports.)

Group therapy programs that meet at airports and culminate in a graduation flight with the therapist are a vailable in many parts of country, including New York, Chicago, Los Angeles, Denver, and Minneapolis. T hey are particularly helpful in overcoming anticipatory anxiety and extending the treatment to the flight itself.

Medical treatment offers no perfect solution. Anti-anxiety medication (usually an SSRI or an SRNI) is helpful to some people who experience panic while flying, but they must be willing to take the drugs every day for a prolonged period of time. And they have little effect on anticipatory anxiety. The benzodiazepines can reduce anticipatory anxiety, but they also interfere with the therapeutic effects of exposure.

Having once been flight phobic myself, now I am constantly rewarded by the pleasure of being able to jump on a plane and fly anywhere in the world.

Martin N. Seif, PhD, ABPP, is a master clinician who has spent the last thirty years developing treatment methods for anxiety disorders. He has also experienced first-hand the crippling effects of anxiety. His path to recovery led him to develop the Anxiety Disorder Treatment Program.

Martin N. Seif, PhD, ABPP

Estrimax ~ Pribalovy Letak, Skupina, Ucinky, Estrimax

Estrimax

PRIBALOVA INFORMACE: INFORMACE PRO UZIVATELE

2 mg potahovane tablety

Prectete si pozorne celou pribalovou informaci drive, nez zacnete tento pripravek uzivat

Ponechte si pribalovou informaci pro pripad, ze si ji budete potrebovat precist znovu.

Mate-li jakekoli dalsi otazky, zeptejte se sveho lekare nebo lekarnika.

Tento pripravek byl predepsan Vam. Nedavejte jej zadne dalsi osobe. Mohl by ji ublizit, a to i tehdy, ma-li stejne priznaky jako Vy.

Pokud se kterykoli z nezadoucich ucinku vyskytne v zavazne mire, nebo pokud si vsimnete jakychkoli nezadoucich ucinku, ktere nejsou uvedeny v teto pribalove informaci, prosim, sdelte to svemu lekari nebo lekarnikovi.

V pribalove informaci naleznete .

Co je pripravek Estrimax a k cemu se pouziva

Cemu musite venovat pozornost, nez zacnete pripravek Estrimax uzivat

Jak se pripravek Estrimax uziva

Mozne nezadouci ucinky

Jak pripravek Estrimax uchovavat

CO JE PRIPRAVEK ESTRIMAXA K CEMU SE POUZIVA

Estrimax obsahuje zensky pohlavni hormon estradiol, ktery je totozny s estradiolem, ktery se vytvari ve vajecnicich zen, a je klasifikovan jako prirozeny estrogen.

Estrimax patri do skupiny pripravku hormonalni substitucni terapie (HST) a uziva k nasledujicim ucelum:

Zmirneni neprijemnych symptomu jako jsou navaly horka, nocni poceni a suchost pochvy, ktere se objevuji pote, co hladina estrogenu poklesne a menstruace se jiz nedostavuje (menopausa).

Jako prevence osteoporozy (ridnuti kosti) u zen po menopauze, ktere maji zvysene riziko budoucich zlomenin a nemohou byt leceny pro toto onemocneni jinymi pripravky.

Estrimax je predepisovan zejmena tem zenam, jimz byla odstranena deloha (podstoupily hysterektomii) a ktere proto nevyzaduji kombinovanou lecbu.

Jsou pouze omezene zkusenosti s lecbou pripravkem Estrimax u zen starsich 65ti let.

CEMU MUSITE VENOVAT POZORNOST, NEZ ZACNETE PRIPRAVEK ESTRIMAXUZIVAT

Krome prinosu ma HST take nektera rizika, ktera musite vzit v uvahu pri zvazovani, zda HST budeteuzivat ci zda budete v lecbe pokracovat.

Nez zacnete lecbu hormonalni substitucni terapii, mel by lekar zjistit Vasi osobni a rodinnou anamnezu. Lekar se muze rozhodnout pro vysetreni prsu a/nebo bricha a rovnez muze provest interni vysetreni, avsak pouze tehdy, pokud jsou tato vysetreni pro Vas nezbytna nebo je-li pro to zvlastniduvod.

Po zahajeni lecby HST byste mela chodit na pravidelna vysetreni (minimalne jednou za 12 mesicu). Pri techto navstevach s Vami lekar muze hovorit o prinosech a rizicich pokracujici lecby hormonalni substitucni terapii.

Pravidelne podstupujte screeningova vysetreni prsu (mamografie) a cervikalni cytologii. Pravidelne si vysetrujte prsy, zda nedoslo ke zmenam jako je vznik dolicku v kuzi, zmeny na bradavkach nebojakekoli zatvrdliny, ktere vidite ci citite.

HST neni doporucovana zenam, ktere maji onemocneni srdce ci toto onemocneni nedavno prodelaly. Jestlize jste nekdy mela srdecni chorobu, sdelte to lekari, aby posoudil, zda byste HST mela uzivat.

HST nepomaha v prevenci srdecnich chorob.

Studie s jednim typem HST (obsahujicim konjugovane estrogeny a progestogen MPA) ukazaly, ze zeny mohou mit v prvnim roce uzivani lehce zvysenou pravdepodobnost srdecniho onemocneni.

Pro dalsi typy HST je riziko pravdepodobne podobne, ackoli to neni doposud zcela jiste.

Pokud pocitite bolest na prsou, ktera se rozsiruje do paze nebo krku, vyhledejte lekare, jakmile to bude mozne a HST dale neuzivejte, dokud Vam to lekar opet nedovoli. Tato bolest muze byt priznakem srdecni choroby.

Cevni mozkova prihoda

Nedavne vyzkumy naznacuji, ze HST lehce zvysuje riziko cevni mozkove prihody. Dalsi faktory zvysujici riziko postizeni cevni mozkovou prihodou jsou:

vysoky krevni tlak,

nadmerna konzumace alkoholu,

nepravidelny srdecni rytmus.

Pokud mate z vyse uvedeneho obavy nebo pokud jste byla v minulosti postizena cevni mozkovou prihodou, sdelte to lekari, aby posoudil, zda byste HST mela uzivat.

U zen ve veku 50-59 let, ktere HST neuzivaji, se predpoklada, ze za petilete obdobi budou cevni mozkovou prihodou postizeny v prumeru 3 zeny z 1000.

U zen ve veku 50-59 let, ktere HST uzivaji, to budou 4 zeny z 1000.

U zen ve veku 60-69 let, ktere HST neuzivaji, se predpoklada, ze za petilete obdobi bude cevni mozkovou prihodou postizeno v prumeru 11 zen z 1000.

U zen ve veku 60-69 let, ktere HST uzivaji, to bude 15 zen z 1000.

Pokud pocitite neobjasnenou bolest hlavy typu migreny s poruchami videni nebo bez nich, vyhledejte lekare, jakmile to bude mozne a HST dale neuzivejte, dokud Vam to lekar opet nedovoli. Tato bolest hlavy muze byt casnym varovnym priznakem cevni mozkove prihody.

HST muze zvysovat riziko krevnich srazenin v zilach (tzv. tromboza hlubokych zil), a to zvlaste v prvnim roce uzivani.

Tyto krevni srazeniny nejsou vzdy vazne, avsak pokud srazenina pronikne do plic, muze zpusobit bolest na prsou, dusnost, kolaps nebo dokonce smrt. Tento stav se nazyva pulmonalni embolie.

Tromboza hlubokych zil a pulmonalni embolie jsou priklady stavu zvanych venozni tromboembolismus, VTE.

