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Stepping down treatment when asthma is well-controlled Consider stepping down treatment once good asthma control has been achieved and maintained for 3 months discount 1mg propecia with amex hair loss 9 year old, to find the lowest treatment that controls both symptoms and exacerbations generic 5mg propecia amex hair loss in men 501, and minimizes side-effects. To ensure effective inhaler use: • Choose the most appropriate device for the patient before prescribing: consider medication, physical problems e. Check and improve adherence with asthma medications Around 50% of adults and children do not take controller medications as prescribed. Some examples with consistent high quality evidence are: • Smoking cessation advice: at every visit, strongly encourage smokers to quit. Advise parents and carers to exclude smoking in rooms/cars used by children with asthma • Physical activity: encourage people with asthma to engage in regular physical activity because of its general health benefits. Although allergens may contribute to asthma symptoms in sensitized patients, allergen avoidance is not recommended as a general strategy for asthma. These strategies are often complex and expensive, and there are no validated methods for identifying those who are likely to benefit. For baby and mother, the advantages of actively treating asthma markedly outweigh any potential risks of usual controller and reliever medications. For some patients, treatment with intranasal corticosteroids improves asthma control. Obesity: to avoid over- or under-treatment, it is important to document the diagnosis of asthma in the obese. Weight reduction should be included in the treatment plan for obese patients with asthma; even 5–10% weight loss can improve asthma control. The elderly: comorbidities and their treatment should be considered and may complicate asthma management. Factors such as arthritis, eyesight, inspiratory flow, and complexity of treatment regimens should be considered when choosing medications and inhaler devices. Symptomatic reflux should be treated for its general health benefits, but there is no benefit from treating asymptomatic reflux in asthma. Anxiety and depression: these are commonly seen in people with asthma, and are associated with worse symptoms and quality of life. Patients should be assisted to distinguish between symptoms of anxiety and of asthma. Food allergy and anaphylaxis: food allergy is rarely a trigger for asthma symptoms. Good asthma control is essential; patients should also have an anaphylaxis plan and be trained in appropriate avoidance strategies and use of injectable epinephrine. Surgery: whenever possible, good asthma control should be achieved pre- operatively. Ensure that controller therapy is maintained throughout the peri- operative period. The management of worsening asthma and exacerbations should be considered as a continuum, from self-management by the patient with a written asthma action plan, through to management of more severe symptoms in primary care, the emergency department and in hospital. Identifying patients at risk of asthma-related death These patients should be identified, and flagged for more frequent review. Patients who deteriorate quickly should be advised to go to an acute care facility or see their doctor immediately. Oral corticosteroids (preferably morning dosing): • Adults - prednisolone 1mg/kg/day up to 50mg, usually for 5–7 days. Arrange immediate transfer to an acute care facility if there are signs of severe exacerbation, or to intensive care if the patient is drowsy, confused, or has a silent chest. Check response of symptoms and saturation frequently, and measure lung function after 1 hour. Titrate oxygen to maintain saturation of 93–95% in adults and adolescents (94–98% in children 6–12 years). In acute care facilities, intravenous magnesium sulfate may be considered if the patient is not responding to intensive initial treatment.

