place of job Tips for Better Managing Your Stress to flamable

place of job Tips for Better Managing Your Stress to flamable

Sir Francis Bacon Tips for Better Managing Your Stress the jobs
 
Photo :Tips for Better Managing Your Stress

you a various types Completely banishing stress from your life may never be an attainable goal. Nor, some would argue, should it be. If you consistently try your hardest and seek new endeavors, you will naturally feel challenged and sometimes even stressed. This is all part of personal growth. But sometimes stress threatens to overwhelm you. Fortunately, there are steps you can take to minimize its negative toll, and to prevent it from getting a grip on you in the first place. These strategies provide you with a sense of control over your life and/or the situation. They also boost your mood and your confidence in handling a stressful situation. Usually there is no one right or wrong way to cope with a stressful situation. The idea is to have as much information as many tools in your toolbox as possible. For stressors that are uncontrollable, the key is to adapt your response to the needs of the situation and/or manage your cognitive or emotional responses in order to minimize stress. For example: Remind yourself that you successfully have handled similar situations in the past. Reassure yourself that you will be fine regardless of what happens. Find some humor in the situation. Reward yourself afterward with something enjoyable. Find a trusted friend to talk with about the experience. Use relaxation exercises to control your physical response to the situation. Make a list of similar situations and how you successfully managed them in the past. Ask others what they have done in similar situations to prepare yourself. Expect surprises in your life and in these situations, and don t let being stressed add to your stress. For stressors you have some control over, you can do things to actively respond to the situation. For example: Make a list of stressors, so that you can prioritize them and tackle them one at a time, in order to minimize feelings of being overwhelmed. Change aspects of a stressful situation that give you problems. Rearrange your schedule, have a problem-solving discussion with the bothersome person, organize your workspace, schedule some time for a break, take a brief walk or ask someone for help. Expect surprises in your life and in these situations, and don t let being stressed add to your stress. Develop systematic problem-solving skills: Identify the stressful situation. Define it as an objective, solvable problem. Brainstorm solutions don t evaluate them yet! Anticipate the possible outcomes of each solution. Choose a solution and act on it. Evaluate the results, and start over if necessary. Don t expect to be perfect. Give it your best shot and learn from the experiences. Improve your coping skills. Practice assertive communication and problem-solving. Find someone who successfully handles stress and imitate him. Surround yourself with confident and competent people. Take care of yourself physically; learn yoga, relaxation exercises and deep muscle relaxation skills. Plan and prepare in advance for problematic situations. For example, anticipate problems and develop a game plan for how to respond, including reminding yourself that the situation has occurred before and that you have survived it before. Make lifestyle changes that are conducive to healthy and less stressful living. Exercise regularly, drink plenty of water, maintain a well-balanced diet and eat regular meals, try to balance work and personal life, schedule time for personal recreation, stay involved with family and friends, and limit social contact with people who are chronically negative. There also are some medications that can calm the physiological response to stressful events. They do not teach you new coping skills to help you get through them. In the long term, learning relaxation skills, coping strategies and how to think through problems, are what will help you with the next unexpected situation. If you find yourself unable to function at the level you used to or at the level you wish to, stress may be interfering with your life. If you find yourself worrying, feeling physical (muscle) tension, have rapid heart rate or do a lot of what-if-ing or postponing work because you feel overwhelmed, talk to your family doctor or see a psychologist or psychiatrist to discuss your stress level and coping skills. Related Articles Related Content from Our Sponsors Read more articles by this author Hot Topics Today 1 PTSD Patients Show Heightened Sensitivity to Deviant Sounds 2 Developing the Evidence Base for Mindfulness Therapies 3 Dominant Hand May Begin in Womb 4 5 Types of People Who Are Naturally Attracted to Each Other 5 What's a Narcissist's Punishment? Most Popular News PTSD Patients Show Heightened Sensitivity to Deviant Sounds Dominant Hand May Begin in Womb Developing the Evidence Base for Mindfulness Therapies Bipolar or Depression? 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a loyal Tips for Better Managing Your Stress really apt
take a look at Effervescent Potassium getting to know

take a look at Effervescent Potassium getting to know

type of Effervescent Potassium this type of
 
Photo :Effervescent Potassium

the ideal Effervescent Potassium Generic Name: potassium bicarbonate (poe tass EE um) Brand Name: Effervescent Potassium, K-Effervescent, K-vescent Overview Side Effects Dosage Professional Interactions More User Reviews Drug Images Support Group Q & A What is Effervescent Potassium (potassium bicarbonate)? Potassium is a mineral that is found naturally in foods and is necessary for many normal functions of your body, especially the beating of your heart. Potassium bicarbonate is used to prevent or to treat a potassium deficiency (hypokalemia). Potassium bicarbonate may also be used for other purposes not listed in this medication guide. Slideshow ADHD and Your Child: Signs and Treatment Options What is the most important information I should know about Effervescent Potassium (potassium bicarbonate)? Avoid taking potassium supplements or using other products that contain potassium without first asking your doctor. Salt substitutes or low-salt dietary products often contain potassium. If you take certain products together you may accidentally get too much potassium. Read the label of any other medicine you are using to see if it contains potassium. There are many other medicines that can interact with potassium bicarbonate. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you. What should I discuss with my healthcare provider before taking Effervescent Potassium (potassium bicarbonate)? Before taking this medication, tell your doctor if you are allergic to any drugs, or if you have: kidney disease; Addison's disease; stomach ulcer or an intestinal blockage; or chronic diarrhea (colitis). If you have any of these conditions, you may not be able to use potassium bicarbonate, or you may need a dose adjustment or special tests during treatment. 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 whether potassium bicarbonate passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. How should I take Effervescent Potassium (potassium bicarbonate)? Use this medication exactly as directed on the label, or as prescribed by your doctor. Do not use it in larger amounts or for longer than recommended. Take each dose with a full glass of water. Take potassium bicarbonate with food or milk to lessen stomach upset. Drop the effervescent tablets into a glass of water (at least 4 ounces, or one-half cup). Allow the tablets to dissolve completely and then drink this mixture right away. Do not save it for later use. Do not stop taking this medication without first talking to your doctor. If you stop taking potassium bicarbonate suddenly, your condition may become worse. Store potassium bicarbonate at room temperature away from moisture and heat. What happens if I miss a dose? Take the missed dose as soon as you remember. If you are more than 2 hours late in taking your medicine, skip the missed dose and wait until your next regularly scheduled dose. Do not take extra medicine to make up the missed dose. What happens if I overdose? Seek emergency medical attention if you think you have used too much of this medicine. Overdose symptoms may include numbness or tingling in your hands or feet, uneven heart rate, paralysis, feeling like you might pass out, chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling, or seizure (convulsions). What should I avoid while taking Effervescent Potassium (potassium bicarbonate)? Avoid taking potassium supplements or using other products that contain potassium without first asking your doctor. Salt substitutes or low-salt dietary products often contain potassium. If you take certain products together you may accidentally get too much potassium. Read the label of any other medicine you are using to see if it contains potassium. Effervescent Potassium (potassium bicarbonate) side effects 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 potassium bicarbonate and call your doctor at once if you have any of these serious side effects: confusion; uneven heartbeat; unusual tiredness, weakness, heavy feeling in your legs; severe stomach pain cramping; or black, bloody, or tarry stools. Less serious side effects may include: nausea, vomiting, diarrhea, or upset stomach; a rash; slight tingling in the hands or feet; or anxiety. This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect. You may report side effects to FDA at 1-800-FDA-1088. Side Effects (complete list) What other drugs will affect Effervescent Potassium (potassium bicarbonate)? The following drugs can interact with potassium bicarbonate. Tell your doctor if you are using any of these: digoxin (Lanoxin); an ACE inhibitor such as benazepril (Lotensin), captopril (Capoten), fosinopril (Monopril), enalapril (Vasotec), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), or trandolapril (Mavik); a beta-blocker such as atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol), propranolol (Inderal, InnoPran), sotalol (Betapace), timolol (Blocadren); a diuretic (water pill) such as amiloride (Midamor, Moduretic), chlorothiazide (Diuril, others), hydrochlorothiazide (Hydrodiuril, HCTZ, others), indapamide (Lozol), metolazone (Zaroxolyn), spironolactone (Aldactone, Aldactazide), or triamterene (Dyrenium, Dyazide, Maxzide); aspirin or other NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn), diclofenac (Voltaren), etodolac (Lodine), indomethacin (Indocin), ketoprofen (Orudis),, and others; or a steroid such as prednisone (Deltasone, Orasone), hydrocortisone (Cortef, Hydrocortone), dexamethasone (Decadron, Hexadrol), and others. This list is not complete and there may be other drugs that can interact with potassium bicarbonate or affect your condition. Tell your doctor about all your prescription and over-the-counter medications, vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start a new medication without telling your doctor. Next Side Effects Print this page Add to My Med List More about Effervescent Potassium (potassium bicarbonate) Side Effects Dosage Information Drug Images Drug Interactions Support Group En Espaรฑol 0 Reviews Add your own review/rating Drug class: minerals and electrolytes Consumer resources Other brands: K-Effervescent , K-vescent , Quick-K Professional resources ToweRx Effervescent Potassium (FDA) Related treatment guides Hypokalemia Prevention of Hypokalemia Where can I get more information? Your pharmacist can provide more information about potassium bicarbonate. Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed. Disclaimer: Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. 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 drugs you are taking, check with your doctor, nurse or pharmacist. Copyright 1996-2012 Cerner Multum, Inc. Version: 4.04. Date modified: December 03, 2017 Last reviewed: December 15, 2010} Drug Status Rx Availability Prescription only C Pregnancy Category Risk cannot be ruled out N/A CSA Schedule Not a controlled drug Drug Class Minerals and electrolytes Related Drugs Hypokalemia potassium chloride , spironolactone , Klor-Con , Aldactone , KCl , K-Dur , Micro-K , More... Prevention of Hypokalemia potassium chloride , Klor-Con , KCl , K-Dur , Micro-K , K-Tab , More... Effervescent Potassium Rating No Reviews - Be the first! No Reviews - Be the first! Not Rated - Be the first! Effervescent Potassium Images Effervescent Potassium 25 mEq (T ) View larger images Help and Support Looking for answers? Ask a question or go join the Effervescent Potassium support group to connect with others who have similar interests.} } beginners


