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Patient Profile for: Amy S. Mandorf

Personal Information

Patient ID:                    # 40505001AN

Attending Physician:      xxxxxxxxxxxxxMD

Patient Name:               Amy S. Mandorf

Address:                       xxxxxxxxxxxxxxxx

City:                            xxxxxxxxxx

State:                            LA

Zipcode:                       xxxxx

Country:                       USA

Phone:                     (xxx) xxx-xxxx

____________________________________________________________________________________

 

Medical Information

____________________________________________________________________________________

 

Diagnosis:         Type I diabetes mellitus

                        Hyperlipidemia

                        Hypertension

                        Peripheral neuropathy

                        Bursitis, Arthritis

                        COPD (Chronic Obstructive Pulmonary Disease)

                        Stage II - B breast cancer

                        Renal impairment ( assessment made by this reviewer from estimated creatinine

                        clearance  calculation based on serum creatinine of 0.8  obtained 10-04.) CrCl =

                        43ml/min

                        Irregular heartbeat not otherwise specified(NOS)

                        Quadruple coronary by-pass 1994

                       

 

General complaints not listed as diagnosis by your doctor:

                        Bowel problems requiring fiber twice daily but poor control colonoscopy scheduled

                        January 24, 2005.

                        Feelings of exhaustion and weakness mid-afternoon

                        Normal to loose stools to diarrhea lasting up to two weeks at a time. Frequently

                        associated with starting new medications

                        reports of  memory problems

                        Complaints of pain to hips, shoulders, knees, fingers and back

                        Involuntary muscle twitches or jerks

                        Legs hurt when walking.

                        Complaints of insomnia described as sleep onset (Chronic)

                        History of pedal edema with doses of Actos greater than 30mg.

                        Complaints of orhtopnea relieved with 1 pillow elevation.

                        Loses sense of direction while driving.

 

Allergies:  No known allergies reported

 

Current Medications:

            Verapamil ER 240mg tablets: One tablet by mouth daily at bedtime.

            Lipitor 10mg tablets: ½ tablet by mouth daily at bedtime.

            Femara 2.5mg tablets: One tablet by mouth daily.

            Aspirin 81mg tablets: One tablet by mouth daily at bedtime.

            Amaryl 4mg tablets: One and one-half tablet by mouth in the mornings, before dinner and at

                                              bedtime.

            Diabeta 5mg tablets: One tablet by mouth daily at lunch and three tablets by mouth at bedtime.

            Actos 30mg tablets: One tablet by mouth daily at dinner.

            Amitriptyline 25mg tablets: Two tablets by mouth daily at bedtime.

            Aleve 220mg tablets: Two tablets by mouth every other day with dinner or at bedtime.

            Juice Pluscapsules: Two capsules by mouth in the morning and the evening with dinner.

            Prandin 2mg tablets: One tablet by mouth daily at bedtime. (noncompliant due to aggravation of

                                              bowel problems)

 

Dosing considerations

 

Gender:                        Female

DOB:                              1/1 /1933         Age: 72

Height:                          60" ( 152.4cm)

Weight:                         169lbs (76.8Kg)

Ideal Body Weight:       45.5kg (100 lbs)    BMI = 33.1( cardiac risk)

Body Surface Area:      1.7392M2

Serum Creatinine:         0.8mg/dl    Date:10-7-04

Estimated Creatinine Clearance:  43ml/min

 

____________________________________________________________________________________

 

Date: 4-11-05

Pharmacology Review and recommendations:

 

Initial review & assessment:

This 72 year old female presents with the above listed diagnosis and pertinent complaints obtained from personal history.  Laboratory values are generally all within normal or acceptable limits. Her mean (average) morning blood pressure readings are well within American Heart Association(AHA), American College of Cardiologist (ACC), and American Diabetes Association (ADA)  goal recommendation for diabetic patients. Her evening mean (average) blood pressures have been above these goals at 142/76mm Hg (SD 6.7mm Hg) /(7.1mm Hg). Overall average  blood pressure 136/76mm Hg (SD 10.23mm Hg).

Her glycohemoglobin (HgbA1C) levels are within acceptable limits and are consistent with the finger-stick readings  obtained twice daily. Her weakness and fatigue may however, be related to lower plasma glucose levels in the afternoons and early evening.         

            The American Diabetes Association and The American College of Endocrinologist recommendations which are in line with findings from three landmark diabetes studies call for lower A1C levels and more stringent FPG levels (see Table 1) than are being achieved in this patient but also call for caution in attempts to achieve intensive control in the elderly population. However, many elderly diabetic patients are able to tolerate intensive therapy or strict control of blood sugar levels and benefit as much as younger patients. This benefit is seen in either prevention or the slowing of the progression of both diabetic complications on all levels. These landmark studies have shown significant improvement in and slowed progression or development of kidney problems, neurological problems and eye problems. Since this patient is tolerating low afternoon blood sugar levels she may also tolerate lower fasting levels. Changing from her current oral therapy to insulin injections will help to achieve better early morning fasting levels and more acceptable after meal levels without weakness or fatigue or other complications.  The role of insulin in type II diabetes has gained increasing support for early intervention. This patient has indicated in her interview that she is in favor of starting insulin therapy. The addition of  basal or background insulin therapy in combination with oral therapy is highly recommended, is a simpler, safer, and more effective alternative for treating diabetes in this patient. The scientific literature is growing daily with studies addressing this approach to therapy lending further support to the clinical logic of this practice. The studies are showing that early addition of insulin therapy to oral therapy significantly improves blood sugar level control, reduces progression of and development of neurological , kidney and eye problems.  Ideally oral combination with either metformin (Glucophage) or one of the thiazolidinediones (Actos or Avandia) is preferred. However, because of this patient's depressed kidney function (estimated CrCl  of 43ml/min) Glucophage should not be used.