Pravdepodobnost, ze se u Vas vyskytne krevni srazenina je vyssi:

pokud mate vyraznou nadvahu,

pokud se u Vas vyskytly problemy s krevnimi srazeninami jiz drive,

pokud se u nekoho z Vasich blizkych pribuznych vyskytly problemy s krevnimi srazeninami,

pokud jste prodelala jeden ci vice samovolnych potratu,

pokud se u Vas vyskytuje problem s krevni srazlivosti, ktery vyzaduje lecbu pripravky jako je warfarin,

pokud jste po delsi dobu upoutana na luzko kvuli slozitejsi operaci, onemocneni ci zraneni,

pokud trpite-li vzacnym stavem znamym jako systemovy lupus erythematodes (SLE).

Pokud se neco z toho na Vas vztahuje, sdelte to svemu lekari, aby posoudil, zda byste HST mela uzivat.

U zen ve veku 50-59 let, ktere HST neuzivaji, se predpoklada, ze za petilete obdobi budou krevni srazeninou postizeny v prumeru 3 zeny z 1000.

U zen ve veku 50-59 let, ktere HST uzivaji, to bude 7 zen z 1000.

U zen ve veku 60-69 let, ktere HST neuzivaji, se predpoklada, ze za petilete obdobi bude krevni srazeninou postizeno v prumeru 8 zen z 1000.

U zen ve veku 60-69 let, ktere HST uzivaji, to bude 17 zen z 1000.

Pokud pocitite bolestivy otok nohy, nahlou bolest na prsou, dychaci obtize, vyhledejte lekare, jakmile to bude mozne a HST dale neuzivejte, dokud Vam to lekar opet nedovoli. Tyto priznaky mohou byt varovnym priznakem krevni srazeniny.

Pokud mate podstoupit operaci, ujistete se, ze Vas lekar o tom vi. Bude mozna treba prestat uzivat HST 4 – 6 tydnu pred operaci, aby se snizilo riziko vzniku krevnich srazenin. Lekar Vam rekne, kdy muzete s uzivanim HST opet zacit.

Vliv na riziko vzniku rakoviny

Zeny majici rakovinu prsu nebo zeny, ktere ji prodelaly v minulosti, by HST nemely uzivat.

Uzivani HST riziko rakoviny prsu mirne zvysuje oddalenim menopauzy. Riziko postmenopauzalnich zen uzivajicich HST zalozenou pouze na bazi estrogenu po dobu 5ti let je priblizne stejne jako u zen

stejneho veku, jez stale menstruuji a neuzivaji HST. Riziko u zen uzivajicich HST na bazi estrogenu a progestogenu je vyssi nez u hormonalni substitucni terapie samotnym estrogenem (avsak lecba estrogenem a progestogenem je prinosem pro endometrium, viz dale „Rakovina endometria“).

Pro vsechny typy HST roste dodatecne riziko rakoviny prsu s delkou uzivani HST. Vraci se vsak k normalu behem 5ti let po ukonceni uzivani HST.

Riziko rakoviny prsu je rovnez vyssi, pokud:

Vase blizke pribuzne (matka, sestra nebo babicka) mely rakovinu prsu,

trpite vyraznou nadvahou.

U zen ve veku 50 let, ktere HST neuzivaji, se predpoklada, ze do dosazeni veku 65 let bude rakovina prsu diagnostikovana v prumeru u 32 zen z 1000.

U zen, jez HST na bazi estrogenu zacnou uzivat ve veku 50 let a ktere ji uzivaji po dobu 5ti let, to bude mezi 33 a 34 zenami z 1000 (tj. 1-2 pripady navic).

Pokud HST na bazi estrogenu uzivaji po dobu 10ti let, bude tento pocet 37 na 1000 (tj. 5 pripadu navic).

U zen, jez zacaly uzivat ve veku 50 let HST na bazi estrogenu a progestogenu a ktere ji uzivaji po dobu 5ti let, bude tento pocet 38 zen z 1000 (tj. 6 pripadu navic).

Pokud HST na bazi estrogenu a progestogenu uzivaji po dobu 10ti let, bude tento pocet 51 na 1000 (tj.19 pripadu navic).

Pokud zaznamenate jakekoli zmeny prsou jako dolicky v kuzi, zmeny na bradavkach, jakekoli zatvrdliny, ktere vidite ci citite, navstivte lekare, jakmile to bude mozne.

Rakovina endometria (rakovina delozni sliznice)

Uzivani HST na bazi samotnych estrogenu po delsi dobu muze zvysit riziko rakoviny delozni sliznice (endometria).

Uzivani progestogenu spolecne s estrogenem napomaha dodatecne riziko snizit.

Pokud Vam nebyla odnata deloha, lekar Vam muze predepsat estrogen spolecne s progestogenem. Muze Vam predepsat kazdou lecivou latku zvlast nebo jako pripravek kombinovane HST.

Pokud Vam byla odnata deloha (prodelala jste hysterektomii), lekar s Vami probere moznost bezpecneho uzivani samotneho estrogenu bez progestogenu.

Pokud Vam byla odnata deloha z duvodu endometriozy, muze jakekoli zbyle endometrium v Vasem tele znamenat riziko. V takovem pripade Vam lekar predepise pripravek HST, ktery obsahuje jak estrogen tak progestogen.

U zen, ktere stale maji delohu a ktere neuzivaji HST, bude diagnostikovana rakovina endometria ve veku 50 - 65 let v prumeru u 5 zen z 1000.

U zen, ktere uzivaji HST na bazi estrogenu, bude pocet 2krat az 12krat vyssi v zavislosti na davce a dobe, po kterou lecbu uzivaji.

Pridani progestogenu k lecbe samotnymi estrogeny podstatne snizuje riziko rakoviny endometria.

Pokud se u Vas objevi krvaceni nebo spineni, neni to obycejne duvod k obavam, zvlaste pak behem nekolika prvnich mesicu uzivani HST.

Nicmene pokud krvaceni nebo spineni

trva dele nez jen nekolik prvnich mesicu,

objevi se az po urcite dobe uzivani HST,

pokracuje i pote, co byla lecba HST ukoncena,

kontaktujte sveho lekare. Muze to byt znamka toho, ze endometrium se zvetsuje.

Rakovina vajecniku je velmi vzacne ale zavazne onemocneni. Muze byt tezke ho diagnostikovat, protoze priznaky tohoto onemocneni jsou casto nezretelne.

Z nekterych studii vyplyva, ze uzivani HST na bazi samotnych estrogenu po dobu delsi nez 5 let, muze zvysovat riziko rakoviny vajecniku. Neni doposud znamo, zda ostatni typy HST zvysuji riziko stejnym zpusobem.

Neuzivejte pripravek Estrimax:

jestlize jste alergicka (precitlivela) na estradiol nebo na kteroukoli dalsi slozku pripravku Estrimax (viz bod 6. „Dalsi informace“),

jestlize je u Vas zjistena rakovina prsu, prodelala jste ji nebo je u Vas na ni podezreni (viz bod 2”Rakovina prsu”),

jestlize je u Vas zjisten estrogenne podmineny nador, napr. rakovina delozni sliznice, nebo je u Vas na nej podezreni,

jestlize trpite nezvyklym vaginalnim krvacenim, ktere nebylo diagnostikovano Vasim lekarem,

jestlize trpite hyperplazii endometria (nadmernym rustem delozni sliznice), ktera neni lecena,

jestlize u Vas dochazi nebo doslo k tvorbe krevnich srazenin (napr. tromboza hlubokych zil nebo plicni embolie) nebo jste je prodelala bez zjevne priciny, napriklad v souvislosti s operaci nebo tehotenstvim (viz bod 2 ”Krevni srazeniny v hlubokych zilach”),

jestlize jste v nedavne dobe prodelala infarkt myokardu, cevni mozkovou prihodu nebo pokud mate anginu pectoris,

jestlize trpite nebo jste trpela onemocnenim jater a hodnoty jaternich testu se nevratily do normalu,

jestlize trpite porfyrii (enzymaticka porucha jater).