rewarding Effervescent Potassium remember that
magnate Rytary the newborn

magnate Rytary the newborn

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Photo :Rytary

a lot of Rytary Generic Name: Carbidopa and Levodopa Extended-Release Capsules (kar bi DOE pa & lee voe DOE pa) Brand Name: Rytary Overview Side Effects Dosage Professional Interactions More Pregnancy Warnings User Reviews Drug Images Support Group Q & A Pricing & Coupons Uses of Rytary: It is used to treat Parkinson's disease. It is used to treat signs like Parkinson's disease caused by other health problems. It may be given to you for other reasons. Talk with the doctor. Slideshow 11 Signs of Alzheimer's Disease - Or Are You Just Getting Older? What do I need to tell my doctor BEFORE I take Rytary? If you have an allergy to levodopa, carbidopa, or any other part of Rytary (carbidopa and levodopa extended-release capsules). If you are allergic to any drugs like this one, any other drugs, foods, or other substances. Tell your doctor about the allergy and what signs you had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs. If you have any of these health problems: Glaucoma, a skin lump or growth, or a history of skin cancer. If you are taking any of these drugs: Reserpine or tetrabenazine. If you have taken certain drugs used for low mood (depression) like isocarboxazid, phenelzine, or tranylcypromine or drugs used for Parkinson's disease like selegiline or rasagiline in the last 14 days. Taking this medicine within 14 days of those drugs can cause very bad high blood pressure. If you are taking another drug that has the same drug in it. This is not a list of all drugs or health problems that interact with Rytary. Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take this medicine with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor. What are some things I need to know or do while I take Rytary? Tell all of your health care providers that you take Rytary. This includes your doctors, nurses, pharmacists, and dentists. Avoid driving and doing other tasks or actions that call for you to be alert until you see how this medicine affects you. To lower the chance of feeling dizzy or passing out, rise slowly if you have been sitting or lying down. Be careful going up and down stairs. This medicine may affect certain lab tests. Tell all of your health care providers and lab workers that you take Rytary. Have blood work checked as you have been told by the doctor. Talk with the doctor. If you have high blood sugar (diabetes), talk with your doctor about which glucose tests are best to use. Have your eye pressure checked. Talk with your doctor. This medicine may "wear off" as the time for your next dose gets closer. Tell your doctor if this happens and it bothers you. Talk with your doctor before you drink alcohol or use other drugs and natural products that slow your actions. The chance of a type of skin cancer called melanoma may be raised in people with Parkinson's disease. It is not known if this medicine may also raise the chance. Have skin exams while you take Rytary. Talk with your doctor. A dark color (red, brown, or black) may show up in your saliva, urine, or sweat. This is not harmful but may discolor your clothes. Some people have fallen asleep during activities like driving, eating, or talking. Some people did not feel sleepy and felt alert right before falling asleep. This has happened up to 1 year after this medicine was started. If you fall asleep during activities, do not drive or do other tasks or actions that call for you to be alert while you take Rytary. Call your doctor right away if this happens or you feel very sleepy. Neuroleptic malignant syndrome (NMS) is a very bad and sometimes deadly health problem that has happened when this medicine was stopped all of a sudden. NMS has also happened when the dose of Rytary was lowered. Call your doctor right away if you have any fever, muscle cramps or stiffness, dizziness, very bad headache, confusion, change in thinking, fast heartbeat, heartbeat that does not feel normal, or are sweating a lot. Tell your doctor if you are pregnant or plan on getting pregnant. You will need to talk about the benefits and risks of using this medicine while you are pregnant. Tell your doctor if you are breast-feeding. You will need to talk about any risks to your baby. How is this medicine (Rytary) best taken? Use Rytary (carbidopa and levodopa extended-release capsules) as ordered by your doctor. Read all information given to you. Follow all instructions closely. Take with or without food. Swallow whole. Do not chew or crush. If you cannot swallow this medicine whole, you may sprinkle the contents on applesauce. If you do this, swallow the mixture right away without chewing. If you take an iron product or a multivitamin that has iron, ask your doctor or pharmacist how to take it with Rytary. Iron may lower how well your body is able to absorb this medicine. Diets high in protein, fat, or calories may lower how well your body absorbs Rytary; tell your doctor if you have a diet like this or if you will be changing your diet. Talk with your doctor. Do not stop taking this medicine all of a sudden or lower your dose without calling your doctor. Side effects may happen. Talk with your doctor. Take even during sign-free periods. Keep a diary of your signs. Keep taking Rytary as you have been told by your doctor or other health care provider, even if you feel well. Take this medicine at the same time of day. To gain the most benefit, do not miss doses. 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. Dosage Information (comprehensive) What are some side effects that I need to call my doctor about right away? WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect: Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat. Signs of low mood (depression), thoughts of killing yourself, nervousness, emotional ups and downs, thinking that is not normal, anxiety, or lack of interest in life. Change in the way you act. Hallucinations (seeing or hearing things that are not there). Feeling confused. Strong urges that are hard to control (such as eating, gambling, sex, or spending money). A skin lump or growth. Change in color or size of a mole. Trouble controlling body movements that is new or worse. Throwing up blood or throw up that looks like coffee grounds. Black, tarry, or bloody stools. Belly pain. Chest pain or pressure or a fast heartbeat. A heartbeat that does not feel normal. Fever or chills. Sore throat. Any unexplained bruising or bleeding. Very bad dizziness or passing out. Very bad headache. Dark urine or yellow skin or eyes. Change in eyesight, eye pain, or very bad eye irritation. Shortness of breath. Feeling very tired or weak. What are some other side effects of Rytary? All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away: Bad dreams. Hard stools (constipation). Dizziness. Feeling sleepy. Dry mouth. Headache. Not able to sleep. Upset stomach or throwing up. These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088. You may also report side effects at http://www.fda.gov/medwatch. Side Effects (complete list) If OVERDOSE is suspected: If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened. How do I store and/or throw out Rytary? Store at room temperature. Store in a dry place. Do not store in a bathroom. Protect from light. Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets. Check with your pharmacist about how to throw out unused drugs. Consumer Information Use and Disclaimer If your symptoms or health problems do not get better or if they become worse, call your doctor. Do not share your drugs with others and do not take anyone else's drugs. Keep a list of all your drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your doctor. Talk with the doctor before starting any new drug, including prescription or OTC, natural products, or vitamins. Some drugs may have another patient information leaflet. Check with your pharmacist. If you have any questions about Rytary, please talk with your doctor, nurse, pharmacist, or other health care provider. If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened. This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. 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 Rytary. 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 the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using Rytary. Review Date: November 1, 2017 Next Side Effects Print this page Add to My Med List More about Rytary (carbidopa / levodopa) Side Effects During Pregnancy Dosage Information Drug Images Drug Interactions Support Group Pricing & Coupons En Espaรฑol 11 Reviews Add your own review/rating Drug class: dopaminergic antiparkinsonism agents Consumer resources Rytary Rytary (Advanced Reading) Other brands: Sinemet , Sinemet CR , Parcopa , Duopa Professional resources Rytary (FDA) Levodopa/Carbidopa (AHFS Monograph) Related treatment guides Parkinson's Disease} Drug Status Rx Availability Prescription only C Pregnancy Category Risk cannot be ruled out N/A CSA Schedule Not a controlled drug Approval History Drug history at FDA Rytary Rating 11 User Reviews 4.2 /10 11 User Reviews 4.2 Rate it! Manufacturer Impax Pharmaceuticals Drug Class Dopaminergic antiparkinsonism agents Related Drugs Parkinson's Disease Exelon , ropinirole , pramipexole , Sinemet , Requip , benztropine , carbidopa / levodopa , Mirapex , amantadine , rivastigmine , Azilect , Cogentin , selegiline , trihexyphenidyl , bromocriptine , entacapone , Neupro , rasagiline , Stalevo , Artane , carbidopa / entacapone / levodopa , Comtan , belladonna , Parlodel , More... Rytary Images Rytary carbidopa 23.75 mg / levodopa 95 mg (IPX066 95) View all images Related: Parkinson's Disease} } together with your


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kit Timoptic-XE Side Effects lately