 Her problem with fluid retention (ie..pedal edema) and her complaints of shortness of breath indicate some other possible cardiac concerns. The patient has stated that her legs swell significantly with Actos doses greater than 30mg. The addition of insulin to Actos increases the risk of fluid retention and could aggravate or  cause heart failure. If Actos were to be continued to preserve its beta islet cell protective function then the dose should be no greater than 15mg in the mornings. However, this is not the most recommended option but could be considered. The best  option is discontinuation of all oral therapy as the patient currently has order for three oral diabetic medications all within the same class resulting in duplication of therapy without further benefit and this seems to be contributing to her afternoon episodes of weakness and fatigue. 

   

TABLE 1

A review of the literature suggest that a reasonable guideline to follow for elderly patients who may not be suited for intensive therapy, would be allowing for a 10% increase in ADA recommended fasting levels for each decade above 65 years of age.

Considering these recommendations the ADA guidelines would convert to the following:

 

   ADA intensive therapy           Alternative for Elderly patients

               Goal recommendations          65-75         76-85          86-95         96...           

                (mg/dl)                                 (mg/dl)       (mg/dl)       (mg/dl)      (mg/dl) 

          

Fasting levels :    90-130                                  100-145     110-155      117-170     126-180

Post prandials:   120-180                                 120-180     120-180      120-180     120-180

Bedtime levels:   110-150                                 110-150     110-150      110-150     110-150

 

 

By patient given history she is also having some cognition problem specifically related to

driving, and also has complaints of chronic insomnia and peripheral neuropathy. The insomnia is a sleep onset type. Perhaps the long term use of amitriptyline has been employed to address both the issue of insomnia and peripheral neuropathy but this agent is not recommended for use in geriatric patients because of its high anticholinergic properties.  These properties result in disruption of the sleep-wake cycle, can induce cognition problems from confusion to delirium and increase risk for falls. It should be discontinued slowly over the next few weeks and consideration should be given to utilizing Effexor XR 75mg at bedtime. The properties of Effexor will allow it to address sleep problems and can help with any peripheral neuropathies problems the patient may be experiencing. Her interview indicated signs and symptoms of depression as well so the addition of Effexor XR 75mg at bedtime is an excellent choice to replace amitriptyline. There are some concerns about blood pressure elevations with this drug but they do not occur until doses of 300mg or greater or used. The patient would continue to monitor blood pressure weekly.

            The patient is also on low dose aspirin and is taking this preparation in the evening at bedtime.

The patient has indicated having problems with pedal edema and is currently receiving Alleve every other day for bursitis and arthritis complaints. This class of drugs(NSAIDs) is know to cause sodium retention (causing swelling in the lower legs or ankles). In the presence of  Verapamil which can also contribute to fluid retention problems this problem is expected to increase. Because of this edema problem the Alleve should be discontinued.  Additonally, ibuprofen is know to counteract any benefits of  aspirin in prevention of thrombotic events. The entire class of NSAIDs with the exception of cataflam should be suspect of the same problem and their use should be avoided. Aspirin therapy should be continued as the patient has a history of quadruple bypass surgery. Consideration could be given to using and enteric coated low dose aspirin if gastric problems arise and switch the dose to early morning.

            Finally, the patient mentioned some type of irregular heartbeat. It isn't noted in her diagnosis. Her blood pressure seems to be under fair control but doesn't meet the goals of therapy expected for diabetic patients. She is currently receiving an extended release verapamil preparation 240mg daily. While a different calcium channel blocker could be considered changing from bedtime dosing to am dosing may be all that is needed to lower the elevated evening blood pressure readings. The drug monograph and literature recommend giving the dose in the morning. The patient is currently taking it at bedtime. If this fails then changing to another calcium channel blocker with greater bioavailability such as diltiazem would be another option.

            Use of Lipitor for this 72 year old female isn't recommended. Use of statins in geriatric patients should be supported by high risk. High risk is defined as a combination of on e of the following conditions:  Stroke, MI, CAD, or angina with cholesterol levels greater than 300mg/dl. Additionally, because of the metabolism of Lipitor which involves the cytochrome P450 pathway there is significant potential for interaction with verapamil. The patient has complaints of joint aches, back ache, signs/symptoms of depression and hypertension all potetntial side effects of statin therapy. The addition of B12, folic acid and vitamin B6 are viable options to Lipitor therapy and poses fewer risk of adverse drug effects than Lipitor.

 

Specific Medication change recommendations:

 

Drug                                         Recommended change:
Verapamil ER 240mg tablets: Change from bedtime to morning dosing

Lipitor 10mg tablets:                Stop

Femara 2.5mg tablets:              Inadequate information recommendations to follow awaiting info

                                                  from oncologist and patient. General duration of therapy 24

                                                  months. Data on current duration of therapy unavailable.

            Aspirin 81mg tablets:               Continue but change to enteric coated if gastric irritation occurs.

            Amaryl 4mg tablets:                  Stop

            Diabeta 5mg tablets:                 Stop

            Actos 30mg tablets:                  Stop

            Amitriptyline 25mg tablets:        See below de-challenge this medication slowly over 2 weeks.

