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By B. Grok. University of Massachusetts at Dartmouth.

Thus cheap finasteride 1 mg on-line, the lev- stage it has reached discount finasteride 5 mg without a prescription, the aggressiveness of the cancer, and els of these substances may be abnormal when certain the extent of its spread. However, laboratory tests alone can- obtained by biopsy defines the cause of the abnormality. Since a biopsy provides the most accurate analysis, it is Blood tests are generally more useful in monitoring the considered the gold standard of diagnostic tests for cancer. Other tech- the American Cancer Society recommends an annual 194 GALE ENCYCLOPEDIA OF GENETIC DISORDERS KEY TERMS (CONTINUED) Prostatectomy—The surgical removal of the Testosterone—Hormone produced in the testicles prostate gland. High-frequency Radiation—High energy rays used in cancer treat- sound waves that cannot be heard by humans are ment to kill or shrink cancer cells. These sound waves produce a pattern of radiation from x-ray machines, cobalt, radium, or echoes that are then used by the computer to create other sources. Rectum—The end portion of the intestine that leads Transvaginal ultrasound—A way to view the ovaries to the anus. Color doppler Semen—A whitish, opaque fluid released at ejacu- imaging measures the amount of blood flow, as lation that contains sperm. Seminal vesicles—The pouches above the prostate Tumor—An abnormal growth of cells. Sore—An open wound or a bruise or lesion on the Ultrasound—An imaging technique that uses sound skin. Whipple procedure—Surgical removal of the pan- creas and surrounding areas including a portion of Stomach—An organ that holds and begins digestion the small intestine, the duodenum. X ray—An image of the body made by the passing Synchronous—Occurring simultaneously. Testicles—Two egg-shaped glands that produce X rays—High energy radiation used in high doses, sperm and sex hormones. Self-examinations for cancers of the breast, The aim of cancer treatment is to remove all or as testes, mouth and skin can also help in detecting tumors. This genetic testing involves looking closely example, if the cancer is very aggressive and a cure is not at certain genes that have been linked to particular can- possible, then the treatment should be aimed at relieving cers. The tests may be uninfor- Cancer treatment can take many different forms and mative and they are useful to a very small number of peo- it is always tailored to the individual patient. Additionally, there are concerns about insurance sion on which type of treatment to use depends on the coverage and employment discrimination for someone type and location of cancer and the extent to which it has who has an increased risk for cancer. The doctor will also consider the tests are reserved only for very specific people. In that it seeks to destroy cancer cells in the tumor and the other cases, the only way to obtain a tissue sample for surrounding area. It can also be systemic, meaning that biopsy is by performing a surgical operation. Chemotherapy, then treats the remaining cancer cells with radiation immunotherapy, and hormone therapy are examples of therapy, chemotherapy, or both. For Surgery can be used for many purposes in cancer example, if the tumor is very large or has spread to therapy. Since cancer usually spreads via the lymphatic Radiation uses high-energy rays to kill cancer cells. For example, 40% of peo- external form, the radiation comes from a machine that ple with a colon disease, called ulcerative colitis, ulti- aims the rays at the tumor. Rather than live with the known as brachytherapy), radioactive material is sealed fear of developing colon cancer, these people may in needles, seeds, or wires and placed directly in or near choose to have their colons removed in order to reduce the tumor. The side effects of detect cancer cells that have spread and are circulating in this immunotherapy are variable but include flu-like the body. Chemotherapy is based on the principle that symptoms, weakness, loss of appetite, and skin rash. Chemotherapeutic drugs can be injected into a vein, the Bone marrow failure is a complication of chemother- muscle, or the skin or they may be taken by mouth. When high dose chemotherapy is used, this failure is When chemotherapy is used before surgery, it is anticipated. Bone marrow transplantation (BMT) or known as primary chemotherapy or “neoadjuvant peripheral stem cell transplantation (PSCT) are tech- chemotherapy.

