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Blood cultures 12 hrs post initiation. Skin care check q 2 hr for burns caused by cold blankets. Begin rewarming 24 hrs after initiation of cooling at a rate of 0.25°c (0.5°f) every hour until the patient returns to normothermia (37°c/98.6°f). Keep artic sun pads on for 48 hours and set temperature at 37°c/98.6°f to maintain normothermia. Maintain paralytic (if started) and sedation until temperature of 36°c/96.8°f degrees is reached. Hypotension, hyperkalemia, hypoglycemia, and hyperthermia may occur during and after the re-warming. Stop iv insulin when glucose <200 mg/kl, unless t1dm. Testing to assess for neurologic prognsosis should be delayed to at least 72 hours after the return to normothermia as patients who have th have delayed neurologic recovery.

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Statins are well tolerated, with less than 4% of patients in clinical trials discontinuing therapy due to adverse side effects (table 12–11). Elevations in liver function tests (lfts) and myopathy, including rhabdomyolysis, are important adverse effects associated with statins. Liver toxicity, defined as lft elevations greater than three times the upper limit of normal, is reported in less than 2% of patients. Incidence is higher at higher doses, but the progression to liver failure is exceedingly rare. Lfts should be obtained at baseline and as clinically indicated thereafter. Myopathy, defined as muscle symptoms with creatine kinase (ck) 10 times the upper limit of normal, is reported to range from 0% to less than 0. 5% for the currently marketed statins at approved doses. Rhabdomyolysis, defined as muscle symptoms with marked elevation in ck at 10 times the upper limit of normal and creatinine elevation usually associated with myoglobinuria and brown urine, is very rare. 27 the risks associated with statin-induced myopathy are28 •• small body frame and frailty •• multisystem disease (eg, chronic renal insufficiency, especially due to dm) •• perioperative periods •• multiple medications (see next bullet) •• specific concomitant medications or consumptions (check specific statin package insert for warnings). Fibrates (especially gemfibrozil, but other fibrates too), nicotinic acid (rarely), cyclosporine, azole antifungals, macrolide antibiotics, protease inhibitors, nefazodone, verapamil, amiodarone, large quantities of grapefruit juice (usually more than 1 quart [about 950 ml] per day), and alcohol abuse (independently predisposes to myopathy). It is reasonable to check a baseline ck in patients at risk for myopathy. Follow-up ck should only be obtained in patients complaining of muscle pain, weakness, tenderness, or brown urine. Patient assessment for symptoms of myopathy should be done 6 to 12 weeks after starting therapy and at each visit. Some evidence suggests that statins increase the risk for development of dm. The food and drug administration (fda) warns of increased blood sugar and glycosylated hemoglobin (hba1c) levels in statin labels. In addition, the fda has added to statin labels that cognitive impairment, such as memory loss, forgetfulness and confusion, has been reported by some statin users. The fda continues to believe the cardiovascular benefits of statins outweigh these small increased risks. With the exception of pravastatin and pitavastatin, the other statins undergo biotransformation by the cytochrome p-450 system. Therefore, drugs known to inhibit statin metabolism should be used cautiously or avoided. Medications such as cyclosporine and gemfibrozil can inhibit drug transporters in the gut and liver that can increase statin concentrations. The time until maximum effect on lipids for statins is generally 4 to 6 weeks. »» cholesterol absorption inhibitors ezetimibe blocks biliary and dietary cholesterol as well as phytosterol (plant sterol) absorption by interacting with the npc1l1 transporter (figure 12–2). 5 less cholesterol is delivered to the liver which leads to an upregulation of ldl receptors. Chapter 12  |  dyslipidemias  219 table 12–10  effects of lipid-lowering drugs on serum lipids at fda-approved doses lipid-lowering drug ldl cholesterol hdl cholesterol triglycerides total cholesterol statins atorvastatin fluvastatin fluvastatin er lovastatin lovastatin er pitavastatin pravastatin rosuvastatin simvastatin bile acid sequestrants cholestyramine   –26% to –60% –22% to –36% –33% to –35% –21% to –42% –24% to –41% –31% to –45% –22% to –34% –45% to –63% –26% to –47%   –15% to –30%   +5% to +13% +3% to +11% +7% to +11% +2% to +10% +9% to +13% +1% to +8% +2% to +12% +8% to +14% +8% to +16%   +3% to +5%   –25% to –45% –16% to –27% –25% –16% to –34% –18% to –29% –23% to –31% –16% to –25% –33% to –46% –19% to –36%   –10% to –25% colesevelam colestipol cholesterol absorption inhibitor ezetimibe nicotinic acid niacin er niacin ir fibric acid derivatives fenofibrate gemfibrozil combination products niacin er and lovastatin niacin er and simvastatina simvastatin and ezetimibe omega-3-fatty acids lovaza vascepa epanova omtryg micosomal transfer protein inhibitors lomitapide antisense oligonucleotide mipomersen –15% to –18% –15% to –30%   +3% to +5% +3% to +5%     –17% to –53% –12% to –25% –19% to –25% –6% to –27% –10% to –25% –13% to –22% –15% to –24% –10% to –35% –12% to –34%   may increase in patients with elevated triglycerides       –18%   –5% to –17% –5% to –25%   –31% to +45% –30% to +30%   –30% to –42% –12% to –14% –46% to –59%   +45% –5% +26% +20% to +45%   +1% to +2%   +14% to +26% +15% to +39%   +9% to +23% +10% to +30%   +20% to +30% +21% to +29% +8% to +12%   +9% –4% +5% 0% to +9%   –7% to –9%   –11% to –38% –20% to –60%   –23% to –54% –20% to –60%   –32% to –44% –27% to –38% –25% to –26%   –45% –27% –31% –25% to -45%   –12% to –13%   –3% to –12% –3% to –25%   –9% to –22% –2% to –16%   not stated –9% to –11% –34% to –43%   –10% –7% –6% –8% to –10%   –40%   –7%   –45%   –36%   –25% +15% –18% –21% –70% to –10% –10% to 25%   er, extended-release. Fda, food and drug administration. Hdl, high-density lipoprotein. Ldl, low-density lipoprotein. A percent change relative to simvastatin 20 mg. This causes a reduction in serum cholesterol and a compensatory increase in cholesterol biosynthesis. Because statins inhibit cholesterol biosynthesis, this compensatory increase by ezetimibe can be blocked when coadministered with a statin. Ezetimibe reduces ldl cholesterol by an average of 18%. However, larger reductions can be seen in some individuals, presumably due to higher absorption of cholesterol.