            Aleve 220mg tablets:                Stop

            Juice Pluscapsules:                   Continue

            Prandin 2mg tablets:                 Stop

 

            Add:

            Lantus 43u subcutaneously at bedtime ( general recommendations for Lantus dosing are to

                                                                               reduce total daily dose of insulin  N requirement by

                                                                               20% and the dosing for obese patients of  Humulin N

                                                                               would be 0.7mg/Kg  or 43u. Titrate to patient response

                                                                               and tolerance by adjusting 1u for each 30-50mg/dl

                                                                               change needed.

            Do FPG finger-stick testing for 2 weeks get fasting levels within recommended goal then address

            2 hour post meal  levels by adding a mealtime insulin. Lispro is preferred because its results are

            more consistent than aspart insulin. Start with 2 units after each meal if 50% or more of the meal

            is consumed otherwise hold the dose if less is consumed. Monitor 2 hour after meal blood

            glucose levels prandial levels by finger-stick testing for 2 weeks. Titrate to patient response and

            tolerance adjusting by 1u for each 30mg/dl change needed.

            Start   B12 injections 1000mcg weekly for 4 weeks then 1000mcg monthly thereafter.

            Start   B6 200mg daily

            Start   Folic acid 1mg daily

           

Start Effexor XR 75mg at bedtime and decrease Amitriptyline to 25mg 1 tablet  at bedtime for

         1week. Then decrease amitriptyline to 25mg every other day at bedtime for 1 week then

         discontinue it. Monitor the patient response  and evaluate for increase in Effexor dose if

          necessary depending on patient insomnia, neuropathy and depression in 1 month.

 

Start  Ultracet 1 tablet every 6 hours as needed for arthritis or bursitis and other pain complaints.

 

            Specific Drug Information:

            Verapamil ER 240mg tablets -

Verapamil tablets

 

What are verapamil tablets?

VERAPAMIL (Calan®, Isoptin®) is a calcium-channel blocker. By relaxing blood vessels, it can improve blood flow to the heart. Verapamil reduces attacks of chest pain (angina); lowers blood pressure (treats hypertension); and controls heart rate in certain conditions. Generic verapamil tablets are available.

 

What should my health care professional know before I take verapamil?

They need to know if you have any of these conditions:

.constipation problems

.heart or blood vessel disease

.heart rhythm disturbances such as sick sinus syndrome, ventricular arrhythmias, Wolff-Parkinson-White syndrome, or Lown-Ganong-Levine syndrome

.liver or kidney disease

.neuromuscular disease such as muscular dystrophy

.slow or irregular heartbeat

.an unusual or allergic reaction to verapamil, other medicines, foods, dyes, or preservatives

.pregnant or trying to get pregnant

.breast-feeding

 

How should I take this medicine?

Take verapamil tablets by mouth. Follow the directions on the prescription label. Swallow the tablets with a drink of water. Do not take with grapefruit juice. If verapamil upsets your stomach, you can take it with food or milk. Take your doses at regular intervals. Do not take your medicine more often then directed. Do not stop taking except on your prescriber's advice.

 

Contact your pediatrician or health care professional regarding the use of this medicine in children. Special care may be needed.

 

Elderly patients over 65 years old may have a stronger reaction to this medicine and need smaller doses.

 

What if I miss a dose?

If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses.

 

What drug(s) may interact with verapamil?

Do not take Verapamil with any of the following:

.astemizole

.cisapride

.disopyramide

.dofetilide

.grapefruit juice

.pimozide

.terfenadine

 

Verapamil may also interact with the following medications:

.alcohol

.alfuzosin

.alosetron

.antiinflammatory drugs (NSAIDs, such as ibuprofen)

.barbiturates such as phenobarbital

.bosentan

.caffeine

.certain antibiotics (clarithromycin, erythromycin, telithromycin, troleandomycin)

.certain medicines used to treat cancer

.certain medicines to treat migraine (ergotamine, dihydroergotamine, methysergide)

.cevimeline

.cilostazol

.cimetidine

.clonidine

.cyclosporine

.fentanyl

.galantamine

.herbal or dietary supplements such as ginger, gingko biloba, ginseng, hawthorn, ma huang (ephedra), melatonin, St. John's wort, went yeast

.lithium

.local anesthetics or general anesthetics

.medicines for anxiety or difficulty sleeping (examples: alprazolam, buspirone, midazolam, triazolam)

.medicines for depression or mental problems (examples: imipramine, fluoxetine, fluvoxamine, nefazodone, ziprasidone)

.medicines for fungal infections (fluconazole, itraconazole, ketoconazole, voriconazole)

.medicines for heart-rhythm problems (amiodarone, digoxin, flecainide, procainamide, quinidine)

.medicines for high cholesterol (atorvastatin, cerivastatin, colesevelam, lovastatin, simvastatin)

.medicines for high blood pressure or heart problems

.medicines for HIV infection or AIDS

.medicines for prostate problems

.medicines for seizures (carbamazepine, clonazepam, ethosuximide, oxcarbazepine, phenobarbital, phenytoin, primidone, zonisamide)

.methadone

.methylprednisolone

.rifampin, rifabutin or rifapentine

.sildenafil

.sirolimus

.sulfinpyrazone

.tacrolimus

.theophylline or aminophylline

.water pills (diuretics)

.yohimbine

.zafirlukast

.zileuton

 

Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

 

What side effects may I notice from taking verapamil?