kit Timoptic-XE Side Effects lately

factor Timoptic-XE Side Effects of goods
 
Photo :Timoptic-XE Side Effects

prescribed drugs Timoptic-XE Side Effects Generic Name: timolol ophthalmic Overview Side Effects Dosage Professional Interactions More Pregnancy Warnings Breastfeeding Warnings User Reviews Support Group Q & A Pricing & Coupons Note: This document contains side effect information about timolol ophthalmic. Some of the dosage forms listed on this page may not apply to the brand name Timoptic-XE. For the Consumer Applies to timolol ophthalmic: ophthalmic gel forming solution, ophthalmic solution Along with its needed effects, timolol ophthalmic (the active ingredient contained in Timoptic-XE) may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention. Check with your doctor immediately if any of the following side effects occur while taking timolol ophthalmic: More common Blurred vision burning or stinging in the eye Less common Arm, back, or jaw pain blisters, hives, welts, or itching blue lips, fingernails, or skin burning, crawling, itching, numbness, prickling, "pins and needles", or tingling feelings change in vision chest pain or discomfort chest tightness or heaviness confusion about identity, place, and time continuing ringing or buzzing or other unexplained noise in ears coughing that sometimes produces a pink frothy sputum depression difficult, fast, noisy breathing difficulty with chewing, swallowing, or talking dilated neck veins discharge, excessive tearing disturbed color perception dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position double vision drooping eyelids dry or itching eyes extreme fatigue false sense of well-being fast, slow, irregular, pounding, or racing heartbeat or pulse fear or nervousness feeling of having something in the eye fever and chills flashes of light, floaters in vision general feeling of discomfort or illness hair loss halos around lights headache inability to speak increased sweating irregular, fast or slow, or shallow breathing large, hive-like swelling on the face, eyelids, lips, tongue, throat, hands, legs, feet, or sex organs lightheadedness, dizziness, or fainting loss of vision memory loss mood swings muscle or joint pain muscle weakness nausea night blindness no blood pressure or pulse overbright appearance of lights pain, tension, and weakness upon walking that subsides during periods of rest pale skin paleness or cold feeling in the fingertips, toes, hands, and feet personality changes pounding in the ears puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue redness of the skin redness, pain, swelling or irritation of the eye, eyelid, or inner lining of the eyelid seeing double seeing, hearing, or feeling things that are not there seizures severe numbness, especially on one side of the face or body severe or sudden headache severe tiredness skin irritation or rash, including rash that looks like psoriasis slurred speech sore throat stopping of heart sweating swelling of the face, fingers, feet, lower legs, and ankles swollen glands temporary blindness tingling or pain in the fingers or toes when exposed to cold tunnel vision unconsciousness unusual tiredness or weakness weakness in arm and/or leg on one side of the body, sudden and severe weight gain Some side effects of timolol ophthalmic may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them: Less common Acid or sour stomach belching body aches or pain diarrhea dry mouth ear congestion hearing loss heartburn indigestion lack or loss of strength loss of appetite loss of voice nightmares runny nose sleepiness or unusual drowsiness sneezing stomach discomfort, upset, or pain stuffy nose trouble sleeping weight loss For Healthcare Professionals Applies to timolol ophthalmic: ophthalmic gel forming solution, ophthalmic solution General The most commonly reported side effects were burning/stinging sensation, blurred vision, and abnormal vision. [ Ref ] Ocular Very common (10% or more): Burning/stinging sensation (up to 38%), blurred/abnormal vision (up to 25%) Common (1% to 10%): Conjunctival hyperemia, foreign body sensation, keratitis, conjunctivitis, cataract, decreased visual acuity Frequency not reported: Itching, tearing, redness, blepharitis, dry eyes, decreased corneal sensitivity, corneal erosion, refractive changes (due to withdrawal of miotic therapy in some cases), diplopia, ptosis and choroidal detachment following filtration surgery, discharge (e.g., crusting), foreign body sensation, cystoid macular edema, pseudopemphigoid [ Ref ] Cardiovascular Common (1% to 10%): Hypertension Frequency not reported: Bradycardia, chest pain, arrhythmia, heart block, congestive heart failure, palpitations, cardiac arrest, atrioventricular block, cardiac failure, edema; AV block (second- or third-degree), sino-atrial block, worsening of arterial insufficiency, worsening of angina pectoris, vasodilation, claudication, hypotension, syncope, Raynaud's phenomenon, cold hands and feet [ Ref ] Respiratory Frequency not reported: Pulmonary edema, bronchospasm (predominantly in patients with pre-existing bronchospastic disease), respiratory failure, dyspnea, cough, rales, sore throat, laryngospasm, respiratory distress Postmarketing reports: Bronchial obstruction [ Ref ] Nervous system Common (1% to 10%): Headache Frequency not reported: Tinnitus, memory loss, diminished concentration, increased dreaming, cerebrovascular accident, cerebral ischemia, dizziness, increase in signs and symptoms of myasthenia gravis, paresthesia, vertigo, local weakness [ Ref ] Psychiatric Frequency not reported: Depression, insomnia, nightmares, catatonia [ Ref ] Dermatologic Frequency not reported: Alopecia, psoriasiform rash or exacerbation of psoriasis, skin rash, sweating, exfoliative dermatitis [ Ref ] Gastrointestinal Frequency not reported: Nausea, diarrhea, dyspepsia, dry mouth, dysgeusia, abdominal pain, vomiting, mesenteric artery thrombosis, ischemic colitis [ Ref ] Immunologic Frequency not reported: Systemic lupus erythematosus [ Ref ] Hypersensitivity Frequency not reported: Anaphylaxis, angioedema, urticaria, localized/generalized rash, anaphylactic reaction Postmarketing reports: Erythematous rash [ Ref ] Genitourinary Frequency not reported: Decreased libido, Peyronie's disease, impotence, micturition difficulties, retroperitoneal fibrosis [ Ref ] Other Frequency not reported: Asthenia, fatigue, extremity pain, decreased exercise tolerance, fever [ Ref ] Hematologic Frequency not reported: Non-thrombocytopenic purpura, thrombocytopenic purpura, agranulocytosis [ Ref ] Musculoskeletal Frequency not reported: Myalgia, arthralgia [ Ref ] Hepatic Postmarketing reports: Hepatomegaly [ Ref ] Metabolic Frequency not reported: Hypoglycemia, hyperglycemia, anorexia [ Ref ] References 1. Cerner Multum, Inc. "UK Summary of Product Characteristics." O 0 2. "Product Information. Timolol Maleate, Ophthalmic (timolol ophthalmic)." Bausch and Lomb, Rochester, NY. 3. "Product Information. Timoptic (timolol ophthalmic)." Merck & Co, Inc, West Point, PA. 4. Cerner Multum, Inc. "Australian Product Information." O 0 Some side effects of Timoptic-XE may not be reported. Always consult your doctor or healthcare specialist for medical advice. You may also report side effects to the FDA . Next Dosage Print this page More about Timoptic-XE (timolol ophthalmic) Side Effects During Pregnancy or Breastfeeding Dosage Information Drug Interactions Support Group Pricing & Coupons En Espaรฑol 0 Reviews Add your own review/rating Generic Availability Drug class: ophthalmic glaucoma agents Consumer resources Timoptic-XE Timoptic XE Timoptic-XE Ocumeter (Advanced Reading) Timoptic-XE Ocumeter Plus (Advanced Reading) Other brands: Betimol , Istalol Professional resources Timoptic XE (FDA) Timolol eent (AHFS Monograph) Other Formulations Timoptic Ocumeter Timoptic Ocudose Related treatment guides Glaucoma, Open Angle Intraocular Hypertension 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 Rx Availability Prescription only C Pregnancy Category Risk cannot be ruled out N/A CSA Schedule Not a controlled drug Approval History Drug history at FDA WADA Class Anti-Doping Classification Manufacturer Valeant Pharmaceuticals International, Inc. Drug Class Ophthalmic glaucoma agents Related Drugs Glaucoma, Open Angle timolol ophthalmic , Lumigan , latanoprost ophthalmic , Travatan , brimonidine ophthalmic , Xalatan , epinephrine ophthalmic , Alphagan , dorzolamide ophthalmic , pilocarpine ophthalmic , Cosopt , Azopt , More... Intraocular Hypertension timolol ophthalmic , Lumigan , latanoprost ophthalmic , Travatan , brimonidine ophthalmic , Xalatan , Combigan , Alphagan , dorzolamide ophthalmic , pilocarpine ophthalmic , Cosopt , Azopt , More... Timoptic-XE Rating No Reviews - Be the first! No Reviews - Be the first! Not Rated - Be the first!} } regular


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accredited corticosteroid (Inhalation) continues to be