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His erectile dysfunction, poor libido, and fatigue have improved viagra online kaufen test since starting testosterone replacement therapy. He has no complaints with his current medication regimen for copd. He takes calcium carbonate (tums) approximately once a week for heartburn after eating spicy meals. He usually spends his day inside the house watching television from his recliner. He states that milk upsets his stomach, so he usually drinks black coffee or diet soda, occasionally fruit juice. Pmh. Copd, dm type 2, htn, hyperlipidemia, gerd, hypogonadism, lactose intolerance fh. Father died at age 76 with alzheimer disease. Mother died at age 92 with history of breast cancer and osteoporotic fracture of the hip. Sister alive and well at age 69 sh. Retired construction worker. Drinks four beers per day. Smoked two packs a day for 40 years, now two cigars daily meds. Albuterol inhaler two puffs as needed, metformin 500 mg twice daily. Lisinopril 10 mg daily. Atorvastatin 40 mg daily, omeprazole 20 mg daily. Calcium carbonate (tums) 500 mg as needed. Testosterone cypionate 200 mg im every 2 weeks. Tiotropium 18 mcg daily do any symptoms suggest the presence of osteoporosis?. What risk factors for osteoporosis does this patient have as defined by the world health organization?. What diseases or medications could contribute to osteoporosis in this patient?. What are the recommended daily intakes for calcium and vitamin d?. How could he incorporate more calcium into his diet?.

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Ibrutinib inhibits bruton tyrosine kinase and has shown activity in mantle cell lymphoma and cll. Idelalisib, in combination with rituximab, is approved for relapsed cll and targets phosphatidylinositol-3-kinase (pi3-k), an essential lipid kinase. Adverse effects associated with these agents are gi disturbances, rash, hematological side effects, fatigue and musculoskeletal pain. Idelalisib has hepatotoxicity, colitis, pneumonitis, and intestinal perforation as black-box warnings. »» epidermal growth factor receptor pathway inibitors (erlotinib, afatinib, and lapatinib) patients with malignancies (eg, non-small cell lung cancer or nsclc) in which the tumors have mutations in exon 19 and/ or 21 in the epidermal growth factor receptor (egfr) pathway will likely respond to egfr tyrosine kinase inhibitors such as erlotinib. These agents are believed to inhibit the intracellular phosphorylation of the egfr. Erlotinib is about 60% absorbed after oral administration. Food increases bioavailability to almost 100%, but this is variable, and experts recommend administering erlotinib on an empty stomach. Erlotinib is eliminated predominately by cyp3a4. Smoking increases the clearance of erlotinib by 24%, which may result in treatment failure. 40 erlotinib is used chapter 88  |  cancer chemotherapy and treatment   1309 in the treatment of nsclc and cancer of the pancreas. Side effects include interstitial lung disease, rash, diarrhea, anorexia, pruritus, conjunctivitis, and dry skin. Again, significant drug interactions have been documented with cyp3a4 inducers and inhibitors. Afatinib is an oral, selective egfr-tki approved for the treatment of metastatic nsclc in patients with egfr exon 19 deletions or exon 21 (l858r) substitution mutations. It is taken on an empty stomach at a dose of 40 mg orally once daily. Adverse effects are similar to those reported with erlotinib.