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Hematologic toxicity symptoms: Suppression of clotting fac- tors II buy finasteride 5 mg overnight delivery, V cheap finasteride 1mg visa, VII, and X and polycythemia. Nasal: 1–2 sprays/nostril/d SUPPLIED: Nasal spray 50 µg/actuation Fluticasone Oral (Flovent, Flovent Rotadisk) COMMON USES: Chronic treatment of asthma ACTIONS: Topical steroid DOSAGE: Adults & adolescents. Maintenance: 90–120 mg/kg/d IV (Monday–Friday) SUPPLIED: Inj 24 mg/mL NOTES: Dosage must be adjusted for renal function; nephrotoxic; monitor ionized calcium closely (causes electrolyte abnormalities); administer through a central line Fosfomycin (Monurol) COMMON USES: Uncomplicated UTI 22 ACTIONS: Inhibits bacterial cell wall synthesis 22 Commonly Used Medications 543 DOSAGE: 3 g PO dissolved in 90–120 mL of water as single dose SUPPLIED: Granule packets 3 g NOTES: May take 2–3 d for symptoms to improve Fosinopril (Monopril) COMMON USES: HTN and heart failure ACTIONS: ACE inhibitor DOSAGE: Initially, 10 mg/d PO; may be ↑ to a max of 80 mg/d PO ÷ qd–bid SUPPLIED: Tabs 10, 20, 40 mg NOTES: ↓ Dose in elderly; may cause nonproductive cough and dizziness Fosphenytoin (Cerebyx) COMMON USES: Status epilepticus ACTION: Inhibits seizure spread in the motor cortex DOSAGE: Dosed as phenytoin equivalents (PE) Loading 15–20 mg PE/kg, maintenance 4–6 mg PE/kg/d SUPPLIED: Inj; 150 mg (= phenytoin 100 mg); 750 mg (= phenytoin 500 mg) NOTES: Requires 15 min to convert the prodrug fosphenytoin to phenytoin; administer at <150 mg PE/min to prevent hypotension; administer with BP monitoring; dosage adjustment/plasma moni- toring may be necessary in hepatic impairment Furosemide (Lasix) Used for emergency cardiac care (see Chapter 21) COMMON USES: Edema, HTN, and CHF ACTIONS: Loop diuretic; inhibits Na and Cl reabsorption in the ascending loop of Henle and the distal renal tubule DOSAGE: Adults. IV: 5 mg/kg IV q12h for 14–21 d, then maintenance of 5 mg/kg/d IV for 7 d/wk or 6 mg/kg/d IV for 5 d/wk. Prevention: 1000 mg PO tid SUPPLIED: Caps 250, 500 mg; inj 500 mg; ocular implant 4. Daily dosing becoming popular Gentamicin, Ophthalmic (Garamycin, Genoptic, Gentacidin, others) COMMON USES: Conjunctival infections ACTIONS: Bactericidal; inhibits protein synthesis DOSAGE: Oint apply bid or tid; soln: 1–2 gtt q2–4h, up to 2 gtt/h for severe infections 22 SUPPLIED: Soln and oint 0. Stimulates the release of insulin from the pancreas; increases insulin sensi- tivity at peripheral sites; reduces glucose output from the liver DOSAGE: 1–4 mg/d, up to max of 8 mg SUPPLIED: Tabs 1, 2, 4 mg Glipizide (Glucotrol) COMMON USES: Type 2 DM ACTION: Sulfonylurea. Stimulates the release of insulin from the pancreas; increases insulin sensi- tivity at peripheral sites; reduces glucose output from the liver DOSAGE: 5–15 mg qd–bid SUPPLIED: Tabs 5, 10 mg; ER tabs 5, 10 mg Glucagon Emergency care (see Chapter 21) COMMON USES: Severe hypoglycemic reactions in diabetic patients with sufficient liver glycogen stores or β-blocker overdose ACTIONS: Accelerates liver gluconeogenesis DOSAGE: Adults. Stimulates the release of insulin from the pancreas; increases insulin sensi- tivity at peripheral sites; reduces glucose output from the liver DOSAGE: Nonmicronized: 1. Initially, 4 mg PO bid; ↑ by 4 mg/d increments at 1–2-wk intervals up to 32 mg bid. Severe symptoms or agitation: 3–5 mg PO bid–tid or 1–5 mg IM q4h PRN (max 100 mg/d). Thrombosis Rx: Loading dose of 50–75 U/kg IV, then 10–20 U/kg IV qh (adjust based on PTT). Children: Loading dose 50 U/kg IV, then 15–25 U/kg cont inf or 100 U/kg/dose q4h IV intermittent bolus SUPPLIED: Inj 10, 100, 1000, 2000, 2500, 5000, 7500, 10,000, 20,000, 40,000 U/mL NOTES: Follow PTT, thrombin time, or activated clotting time to assess effectiveness; heparin has little effect on the prothrombin time; with proper dose, PTT is about 1. Leuka- pheresis: 250–700 mL SUPPLIED: Inj 6 g/100 mL NOTES: NOT a substitute for blood or plasma; contra in patients with severe bleeding disorders, se- 22 vere CHF, or renal failure with oliguria or anuria 22 Commonly Used Medications 549 Hydralazine (Apresoline, others) COMMON USES: Moderate to severe HTN ACTIONS: Peripheral vasodilator DOSAGE: Adults. Ulcerative colitis 10–100 mg rectally qd–bid 2–3 wk 1–2×/d for 2–3 wk