Zvlastni opatrnosti pri pouziti pripravku Estrimax je zapotrebi:

Informujte sveho lekare, trpite-li dale uvedenymi stavy nebo jestlize se u Vas takove stavy vyskytly jiz drive. Vas lekar muze Vasi lecbu pecliveji sledovat. Tyto stavy se mohou ve vzacnych pripadech behem lecby pripravkem Estrimax projevit znovu nebo se mohou zhorsit:

mate-li jakekoli onemocneni ovlivnujici delozni sliznici jako jsou myomy (nezhoubne nadory tkane), endometrioza (vyskyt delozni sliznice mimo delohu) nebo jestlize jste trpela hyperplasii endometria (nadmernym rustem delozni sliznice),

v anamneze uvadene krevni srazeniny (tromboza) nebo rizikove faktory podminujici vznik krevnich srazenin (tyto rizikove faktory a priznaky krevnich srazenin jsou uvedeny v bode 2„Krevni srazeniny“)

mel-li nekdo z Vasich blizkych pribuznych rakovinu prsu nebo jine typy rakoviny podminene estrogeny (rakovina endometria),

mate-li vysoky krevni tlak,

jestlize se u Vas vyskytly jaterni poruchy, jako je adenom jater (nezhoubny nador),

mate-li onemocneni ledvin nebo srdce,

mate-li cukrovku (diabetes mellitus) nebo zlucove kameny,

mate-li epilepsii ci astma,

trpite-li migrenou nebo tezkymi bolestmi hlavy,

mate-li systemovy lupus erythematodes (SLE, autoimunitni onemocneni pojiva, ktere muze postihnout mnohe organove systemy),

mate-li vysoke hladiny tuku v krvi (hypertriglyceridemie),

mate-li otosklerozu (ztrata sluchu).

Mate-li podstoupit vysetreni krve, oznamte svemu lekari, ze uzivate pripravek Estrimax, protoze estrogeny mohou ovlivnit vysledky nekterych vysetreni.

Planujete-li operaci, oznamte to svemu lekari. Mozna bude treba ukoncit lecbu pripravkem Estrimax 4 az 6 tydnu pred operaci, aby se snizilo riziko vzniku krevnich srazenin. Lekar Vam oznami, kdy budete s lecbou opet moci zacit.

Vysazeni lecby pripravkem Estrimax

Vyskytne-li se u Vas kterykoli z nasledujicich stavu, ukoncete lecbu pripravkem Estrimax a okamzite kontaktujte sveho lekare:

objevi-li se u Vas vubec poprve bolest hlavy typu migreny,

objevi-li se u Vas zlute zbarveni kuze a oci (zloutenka) nebo jine jaterni onemocneni,

objevi-li se u Vas priznaky vysokeho krevniho tlaku (napr. bolest hlavy),

objevi-li se nektery ze stavu uvedeny v bode 2 „Neuzivejte pripravek Estrimax“.

Vzajemne pusobeni s dalsimi lecivymi pripravky

Prosim, informujte sveho lekare nebo lekarnika o vsech lecich, ktere uzivate nebo jste uzivala v nedavne dobe, a to i o lecich, ktere jsou dostupne bez lekarskeho predpisu.

Nektere lecive pripravky mohou snizovat ucinek pripravku Estrimax:

Leky pouzivane k lecbe epilepsie (napr. fenobarbital, fenytoin a karbamazepin);

Leky pouzivane k lecbe tuberkulozy (napr. rifampicin, rifabutin);

Leky pouzivane k lecbe HIV infekci (napr. nevirapin, efavirenz, ritonavir a nelfinavir);

Bylinne pripravky obsahujici trezalku teckovanou (Hypericum perforatum).

Uzivani pripravku Estrimax s jidlem a pitim

Tablety lze uzivat jak behem jidla a piti, tak i mimo nej.

Tehotenstvi a kojeni

Poradte se se svym lekarem nebo lekarnikem drive, nez zacnete uzivat jakykoli pripravek.

Neuzivejte pripravek Estrimax, mate-li podezreni, ze jste tehotna, jste-li tehotna nebo jestlize kojite.

Rizeni dopravnich prostredku a obsluha stroju

Ucinek pripravku Estrimax na schopnost ridit dopravni prostredky nebo obsluhovat stroje neni znam.

Dulezite informace o nekterych slozkach pripravku Estrimax:

Estrimax obsahuje monohydrat laktosy. Pokud trpite nesnasenlivosti nekterych cukru, poradte se pred uzitim pripravku Estrimax se svym lekarem.

JAK SE PRIPRAVEK ESTRIMAX UZIVA

Vzdy uzivejte pripravek Estrimax presne podle pokynu sveho lekare. Pokud si nejste jista, poradte se se svym lekarem nebo lekarnikem.

Pokud Vam byla odebrana deloha nebo pokud jiz nemate menstruaci a neuzivate jine pripravky hormonalni terapie, muzete zacit lecbu v jakykoli vhodny den.

Uzivejte jednu tabletu denne, priblizne ve stejnou denni dobu.

Tabletu zapijte sklenici vody.

Uzivejte tabletu kazdy den bez preruseni . Jakmile vyberete vsech 28 tablet kalendaroveho baleni, pokracujte ihned s uzivanim tablet z dalsiho baleni.

Lekar by Vam mel predepsat nejnizsi ucinnou davku estradiolu, ktera zmirni Vase priznaky, a to po co mozna nejkratsi dobu.

Informujte sveho lekare, pokud se Vase priznaky po trech mesicich nezmirni.

Pokud Vam byla odebrana deloha, lekar Vam predepise uzivani progestogenu (dalsi zensky hormon)jen tehdy, pokud trpite stavem zvanym endometrioza (ukladani delozni sliznice mimo delohu).

Jestlize jste doposud uzivala jiny pripravek HST, poradte se, prosim, se svym lekarem nebo lekarnikem, kdy byste mela zacit pripravek Estrimax uzivat.

Jestlize jste uzila vice pripravku Estrimax, nez jste mela

Pokud jste uzila vice tablet pripravku Estrimax, nez jste mela, poradte se s lekarem nebo s lekarnikem. Predavkujete-li se pripravkem Estrimax, muzete citit nevolnost nebo zvracet.

Jestlize jste zapomnela uzit pripravek Estrimax:

Jestlize jste zapomnela uzit tabletu v obvyklou dobu, pokuste se ji uzit behem nasledujicich dvanacti hodin. Pokud jiz uplynulo vice nez 12 hodin, pokracujte s lecbou druhy den jako normalne. Nezdvojujte davku, abyste doplnila vynechanou davku.

Chcete-li lecbu pripravkem Estrimax ukoncit.

Chcete-li lecbu pripravkem Estrimax ukoncit, promluvte si nejprve o svem rozhodnuti se svym lekarem. Vysvetli Vam ucinky ukonceni lecby a seznami Vas s dalsimi moznostmi.

Mate-li jakekoli dalsi otazky, tykajici se uzivani tohoto pripravku, zeptejte se sveho lekare nebo lekarnika.

MOZNE NEZADOUCI UCINKY

Podobne jako vsechny leky, muze mit i Estrimax nezadouci ucinky, ktere se ale nemusi vyskytnout u kazdeho.