Side effects that you should report to your prescriber or health care professional as soon as possible:

More common:

.dizziness

.slow heartbeat (less than 50 beats per minute)

.lightheadedness

.swelling of the legs or ankles

Rare or uncommon:

.difficulty breathing

.fast heartbeat, palpitations, irregular heartbeat, chest pain, or

.fainting

.skin rash

 

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):

.constipation

.facial flushing

.headache

.nausea, vomiting

.sexual dysfunction

.weakness or tiredness

 

What should I watch for while taking verapamil?

Check your blood pressure and pulse rate regularly; this is important while you are taking verapamil. Ask your prescriber or health care professional what your blood pressure and pulse rate should be and when you should contact him or her.

 

You may feel dizzy or lightheaded. Do not drive, use machinery, or do anything that needs mental alertness until you know how verapamil affects you. To reduce the risk of dizzy or fainting spells, do not sit or stand up quickly, especially if you are an older patient. Alcohol can make you more dizzy or increase flushing and rapid heartbeats. Avoid alcoholic drinks.

 

Do not suddenly stop taking verapamil. Ask your prescriber or health care professional how to gradually reduce the dose.

 

If you are going to have surgery, tell your prescriber or health care professional that you are taking verapamil.

 

Where can I keep my medicine?

Keep out of the reach of children in a container that small children cannot open.

 

Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F). Protect from light. Keep container tightly closed.

Femara 2.5mg tablets

Letrozole tablets

 

What are letrozole tablets?

LETROZOLE (Femara®) blocks the formation of the hormone estrogen. Some types of breast cancer need estrogen, and letrozole stops tumor growth by decreasing estrogen levels. Letrozole is for the treatment of breast cancer in postmenopausal women only. Generic letrozole tablets are not yet available.

 

What should my health care professional know before I take letrozole?

They need to know if you have any of these conditions:

.liver disease

.osteoporosis

.an unusual or allergic reaction to letrozole, other medicines, foods, dyes, or preservatives

.pregnant or trying to get pregnant

.breast-feeding

 

How should I take this medicine?

Take letrozole tablets by mouth at the same time each day. Follow the directions on the prescription label. Swallow the tablets with a drink of water. Do not take your medicine more often than directed. Do not stop taking except on your prescriber's advice.

 

Contact your pediatrician or health care professional regarding the use of this medicine in children. Special care may be needed.

 

What if I miss a dose?

If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses. If you vomit after taking a dose, call your prescriber or health care professional for advice.

 

What drug(s) may interact with letrozole?

.androstenedione

.any medicine containing estrogens (This may include some herbal products and some birth control pills)

.DHEA

 

Tell your prescriber or health care professional about all other medicines you are taking, including nonprescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

 

What side effects may I notice from taking letrozole?

Side effects that you should report to your prescriber or health care professional as soon as possible:

.difficulty breathing

.chest pain

.leg pain or swelling

.skin rash

 

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):

.back or bone pain

.cough, or throat infection

.diarrhea or constipation

.dizziness

.headache

.hair loss

.hot flashes

.loss of appetite

.nausea, vomiting

.stomach pain or upset stomach

.sweating

.weakness or tiredness

.weight gain

 

What should I watch for while taking letrozole?

Visit your prescriber or health care professional for regular checks on your progress. Let your prescriber or health care professional know about any unusual vaginal bleeding.

 

Do not treat yourself for diarrhea, nausea, vomiting or other side effects. Ask your prescriber or health care professional for advice.

 

Where can I keep my medicine?

Keep out of the reach of children in a container that small children cannot open.

 

Store between 15 and 30 degrees C (59 and 86 degrees F). Throw away any unused medicine after the expiration date.

Lantus insulin

 

What is insulin injection?

INSULIN ( Iletin II®, Humulin®, Humalog®, Novolin®, NovologT, etc.) is a hormone produced naturally by the pancreas. Insulin regulates the amount of sugar in your blood and prevents or reduces long-term complications including damage to the blood vessels, eyes, kidneys, or nerves.

 

There are different types of insulin available. Each type has a different onset of action and a different duration of action in the body. You should learn which types you take and how you should administer them, and how each type acts in your body. Insulin is labeled with a large, black letter (example: R for regular, L for lente) to help you easily identify the type, or with the name of the type you take (examples: Humalog®, NovoLogT, Humalog®MixT, Lantus®, NovologTMixT). Only certain types of insulin may be used in insulin pumps.

 

Insulin is obtained from beef, pork or human sources. Beef insulin is no longer being produced in the US due to concerns of transmission of certain infections through cow tissues. Talk to your prescriber if you take beef insulin currently.

 

Once you are stabilized, do not change the type of insulin you use unless directed to do so by your health care professional. If you must switch the type of insulin you use, you should realize that you may need to monitor your blood sugar more frequently and that dosage adjustments may be needed before you are stabilized on the new type. Take care to learn and recognize the symptoms of hypoglycemia (low blood sugar) and know how you should treat these reactions.

 

Insulin is available from several manufacturers. Some types of insulin can only be obtained by prescription; your prescriber or health care professional will probably write one. A prescription to obtain insulin syringes may or may not be required in the state where you live.

 

What does my health care professional need to know before I receive insulin?

They need to know if you have any of these conditions:

.adrenal or pituitary gland problems

.diarrhea

.fever or infection

.injury or trauma

.kidney disease

.nausea, vomiting

.recent surgery

.thyroid disease

.an unusual or allergic reaction to insulin, beef or pork products, other medicines, foods, dyes, or preservatives

 

How should I use this medicine?