SUPPLIED: Hydrocortisone acetate: Rectal aerosol 90 mg/applicator; supp 25 mg; Hydrocortisone base: Rectal 1%; rectal susp: 100 mg/60 mL Hydrocortisone, Topical (see also Table 22–6, pages 628–630) Hydromorphone (Dilaudid) [C-II] COMMON USES: Moderate to severe pain ACTIONS: Narcotic analgesic DOSAGE: 1–4 mg PO, IM, IV, or PR q4–6h PRN; 3 mg PR q6–8h PRN SUPPLIED: Tabs 1, 2, 3, 4, 8 mg; liq 5 mg/mL; inj 1, 2, 4, 10 mg/mL; supp 3 mg 22 NOTES: 1. HIV: 1000–1500 mg/d in single or ÷ doses SUPPLIED: Caps 200, 300, 400, 500 mg NOTES: Toxicity symptoms: Myelosuppression (primarily leukopenia), nausea and vomiting, rashes, facial erythema, radiation recall reactions, and renal dysfunction; dosage adjustment in renal dys- function Hydroxyzine (Atarax, Vistaril) COMMON USES: Anxiety, tension, sedation, itching ACTIONS: Antihistamine, anxiety DOSAGE: Adults. Hospitalized: Start at 100 mg/24h PO in ÷ doses; can ↑ over several weeks to 250–300 mg/24h. Enuresis: >6 y: 10–25 mg PO hs; ↑ by 10–25 mg at 1–2-wk intervals; treat for 2–3 mo, then taper SUPPLIED: Tabs 10, 25, 50 mg; caps 75, 100, 125, 150 mg NOTES: Do NOT use with MAO inhibitors; less sedation than with amitriptyline Imiquimod Cream, 5% (Aldara) COMMON USES: External genital warts ACTIONS: Exact mechanism unknown; may induce cytokines DOSAGE: Applied 3×/wk; leave on skin for 6–10 h, continue therapy for a max of 16 wk SUPPLIED: Single-dose packets (250 mg of the cream) NOTES: Local skin reactions common Immune Globulin, Intravenous (Gamimmune N, Sandoglobulin, Gammar IV) COMMON USES: IgG antibody deficiency disease states (eg, congenital agammaglobulinemia), CVH, and BMT; and ITP ACTIONS: IgG supplementation DOSAGE: Adults & Peds. BMT: 500 mg/kg/wk SUPPLIED: Inj NOTES: Adverse effects associated mostly with rate of infusion Indapamide (Lozol) COMMON USES: HTN and CHF ACTIONS: Thiazide diuretic; enhances Na, Cl, and water excretion in the proximal segment of the distal tubule DOSAGE: 1. RA: 3 mg/kg IV inf at 0, 2, 6 wk, followed by q 8 wk SUPPLIED: Inj NOTES: May cause hypersensitivity reaction, made up of human constant and murine variable re- gions; patients are predisposed to infection Influenza Vaccine (Fluzone, Fluogen, Flushield, Flu-immune) COMMON USES: Prevention of influenza in high-risk populations (chronic medical conditions, eg, heart disease, lung disease, or diabetes; children with asthma; residents of chronic care facilities; and any person >50 y). Health care workers or members of households who may come into contact with these patients also encouraged to be immunized ACTIONS: Active immunization to inactivated virus grown in eggs DOSAGE: 0. Alfa-2b (Intron A): 2 million IU/m2 IM or SC 3×/wk for 2–6 mo; intravesical 50–100 million IU in 50 mL/wk NS × 6 SUPPLIED: Injectable forms NOTES: May cause flu-like symptoms; fatigue common; anorexia occurs in 20–30% of patients; neurotoxicity may occur at high doses; neutralizing antibodies can occur in up to 40% of patients receiving prolonged therapy Interferon Alfa-2B and Ribavirin Combination (Rebetron) COMMON USES: Chronic hepatitis C in patients with compensated liver disease who have relapsed following α-interferon therapy ACTIONS: Combination antiviral agents DOSAGE: 3 million U Intron A SC 3×/wk with 1000–1200 mg of Rebtrol PO ÷ bid dose for 24 wk; Patients <75 kg: 1000 mg of Rebetrol/d SUPPLIED: Patients <75 kg: Combination pack; 6 vials Intron A (3 million U/0. Patients >75 kg: Identical except for 84 Rebe- trol caps/pack NOTES: Instruct patients in self-administration of SC Intron A Interferon Alfacon-1 (Infergen) COMMON USES: Management of chronic hepatitis C ACTIONS: Biologic response modifier DOSAGE: 9 µg SC 3×/wk SUPPLIED: Inj 9, 15 µg NOTES: At least 48 h between inj Interferon β-1B (Betaseron) COMMON USES: Management of MS ACTIONS: Biologic response modifier DOSAGE: 0. Children 6–12 mo: 5–10 mL PO, followed by 10–20 mL/kg of water; if no 22 Commonly Used Medications 555 emesis occurs in 20 min, may repeat once. Children 1–12 y: 15 mL PO followed by 10–20 mL/kg of water; if no emesis occurs in 20 min, may repeat once SUPPLIED: Syrup 15, 30 mL NOTES: Do NOT use for ingestion of petroleum distillates or strong acid, base, or other corrosive or caustic agents; NOT for use in comatose or unconscious patients; caution in CNS depressant over- dose