Caste nezadouci ucinky (mohou se projevit u vice nez 1 zeny ze 100)

DepreseBolest hlavyBolesti bricha (zaludku)Pocity nevolnosti (nausea)Krece v nohouCitlivost prsu, zvetseni prsu a bolestivost prsuEdem (zadrzovani tekutin)Hmotnostni prirustek.

Mene caste nezadouci ucinky (mohou se projevit u mene nez 1 zeny ze 100)

Poruchy videniKrevni srazeniny v zilach (venozni tromboticke onemocneni)Paleni zahy (pyroza)ZvraceniNadymani a plynatostZlucove kamenyVyrazka nebo koprivka

Nezadouci ucinky s neznamou frekvenci vyskytu (mohou se projevit u mene nez 1 zeny z 10000)

Nepravidelne vaginalni krvaceni*Migrena, zhorseni migrenyCevni mozkova prihodaNespavostEpilepsieZmeny libidaVaginalni plisnove infekceZhorseni astmatuZavratePrujemVypadavani vlasu (alopecie)Zvyseni krevniho tlaku

* Je-li pripravek Estrimax predepsan zenam, ktere neprodelaly hysterektomii

Dalsi nezadouci ucinky HST

Nasledujici nezadouci ucinky byly hlaseny po pouziti jinych pripravku obsahujicich estrogen ci estrogen/progestogen. Dalsi informace viz bod 2 ”Cemu musite venovat pozornost, nez zacnete pripravek Estrimax uzivat”.

- Cevni mozkova prihoda - Krevni srazeniny - Rakovina prsu - Rakovina endometria - Rakovina vajecniku

HST nepomuze zlepsit ztratu pameti. V jedne studii bylo pozorovano u zen, ktere zacaly uzivat kombinovanou HST po 65. roce veku, mirne zvyseni rizika demence. Neni znamo, zda lze tyto zavery aplikovat take na zeny, ktere jsou v dobe zahajeni lecby mladsi nez 65 let nebo na zeny uzivajici jine pripravky HST.

Po estrogen/progesteronove lecbe bylo hlaseno onemocneni zlucniku.

Hnede pigmentove skvrny v obliceji (chloasma), kozni vyrazka vcetne zanetu rukou nebo nohou (multiformni erytem), vznik citlivych mist, cervene uzliky na prednich stranach nohou/kolenou (nodozni erytem) nebo modrinam podobne vyrazky (vaskularni purpura) a svedeni (pruritus).

Pokud se kterykoli z nezadoucich ucinku vyskytne v zavazne mire, nebo pokud si vsimnete jakychkoli nezadoucich ucinku, ktere nejsou uvedeny v teto pribalove informaci, prosim, sdelte to svemu lekari nebo lekarnikovi.

JAK PRIPRAVEK ESTRIMAX UCHOVAVAT

Uchovavejte mimo dosah a dohled deti.

Uchovavejte blistr v papirovem pouzdre, aby byl pripravek chranen pred svetlem.

Pripravek Estrimax nepouzivejte po uplynuti doby pouzitelnosti, uvedene na krabicce. Doba pouzitelnosti se vztahuje k poslednimu dni uvedeneho mesice.

Lecive pripravky se nesmi vyhazovat do odpadnich vod nebo domaciho odpadu. Zeptejte se sveho lekarnika, jak mate likvidovat pripravky, ktere jiz nepotrebujete. Tato opatreni pomahaji chranit zivotni prostredi.

Co pripravek Estrimax obsahuje

- Lecivou latkou je estradiolum 2 mg (ve forme estradiolum hemihydricum 2,070 mg) v jedne

- Pomocnymi latkami jsou :

Jadro tablety: koloidni bezvody oxid kremicity, magnesium-stearat, povidon, mastek, bramborovy skrob, kukuricny skrob, monohydrat laktosy.

Potah tablety: koloidni bezvody oxid kremicity, oxid titanicity, makrogol 6000, hypromelosa, makrogol-stearat, cerny oxid zelezity.

Jak pripravek Estrimax vypada a co obsahuje toto baleni

Svetle sede, kulate, bikonvexni, potahovane tablety.

3 x 28 potahovanych tablet v Al/PVC blistrech, kartonove pouzdro, papirova krabicka.

Drzitel rozhodnuti o registraci a vyrobce

Gedeon Richter Plc.,Gyomroi ut 19-21,H-1103 Budapest, Madarsko

Tato pribalova informace byla naposledy schvalena:

Lecba se ma okamzite prerusit, pokud se objevi stavy uvedene v kontraindikacich a v nasledujicich situacich:

Zloutenka nebo zhorseni jaternich funkci;

Vyznamne zvyseni krevniho tlaku;

Nove vznikla bolest hlavy migrenozniho typu;

Zeny s intaktni delohou, ktere byly jiz drive leceny samotnymi estrogeny, by mely byt peclive vysetreny, aby se pred zacatkem lecby pripravkem Estrimax vyloucila mozna hyperstimulace ci malignita endometria.

Riziko hyperplazie endometria a karcinomu stoupa, pokud jsou estrogeny podavane samostatne v delsim obdobi (viz bod 4.8). Pridani progestogenu po dobu nejmene 12ti dnu v cyklu u zen s intaktni delohou toto riziko znacne snizi.

Pridani progestogenu u peroralnich davek > 2 mg estradiolu denne na bezpecnost endometria nebylo overovano v klinicke studii.

V prvnich mesicich lecby se muze objevit intermenstrualni krvaceni a spineni. Pokud se tyto priznaky projevi i po delsi dobe lecby nebo pretrvavaji i po vysazeni lecby, je nutne vysetrit jejich pricinu, nekdy i endometrialni biopsii k vylouceni endometrialni malignity.

Neomezena stimulace estrogeny muze vest k premalignim nebo malignim zmenam zbytkovych lozisek endometriozy. Z toho duvodu se ma uvazit doplneni estrogenove substitucni terapie progestogenem u tech zen, ktere podstoupily hysterektomii z duvodu endometriozy, pokud se o nich vi, ze maji rezidualni endometriozu.

Randomizovana placebem kontrolovana studie „Women’s Health Initiative study„ (WHI) a epidemiologicke studie, vcetne „Million Women Study„ (MWS) zaznamenaly zvysene riziko karcinomu prsu u zen uzivajicich nekolik let estrogenni, estrogen-progestogenovou nebo tibolonovou hormonalni substitucni terapii (HST) (viz bod 4.8). U vsech HST se zvysene riziko projevi po nekolika letech uzivani a stoupa s delkou uzivani, ale vraci se k puvodnimu riziku nejdele do peti let po preruseni lecby.

V MWS relativni riziko rakoviny prsu s konjugovanym konskym estrogenem (CEE) nebo estradiolem(E2) bylo vyssi v pripade, kdy byl pridan progestogen bud v sekvencnim nebo v kontinualnim davkovani a to bez ohledu na typ progestogenu. Nebyly rozdily mezi ruznymi zpusoby podavani.

Ve studii WHI bylo spojeno kontinualni podavani pripravku obsahujiciho kombinaci konjugovaneho konskeho estrogenu a medroxyprogesteron acetatu (CEE + MPA) s rakovinou prsu, ktera byla rozsahlejsi a s castejsim vyskytem lokalnich metastaz do lymfatickych uzlin ve srovnani se skupinou dostavajici placebo.

HST, zejmena kombinace estrogen - progestogen zvysuje denzitu mamografickych zobrazeni, a tim muze nezadoucim zpusobem ovlivnit radiologicke odhaleni karcinomu prsu.