Insulin is for injection under the skin. Use daily exactly as directed. Do not use more insulin than prescribed. Do not use more or less often than prescribed.

 

To prepare a dose: Clean the rubber stopper of the vial with an alcohol wipe. Roll the bottle gently between the palms of your hands to mix and warm the solution (not necessary for regular insulin, insulin aspart, or insulin lispro). Be sure to mix the solution well, but do not shake vigorously. Pull back the plunger of a disposable syringe to fill the syringe with an amount of air equal to your dose of insulin (if your dose is 30 units, pull the plunger to the 30 unit mark). Insert the needle into the rubber stopper of the vial, and inject the air into the vial (this will make the insulin easier to remove). Turn the vial upside down, and pull back on the plunger to fill the syringe with prescribed number of units of insulin. Remove any air bubbles trapped in the syringe. If you are mixing two types of insulin in the syringe, measure the regular, aspart, or lispro insulin first.

 

To inject a dose: Select an injection site on the stomach, arm, buttocks, or thigh, and clean with an alcohol wipe. Pinch the skin up with your fingers about three inches apart, and insert the needle at an angle of 45-90 degrees. Pull back on the plunger to make sure the needle is not in a blood vessel before injecting the insulin. If blood appears, remove the needle, reinsert it in a different (nearby) location, and repeat the process. If no blood appears, press the plunger to deliver the insulin. Remove the needle from the skin and press gently on the injection site for a moment (but do not rub or massage). Rotate your injection site such that each site is not used more than once every 1-2 months.

 

If you utilize a insulin injector device, you will be taught how to use it and how to refill the device with the insulin cartridges. Depending on the type of insulin and the type of injector device you use, you should gently roll the injector device between your hands or gently tip it up-side down then right-side up, until the insulin appears uniformly white and cloudy. You will be taught how to administer doses for meals or adjust doses for activities. Your health care prescriber and diabetic educators will teach you.

 

If you utilize an insulin pump, you will be taught how to program the pump; refill the pump cartridges; and how to administer doses for meals or adjust doses for activities. Your health care prescriber and diabetic educators will teach you.

 

What if I miss a dose?

It is important not to miss a dose. If you do miss a dose, use it as soon as you can. If it is almost time for your next dose, use only that dose, do not take double doses. Know the signs of low and high blood sugar and make sure a close family contact or friend can also recognize these signs. Contact your prescriber or health care professional at once if you have any problems.

 

What drug(s) may interact with insulin?

.diazoxide

.epinephrine

.glucagon

.guanethidine

.other medicines for diabetes

 

Many medications may cause changes (increase or decrease) in blood sugar, these include:

.alcohol containing beverages

.aspirin and aspirin-like drugs

.beta-blockers, often used for high blood pressure or heart problems (examples include atenolol, metoprolol, propranolol)

.chromium

.female hormones, such as estrogens, progestins, or contraceptive pills

.isoniazid

.male hormones or anabolic steroids

.medications to suppress appetite or for weight loss

.medicines for allergies, asthma, cold, or cough

.niacin

.pentamidine

.phenytoin

.some herbal dietary supplements

.steroid medicines such as prednisone or cortisone

.thyroid hormones

.water pills (diuretics)

 

Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

 

What side effects may I notice from receiving insulin?

Learn how and when you should monitor your blood sugar, and what you should do if high or low blood sugar occurs. Side effects that you should report to your prescriber or health care professional as soon as possible:

 

Symptoms of hypoglycemia (low blood glucose). Contact your health care professional if you experience symptoms of low blood sugar, which may include:

.anxiety or nervousness, confusion, difficulty concentrating, hunger, pale skin, nausea, fatigue, sweating, headache, palpitations, numbness of the mouth, tingling in the fingers, tremors, muscle weakness, blurred vision, cold sensations, uncontrolled yawning, irritability, rapid heartbeat, shallow breathing, and loss of consciousness. Hypoglycemia may cause you to not be aware of your actions or surroundings if it is severe, so you should let others know what to do if you cannot help yourself in a severe reaction.

 

Symptoms of high blood sugar (hyperglycemia) include:

.dizziness, dry mouth, flushed dry-skin, fruit-like breath odor, loss of appetite, nausea, stomach ache, unusual thirst, frequent passing of urine

 

Insulin also can cause rare but serious allergic reactions in some patients, including:

.severe skin rash and itching (hives)

.difficulty breathing

 

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):

.increase or decrease in fatty tissue under the skin, through overuse of a particular injection site

.itching, burning, swelling, or rash at the injection site

 

What should I watch for while taking insulin?

Visit your prescriber or health care professional for regular checks on your progress. To control your diabetes properly you must use insulin regularly, follow a regular diet and exercise schedule. Diabetes cannot be cured. Careful, daily control of blood sugar can postpone or prevent many of the long-term complications of diabetes.

 

Dangerously high or low blood sugar can occur when meals and insulin are not spaced properly. Checking and recording your blood glucose and urine ketone levels regularly is important. It is sometimes hard to tell the difference between low and high blood sugar on the basis of symptoms (see side effects). Use a glucometer (blood glucose or sugar measuring device), whenever possible, before treating a suspected increase or decrease in blood sugar.

 

Make sure that you have the right kind of syringe for the type of insulin you use. Try not to change the brand and type of insulin syringe unless told to switch by your prescriber. Use a syringe only once and throw away syringe and needle in a closed container to prevent accidental needle sticks.