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on condition that corticosteroid (Inhalation) Class Name: corticosteroid (Inhalation route) Commonly used brand name(s) In the U.S. Aerobid Aerobid-M Alvesco Arnuity Ellipta Asmanex HFA Asmanex Twist Azmacort Beclovent Flovent Pulmicort Pulmicort Turbuhaler Qvar In Canada Asmanex Twisthaler Azmax Twisthaler Becloforte Flovent Diskus Flovent Hfa Flovent Nebules Pulmicort Nebuamp Available Dosage Forms: Aerosol Liquid Aerosol Powder Capsule Spray Suspension Powder Solution Disk Uses For This Medicine Inhalation corticosteroids are cortisone-like medicines. They are used to help prevent the symptoms of asthma. When used regularly every day, inhalation corticosteroids decrease the number and severity of asthma attacks. However, they will not relieve an asthma attack that has already started. Inhaled corticosteroids work by preventing certain cells in the lungs and breathing passages from releasing substances that cause asthma symptoms. This medicine may be used with other asthma medicines, such as bronchodilators (medicines that open up narrowed breathing passages) or other corticosteroids taken by mouth. Inhalation corticosteroids are available only with your doctor's prescription. Before Using This Medicine Allergies Tell your doctor if you have ever had any unusual or allergic reaction to medicines in this group or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully. Pediatric Inhalation corticosteroids have been tested in children and, except for the possibility of slowed growth, in low effective doses, have not been shown to cause different side effects or problems than they do in adults. Studies have shown that slowed growth or reduced adrenal gland function may occur in some children using inhaled corticosteroids in recommended doses. However, poorly controlled asthma may cause slowed growth, especially when corticosteroids taken by mouth are needed. Your doctor will want you to use the lowest possible dose of an inhaled corticosteroid that will control the asthma. This will lessen the chance of an effect on growth or adrenal gland function. It is also important that children taking inhaled corticosteroids visit their doctors regularly so that their growth rates may be monitored. Regular use of inhaled corticosteroids may allow some children to stop using or decrease the amount of corticosteroids taken by mouth. This also will reduce the risk of slowed growth or reduced adrenal function. Children who are using inhaled corticosteroids in large doses should avoid exposure to chickenpox or measles. When a child is exposed or the disease develops, the doctor should be contacted and his or her directions should be followed carefully. Before this medicine is given to a child, you and your child's doctor should talk about the good this medicine will do as well as the risks of using it. Follow the doctor's directions very carefully to lessen the chance that unwanted effects will occur. Geriatric Appropriate studies on the relationship of age to the effects of inhaled corticosteroids have not been performed in the geriatric population. However, no geriatric-specific problems have been documented to date. Pregnancy Although studies in animals have shown that inhaled corticosteroids cause birth defects and other problems, in humans these medicines, when used in regular daily doses during pregnancy to keep the mother's asthma under control, have not been reported to cause breathing problems or birth defects in the newborn. Also, corticosteroids may prevent the effects of poorly controlled asthma, which are known to be harmful to the baby. Before taking an inhaled corticosteroid, make sure your doctor knows if you are pregnant or if you may become pregnant. Breast Feeding It is not known whether inhaled corticosteroids pass into breast milk. Although most medicines pass into breast milk in small amounts, many of them may be used safely while breast-feeding. Mothers who are using this medicine and who wish to breast-feed should discuss this with their doctor. Interactions with Medicines Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. Tell your healthcare professional if you are taking any other prescription or nonprescription (over-the-counter [OTC]) medicine. Interactions with Food/Tobacco/Alcohol Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. Discuss with your healthcare professional the use of your medicine with food, alcohol, or tobacco. Other Medical Problems The presence of other medical problems may affect the use of medicines in this class. Make sure you tell your doctor if you have any other medical problems, especially: Asthma attack, acute (e.g., status asthmaticus) Triamcinolone should not be used in patients with this condition. Cirrhosis (liver disease) The effect of inhaled corticosteroids may be stronger in patients with this disease Glaucoma Use with caution. May increase the pressure in the eye. Hypothyroidism (decreased production of thyroid hormone) The effect of inhaled corticosteroids may be stronger in patients with this condition. Infections, untreated (bacteria, fungal, or viral) Use with caution. May make this condition worse. Osteoporosis (bone disease) Inhaled corticosteroids in high doses may make this condition worse in women who are past menopause and who are not receiving an estrogen replacement. Tuberculosis, history of Use of this medicine may cause a tuberculosis infection to occur again. Proper Use of This Medicine Inhaled corticosteroids will not relieve an asthma attack that has already started. However, your doctor may want you to continue taking this medicine at the usual time, even if you use another medicine to relieve the asthma attack. Use this medicine only as directed. Do not use more of it and do not use it more often than your doctor ordered. To do so may increase the chance of side effects. Do not stop taking this medicine abruptly. This medicine should be discontinued only under the supervision of your doctor. In order for this medicine to help prevent asthma attacks, it must be used every day in regularly spaced doses, as ordered by your doctor . Up to 4 to 6 weeks may pass before you begin to notice improvement in your condition. It may take several months before you feel the full effects of this medicine. This may not take as long if you have already been taking certain other medicines for your asthma. Gargling and rinsing your mouth with water after each dose may help prevent hoarseness, throat irritation, and infection in the mouth. However, do not swallow the water after rinsing. Your doctor may also want you to use a spacer device to lessen these problems. Inhaled corticosteroids are used with a special inhaler and usually come with patient directions. Read the directions carefully before using this medicine . If you do not understand the directions or you are not sure how to use the inhaler, ask your health care professional to show you what to do. Also, ask your health care professional to watch how you use the inhaler to make sure you are using it properly . For patients using beclomethasone, flunisolide, or triamcinolone inhalation aerosol : When you use the inhaler for the first time, or if you have not used it in a while, it may not deliver the right amount of medicine with the first puff. So, before using the inhaler, test or prime it. To test or prime most inhalers: Insert the metal canister firmly into the clean mouthpiece according to the manufacturer's instructions. Check to make sure the canister is placed properly into the mouthpiece. Take the cover off the mouthpiece and shake the inhaler three or four times. Hold the inhaler well away from you at arm's length and press the top of the canister, spraying the medicine into the air two times. The inhaler will now be ready to provide the right amount of medicine when you use it. To use most inhalers: Using your thumb and one or two fingers, hold the inhaler upright with the mouthpiece end down and pointing toward you. Take the cover off the mouthpiece. Check the mouthpiece and remove any foreign objects. Then gently shake the inhaler three or four times. Hold the mouthpiece away from your mouth and breathe out slowly to the end of a normal breath. Use the inhalation method recommended by your doctor: Open-mouth method Place the mouthpiece about 1 or 2 inches (2 finger widths) in front of your widely opened mouth. Make sure the inhaler is aimed into your mouth so that the spray does not hit the roof of your mouth or your tongue. Closed-mouth method Place the mouthpiece in your mouth between your teeth and over your tongue with your lips closed tightly around it. Do not block the mouthpiece with your teeth or tongue. Start to breathe in slowly through your mouth and, at the same time, press the top of the canister one time to get 1 puff of medicine. Continue to breathe in slowly for 3 to 5 seconds. Count the seconds while inhaling. It is important to press the top of the canister and breathe in slowly at the same time so the medicine gets into your lungs. This step may be difficult at first. If you are using the closed-mouth method and you see a fine mist coming from your mouth or nose, the inhaler is not being used correctly. Hold your breath as long as you can up to 10 seconds. This gives the medicine time to settle in your airways and lungs. Take the mouthpiece away from your mouth and breathe out slowly. If your doctor has told you to inhale more than 1 puff of medicine at each dose, gently shake the inhaler again, and take the next puff, following exactly the same steps you used for the first puff. Press the canister one time for each puff of medicine. When you are finished, wipe off the mouthpiece and replace the cap. Your doctor, nurse, or pharmacist may want you to use a spacer device with the inhaler. A spacer helps get the medicine into the lungs and reduces the amount of medicine that stays in your mouth and throat. To use a spacer device with the inhaler: Attach the spacer to the inhaler according to the manufacturer's directions. There are different types of spacers available, but the method of breathing remains the same with most spacers. Gently shake the inhaler and spacer three or four times. Hold the mouthpiece of the spacer away from your mouth and breathe out slowly to the end of a normal breath. Place the mouthpiece into your mouth between your teeth and over your tongue with your lips closed around it. Press down on the canister top once to release 1 puff of medicine into the spacer. Within one or two seconds, start to breathe in slowly through your mouth for 3 to 5 seconds. Count the seconds while inhaling. Do not breathe in through your nose. Hold your breath as long as you can up to 10 seconds. Breathe out slowly. Do not remove the mouthpiece from your mouth. Breathe in and out slowly two or three times to make sure the spacer device is emptied. If your doctor has told you to take more than 1 puff of medicine at each dose, gently shake the inhaler and spacer again and take the next puff, following exactly the same steps you used for the first puff. Do not spray more than 1 puff at a time into the spacer. When you are finished, remove the spacer device from the inhaler and replace the cover of the mouthpiece. Clean the inhaler mouthpiece, and spacer at least once a week. To clean the inhaler: Remove the canister from the inhaler and set the canister aside. Wash the mouthpiece, cap, and spacer with warm, soapy water. Then, rinse well with warm, running water. Shake off the excess water and let the inhaler parts air-dry completely before putting the inhaler back together. Check with your pharmacist to see if you should save the inhaler piece that comes with this medicine after the medicine is used up. Refill units may be available at a lower cost. However, remember that the inhaler is meant to be used only for the medicine that comes with it. Do not use the inhaler for any other inhalation aerosol medicine, even if the cartridge fits. For patients using beclomethasone capsules for inhalation : Do not swallow the capsules. The medicine will not work if you swallow it. To load the inhaler: Make sure your hands are clean and dry. Do not insert the capsule into the inhaler until just before you are ready to use this medicine. Take the inhaler from its container. Hold the inhaler by the mouthpiece and twist the barrel in either direction until it stops. Take a capsule from its container. Hold the inhaler upright with the mouthpiece pointing downward. Press the capsule, with the clear end first, firmly into the raised small hole. Make sure the top of the capsule is even with the top of the hole. This will push the old used capsule shell, if there is one, into the inhaler. Hold the inhaler on its side with the white dot facing up. Twist the barrel quickly until it stops. This will break the capsule into two halves so the powder can be inhaled. To use the inhaler: Hold the inhaler away from your mouth and breathe out slowly to the end of a normal breath. Keep the inhaler on its side and place the mouthpiece in your mouth. Close your lips around it, and tilt your head slightly back. Do not block the mouthpiece with your teeth or tongue Breathe in slowly through your mouth until you have taken a full deep breath. Take the inhaler from your mouth and hold your breath as long as you can up to 10 seconds. This gives the medicine time to settle in your airways and lungs. Hold the inhaler well away from your mouth and breathe out to the end of a normal breath. If your doctor has told you to use a second capsule, follow the same steps you used for the first capsule. When you have finished using the inhaler, pull the two halves of the inhaler apart and throw away the empty capsule shells. There is no need to remove the shell left in the small hole, except before cleaning. Put the two halves of the inhaler back together again and place it into its container to keep it clean. To clean the inhaler: Every two weeks, take the inhaler apart and wash the two halves of the inhaler in clean, warm water. Make sure the empty capsule shell is removed from the small raised hole. Shake out the excess water. Allow all parts of the inhaler to dry before you put it back together. The inhaler should be replaced every 6 months. For patients using beclomethasone powder for inhalation : To load the inhaler: Make sure your hands are clean and dry. Do not insert the cartridge until just before you are ready to use this medicine. Take off the dark brown mouthpiece cover and make sure the mouthpiece is clean. Hold the white cartridge by the exposed corners and gently pull it out until you see the ribbed sides of the cartridge. Squeeze the ribbed sides and take out the cartridge unit from the body of the inhaler. Place the disk containing the medicine onto the white wheel with the numbers facing up. Allow the underside of the disk to fit into the holes of the wheel. Slide the cartridge unit with wheel and disk back into the body of the inhaler. Gently push the cartridge in and pull it out again. The disk will turn. Continue to turn the disk in this way until the number 8 appears in the side indicator window. Each disk has eight blisters containing the medicine. The window will display how many doses you have left after you use it each time, by counting down from 8. For example, when you see the number 1, you have one dose left. To replace the empty disk with a full disk, follow the same steps you used to load the inhaler. Do