Pouzivani hormonalni substitucni terapie je spojeno s vyssim rizikem vyvoje venozniho tromboembolismu (VTE), jako je hluboka zilni tromboza a plicni embolie.

Randomizovana kontrolovana studie a epidemiologicke studie prokazaly dvojnasobne az trojnasobne zvysene riziko u pacientek s HST nez u zen bez HST. U zen, ktere HST neuzivaji, se predpokladany pocet pripadu VTE v 5tiletem obdobiodhaduje na 3 z 1000 zen ve veku 50-59 a 8 z 1000 zen ve veku 60-69 let. Predpoklada se, ze u zdravych zen, uzivajicich HST po dobu 5ti let a vice, se pocet pripadu zvysuje o 2 az 6 (odhad 4) na 1000 zen ve veku 50-59 let a o 5 az 15 (odhad 9) ve veku 60-69 let. Vyskyt techto pripadu je spise v prvnim roce lecby nez pozdeji.

Mezi vseobecne uznavane rizikove faktory VTE patri pozitivni osobni nebo rodinna anamneza, tezka obezita (BMI > 30 kg/m

2) a systemovy lupus erythematodes (SLE). Na moznou roli varikosnich zil

neni jednoznacny nazor.

U pacientek s anamnezou VTE nebo znamou trombofilii je zvysene riziko VTE. HST toto riziko jeste zvysuje. Osobni nebo vyznamnou rodinnou anamnezu tromboembolismu nebo opakujicich se spontannich potratu je nutne vysetrit s ohledem na vylouceni predispozice k trombofilii. Dokud nejsou zhodnoceny faktory trombofilie nebo nasazena antikoagulacni lecba, uzivani HST se u takovych pacientek povazuje za kontraindikovane. U zen jiz uzivajicich antikoagulacni lecbu je potrebne peclive zvazit pomer prinosu a rizika uzivani HST.

Riziko VTE muze byt prechodne zvyseno u delsi imobilizace, po vetsim traumatu nebo chirurgickem zakroku. Tak, jako u vsech pacientek po operaci, je potreba venovat zvysenou pozornost profylaktickym opatrenim v prevenci VTE, zejmena u operace brisni a ortopedicke na dolnich koncetinach. V uvahu je treba vzit, pokud je to mozne, i prechodne vysazeni HST na 4 az 6 tydnu pred operaci. Opetovne nasazeni se nedoporucuje drive, nez je pacientka opet kompletne mobilni.

Pokud dojde k rozvoji VTE pri zahajeni lecby, lecba se ma prerusit. Pacientky se maji poucit, ze pokud se objevi priznaky podezrele z rozvoje VTE (bolestive krece nohou, nahla bolest na hrudi, dusnost), musi okamzite vyhledat sveho lekare.

Onemocneni koronarnich arterii (Coronary artery disease - CAD)

Na zaklade sledovani v randomizovanych kontrolovanych studiich nejsou zadne dukazy o kardiovaskularnich vyhodach pri kontinualnim podavani kombinovanych pripravku obsahujicich estrogen a medroxyprogesteron acetat (MPA). Dve rozsahle klinicke studie (WHI a HERS - tj. Heart and Estrogen/progestin Replacement Study) ukazaly na mozne zvysene riziko kardiovaskularni morbidity v prvnim roce podavani, ale i na zadny celkovy prinos. Pro ostatni HST jsou jen omezene udaje z randomizovanych kontrolovanych klinickych studii sledujicich ucinek na kardiovaskularni mortalitu a morbiditu. Z toho duvodu neni jiste, zda se tato zjisteni budou vztahovat i na ostatni HSTpripravky.

Cevni mozkova prihoda

Z jedne rozsahle randomizovane klinicke studie (WHI - studie) bylo jako druhotny vystup zjisteni zvyseneho rizika ischemickych iktu u zdravych zen v prubehu lecby pripravkem obsahujicim estrogen a medroxyprogesteron acetat (MPA). U zen, ktere neuzivaji HST, je odhad poctu postizeni iktem v petiletem obdobi stanoven na 3 pripady z 1000 ve veku 50-59 let a 11 pripadu z 1000 zen ve veku 60-69 let. U zen uzivajicich konjugovany estrogen a MPA je odhad navyseni o 0-3 (predpoklad 1) na 1000 ve skupine 50-59tiletych a mezi 1-9 (predpoklad 4) na 1000 ve veku 60-69 let. Neni znamo, zda se zvysene riziko vztahuje i na ostatni HST pripravky.

Dlouhodobe uzivani (5-10 let) pouze estrogenovych HST pripravku u zen po hysterektomii bylo v nekterych epidemiologickych studiich spojeno se zvysenym rizikem vzniku karcinomu ovaria. Nenijiste, zda dlouhodobe uzivani kombinovane HST odpovida jinemu riziku nez pouze tomu pro estrogenove pripravky.

Estrogeny pusobi retenci tekutin, z tohoto duvodu musi byt pod peclivym dohledem pacientky se srdecni a ledvinovou dysfunkci. Pacientky s terminalni renalni insuficienci se musi sledovat dukladne, protoze se predpoklada, ze je obsah lecive latky v cirkulujici krvi u techto pacientekzvyseny.

Zeny s jiz existujici hypertriglyceridemii se musi v prubehu estrogenove substitucni lecbysledovat pecliveji, protoze v ojedinelych pripadech vedlo vyrazne zvyseni plasmatickych triglyceridu k pankreatitide.

Estrogeny zvysuji globuliny vazajici tyroxin (TBG), coz vede k celkovemu zvyseni cirkulujiciho thyroidalniho hormonu, jak bylo zjisteno merenim proteinu, ktery vaze jod (PBI), hladiny T4 a T3 (mereno radioimmunoesseji). Zpetna absorpce T3 je snizena, coz odrazi zvyseny TBG. Koncentrace volneho T3 a T4 jsou nezmenene. Ostatni vazebne proteiny mohou byt v seru zvysene, napr. kortikoidy vazajici globuliny (CBG), globuliny vazajici pohlavni hormony (SHBG) a tim mohou zpusobit zvyseni cirkulujicich kortikosteroidu a pohlavnich hormonu. Koncentrace volnych nebo biologicky aktivnich hormonu jsou nezmenene. Ostatni proteiny v plasme mohou byt zvysene (angiotensinogen/renin substrat, alfa-1-antitrypsin, ceruloplazmin).

Nejsou dostatecne dukazy pro zlepseni kognitivnich funkci. Nektere udaje ze studie WHI naznacuji zvysene riziko mozne demence u zen, ktere zacinaji s uzivanim pripravku po 65. roku. Neni znamo, zda se zjisteni tyka i mladsich zen po menopauze nebo i jinych HST pripravku.

Pripravek Estrimax nema antikoncepcni ucinek.

Pripravek Estrimax obsahuje laktosu. Pacientky trpici vzacnymi dedicnymi problemy intolerance galaktosy, hereditarni deficienci laktazy nebo pri malabsorpci glukosy-galaktosy by nemely tento pripravek uzivat.

Interakce s jinymi lecivymi pripravky a jine formy interakce

S pripravky indukujicimi aktivitu jaternich enzymu, zejmena enzymu cytochromu P450 (jako napr. s barbituraty, karbamazepinem, rifampicinm, fenylbutazonem, meprobamatem a hydantoiny) dochazi ke snizeni ucinnosti estradiolu.

Antiretrovirove pripravky: ritonavir a nelfinavir, ackoli jsou znamy jako silne inhibitory enzymu, vykazuji naopak pri soucasnem uzivanim se steroidnimi hormony indukcni vlastnosti.