 

Do not switch brands or types of insulin without consulting your prescriber or health care professional; this can result in dangerously high or low blood sugar.

 

Wear a Medic Alert bracelet or necklace and/or carry an identification card with your name and address, condition, medication, and prescriber's name and address.

 

If you develop a cold, diarrhea, vomiting or other acute infection or illness, you should contact your health care prescriber. "Sick-days" may require adjustments to your insulin dosage or your illness may need to be evaluated. Ask your prescriber what you should do if you become ill. Do not stop taking your insulin; check with your prescriber for advice.

 

If you are a long time smoker and suddenly stop, you may need a change in insulin dose. Talk to your prescriber or health care professional first.

 

Many nonprescription cough and cold products contain sugar or alcohol. These can affect diabetes control or can alter the results of tests used to monitor blood sugar control. Avoid alcohol and products that contain alcohol or sugar.

 

If you are going to have surgery, make sure you tell the health care professionals that you take insulin.

 

Where can I keep my medicine?

Keep out of the reach of children.

 

Store unopened insulin vials or pen-injector cartridges in a refrigerator between 2-8 degrees C (36-46 degrees F). Do not freeze. Return to room temperature before use. Opened vials (vials currently in use) may be safely stored at room temperature, at approximately 25 degrees C (77 degrees F) or cooler for up to 28 days. Pen-injector cartridges in use may be kept at room temperature, approximately 25 degrees C (77 degrees F or cooler) for up to 10 days. Protect from light and excessive heat. Throw away any unused medicine after the expiration date or after the specified time for room temperature storage has passed.

Aspirin

Aspirin, ASA chewing gum

 

What is aspirin, ASA chewing gum?

ASPIRIN, ASA (Aspergum®) treats fever, pain, and inflammation (swelling and redness) and reduces the ability of the blood to clot. Aspirin relieves the mild to moderate discomfort caused by a variety of conditions including arthritis, headaches, infections, menstrual cramps or pain, minor injuries, and other conditions. It can also be part of therapy to reduce the risk of a heart attack or stroke.

 

What should my health care professional know before I take aspirin, ASA?

They need to know if you have any of these conditions:

.anemia

.asthma

.bleeding or clotting problems

.drink more than 3 alcohol-containing beverages a day

.heart disease, including heart failure

.high blood pressure

.gout

.kidney disease

.liver disease

.nasal polyps

.smoke tobacco

.stomach ulcers, or other stomach problems

.systemic lupus erythematosus (SLE)

.thrombotic thrombocytopenic purpura (TTP)

.ulcerative colitis

.vitamin K deficiency

.an unusual or allergic reaction to aspirin, tartrazine dye, other medicines, dyes, or preservatives

.pregnant or trying to get pregnant

.breast-feeding

 

How should I take this medicine?

Chew 2-3 pieces of apirin chewing gum every 4-6 hours as needed or as directed by your prescriber or health care professional. Adults should not use more than 17 pieces per day unless directed to by your prescriber or health care professional. If aspirin upsets your stomach, take the tablets with food or milk. Do not take your medicine more often than directed.

 

Contact your pediatrician or health care professional regarding the use of this medicine in children. Special care may be needed. Do not give adult preparations to children. Avoid aspirin in children with chickenpox, the flu, or other viral infections.

 

What if I miss a dose?

If you are taking aspirin on a regular schedule and miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses.

 

What drug(s) may interact with aspirin, ASA?

.alcohol

.alendronate

.antacids (in large doses)

.antiinflammatory drugs (NSAIDs, such as ibuprofen)

.herbal supplements that contain feverfew, garlic, ginger, ginkgo biloba, horse chestnut

.hormones such as prednisone or cortisone

.medicines used to treat or prevent blood clots

.medicines for diabetes that are taken by mouth

.medicines for gout

.methotrexate

.other medicines that contain aspirin or aspirin-related ingredients (e.g., Pepto-Bismol®)

.seizure (convulsion) or epilepsy medicine

 

Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

 

What side effects may I notice from taking aspirin, ASA?

Side effects that you should report to your prescriber or health care professional as soon as possible:

.signs or symptoms of bleeding from the stomach or intestine such as black, tarry stools, stomach pain, vomiting up blood, or what looks like coffee grounds

.confusion

.difficulty breathing, wheezing

.redness, blistering, peeling or loosening of the skin, including inside the mouth or nose

.ringing in the ears or changes in hearing

.skin rash, hives

.unusual bleeding or bruising, red or purple spots on the skin

 

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):

.diarrhea or constipation

.nausea, vomiting

.stomach gas, heartburn

 

What should I watch for while taking aspirin?

Check with your prescriber or health care professional if you are treating yourself for a pain that does not go away after 10 days; and for a fever that does not go away after 3 days or keeps coming back. Only take aspirin to prevent heart attacks or blood clotting if prescribed by your prescriber or health care professional.

 

Many non-prescription products contain aspirin or aspirin-like medicines as an ingredient. To prevent accidental aspirin overdose, read labels carefully. Do not take more than one product that contains aspirin or aspirin-like agents (e.g., Pepto-Bismol®).

 

If you are taking oral medicines to decrease your blood sugar, large doses of aspirin may increase the levels of these drugs. Check with your prescriber or health care professional before you change your diet or the dose of your diabetic medicine.

 

Aspirin can irritate your stomach. Do not smoke cigarettes or drink alcohol; these increase irritation in your stomach and may cause ulcers or bleeding problems. Do not lie down for 30 minutes after taking aspirin to prevent irritation to your throat.