not throw away the wheel when you discard the empty disk. To use the inhaler: Hold the inhaler flat in your hand. Lift the rear edge of the lid until it is fully upright. The plastic needle on the front of the lid will break the blister containing one inhalation of medicine. When the lid is raised as far as it will go, both the upper and the lower surfaces of the blister will be pierced. Do not lift the lid if the cartridge is not in the inhaler. Doing this will break the needle and you will need a new inhaler. Raise the inhaler to your mouth, and place the mouthpiece in your mouth. Close your lips around the mouthpiece and tilt your head slightly back. Do not block the mouthpiece with your teeth or tongue. Do not cover the air holes on the side of the mouthpiece. Breathe in through your mouth as fast as you can until you have taken a full deep breath. Hold your breath and remove the mouthpiece from your mouth. Continue holding your breath as long as you can up to 10 seconds before breathing out. This gives the medicine time to settle in your airways and lungs. Hold the inhaler well away from your mouth and breathe out to the end of a normal breath. Prepare the cartridge for your next inhalation. Pull the cartridge out once and push it in once. The disk will turn to the next numbered dose as seen in the indicator window. Do not pierce the blister until just before the inhalation. To clean the inhaler: Brush away the loose powder each day with the brush provided. The inhaler should be replaced every 6 months. For patients using budesonide powder for inhalation To prime the inhaler: Unscrew the cover of the inhaler and lift it off. Hold the inhaler upright with the brown piece pointing downward. Turn the brown piece of the inhaler in one direction as far as it will go. Then twist it back until it clicks. Repeat this step one more time and the inhaler will be primed. Prime each new inhaler before using it the first time. After it has been primed, it is not necessary to prime it again, even if you put it aside for a long period of time To load the inhaler: Unscrew the cover of the inhaler and lift it off. Hold the inhaler upright with the brown piece pointing downward. Turn the brown piece of the inhaler in one direction as far as it will go. Then twist it back until it clicks. To use the inhaler: Hold the inhaler away from your mouth and breathe out slowly to the end of a normal breath. Place the mouthpiece in your mouth and close your lips around it. Tilt your head slightly back. Do not block the mouthpiece with your teeth or tongue. Breathe in quickly and evenly through your mouth until you have taken a full deep breath. Hold your breath and remove the inhaler from your mouth. Continue holding your breath as long as you can up to 10 seconds before breathing out. This gives the medicine time to settle in your airways and lungs. Hold the inhaler well away from your mouth and breathe out to the end of a normal breath. Replace the cover on the mouthpiece to keep it clean. This inhaler delivers the medicine as a very fine powder. You may not taste, smell, or feel this medicine. This inhaler should not be used with a spacer. When the indicator window begins to show a red mark, there are about 20 doses left. When the red mark covers the window, the inhaler is empty. For patients using budesonide suspension for inhalation : This medicine is to be used in a power-operated nebulizer equipped with a face mask or mouthpiece. Your doctor will advise you on which nebulizer to use. Make sure you understand how to use the nebulizer. If you have any questions about this, check with your doctor. Any opened ampul should be protected from light. The medicine in an open ampul must be used promptly after the ampul is opened. Ampuls should be used within 2 weeks after the envelope containing them is opened. To prepare the medicine for use in the nebulizer: Remove one ampul from the sheet of five units and shake it gently. Hold the ampul upright. Open it by twisting off the wing. Squeeze the contents of the ampul into the cup of the nebulizer. If you use only half of the contents of an ampul, add enough of the sodium chloride solution provided to dilute the solution. Gently shake the nebulizer. Then attach the face mask to the nebulizer and connect the nebulizer to the air pump. To use the medicine in the nebulizer: This medicine should be inhaled over a period of 10 to 15 minutes. Breathe slowly and evenly, in and out, until no more mist is left in the nebulizer cup. Rinse your mouth when you are finished with the treatment. Wash your face if you used a face mask. To clean the nebulizer: After each treatment, wash the cup of the nebulizer and the mask or mouthpiece in warm water with a mild detergent. Allow the nebulizer parts to dry before putting them back together again. Dosing The dose medicines in this class will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of these medicines. If your dose is different, do not change it unless your doctor tells you to do so. The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine. For beclomethasone For inhalation aerosol: For bronchial asthma: Adults and children 12 years of age and older For the 42- or 50-mcg-per-metered-spray products 2 puffs (84 to 100 micrograms [mcg]) three or four times a day, or 4 puffs (168 to 200 mcg) two times a day. In severe asthma, your doctor may want you to take a higher dose. For the 84-mcg-per-metered-spray product 2 puffs (168 mcg) two times a day. In severe asthma, your doctor may want you to take a higher dose. Children 6 to 12 years of age For the 42- or 50-mcg-per-metered-spray products 1 or 2 puffs (42 to 100 micrograms [mcg]) three or four times a day, or 4 puffs (168 to 200 mcg) two times a day. For the 84-mcg-per-metered-spray product 2 puffs (168 mcg) two times a day. Children up to 6 years of age Use and dose must be determined by your doctor. For capsules for inhalation or powder for inhalation: For bronchial asthma: Adults and teenagers 14 years of age and older At first, 200 micrograms (mcg) three or four times a day. Then your doctor may reduce the dose, based on your condition. Children 6 to 14 years of age At first, 100 micrograms (mcg) two to four times a day. Then your doctor may reduce the dose, based on your condition. Children up to 6 years of age Use and dose must be determined by your doctor. For beclomethasone dipropionate HFA For inhalation aerosol: For bronchial asthma: Adults and children 12 years of age and older For the 40-mcg-per-metered-spray products 1 to 4 puffs (40 to 160 micrograms [mcg]) two times a day. The higher doses generally are used for patients previously treated with other corticosteroids. For the 50-mcg-per-metered-spray products 1 to 2 puffs (50 to 100 mcg) two times a day if your asthma is mild or 2 to 5 puffs (100 to 250 mcg) two times a day if your asthma is more severe. For the 80-mcg-per-metered-spray products 1 or 2 puffs (80 to 160 mcg) two times a day. The higher dose generally is used for patients previously treated with other corticosteroids. For the 100-mcg-per-metered-spray products 3 to 4 puffs (300 to 400 mcg) two times a day. Children 5 to 11 years of age 40 micrograms (mcg) (1 puff) two times a day. Children up to 5 years of age Use and dose must be determined by your doctor. For budesonide For powder for inhalation: For bronchial asthma: Adults 200 to 800 micrograms (mcg) two times a day. A lower dose of 200 mcg or 400 mcg once daily, either in the morning or in the evening, may sometimes be used for mild to moderate asthma when the symptoms are well controlled. The higher doses generally are used for patients previously treated with other corticosteroids. Then your doctor may increase or decrease the dose, depending on your condition. Children 6 years of age and older At first, 200 micrograms (mcg) two times a day. Then your doctor may increase the dose to 400 mcg two times a day, depending on your condition. A lower dose of 200 mcg or 400 mcg once daily, either in the morning or in the evening, may sometimes be used for mild to moderate asthma when the symptoms are well controlled. Children up to 5 years of age Use and dose must be determined by your doctor. For suspension for inhalation: For bronchial asthma: Adults and children 8 years of age and older 1000 to 2000 micrograms (mcg) mixed with enough sterile sodium chloride solution for inhalation, if necessary, to make 2 to 4 milliliters (mL). This solution is used in a nebulizer for a period of ten to fifteen minutes. The medicine should be used two times a day. Children 12 months to 8 years of age 250 to 500 micrograms (mcg) mixed with enough sterile sodium chloride solution for inhalation, if necessary, to make 2 to 4 milliliters (mL). This solution is used in a nebulizer for a period of ten to fifteen minutes. The medicine should be used two times a day. Children up to 12 months of age Use and dose must be determined by your doctor. For flunisolide For inhalation aerosol: For bronchial asthma: Adults and children 4 years of age and older 500 micrograms (mcg) (2 puffs) two times a day, morning and evening. Children up to 4 years of age Use and dose must be determined by your doctor. For triamcinolone For inhalation aerosol: For bronchial asthma: Adults and children older than 12 years of age The usual dose is 150 micrograms (mcg) (2 puffs) three to four times per day or 300 mcg (4 puffs) 2 times per day. Then your doctor may reduce the dose, based on your condition. In severe asthma, your doctor may want you to take a higher dose. However, your dose should not be more than 1200 mcg per day . Children 6 to 12 years of age The usual dose is 75 to 150 micrograms (mcg) (1 or 2 puffs) three or four times a day or 150 to 300 mcg (2 to 4 puffs) 2 times per day. Then your doctor may adjust your dose, based on your condition. However, your dose should not be more than 900 mcg per day. Children below 6 years of age Use and dose must be determined by your doctor. Missed Dose If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses. If you miss a dose of this medicine, use it as soon as possible. Then use any remaining doses for that day at regularly spaced times. Storage Keep out of the reach of children. Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing. Do not keep outdated medicine or medicine no longer needed. The 84-mcg-per-metered-spray product of beclomethasone should not be stored for longer than 6 months after it has been removed from its moisture-protective pouch. After 6 months, any remaining medicine should be discarded. Do not puncture, break, or burn the aerosol container, even after it is empty. Precautions While Using This Medicine It is very important that your doctor check your progress at regular visits to make sure this medicine is working properly and to check for unwanted effects. Check with your doctor if : You go through a period of unusual stress to your body, such as surgery, injury, or infection You have an asthma attack that does not improve after you take a bronchodilator medicine. You are exposed to viral infections, such as chickenpox or measles. Signs of infection occur, especially in your mouth, throat, or lung Your doctor may want you to carry a medical identification card stating that you are using this medicine and that you may need additional medicine during times of emergency, a severe asthma attack or other illness, or unusual stress. Before you have any kind of surgery (including dental surgery) or emergency treatment, tell the medical doctor or dentist in charge that you are using this medicine . For patients who are also regularly taking a corticosteroid by mouth in tablet or liquid form: Do not stop taking the corticosteroid taken by mouth without your doctor's advice, even if your asthma seems better. Your doctor may want you to reduce gradually the amount you are taking before stopping completely to lessen the chance of unwanted effects. When your doctor tells you to reduce the dose, or to stop taking the corticosteroid taken by mouth, follow the directions carefully. Your body may need time to adjust to the change. The length of time this takes may depend on the amount of medicine you were taking and how long you took it. It is especially important that your doctor check your progress at regular visits during this time. Ask your doctor if there are special directions you should follow if you have a severe asthma attack, if you need any other medical or surgical treatment, or if certain side effects occur. Be certain that you understand these directions, and follow them carefully. Side Effects of This Medicine Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention. Check with your doctor immediately if any of the following side effects occur: Rare Shortness of breath, troubled breathing, tightness in chest, or wheezing signs of hypersensitivity reactions, such as swelling of face, lips, or eyelids Check with your doctor as soon as possible if any of the following side effects occur: Less common burning or pain while urinating, blood in urine, or frequent urge to urinate chest pain creamy white, curd-like patches in the mouth or throat and/or pain when eating or swallowing dizziness or sense of constant movement or surroundings general feeling of discomfort or illness irregular or fast heartbeat itching, rash, or hives sinus problems stomach or abdominal pain swelling of fingers, ankles, feet, or lower legs unusual tiredness or weakness weight gain Rare Bleeding from rectum or bloody stools blurred vision or other changes in vision diarrhea or nausea fainting or feeling faint fever frequent urination or unusual thirst growth inhibition in children high blood pressure increased fat deposits in face, neck, and trunk increased skin pigmentation loss of appetite menstrual changes mood or mental changes numbness pain or burning in chest vomiting Additional side effects may occur if you take this medicine for a long time. Check with your doctor if any of the following side effects occur: Pain in the back, ribs, arms, or legs (osteoporosis) Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them: More common Cold-like symptoms cough dry mouth or throat headache sore throat, hoarseness or voice change Less common or rare Constipation nosebleeds trouble in sleeping Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional. Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088. The information contained in the Thomson Healthcare (Micromedex) products as delivered by Drugs.com is intended as an educational aid only. It is not intended as medical advice for individual conditions or treatment. It is not a substitute for a medical exam, nor does it replace the need for services provided by medical professionals. Talk to your doctor, nurse or pharmacist before taking any prescription or over the counter drugs (including any herbal medicines or supplements) or following any treatment or regimen. Only your doctor, nurse, or pharmacist can provide you with advice on what is safe and effective for you. The use of the Thomson Healthcare products is at your sole risk. These products are provided "AS IS" and "as available" for use, without warranties of any kind, either express or implied. Thomson Healthcare and Drugs.com make no representation or warranty as to the accuracy, reliability, timeliness, usefulness or completeness of any of the information contained in the products. Additionally, THOMSON HEALTHCARE MAKES NO REPRESENTATION OR WARRANTIES AS TO THE OP enterprise