Fytofarmaka obsahujici trezalku teckovanou (Hypericum perforatum) mohou zvysovat metabolismus estrogenu.

Z klinickeho hlediska muze zvyseny metabolismus estrogenu a progestogenu vest ke snizeni ucinku a zmenam v profilu delozniho krvaceni.

4.6 Tehotenstvi a kojeni

Pripravek Estrimax by nemel byt podavan v tehotenstvi ani v obdobi kojeni. Dosud neexistuji zadne udaje ani studie prokazujici riziko embryonalnich ci fetalnich malformaci.

4.7 Ucinky na schopnost ridit a obsluhovat stroje

Pripravek neovlivnuje schopnost ridit motorova vozidla a obsluhovat stroje.

V klinickych studiich se nezadouci ucinky vyskytly u mene nez 10 % pacientek. Nejcasteji hlasene nezadouci ucinky jsou: citlivost prsou/bolest prsou, bolest bricha, otoky a bolest hlavy.

Behem lecby pripravkem Estrimax se mohou vyskytnout nasledujici nezadouci ucinky:

Trida organovych systemu

Mene caste ( ? 1/1000 az <1/100)

Vzacne ( ? 1/10000 az < 1/1000)

Poruchy nervoveho systemu

5. FARMAKOLOGICKE VLASTNOSTI

Farmakoterapeuticka skupina: zensky pohlavni hormon, prirozeny estrogen.

ATC skupina: G03CA03.

Leciva latka, synteticky 17?-estradiol je chemicky a biologicky identicky s endogennim lidskym estradiolem. Nahrazuje ubytek produkce estrogenu u zen v menopauze a zmirnuje symptomy menopauzy. Estrogen brani ubytku kostni tkane v dusledku menopauzy nebo ovariektomie.

Endogenni 17?-estradiol vyvolava a udrzuje primarni a sekundarni pohlavni znaky. Biologicky ucinek17?-estradiolu je zprostredkovan mnozstvim specifickych estrogenovych receptoru. Komplex steroidnich receptoru je vazan na bunecnou DNA a indukuje syntezu specifickych proteinu.

17?-estradiol zvysuje SHBG-BC (vazebnou kapacitu globulinu vazajiciho pohlavni hormony) a CBG-BC (vazebnou kapacitu globulinu vazajiciho kortikosteroidy). Gonadotropiny FSH (folikuly stimulujici hormon) a LH (luteinizacni hormon) jsou potlaceny.

Nedostatek estrogenu v menopauze je spojen se zvysenim kostniho metabolismu a ubytkem kostni hmoty. Ucinek estrogenu na denzitu kostniho mineralu je zavisly na velikosti davky. Ochrana je ucinna, dokud lecba pokracuje. Po ukonceni HST je rychlost ubytku kostni hmoty podobna jako u nelecenych zen.

Dukazy ze studie WHI a meta-analytickych studii dokladaji ze HST podavana prevazne zdravym

zenam, at jiz samotneho estrogenu nebo kombinovaneho s progestogenem, snizuje riziko zlomenin kycle, patere a jinych osteoporotickych zlomenin. HST take muze zabranit zlomeninam u zen s nizkou hustotou kostni hmoty a/nebo zjistenou osteoporozou, avsak udaje o tom jsou omezene.

Ucinek estradiolu na denzitu kostniho mineralu byl sledovan ve dvoulete, randomizovane, dvojite zaslepene, placebem kontrolovane klinicke studii u zen kratce po menopauze (n = 166, vcetne 41 pacientek uzivajicich 1 mg estradiolu a 42 uzivajicich 2 mg estradiolu). Preventivni pusobeni estradiolu v davce 1 mg a 2 mg proti ubytku kostni hmoty v bederni pateri a v cele kycli bylo ve srovnani s zenami uzivajicimi placebo vyznamne. Celkovy rozdil v prumerne zmene denzity kostniho mineralu, oproti placebu, cinil u 1 mg 4,3 % a u 2 mg 5,3 % v pripade bederni patere, a v pripade krcku femuru pak 4,0 % u 1 mg a 3,9 % u 2 mg. Odpovidajici hodnoty u trochanteru femuru cinily po dvoulete lecbe 3,3 % a 3,2 %.

Podil zen, u nichz denzita kostniho mineralu v bederni oblasti behem lecby zustala zachovana nebo se zvysila, predstavoval 61 % u zen lecenych 1 mg estradiolu a 68 % u zen lecenych 2 mg estradiolu.

Peroralne podavany mikronizovany 17? - estradiol, ktery je obsazeny v pripravku Estrimax, je rychle a ucinne vstrebavan z gastrointestinalniho traktu, vrcholu dosahuji koncentrace v plasme behem 4 - 6 hodin. Polocas 17? - estradiolu je priblizne 14 - 16 hodin. Vice nez 90% 17? - estradiolu je vazano na plasmaticke proteiny. 17? - estradiol a jeho metabolity jsou pak vylucovany moci (90 – 95%) jako biologicky neaktivni glukuronid a konjugovany sulfat, nebo ve stolici (5 – 10%) vetsinou jako nekonjugovane.

Predklinicke udaje vztahujici se k bezpecnosti

Akutni toxicita estrogenu je nizka. Z duvodu vyraznych rozdilu mezi ruznymi zivocisnymi druhy a mezi zviraty a clovekem maji predklinicke vysledky z hlediska aplikace estrogenu u cloveka jen omezenou predikcni hodnotu.

U pokusnych zvirat byl zjisten embryoletalni ucinek estradiolu a estradiol-valeratu jiz pri relativne nizkych davkach; byly zjisteny malformace urogenitalniho traktu a feminizace plodu muzskeho pohlavi.

Predklinicke udaje vychazejici z klasickych studii toxicity opakovanych davek, genotoxicity a kancerogenity nedokladaji zadne zvlastni riziko pro cloveka krome rizik uvedenych v dalsich castech souhrnu udaju o pripravku.

6. FARMACEUTICKE UDAJE

6.1 Seznam pomocnych latek

Jadro tablety: koloidni bezvody oxid kremicity, magnesium-stearat, povidon, mastek, bramborovy skrob, kukuricny skrob, monohydrat laktosy.

Potah tablety: koloidni bezvody oxid kremicity, oxid titanicity, makrogol 6000, hypromelosa, makrogol-stearat, cerny oxid zelezity.

6.3 Doba pouzitelnosti

Zvlastni opatreni pro uchovavani

Uchovavejte blistr v papirovem pouzdre, aby byl pripravek chranen pred svetlem.

Druh obalu a velikost baleni

Al/PVC blistr, kartonove pouzdro, krabicka.

3 x 28 potahovanych tablet.

6.6. Navod k pouziti pripravku, zachazeni s nim a k jeho likvidaci

Zadne zvlastni pozadavky.

Vsechen nepouzity pripravek nebo odpad musi byt zlikvidovan v souladu s mistnimi pozadavky.

DRZITEL ROZHODNUTI REGISTRACI

Gedeon Richter Plc.,Gyomroi ut 19-21,1103 Budapest, Madarsko

9. DATUM PRVNI REGISTRACE/ PRODLOUZENI REGISTRACE

Estrimax2 mg potahovane tabletyestradiolum

OBSAH LECIVE LATKY/LECIVYCH LATEK

Jedna potahovana tableta obsahuje 2 mg estradiolum (ve forme estradiolum hemihydricum).

SEZNAM POMOCNYCH LATEK

Obsahuje monohydrat laktosy. Viz pribalova informace pro dalsi udaje.