 

If you are receiving cancer chemotherapy or have had an organ transplant, do not take aspirin without checking with your prescriber or health care professional. Aspirin may hide the signs of an infection such as fever or pain and increase your risk of bleeding.

 

Prior to and after surgery or dental procedures, you may need to avoid taking aspirin. However, in some cases your prescriber may tell you to continue taking aspirin for its heart protection effects. Aspirin can interfere with your body's ability to stop bleeding. Discuss your aspirin therapy with your surgeon or dentist at least 1 week prior to any procedures

 

Where can I keep my medicine?

Keep out of the reach of children in a container that small children cannot open. Even small doses of aspirin can be dangerous to small children and pets.

 

Store at room temperature, between 15-30 degrees C (59-86 degrees F). Heat and moisture can cause aspirin to break down, becoming inactive and possibly dangerous to use. Do not use products that have a strong vinegar smell; throw them away at once.

 

Effexor XR

 

Venlafaxine extended-release capsules

 

What are venlafaxine extended-release capsules?

VENLAFAXINE (Effexor® XR) is an antidepressant, a medicine that helps to lift mental depression. Venlafaxine can help patients whose depression has not responded to other medications. Venlafaxine is also effective for the treatment of anxiety or other nervous conditions. Occasionally it is prescribed for other purposes. Generic venlafaxine tablets are not yet available.

 

What should my health care professional know before I take venlafaxine?

They need to know if you have any of these conditions:

.anorexia or weight loss

.attempted suicide

.high blood pressure, heart problems or a recent heart attack

.high cholesterol levels or receiving treatment for high cholesterol

.kidney disease

.liver disease

.mania or bipolar disorder

.seizures (convulsions)

.suicidal thoughts or a previous suicide attempt

.thyroid problems

.an unusual or allergic reaction to venlafaxine, other medicines, foods, dyes, or preservatives

.pregnant or trying to get pregnant

.breast-feeding

 

How should I take this medicine?

Take venlafaxine capsules by mouth. Follow the directions on the prescription label. Do not cut, crush, chew or divide the capsules; swallow them whole with plenty of water. Take venlafaxine capsules with food. Try to take your dose at about the same time each day, in the morning or evening. Do not take your medicine more often than directed. Do not stop taking the capsules except on your prescriber's advice.

 

Contact your pediatrician or health care professional regarding the use of this medicine in children. Special care may be needed.

 

What if I miss a dose?

If you miss a dose, take it as soon as you can. If it is less than two hours to your next dose, take only that dose and skip the missed dose. Do not take double or extra doses.

 

What drug(s) may interact with venlafaxine?

.alcohol

.amphetamine

.certain migraine headache medicines (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan)

.cimetidine

.clozapine

.dextroamphetamine

.furazolidone

.linezolid

.lithium

.medicines for heart rhythm or blood pressure

.medications for weight control or appetite

.medicines called MAO inhibitors-phenelzine (Nardil®), tranylcypromine (Parnate®), isocarboxazid (Marplan®)

.other medicines for mental depression, mania, psychosis, or anxiety

.procarbazine

.selegiline

.St. John's wort, Hypericum perforatum

.warfarin

 

Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

 

What side effects may I notice from taking venlafaxine?

Side effects that you should report to your prescriber or health care professional as soon as possible:

Rare or uncommon:

.abnormal body movements, for example, of your tongue or upper body

.bruising or bleeding

.difficulty breathing

.fainting spells

.mania (over-active behavior)

.problems passing urine (increase or decrease in frequency)

.rapid heartbeat, or palpitations

.seizures (convulsions)

More common:

.agitation, anxiety, or restlessness, especially in the first week of treatment or when doses are changed

.changes in vision (blurred vision)

.sexual difficulties (abnormal ejaculation or orgasm, difficult or painful erections, impotence)

.vomiting

 

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):

.dry mouth

.constipation

.dizziness, drowsiness

.increased sweating

.loss of appetite, loss of weight

.nausea

.tremor

.weakness or tiredness

 

What should I watch for while taking venlafaxine?

Visit your prescriber or health care professional for regular checks on your progress. You may have to take venlafaxine for 4 weeks before you feel better. If you have been taking venlafaxine for some time, do not suddenly stop taking it. You must gradually reduce the dose to avoid side effects. Ask your prescriber or health care professional for advice.

 

Patients and their families should watch out for worsening depression or thoughts of suicide. Also watch out for sudden or severe changes in feelings such as feeling anxious, agitated, panicky, irritable, hostile, aggressive, impulsive, severely restless, overly excited and hyperactive, or not being able to sleep. If this happens, especially at the beginning of antidepressant treatment or after a change in dose, call your health care professional.

 

Venlafaxine can cause an increase in blood pressure or a faster heart beat. Check with your prescriber or health care professional; you may be able to measure your own blood pressure and pulse. Find out what your blood pressure and heart rate should be and when you should contact him or her.

 

You may get drowsy, dizzy or have blurred vision. Do not drive, use machinery, or do anything that needs mental alertness until you know how venlafaxine affects you. Do not stand or sit up quickly, especially if you are an older patient. This reduces the risk of dizzy or fainting spells. Alcohol may increase dizziness or drowsiness; avoid alcoholic drinks.

 

Venlafaxine can make your mouth dry. Chewing sugarless gum, sucking hard candy and drinking plenty of water will help.

 

Do not treat yourself for coughs, colds, or allergies without asking your prescriber or health care professional for advice. Some ingredients may increase possible side effects.