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could Atracurium Besylate Injection Dosage Form: injection, solution Overview Side Effects Professional Interactions Reviews More Support Group Q & A Pricing & Coupons Rx ONLY This drug should be used only by adequately trained individuals familiar with its actions, characteristics, and hazards. Atracurium Besylate Injection Description Atracurium besylate is an intermediate-duration, nondepolarizing, skeletal muscle relaxant for intravenous administration. Atracurium besylate is designated as 2-(2-Carboxyethyl)-1,2, 3, 4-tetrahydro-6,7-dimethoxy-2-methyl-1-veratrylisoquinolinium benzenesulfonate, pentamethylene ester. It has a molecular weight of 1243.49, and its molecular formula is C 65 H 82 N 2 O 18 S 2 . The structural formula is: Atracurium besylate is a complex molecule containing four sites at which different stereochemical configurations can occur. The symmetry of the molecule, however, results in only ten, instead of sixteen, possible different isomers. The manufacture of atracurium besylate results in these isomers being produced in unequal amounts but with a consistent ratio. Those molecules in which the methyl group attached to the quaternary nitrogen projects on the opposite side to the adjacent substituted-benzyl moiety predominate by approximately 3:1. Atracurium Besylate Injection, USP is a sterile, non-pyrogenic aqueous solution. Each mL contains 10 mg atracurium besylate. The pH is adjusted to 3.00 to 3.65 with benzenesulfonic acid. The multiple dose vial contains 0.9% benzyl alcohol added as a preservative. Atracurium Besylate Injection slowly loses potency with time at the rate of approximately 6% per yearunder refrigeration (5 C). Atracurium Besylate Injection should be refrigerated at 2 to 8 C (36 to 46 F) to preserve potency. Rate of loss in potency increases to approximately 5% per monthat 25 C (77 F). Upon removal from refrigeration to room temperature storage conditions (25 C / 77 F), use Atracurium Besylate Injection within 14 days even if rerefrigerated. Slideshow ADHD and Your Child: Signs and Treatment Options Atracurium Besylate Injection - Clinical Pharmacology Atracurium besylate is a nondepolarizing skeletal muscle relaxant. Nondepolarizing agents antagonize the neurotransmitter action of acetylcholine by binding competitively with cholinergic receptor sites on the motor end-plate. This antagonism is inhibited, and neuromuscular block reversed, by acetylcholinesterase inhibitors such as neostigmine, edrophonium, and pyridostigmine. Atracurium can be used most advantageously if muscle twitch response to peripheral nerve stimulation is monitored to assess degree of muscle relaxation. The duration of neuromuscular block produced by atracurium is approximately one-third to one-half the duration of block by d-tubocurarine, metocurine, and pancuronium at initially equipotent doses. As with other nondepolarizing neuromuscular blockers, the time to onset of paralysis decreases and the duration of maximum effect increases with increasing atracurium doses. The ED 95 (dose required to produce 95% suppression of the muscle twitch response with balanced anesthesia) has averaged 0.23 mg/kg (0.11 to 0.26 mg/kg in various studies). An initial atracurium dose of 0.4 to 0.5 mg/kg generally produces maximum neuromuscular block within 3 to 5 minutes of injection, with good or excellent intubation conditions within 2 to 2.5 minutes in most patients. Recovery from neuromuscular block (under balanced anesthesia) can be expected to begin approximately 20 to 35 minutes after injection. Under balanced anesthesia, recovery to 25% of control is achieved approximately 35 to 45 minutes after injection, and recovery is usually 95% complete approximately 60 to 70 minutes after injection. The neuromuscular blocking action of atracurium is enhanced in the presence of potent inhalation anesthetics. Isoflurane and enflurane increase the potency of atracurium and prolong neuromuscular block by approximately 35%; however, halothane s potentiating effect (approximately 20%) is marginal (see DOSAGE AND ADMINISTRATION ). Repeated administration of maintenance doses of atracurium has no cumulative effect on the duration of neuromuscular block if recovery is allowed to begin prior to repeat dosing. Moreover, the time needed to recover from repeat doses does not change with additional doses. Repeat doses can therefore be administered at relatively regular intervals with predictable results. After an initial dose of 0.4 to 0.5 mg/kg under balanced anesthesia, the first maintenance dose (suggested maintenance dose is 0.08 to 0.10 mg/kg) is generally required within 20 to 45 minutes, and subsequent maintenance doses are usually required at approximately 15 to 25 minute intervals. Once recovery from atracurium s neuromuscular blocking effects begins, it proceeds more rapidly than recovery from d-tubocurarine, metocurine, and pancuronium. Regardless of the atracurium dose, the time from start of recovery (from complete block) to complete (95%) recovery is approximately 30 minutes under balanced anesthesia, and approximately 40 minutes under halothane, enflurane or isoflurane. Repeated doses have no cumulative effect on recovery rate. Reversal of neuromuscular block produced by atracurium can be achieved with an anticholinesterase agent such as neostigmine, edrophonium, or pyridostigmine, in conjunction with an anticholinergic agent such as atropine or glycopyrrolate. Under balanced anesthesia, reversal can usually be attempted approximately 20 to 35 minutes after an initial atracurium besylate dose of 0.4 to 0.5 mg/kg, or approximately 10 to 30 minutes after a 0.08 to 0.10 mg/kg maintenance dose, when recovery of muscle twitch has started. Complete reversal is usually attained within 8 to 10 minutes of the administration of reversing agents. Rare instances of breathing difficulties, possibly related to incomplete reversal, have been reported following attempted pharmacologic antagonism of atracurium-induced neuromuscular block. As with other agents in this class, the tendency for residual neuromuscular block is increased if reversal is attempted at deep levels of block or if inadequate doses of reversal agents are employed. The pharmacokinetics of atracurium in humans are essentially linear within the 0.3 to 0.6 mg/kg dose range. The elimination half-life is approximately 20 minutes. THE DURATION OF NEUROMUSCULAR BLOCK PRODUCED BY ATRACURIUM BESYLATE DOES NOT CORRELATE WITH PLASMA PSEUDOCHOLINESTERASE LEVELS AND IS NOT ALTERED BY THE ABSENCE OF RENAL FUNCTION. This is consistent with the results of in vitro studies which have shown that atracurium is inactivated in plasma via two nonoxidative pathways: ester hydrolysis, catalyzed by nonspecific esterases; and Hofmann elimination, a nonenzymatic chemical process which occurs at physiological pH. Some placental transfer occurs in humans. Radiolabel studies demonstrated that atracurium undergoes extensive degradation in cats, and that neither kidney nor liver plays a major role in this elimination. Biliary and urinary excretion were the major routes of excretion of radioactivity (totaling >90% of the labeled dose within 7 hours of dosing), of which atracurium represented only a minor fraction. The metabolites in bile and urine were similar, including products of Hofmann elimination and ester hydrolysis. Elderly patients may have slightly altered pharmacokinetic parameters compared to younger patients, with a slightly decreased total plasma clearance which is offset by a corresponding increase in volume of distribution. The net effect is that there has been no significant difference in clinical duration and recovery from neuromuscular block observed between elderly and younger patients receiving atracurium besylate. Atracurium is a less potent histamine releaser than d-tubocurarine or metocurine. Histamine release is minimal with initial atracurium besylate doses up to 0.5 mg/kg, and hemodynamic changes are minimal within the recommended dose range. A moderate histamine release and significant falls in blood pressure have been seen following 0.6 mg/kg of atracurium besylate. The histamine and hemodynamic responses were poorly correlated. The effects were generally short-lived and manageable, but the possibility of substantial histamine release in sensitive individuals or in patients in whom substantial histamine release would be especially hazardous (e.g., patients with significant cardiovascular disease) must be considered. lt is not known whether the prior use of other nondepolarizing neuromuscular blocking agents has any effect on the activity of atracurium. The prior use of succinylcholine decreases by approximately 2 to 3 minutes the time to maximum block induced by atracurium besylate, and may increase the depth of block. Atracurium should be administered only after a patient recovers from succinylcholine-induced neuromuscular block. Indications and Usage for Atracurium Besylate Injection Atracurium Besylate Injection, USP is indicated, as an adjunct to general anesthesia, to facilitate endotracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation. Contraindications Atracurium besylate is contraindicated in patients known to have a hypersensitivity to it. Use of atracurium besylate from multiple dose vials containing benzyl alcohol as a preservative is contraindicated in patients with a known hypersensitivity to benzyl alcohol. Warnings ATRACURIUM SHOULD BE USED ONLY BY THOSE SKILLED IN AIRWAY MANAGEMENT AND RESPIRATORY SUPPORT. EQUIPMENT AND PERSONNEL MUST BE IMMEDIATELY AVAILABLE FOR ENDOTRACHEAL INTUBATION AND SUPPORT OF VENTILATION, INCLUDING ADMINISTRATION OF POSITIVE PRESSURE OXYGEN. ADEQUACY OF RESPIRATION MUST BE ASSURED THROUGH ASSISTED OR CONTROLLED VENTILATION. ANTICHOLINESTERASE REVERSAL AGENTS SHOULD BE IMMEDIATELY AVAILABLE. DO NOT GIVE ATRACURIUM BESYLATE BY INTRAMUSCULAR ADMINISTRATION. Atracurium has no known effect on consciousness, pain threshold, or cerebration. It should be used only with adequate anesthesia. Atracurium Besylate Injection, which has an acid pH, should not be mixed with alkaline solutions (e.g., barbiturate solutions) in the same syringe or administered simultaneously during intravenous infusion through the same needle. Depending on the resultant pH of such mixtures, atracurium may be inactivated and a free acid may be precipitated. Atracurium Besylate Injection 10 mL multiple dose vials contain benzyl alcohol. In neonates, benzyl alcohol has been associated with an increased incidence of neurological and other complications which are sometimes fatal. (see PRECAUTIONS : Pediatric Use ). Anaphylaxis Severe anaphylactic reactions to neuromuscular blocking agents, including atracurium besylate, have been reported. These reactions have in some