LEKOVA FORMA A VELIKOST BALENI

3x28 potahovanych tablet

ZPUSOB A CESTA/CESTY PODANI

K peroralnimu podani. Pred pouzitim si prectete pribalovou informaci.

ZVLASTNI UPOZORNENI, ZE LECIVY PRIPRAVEK MUSI BYT UCHOVAVAN MIMO DOSAH A DOHLED DETI

Uchovavejte mimo dosah a dohled deti.

DALSI ZVLASTNI UPOZORNENI, POKUD JE POTREBNE

ZVLASTNI PODMINKY PRO UCHOVAVANI

Uchovavejte v papirovim pouzdre, aby byl pripravek chranen pred svetlem.

ZVLASTNI OPATRENI PRO LIKVIDACI NEPOUZITYCH LECIVYCH PRIPRAVKU NEBO ODPADU Z TAKOVYCH LECIVYCH PRIPRAVKU, POKUD JE TO VHODNE

Nepouzitelne lecivo vrat’te do lekarny.

NAZEV A ADRESA DRZITELE ROZHODNUTI O REGISTRACI

Gedeon Richter Plc.1103 BudapestGyomroi ut 19-21.Madarsko

Toi On Sunset, Toi

Welcome to TOI. A rock-n-roll ensemble of undeniably delicious Thai food served among a legendary decor inspired by the merciless history of Hollywood's rock bands, movie stars and hit films. TOI's unique and fascinating collection of artifacts captures an untold version of cultural art and culinary tradition with an atmosphere that honors a diverse combination of influences in the menu, the ambiance and, of course… the rare and funky, opportunity to feel like a ROCKSTAR.

TOI serves LA’s healthiest Thai food using all fresh veggies, no MSG or preservatives and all dishes are cooked fresh to order! TOI offers to-go orders and free delivery.

Buy Thrionipen - Nimodipine - Online Without Prescriptions, Thrionipen

Nimotop (Thrionipen)

Nimotop (Nimodipine) is in a group of drugs called calcium channel blockers. Nimodipine relaxes (widens) blood vessels and improves blood flow.

Nimodipine is used to prevent brain damage caused by reduced blood flow to the brain resulting from aneurysm (AN-yor-iz-m), a dilated or ruptured blood vessel in the brain.

Nimodipine may also be used for purposes other than those listed here.

Take nimodipine exactly as it was prescribed for you. Do not take it in larger doses or for longer than recommended by your doctor.

Nimodipine gel capsules are to be taken by mouth only. The medicine in the capsule should never be placed into a needle and syringe and injected into a vein. If the person taking nimodipine cannot swallow the capsule, use a needle to make a hole in each end of the capsule, and squeeze the medicine out into an oral syringe. The syringe can then be used to give the medicine through a nasogastric (through the nose and into the stomach) tube. If you are able to swallow capsules, take nimodipine on an empty stomach, one hour before or two hours after meals. Take each dose with a full glass of water.

It is important to take nimodipine regularly to get the most benefit. Do not stop taking nimodipine without first talking to your doctor, even if you begin to feel better. If you stop taking the medication, your condition could become worse.

To be sure this medication is helping your condition, your blood pressure will need to be tested on a regular basis. Your liver function may also need to be tested. It is important that you not miss any scheduled visits to your doctor.

Take the medicine as prescribed by your doctor.

Store nimodipine at room temperature away from moisture and heat.

Active ingredient: Nimodipine

Nimotop (nimodipine) belongs to the class of pharmacological agents known as calcium channel blockers.

Before taking nimodipine, tell your doctor if you have liver disease, low blood pressure, high blood pressure (hypertension) for which you take medicine, or a history of heart problems such as a slow heart rate, congestive heart failure, or heart attack.

Nimodipine gel capsules are to be taken by mouth only. The medicine in the capsule should never be placed into a needle and syringe and injected into a vein. If the person taking nimodipine cannot swallow the capsule, use a needle to make a hole in each end of the capsule, and squeeze the medicine out into an oral syringe. The syringe can then be used to give the medicine through a nasogastric (through the nose and into the stomach) tube.

If you are able to swallow capsules, take nimodipine on an empty stomach, one hour before or two hours after meals. Avoid drinking alcohol while you are taking nimodipine. Alcohol and nimodipine may cause low blood pressure, drowsiness, or dizziness. Do not stop taking nimodipine without first talking to your doctor, even if you begin to feel better. If you stop taking the medication, your condition could become worse.

FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known if nimodipine passes into breast milk or if it could harm a nursing infant. Do not take nimodipine without telling your doctor if you are breast-feeding a baby. If you are over 65 years of age, you may be more likely to have side effects from nimodipine. Your doctor may prescribe a lower dose of this medication.

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop using nimodipine and call your doctor at once if you have any of these serious side effects:

unusually fast or slow heartbeats;

fainting or severe dizziness;

easy bruising or bleeding, unusual weakness;

swelling in your legs or ankles.

Other, less serious side effects may be more likely. Continue taking nimotop and talk to your doctor if you have any of these less serious side effects:

flushing (redness, warmth, or tingling feeling);

nausea, constipation; or

Side effects other than those listed here may also occur.

Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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Star Wars The Old Republic - Vireth Danea, My Sith Apprentice Oc, Vireth

Vireth Danea, my Sith Apprentice OC.

Hey people, I've been having a case of creativity again and I just thought I'd share my Sith OC with you guys and girls. Vireth was written and designed by yours truly, and brought to life by some wonderful and talented people. Enjoy!

If you guys and girls are interested in learning more about her, you can read the story thus far on my deviantart page. Thanks for watching!

"Should we arrive at certainty without doubt and truth without error, it behooves us to place the foundations of knowledge in mathematics." - Roger Bacon This is Vireth Danea, my Sith OC.

LucasArts, the LucasArts logo, STAR WARS and related properties are trademarks in the United States and/or in other countries of Lucasfilm Ltd. and/or its affiliates. © 2011-2012 Lucasfilm Entertainment Company Ltd. or Lucasfilm Ltd. All rights reserved. BioWare and the BioWare logo are trademarks of EA International (Studio and Publishing) Ltd. EA and the EA logo are trademarks of Electronic Arts Inc. All other trademarks are the property of their respective owners.

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Vireth Danea, my Sith Apprentice OC.

Hey people, I've been having a case of creativity again and I just thought I'd share my Sith OC with you guys and girls. Vireth was written and designed by yours truly, and brought to life by some wonderful and talented people. Enjoy!

If you guys and girls are interested in learning more about her, you can read the story thus far on my deviantart page. Thanks for watching!

"Should we arrive at certainty without doubt and truth without error, it behooves us to place the foundations of knowledge in mathematics." - Roger Bacon This is Vireth Danea, my Sith OC.

LucasArts, the LucasArts logo, STAR WARS and related properties are trademarks in the United States and/or in other countries of Lucasfilm Ltd. and/or its affiliates. © 2011-2012 Lucasfilm Entertainment Company Ltd. or Lucasfilm Ltd. All rights reserved. BioWare and the BioWare logo are trademarks of EA International (Studio and Publishing) Ltd. EA and the EA logo are trademarks of Electronic Arts Inc. All other trademarks are the property of their respective owners.

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Alerfan, Alerfan

www. Alerfan. com

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This physician locator tool is being provided by Allergan, Inc. (“Allergan”) solely to assist you in locating a physician who has experience with its aesthetic brands. For your convenience and based on your election, Allergan may highlight certain physicians in your area who are frequent users of this Find a Doctor’s product. Notwithstanding the above, this physician locator tool should not be construed in any way as an endorsement or recommendation by Allergan as to the qualifications of any physician listed in this tool or the quality of medical care they can provide. Allergan makes no guarantees that using a physician from this list will result in your desired outcome. It is wholly and solely your responsibility to assess the qualifications of a potential physician. Allergan recommends that you meet and discuss the benefits and risks of aesthetic treatments and the procedure to administer the product with the potential physician.