 

If you are going to have surgery, tell your prescriber or health care professional that you are taking venlafaxine.

 

Where can I keep my medicine?

Keep out of the reach of children in a container that small children cannot open.

 

Store at a controlled temperature between 20 degrees and 25 degrees C (68 degrees and 77 degrees F), in a dry place. Throw away any unused medicine after the expiration date.

Ultracet

 

What are acetaminophen; tramadol tablets?

ACETAMINOPHEN; TRAMADOL (Ultracet®) is a combination analgesic that is used to relieve moderate, acute pain such as pain following surgical procedures, including dental surgery. Acetaminophen; tramadol may be used for other types of pain as determined by your health care provider. Generic acetaminophen; tramadol tablets are not yet available.

 

What should my health care professional know before I take acetaminophen; tramadol?

They need to know if you have any of these conditions:

.an alcohol or drug abuse problem

.blood disease, such as anemia

.breathing difficulty or asthma

.drink more than 3 alcohol-containing drinks per day

.drive or operate machinery or perform hazardous activities

.head injury or brain tumor

.kidney disease

.liver disease

.receiving drugs that lower your ability to fight infection

.seizures (convulsions) or seizure disorder (epilepsy)

.stomach or intestinal problems

.an unusual or allergic reaction to acetaminophen, tramadol, codeine, other pain medicines, foods, dyes, or preservatives

.pregnant or trying to get pregnant

.breast-feeding

 

How should I take this medicine?

Take acetaminophen; tramadol tablets by mouth. Follow the directions on the prescription label. Swallow the tablets with a drink of water. If acetaminophen; tramadol upsets your stomach, take it with food or milk. Do not take more than 2 tablets at a time or more than 8 tablets per day. Higher doses may cause severe side effects, do not take more medication than your prescriber has instructed.

 

Contact your pediatrician or health care professional regarding the use of this medicine in children. Special care may be needed.

 

Older patients (> 60 years of age) may have a stronger reaction to this medicine, especially if they have kidney or liver disease.

 

What if I miss a dose?

If it is almost time for your next dose, take only that dose. Do not take double or extra doses.

 

What drug(s) may interact with acetaminophen; tramadol?

.alcohol

.antacids

.antihistamines (commonly found in allergy or cold products)

.busulfan

.bupropion

.cocaine

.diflunisal

.digoxin

.droperidol

.drugs to regulate heart rhythm such as amiodarone, propafenone, quinidine

.furazolidone

.imatinib

.isoniazid, INH

.linezolid

.medicines called MAO inhibitors-phenelzine (Nardil®), tranylcypromine (Parnate®), isocarboxazid (Marplan®), selegiline (Eldepryl®)

.medicines for anxiety, depression, or sleeping problems

.medicines for nausea or vomiting

.medicines for Parkinson's disease such as entacapone, pramipexole, ropinirole or tolcapone

.medicines for mental problems like schizophrenia

.muscle relaxants

.naloxone

.other medicines for pain such as codeine, morphine, nalbuphine, pentazocine, or propoxyphene

.procarbazine

.rifampin

.ritonavir

.seizure medicines

.stimulants such as amphetamine or dextroamphetamine

.St. John's wort

.sulfinpyrazone

.warfarin

 

Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

 

What side effects may I notice from taking acetaminophen; tramadol?

Side effects that you should report to your prescriber or health care professional as soon as possible:

Rare or uncommon:

.changes in vision

.difficulty breathing, shortness of breath

.fast or irregular heartbeat

.hallucinations (seeing and hearing things that are not really there)

.not passing urine as often as usual

.redness, blistering, peeling or loosening of the skin, including inside the mouth

.skin rash, itching

.seizures (convulsions)

.yellow tint to your skin or whites of your eyes

More common:

.anxiety, agitation

.vomiting

 

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):

.constipation or diarrhea

.difficulty sleeping

.dizziness, drowsiness

.dry mouth

.false sense of well being, feeling of unreality, mood changes

.headache

.indigestion

.itching

.nausea

.sweating or flushing

 

What should I watch for while taking acetaminophen; tramadol?

Tell your prescriber or health care professional if your pain does not go away.

 

Do not drive, use machinery, or do anything that needs mental alertness until you know how acetaminophen; tramadol affects you. Be careful taking other medicines which may also make you tired. This effect may be worse when taking these medicines with acetaminophen; tramadol. Alcohol can increase possible drowsiness, dizziness, confusion and affect your breathing. Do not drink alcoholic beverages while taking tramadol.

 

Your mouth may get dry. Chewing sugarless gum, sucking hard candy and drinking plenty of water will help.

 

If you are going to have surgery, tell your prescriber or health care professional that you are taking Ultracet®.

 

Many non-prescription medicines contain acetaminophen as an ingredient. Additional acetaminophen taken with Ultracet® can be dangerous. Always read the labels carefully to avoid taking an accidental overdose of acetaminophen. Report any possible overdose of acetaminophen; tramadol promptly to your health care provider.

 

Acetaminophen can affect the results from some blood-sugar tests used by diabetic patients. Check with your prescriber or health care professional before you change your diet or the dose of your diabetic medicine.

 

Where can I keep my medicine?

Keep out of reach of children in a container that small children cannot open.

 

Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F). Throw away any unused medicine after the expiration date.

NOTE: The information provided above on these medications is not intended to cover all possible uses, precautions, interactions, or adverse effects for these drugs. If you have any further questions about the drug(s) you are taking, please don't hesitate to call us.

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