cases been life-threatening and fatal. Due to the potential severity of these reactions, the necessary precautions, such as the immediate availability of appropriate emergency treatment, should be taken. Precautions should also be taken in those individuals who have had previous anaphylactic reactions to other neuromuscular blocking agents since cross-reactivity between neuromuscular blocking agents, both depolarizing and non-depolarizing, has been reported in this class of drugs. Precautions Since allergic cross-reactivity has been reported in this class, request information from your patients about previous anaphylactic reactions to other neuromuscular blocking agents. In addition, inform your patients that severe anaphylactic reactions to neuromuscular blocking agents, including atracurium besylate have been reported. General Although atracurium is a less potent histamine releaser than d-tubocurarine or metocurine, the possibility of substantial histamine release in sensitive individuals must be considered. Special caution should be exercised in administering atracurium to patients in whom substantial histamine release would be especially hazardous (e.g., patients with clinically significant cardiovascular disease) and in patients with any history (e.g., severe anaphylactoid reactions or asthma) suggesting a greater risk of histamine release. In these patients, the recommended initial atracurium besylate dose is lower (0.3 to 0.4 mg/kg) than for other patients and should be administered slowly or in divided doses over one minute. Since atracurium has no clinically significant effects on heart rate in the recommended dosage range, it will not counteract the bradycardia produced by many anesthetic agents or vagal stimulation. As a result, bradycardia during anesthesia may be more common with atracurium than with other muscle relaxants. Atracurium may have profound effects in patients with myasthenia gravis, Eaton-Lambert syndrome, or other neuromuscular diseases in which potentiation of nondepolarizing agents has been noted. The use of a peripheral nerve stimulator is especially important for assessing neuromuscular block in these patients. Similar precautions should be taken in patients with severe electrolyte disorders or carcinomatosis. Multiple factors in anesthesia practice are suspected of triggering malignant hyperthermia (MH), a potentially fatal hypermetabolic state of skeletal muscle. Halogenated anesthetic agents and succinylcholine are recognized as the principal pharmacologic triggering agents in MH-susceptible patients; however, since MH can develop in the absence of established triggering agents, the clinician should be prepared to recognize and treat MH in any patient scheduled for general anesthesia. Reports of MH have been rare in cases in which atracurium has been used. In studies of MH-susceptible animals (swine) and in a clinical study of MH-susceptible patients, atracurium did not trigger this syndrome. Resistance to nondepolarizing neuromuscular blocking agents may develop in burn patients. Increased doses of nondepolarizing muscle relaxants may be required in burn patients and are dependent on the time elapsed since the burn injury and the size of the burn. The safety of atracurium has not been established in patients with bronchial asthma. Long-Term Use in Intensive Care Unit (ICU) When there is a need for long-term mechanical ventilation, the benefits-to-risk ratio of neuromuscular block must be considered. The long-term (1 to 10 days) infusion of atracurium besylate during mechanical ventilation in the ICU has been evaluated in several studies. Average infusion rates of 11 to 13 mcg/kg per minute (range: 4.5 to 29.5) were required to achieve adequate neuromuscular block. These data suggest that there is wide interpatient variability in dosage requirements. In addition, these studies have shown that dosage requirements may decrease or increase with time. Following discontinuation of infusion of atracurium besylate in these ICU studies, spontaneous recovery of four twitches in a train-of-four occurred in an average of approximately 30 minutes (range: 15 to 75 minutes) and spontaneous recovery to a train-of-four ratio >75% (the ratio of height of the fourth to the first twitch in a train-of-four) occurred in an average of approximately 60 minutes (range: 32 to 108 minutes). Little information is available on the plasma levels and clinical consequences of atracurium metabolites that may accumulate during days to weeks of atracurium administration in ICU patients. Laudanosine, a major biologically active metabolite of atracurium without neuromuscular blocking activity, produces transient hypotension and, in higher doses, cerebral excitatory effects (generalized muscle twitching and seizures) when administered to several species of animals. There have been rare spontaneous reports of seizures in ICU patients who have received atracurium or other agents. These patients usually had predisposing causes (such as head trauma, cerebral edema, hypoxic encephalopathy, viral encephalitis, uremia). There are insufficient data to determine whether or not laudanosine contributes to seizures in ICU patients. WHENEVER THE USE OF ATRACURIUM OR ANY NEUROMUSCULAR BLOCKING AGENT IS CONTEMPLATED IN THE ICU, IT IS RECOMMENDED THAT NEUROMUSCULAR TRANSMISSION BE MONITORED CONTINUOUSLY DURING ADMINISTRATION WITH THE HELP OF A NERVE STIMULATOR. ADDITIONAL DOSES OF ATRACURIUM OR ANY OTHER NEUROMUSCULAR BLOCKING AGENT SHOULD NOT BE GIVEN BEFORE THERE IS A DEFINITE RESPONSE TO T 1 OR TO THE FIRST TWITCH. IF NO RESPONSE IS ELICITED, INFUSION ADMINISTRATION SHOULD BE DISCONTINUED UNTIL A RESPONSE RETURNS. Hemofiltration has a minimal effect on plasma levels of atracurium and its metabolites, including laudanosine. The effects of hemodialysis and hemoperfusion on plasma levels of atracurium and its metabolites are unknown. Drug Interactions Drugs which may enhance the neuromuscular blocking action of atracurium include: enflurane; isoflurane; halothane; certain antibiotics, especially the aminoglycosides and polymyxins; lithium; magnesium salts; procainamide; and quinidine. If other muscle relaxants are used during the same procedure, the possibility of a synergistic or antagonist effect should be considered. The prior administration of succinylcholine does not enhance the duration, but quickens the onset and may increase the depth, of neuromuscular block induced by atracurium besylate. Atracurium should not be administered until a patient has recovered from succinylcholine-induced neuromuscular block. Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis and fertility studies have not been performed. Atracurium was evaluated in a battery of three short-term mutagenicity tests. It was non-mutagenic in both the Ames Salmonella assay at concentrations up to 1000 mcg/plate, and in a rat bone marrow cytogenicity assay at up to paralyzing doses. A positive response was observed in the mouse lymphoma assay under conditions (80 and 100 mcg/mL, in the absence of metabolic activation) which killed over 80% of the treated cells; there was no mutagenicity at 60 mcg/mL and lower, concentrations which killed up to half of the treated cells. A far weaker response was observed in the presence of metabolic activation at concentrations (1200 mcg/mL and higher) which also killed over 80% of the treated cells. Mutagenicity testing is intended to simulate chronic (years to lifetime) exposure in an effort to determine potential carcinogenicity. Thus, a single positive mutagenicity response for a drug used infrequently and/or briefly is of questionable clinical relevance. Pregnancy Teratogenic Effects: Pregnancy Category C Atracurium besylate has been shown to be potentially teratogenic in rabbits when given in doses up to approximately one-half the human dose. There are no adequate and well-controlled studies in pregnant women. Atracurium should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Atracurium besylate was administered subcutaneously on days 6 through 18 of gestation to non-ventilated Dutch rabbits. Treatment groups were given either 0.15 mg/kg once daily or 0.10 mg/kg twice daily. Lethal respiratory distress occurred in two 0.15 mg/kg animals and in one 0.10 mg/kg animal, with transient respiratory distress or other evidence of neuromuscular block occurring in 10 of 19 and in 4 of 20 of the 0.15 mg/kg and 0.10 mg/kg animals, respectively. There was an increased incidence of certain spontaneously occurring visceral and skeletal anomalies or variations in one or both treated groups when compared to non-treated controls. The percentage of male fetuses was lower (41% vs. 51%) and the post-implantation losses were increased (15% vs. 8%) in the group given 0.15 mg/kg once daily when compared to the controls; the mean numbers of implants (6.5 vs. 4.4) and normal live fetuses (5.4 vs. 3.8) were greater in this group when compared to the control group. Labor and Delivery It is not known whether muscle relaxants administered during vaginal delivery have immediate or delayed adverse effects on the fetus or increase the likelihood that resuscitation of the newborn will be necessary. The possibility that forceps delivery will be necessary may increase. Atracurium besylate (0.3 mg/kg) has been administered to 26 pregnant women during delivery by cesarean section. No harmful effects were attributable to atracurium in any of the neonates, although small amounts of atracurium were shown to cross the placental barrier. The possibility of respiratory depression in the neonate should always be considered following cesarean section during which a neuromuscular blocking agent has been administered. In patients receiving magnesium sulfate, the reversal of neuromuscular block may be unsatisfactory and the dose of atracurium besylate should be lowered as indicated. Nursing Mothers It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when atracurium besylate is administered to a nursing woman. Pediatric Use Safety and effectiveness in pediatric patients below the age of 1 month have not been established. Geriatric Use Since marketing in 1983, uncontrolled clinical experience and limited data from controlled trials have not identified differences in effectiveness, safety, or dosage requirements between healthy elderly and younger patients (see CLINICAL PHARMACOLOGY ); however, as with other neuromuscular blocking agents, the use of a peripheral nerve stimulater to monitor neuromuscular function is suggested (see DOSAGE AND ADMINISTRATION ). Adverse Reactions Observed in Controlled Clinical Studies Atracurium was well tolerated and produced few adverse reactions during extensive clinical trials. Most adverse reactions were suggestive of histamine release. In studies including 875 patients, atracurium was discontinued