Allergan and its affiliates hereby disclaim any and all liability arising from your use of and/or reliance on the information contained in this physician locator tool.

BOTOX ® Cosmetic (onabotulinumtoxinA) JUVEDERM ® Family of Fillers KYBELLA ® (deoxycholic acid) injection 10 mg/mL LATISSE ® (bimatoprost ophthalmic solution) 0.03% Natrelle ® Breast Implants SkinMedica ® Skin Care Brilliant Distinctions ® Program

Approved Uses BOTOX ® Cosmetic is a prescription medicine that is injected into muscles and used to temporarily improve the look of both moderate to severe crow’s feet lines and frown lines between the eyebrows in adults.

IMPORTANT SAFETY INFORMATION BOTOX ® Cosmetic may cause serious side effects that can be life threatening. Get medical help right away if you have any of these problems any time (hours to weeks) after injection of BOTOX ® Cosmetic:

Problems swallowing, speaking, or breathing, due to weakening of associated muscles, can be severe and result in loss of life. You are at the highest risk if these problems are pre-existing before injection. Swallowing problems may last for several months

Spread of toxin effects. The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms including: loss of strength and

IMPORTANT SAFETY INFORMATION AND APPROVED USES BOTOX ® Cosmetic may cause serious side effects that can be life threatening. Call your doctor or get medical help right away if you have any of these problems any time (hours to weeks) after injection of BOTOX ® Cosmetic:

Problems swallowing, speaking, or breathing, due to weakening of associated muscles, can be severe and result in loss of life. You are at the highest risk if these problems are pre-existing before injection. Swallowing problems may last for several months

Spread of toxin effects. The effect of botulinum toxin may affect areas

Approved Uses BOTOX ® Cosmetic is a prescription medicine that is injected into muscles and used to temporarily improve the look of both moderate to severe crow’s feet lines and frown lines between the eyebrows in adults.

IMPORTANT SAFETY INFORMATION AND APPROVED USES BOTOX ® Cosmetic may cause serious side effects that can be life threatening. Get medical help right away if you have any of these problems any time (hours to weeks) after injection of BOTOX ® Cosmetic:

IMPORTANT SAFETY INFORMATION BOTOX ® Cosmetic may cause serious side effects that can be life threatening. Get medical help right away if you have any of these problems any time (hours to weeks) after injection of BOTOX ® Cosmetic:

Problems swallowing, speaking, or breathing, due to weakening of associated muscles, can be severe and result in loss of life. You are at the highest risk if these problems are pre-existing before injection. Swallowing problems may last for several months

Spread of toxin effects. The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms including: loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing

BOTOX ® Cosmetic dosing units are not the same as, or comparable to, any other botulinum toxin product.

There has not been a confirmed serious case of spread of toxin effect when BOTOX ® Cosmetic has been used at the recommended dose to treat frown lines, crow’s feet lines, or both at the same time.

BOTOX ® Cosmetic may cause loss of strength or general muscle weakness, vision problems, or dizziness within hours to weeks of taking BOTOX ® Cosmetic. If this happens, do not drive a car, operate machinery, or do other dangerous activities.

Serious and/or immediate allergic reactions have been reported. They include: itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint. Get medical help right away if you are wheezing or have asthma symptoms, or if you become dizzy or faint.

Do not take BOTOX ® Cosmetic if you: are allergic to any of the ingredients in BOTOX ® Cosmetic (see Medication Guide for ingredients); had an allergic reaction to any other botulinum toxin product such as Myobloc ® (rimabotulinumtoxinB), Dysport ® (abobotulinumtoxinA), or Xeomin ® (incobotulinumtoxinA); have a skin infection at the planned injection site.

Tell your doctor about all your muscle or nerve conditions, such as ALS or Lou Gehrig’s disease, myasthenia gravis, or Lambert-Eaton syndrome, as you may be at increased risk of serious side effects including difficulty swallowing and difficulty breathing from typical doses of BOTOX ® Cosmetic.

Tell your doctor about all your medical conditions, including: plans to have surgery; had surgery on your face; weakness of forehead muscles: trouble raising your eyebrows; drooping eyelids; any other abnormal facial change; are pregnant or plan to become pregnant (it is not known if BOTOX ® Cosmetic can harm your unborn baby); are breast-feeding or plan to (it is not known if BOTOX ® Cosmetic passes into breast milk).

Tell your doctor about all the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal products. Using BOTOX ® Cosmetic with certain other medicines may cause serious side effects. Do not start any new medicines until you have told your doctor that you have received BOTOX ® Cosmetic in the past.

Tell your doctor if you have received any other botulinum toxin product in the last 4 months; have received injections of botulinum toxin such as Myobloc ®. Dysport ®. or Xeomin ® in the past (tell your doctor exactly which product you received); have recently received an antibiotic by injection; take muscle relaxants; take an allergy or cold medicine; take a sleep medicine; take aspirin-like products or blood thinners.

Other side effects of BOTOX ® Cosmetic include: discomfort or pain at the injection site; headache; and eye problems: double vision, blurred vision, drooping eyelids, and swelling of your eyelids.

For more information refer to the Medication Guide or talk with your doctor.

To report a side effect, please call Allergan at 1-800-433-8871.

Approved Uses BOTOX ® Cosmetic is a prescription medicine that is injected into muscles and used to temporarily improve the look of both moderate to severe crow’s feet lines and frown lines between the eyebrows in adults.

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The Integration of Technology and Life Safety

Welcome to TriTek Fire & Security, LLC

Thank you for visiting the TriTek Fire & Security, LLC website. TriTek Fire & Security, LLC is the foremost leader for commercial fire, security, and communications systems. The owners of TriTek Fire & Security have over 40 years of experience in the low voltage industry. TriTek carries a full line of Fire, CCTV, CATV, Intrusion, Access Control, and Building Communication Systems products. TriTek is fully equipped with installation crews along with a staff of factory trained technicians. We are a UL Certificated Company with all NICET II Certified technical staff. TriTek Fire & Security, LLC also has two NICET IV Certified personnel on its design staff.

TriTek provides a total systems approach to satisfying our customer’s needs by combining outstanding products, sophisticated design and support tools with talented people to match the resource, needs and capabilities of our clients. While TriTek has the capabilities and resources to support the largest of applications, we can also design our offering to enable small commercial customers to implement and afford advanced integrated low voltage systems that grow with their business.

TriTek Fire & Security, LLC is headquarted out of Columbia, SC with Branch Offices in Augusta, GA. With remote technicians located around the state. Our offices are fully stocked with service parts to meet any need, 24 hours a day.

We at TriTek are about forming relationships with our customers. We greatly appreciate the fact our customers choose TriTek for their life safety and communication needs and in return we pledge to offer them the best service possible. At TriTek we believe it’s the service that goes with the sale that makes for the total package.

Please visit the other areas of our site to read more information about our services and product lines, and read some case studies from a few of our successful installations.

Our Mission Statement

TriTek Fire & Security, LLC’s mission is to work with businesses to develop and maintain Life Safety, Security, and Communications Systems for facilities and to provide a lifelong partnership to fulfill the customer’s peace of mind and well being.

TriTek is licensed in SC, NC & GA as Certified Low Voltage Contractors:

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