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Although these fndings are concerning purchase propecia 1mg free shipping revlon anti hair loss, they are insuffcient to warrant dose modifcations (in mg/kg bw) of any antimalarial drug in patients with malnutrition buy propecia 5 mg low price caboki hair loss concealer, however, their response to treatment should be monitored more closely. In principle, dosing of large adults should be based on achieving the target mg/kg bw dose for each antimalarial regimen. The practical consequence is that two packs of an antimalarial drug might have to be opened to ensure adequate treatment. For obese patients, less drug is often distributed to fat than to other tissues; therefore, they should be dosed on the basis of an estimate of lean body weight, ideal body weight. Patients who are heavy but not obese require the same mg/kg bw doses as lighter patients. In the past, maximum doses have been recommended, but there is no evidence or justifcation for this practice. As the evidence for an association between dose, pharmacokinetics and treatment outcome in overweight or large adults is limited, and alternative dosing options have not been assessed in treatment trials, it is recommended that this gap in knowledge be assessed urgently. In the absence of data, treatment providers should attempt to follow up the treatment outcomes of large adults whenever possible. Data on the safety of nevirapine-based regimens in people receiving amodiaquine + artesunate are lacking, but lower levels of amodiaquine and its metabolite desethylamodiaquine have been reported when they were given together with nevirapine. More data are available on use of artemether + lumefantrine with antiretroviral treatment. A study in children with uncomplicated malaria in a high-transmission area of Africa showed a decreased risk for recurrent malaria after treatment with artemether + lumefantrine in children receiving lopinavir–ritonavir-based antiretroviral treatment as compared with non-nucleoside reverse transcriptase inhibitor-based antiretroviral treatment. Evaluation of pharmacokinetics in these children and in healthy volunteers showed signifcantly higher exposure to lumefantrine and lower exposure to dihydroartemisinin with lopinavir–ritonavir-based antiretroviral treatment, but no adverse consequences. Conversely, efavirenz-based antiretroviral treatment was associated with a two- to fourfold decrease in exposure to lumefantrine in healthy volunteers and malaria-infected adults and children, with increased rates of recurrent malaria after treatment. Increasing artemether + lumefantrine dosing with efavirenz-based antiretroviral treatment has not yet been studied. Exposure to lumefantrine and other non-nucleoside reverse transcriptase inhibitor-based antiretroviral treatment, namely nevirapine and etravirine, did not show consistent changes that would require dose adjustment. Studies of administration of quinine with lopinavir–ritonavir or ritonavir alone in healthy volunteers gave conficting results. Single-dose atovaquone – proguanil with efavirenz, lopinavir–ritonavir or atazanavir–ritonavir were all associated with a signifcantly decreased area under the concentration–time curve for atovaquone (two- to fourfold) and proguanil (twofold), which could well compromise treatment or prophylactic effcacy. There is insuffcient evidence to change the current mg/kg bw dosing recommendations; however, these patients should also be monitored closely. Concomitant administration of rifampicin during quinine treatment of adults with malaria was associated with a signifcant decrease in exposure to quinine and a fve-fold higher recrudescence rate. Similarly, concomitant rifampicin with mefoquine in healthy adults was associated with a there-fold decrease in exposure to mefoquine. There is insuffcient evidence at this time to change the current mg/kg bw dosing recommendations; however, as these patients are at higher risk of recrudescent infections they should be monitored closely. Travellers who acquire malaria are often non-immune people living in cities in endemic countries with little or no transmission or are visitors from non-endemic countries travelling to areas with malaria transmission. In a malaria-endemic country, they should be treated according to national policy, provided the treatment recommended has a recent proven cure rate > 90%. Travellers who return to a non-endemic country and then develop malaria present a particular problem, and the case fatality rate is often high; doctors in non-malarious areas may be unfamiliar with malaria and the diagnosis is commonly delayed, and effective antimalarial drugs may not be registered or may be unavailable. However prevention of transmission or the emergence of resistance are not relevant outside malaria-endemic areas. If the patient has taken chemoprophylaxis, the same medicine should not be used for treatment. There may be delays in obtaining artesunate, artemether or quinine for the management of severe malaria outside endemic areas. If only parenteral quinidine is available, it should be given, with careful clinical and electrocardiographic monitoring (see section 7). They are at increased risk for severe malaria and for treatment failure and are considered an important source of antimalarial drug resistance.