in only one patient (who required treatment for bronchial secretions) and six other patients required treatment for adverse reactions attributable to atracurium (wheezing in one, hypotension in five). Of the five patients who required treatment for hypotension, three had a history of significant cardiovascular disease. The overall incidence rate for clinically important adverse reactions, therefore, was 7/875 or 0.8%. Table 1 includes all adverse reactions reported attributable to atracurium during clinical trials with 875 patients. TABLE 1: PERCENT OF PATIENTS REPORTING ADVERSE REACTIONS Adverse Reaction Initial Atracurium Dose (mg/kg) 0.00 to 0.30 (n=485) 0.31 to 0.50* (n=366) 0.60 (n=24) Total (n=875) Skin Flush 1.0% 8.7% 29.2% 5.0% Erythema 0.6% 0.5% 0% 0.6% Itching 0.4% 0% 0% 0.2% Wheezing/Bronchial Secretions 0.2% 0.3% 0% 0.2% Hives 0.2% 0% 0% 0.1% *Includes the recommended initial dosage range for most patients Most adverse reactions were of little clinical significance unless they were associated with significant hemodynamic changes. Table 2 summarizes the incidences of substantial vital sign changes noted during atracurium clinical trials with 530 patients, without cardiovascular disease, in whom these parameters were assessed. TABLE 2: PERCENT OF PATIENTS SHOWING >30% VITAL SIGN CHANGES FOLLOWING ADMINISTRATION OF ATRACURIUM Vital Sign Change Initial Atracurium Dose (mg/kg) 0.00 to 0.30 (n=365) 0.31 to 0.50* (n=144) 0.60 (n=21) Total (n = 530) Mean Arterial Pressure Increase 1.9% 2.8% 0% 2.1% Decrease 1.1% 2.1% 14.3% 1.9% Heart Rate Increase 1.6% 2.8% 4.8% 2.1% Decrease 0.8% 0% 0% 0.6% * Includes the recommended initial dosage range for most patients. Observed in Clinical Practice Based on initial clinical practice experience in approximately 3 million patients who received atracurium in the U.S. and in the United Kingdom, spontaneously reported adverse reactions were uncommon (approximately 0.01% to 0.02%). The following adverse reactions are among the most frequently reported, but there are insufficient data to support an estimate of their incidence: General: Allergic reactions (anaphylactic or anaphylactoid responses) which, in rare instances, were severe (e.g., cardiac arrest) Musculoskeletal: Inadequate block, prolonged block Cardiovascular: Hypotension, vasodilatation (flushing), tachycardia, bradycardia Respiratory: Dyspnea, bronchospasm, laryngospasm Integumentary: Rash, urticaria, reaction at injection site There have been rare spontaneous reports of seizures in ICU patients following long-term infusion of atracurium to support mechanical ventilation. There are insufficient data to define the contribution, if any, of atracurium and/or its metabolite laudanosine. (See PRECAUTIONS : Long-Term Use in Intensive Care Unit (ICU) ). There have been post-marketing reports of severe allergic reactions (anaphylactic and anaphylactoid reactions) associated with use of neuromuscular blocking agents, including atracurium besylate. These reactions, in some cases, have been life-threatening and fatal. Because these reactions were reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency (see WARNINGS and PRECAUTIONS ). Overdosage There has been limited experience with overdosage of atracurium besylate. The possibility of iatrogenic overdosage can be minimized by carefully monitoring muscle twitch response to peripheral nerve stimulation. Excessive doses of atracurium can be expected to produce enhanced pharmacological effects. Overdosage may increase the risk of histamine release and cardiovascular effects, especially hypotension. If cardiovascular support is necessary, this should include proper positioning, fluid administration, and the use of vasopressor agents if necessary. The patient s airway should be assured, with manual or mechanical ventilation maintained as necessary. A longer duration of neuromuscular block may result from overdosage and a peripheral nerve stimulator should be used to monitor recovery. Recovery may be facilitated by administration of an anticholinesterase reversing agent such as neostigmine, edrophonium, or pyridostigmine, in conjunction with an anticholinergic agent such as atropine or glycopyrrolate. The appropriate package inserts should be consulted for prescribing information. Three pediatric patients (3 weeks, 4 and 5 months of age) unintentionally received doses of 0.8 mg/kg to 1 mg/kg of atracurium besylate. The time to 25% recovery (50 to 55 minutes) following these doses, which were 5 to 6 times the ED 95 dose, was moderately longer than the corresponding time observed following doses 2 to 2.5 times the atracurium ED 95 dose in infants (22 to 36 minutes). Cardiovascular changes were minimal. Nonetheless the possibility of cardiovascular changes must be considered in the case of overdose. An adult patient (17 years of age) unintentionally received an initial dose of 1.3 mg/kg of atracurium besylate. The time from injection to 25% recovery (83 minutes) was approximately twice that observed following maximum recommended doses in adults (35 to 45 minutes). The patient experienced moderate hemodynamic changes (13% increase in mean arterial pressure and 27% increase in heart rate) which persisted for 40 minutes and did not require treatment. The intravenous LD 50 s determined in non-ventilated male and female albino mice and male Wistar rats were 1.9, 2.01 and 1.31 mg/kg, respectively. Deaths occurred within 2 minutes and were caused by respiratory paralysis. The subcutaneous LD 50 determined in non-ventilated male Wistar rats was 282.8 mg/kg. Tremors, ptosis, loss of reflexes and respiratory failure preceded death which occurred 45 to 120 minutes after injection. Atracurium Besylate Injection Dosage and Administration To avoid distress to the patient, atracurium should not be administered before unconsciousness has been induced. Atracurium should not be mixed in the same syringe, or administered simultaneously through the same needle, with alkaline solutions (e.g., barbiturate solutions). Atracurium besylate should be administered intravenously. DO NOT GIVE ATRACURIUM BESYLATE BY INTRAMUSCULAR ADMINISTRATION. Intramuscular administration of atracurium besylate may result in tissue irritation and there are no clinical data to support this route of administration. As with other neuromuscular blocking agents, the use of a peripheral nerve stimulator will permit the most advantageous use of atracurium besylate, minimizing the possibility of overdosage or underdosage, and assist in the evaluation of recovery. Bolus Doses for Intubation and Maintenance of Neuromuscular Block Adults An atracurium besylate dose of 0.4 to 0.5 mg/kg (1.7 to 2.2 times the ED 95 ), given as an intravenous bolus injection, is the recommended initial dose for most patients. With this dose, good or excellent conditions for nonemergency intubation can be expected in 2 to 2.5 minutes in most patients, with maximum neuromuscular block achieved approximately 3 to 5 minutes after injection. Clinically required neuromuscular block generally lasts 20 to 35 minutes under balanced anesthesia. Under balanced anesthesia, recovery to 25% of control is achieved approximately 35 to 45 minutes after injection, and recovery is usually 95% complete approximately 60 minutes after injection. Atracurium is potentiated by isoflurane or enflurane anesthesia. The same initial atracurium besylate dose of 0.4 to 0.5 mg/kg may be used for intubation prior to administration of these inhalation agents; however, if atracurium is first administered under steady-state of isoflurane or enflurane, the initial atracurium besylate dose should be reduced by approximately one-third, i.e., to 0.25 to 0.35 mg/kg, to adjust for the potentiating effects of these anesthetic agents. With halothane, which has only a marginal (approximately 20%) potentiating effect on atracurium, smaller dosage reductions may be considered. Atracurium besylate doses of 0.08 to 0.10 mg/kg are recommended for maintenance of neuromuscular block during prolonged surgical procedures. The first maintenance dose will generally be required 20 to 45 minutes after the initial Atracurium Besylate Injection, but the need for maintenance doses should be determined by clinical criteria. Because atracurium lacks cumulative effects, maintenance doses may be administered at relatively regular intervals for each patient, ranging approximately from 15 to 25 minutes under balanced anesthesia, slightly longer under isoflurane or enflurane. Higher atracurium doses (up to 0.2 mg/kg) permit maintenance dosing at longer intervals. Pediatric Patients No atracurium dosage adjustments are required for pediatric patients two years of age or older. An atracurium besylate dose of 0.3 to 0.4 mg/kg is recommended as the initial dose for infants (1 month to 2 years of age) under halothane anesthesia. Maintenance doses may be required with slightly greater frequency in infants and children than in adults. Special Considerations An initial atracurium besylate dose of 0.3 to 0.4 mg/kg, given slowly or in divided doses over one minute, is recommended for adults, children, or infants with significant cardiovascular disease and for adults, children, or infants with any history (e.g., severe anaphylactoid reactions or asthma) suggesting a greater risk of histamine release. Dosage reductions must be considered also in patients with neuromuscular disease, severe electrolyte disorders, or carcinomatosis in which potentiation of neuromuscular block or difficulties with reversal have been demonstrated. There has been no clinical experience with atracurium in these patients, and no specific dosage adjustments can be recommended. No atracurium dosage adjustments are required for patients with renal disease. An initial atracurium besylate dose of 0.3 to 0.4 mg/kg is recommended for adults following the use of succinylcholine for intubation under balanced anesthesia. Further reductions may be desirable with the use of potent inhalation anesthetics. The patient should be permitted to recover from the effects of succinylcholine prior to atracurium administration. Insufficient data are available for recommendation of a specific initial atracurium dose for administration following the use of succinylcholine in children and infants. Use by Continuous Infusion Infusion in the Operating Room (OR) After administration of a recommended initial bolus dose of Atracurium Besylate Injection (0.3 to 0.5 mg/kg), a diluted solution of atracurium besylate can be administered by continuous infusion to adults and pediatric patients aged 2 or more years for maintenance of neuromuscular block during extended surgical procedures. Infusion of atracurium should be individualized for each patient. The rate of administration should to confess


the sorts Atracurium Besylate Injection responsibilities