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gore vidal online essays 1% and 0. 15% solution (alphagan-p) has similar efficacy compared with the brimonidine 0. 2% solution, because the purite solution’s higher ph allows for more drug to penetrate the cornea. 32,33 brimonidine cause both local and systemic effects. Local effects include blepharoconjunctivitis, conjunctivitis, and ocular allergy. Systemic effects include headache, dry mouth, and fatigue. 30,32,33 the frequency of dosing and local adverse effects may lead to nonadherence in some patients. Patients prescribed brimonidine should be counseled on the nasolacrimal occlusion technique to reduce systemic adverse effects and to improve efficacy. 32,33 »» carbonic anhydrase inhibitors carbonic anhydrase inhibitors decrease aqueous humor production by inhibition of the carbonic anhydrase isoenzyme ii located in the ciliary body.

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http://www.cs.odu.edu/~iat/papers/?autumn=i-need-help-writing-a-scholarship-essay i need help writing a scholarship essay Roflumilast is an option in patients with chronic bronchitis who are not adequately controlled by optimal inhaled medications. 1 it should not be combined with theophylline because both inhibit pde-4. 23 »» combination therapy for patients who remain symptomatic on monotherapy, a combination of bronchodilators can be used. 1,2 combining longacting inhaled medications is preferred over short-acting agents or theophylline. Combining an laba with a long-acting anticholinergic produces a greater change in spirometry than either drug alone. 26,27 triple therapy with inhaled corticosteroid, laba, and longacting anticholinergic is commonly used in patients who remain symptomatic on dual therapy. Triple therapy appears to improve lung function and quality of life but may not further reduce exacerbations or dyspnea. 28–30 a large, randomized trial found no deleterious effect on exacerbation rates when inhaled fluticasone was withdrawn over 12 weeks from patients with stable, severe copd treated with tiotropium, salmeterol, and fluticasone. 31 based on these results, a step-down in therapy by gradually withdrawing the inhaled corticosteroid can be considered in patients with stable copd. Further studies are needed to determine if the benefits of triple therapy outweigh the increased risk of adverse effects and added cost. Potential benefits and risks of any combination therapy should be considered on a case-by-case basis. Patients should be monitored closely and therapy should be changed if the combination is not more effective. »» vaccinations serious illness and death in copd patients can be reduced by about 50% with annual influenza vaccination. The optimal time for vaccination is usually from early october through mid-november. A onetime pneumococcal polysaccharide vaccine (ppsv23) should be administered to all adults with copd. Patients older than 65 years should be revaccinated if it has been more than 5 years since initial vaccination and they were younger than 65 years at the time. Pneumococcal conjugate vaccine (pcv13) is recommended in all persons 65 years old and older who have not previously received pcv13. Pcv13 should be administered first with ppsv23 administered 6 to 12 months later. »» α1-antitrypsin augmentation therapy augmentation therapy consists of weekly transfusions of pooled human aat with the goal of maintaining adequate plasma levels of the enzyme. It is recommended for individuals with aat deficiency and moderate airflow obstruction (fev1 35%–60% predicted). 32 in these patients, augmentation therapy appears to reduce overall mortality and slow decline in fev1, although large randomized controlled trials have not been conducted. The benefits of augmentation therapy are unclear in patients with severe (fev1 less than 35% predicted) or mild (fev1 greater than 60% predicted) airflow obstruction. It is not recommended for individuals with aat deficiency who do not have lung disease. »» other pharmacologic therapies leukotriene modifiers (eg, zafirlukast and montelukast) have not been adequately evaluated in copd patients and are not recommended for routine use.

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