Guidelines for the Diagnosis and Treatment of Malaria in Zambia 60 • Monitor vital signs (temperature cheap propecia 5mg overnight delivery hair loss cure latest news, pulse rate buy propecia 5mg line hair loss in men and women, respiratory rate, and blood pressure). Insert about 5 cm length of a naso- gastric tube into the rectum, inject the diazepam into the naso-gastric tube and thereafter flush with 5 ml of water. Note: Make sure the patient has received glucose and that Guidelines for the Diagnosis and Treatment of Malaria in Zambia 61 the temperature is controlled. Indication for urgent blood transfusion Blood transfusion should be considered if the haematocrit falls below 15% or haemoglobin concentration is < 5 g/dl. Packed cells should be given; in cases of hypovolemic shock, whole blood is preferred. Patients with very low Hb may also have the following conditions: • Signs of heart failure • Signs of respiratory distress • Hyperparasitaemia • Impaired consciousness Management of life-threatening anaemia (Hb < 5 g/dl) Guidelines for the Diagnosis and Treatment of Malaria in Zambia 62 associated with malaria • Administer oxygen 2. How to administer blood Packed cells are given at l0 ml/kg and whole blood at 20 ml/kg. An intravenous stat (bolus) dose of a loop diuretic like furosemide at 1 to 2 mg/kg may be given (provided the blood pressure is not low) during blood transfusion to avoid circulatory overload. Drip: drops/mm = Volume to be transfused in ml x 20 (or 15) drop factor Time of transfusion in hours (4 to 6 hours) x 60 minutes 1 ml whole blood = 20 drops l ml packed cell = 15 drops Fresh blood is preferred because it contains clotting factors and platelets. Note: Impaired tissue oxygenation (which may present as lethargy, breathlessness, or confusion) in anaemia is due to Guidelines for the Diagnosis and Treatment of Malaria in Zambia 63 impaired oxygen-carrying capacity by red blood cells, which cannot be corrected by fluid infusions and/or giving oxygen. Give small intravenous doses of furosemide 20 mg as necessary during the blood transfusion to avoid circulatory overload. Follow-up after discharge After discharge, it is important to continue monitoring the patient’s condition: • Discharge the patient on folic acid and ferrous sulphate (do not give ferrous sulphate to patients with sickle cell disease). It occurs in three different (but potentially overlapping) groups of patients: Guidelines for the Diagnosis and Treatment of Malaria in Zambia 65 • Patients with severe disease, especially young children. In conscious patients, hypoglycaemia may present with classical symptoms of anxiety, sweating, dilatation of the pupils, breathlessness, oliguria, a feeling of coldness, tachycardia, and light-headedness. This clinical picture may develop into deteriorating consciousness, generalized convulsions, extensor posturing, shock, and coma. The diagnosis is easily overlooked because all these clinical features also occur in severe malaria itself. If possible, confirm by biochemical testing, especially in the high-risk groups mentioned above. Guidelines for the Diagnosis and Treatment of Malaria in Zambia 66 • Monitoring of the clinical condition and blood sugar must continue even if hypoglycaemia is initially controlled and the patient is receiving injectable glucose. For children • All children with severe malaria should be assumed to have hypoglycaemia and receive treatment as above even where a test cannot be done. For children who are unable to take food orally, a naso-gastral tube should be inserted and feeds initiated. Where dextrose is not available, mix 20 g of sugar (about 4 level teaspoons) with 200 ml of clean water; give 50 ml of this solution orally. A systolic blood pressure below 50 mm Hg (in children) and below 80 mm Hg in the supine position (in adults) indicates a state of shock. Correct any reversible cause of acidosis (in particular, dehydration in severe anaemia). Convulsions may contribute to lactic acidosis; therefore, Guidelines for the Diagnosis and Treatment of Malaria in Zambia 67 prevention of further seizures may be beneficial. If haemoglobin is above 5 g/dl, give 20 ml/kg of isotonic saline by intravenous infusion over 30 minutes. If the Hb is less than 5 g/dl, give a blood transfusion (whole blood 10 ml/kg over 30 minutes and a further 10 ml/kg over 1 to 2 hours without diuretics). Monitor response by continuous clinical observation supported by repeated measurement of acid/base status, Hb, blood sugar, and urea and electrolyte levels. Guidelines for the Diagnosis and Treatment of Malaria in Zambia 68 Chapter 8: Malaria in Pregnancy 8. Pregnant women are particularly at risk due to the lowered acquired partial immunity during pregnancy.

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