Ipratropium (Atrovent) COMMON USES: Bronchospasm associated with COPD, bronchitis, and emphysema; rhinorrhea ACTIONS: Synthetic anticholinergic agent similar to atropine DOSAGE: Adults & Peds >12 y. Nasal: 2 sprays/nostril bid–tid SUPPLIED: Met-dose inhaler 18 µg/dose; soln for inhal 0. Diarrhea dose-limiting in many studies; acute diarrhea associ- ated with crampy abdominal pain successfully treated with atropine; subacute diarrhea treated with Imodium or loperamide. Diarrhea correlated to levels of metabolite SN-38 Iron Dextran (Dexferrum, InFeD) COMMON USES: Iron deficiency when oral supplementation not possible ACTIONS: Parenteral iron supplementation DOSAGE: Based on estimate of iron deficiency, given IM/IV. Prophylaxis: 10 mg/kg/24h PO SUPPLIED: Tabs 50, 100, 300 mg; syrup 50 mg/5 mL; inj 100 mg/mL NOTES: Can cause severe hepatitis; given with other antituberculous drugs for active TB; consult MMWR for the latest recommendations on the treatment and prophylaxis of TB; IM route rarely used; to prevent peripheral neuropathy, give pyridoxine 50–100 mg/d; dosage adjustment in hepatic impairment Isoproterenol (Isuprel, Medihaler-Iso) Used for emergency cardiac care (see Chapter 21) COMMON USES: Shock, cardiac arrest, and AV nodal block; antiasthmatic ACTIONS: β1- and β2-receptor stimulant DOSAGE: Adults.

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Both alkylation and carbamoylation contribute Alkyl Sulfonates to the therapeutic and toxic effects of the nitrosoureas finasteride 5mg without prescription. Busulfan These agents can kill cells in all phases of the cell Busulfan (Myleran) is a bifunctional methanesulfonic cycle discount finasteride 1 mg line. Oral absorption of lomustine and semustine is com- The drug is well absorbed after oral administration and plete, but degradation and metabolism are so rapid that has a plasma half-life of less than 5 minutes. Metabolites the parent drug cannot be detected after oral adminis- and degradation products are excreted primarily in the tration. Daily oral therapy re- Carmustine and lomustine can produce remissions sults in decreased peripheral white blood cells and im- that last from 3 to 6 months in 40 to 50% of patients proved symptoms in almost all patients during the with primary brain tumors. Unusual side effects of busulfan include gyneco- ing in most patients 4 to 6 hours after administration. Ethylenimines Pulmonary toxicity, manifested by cough, dyspnea, and Thiotepa interstitial fibrosis, is becoming increasingly recognized Although thiotepa is chemically less reactive than the ni- as a complication of long-term nitrosourea treatment. However, it has been Streptozocin (Zanosar), a water-soluble nitrosourea largely supplanted by cyclophosphamide and other ni- produced by the fungus Streptomyces achromogenes, trogen mustards for treatment of these diseases. Streptozocin is not well absorbed from the gastroin- testinal tract and must be administered intravenously or Triazenes intraarterially. Streptozocin produces remission in 50 to 60% of pa- Dacarbazine (DTIC-Dome) is activated by photode- tients with islet cell carcinomas of the pancreas. The in methylation of DNA and RNA and inhibition of nu- major toxicity is renal tubular damage, which may be se- cleic acid and protein synthesis. Less severe toxicities include diarrhea, a distribution phase of 19 minutes and an elimination anemia, and mild alterations in glucose tolerance or phase of 5 hours. Urinary excretion of unchanged drug is by renal tracellular dihydrofolate reductase levels, appearance tubular secretion. Dacarbazine metabolism and decom- of altered forms of dihydrofolate reductase with de- position is complex. It is also relative importance of each of these mechanisms of re- combined with doxorubicin and other agents in the treat- sistance in various human tumors is not known. Drug resistance due to decreased Leukopenia and thrombocytopenia occur 2 weeks after transport can be overcome by greatly increasing extra- treatment, with recovery by 3 to 4 weeks. Less common cellular methotrexate concentration, which provides a is a flulike syndrome of fever, myalgias, and malaise. Since Alopecia and transient abnormalities in renal and he- bone marrow and gastrointestinal cells do not have im- patic function also have been reported. Leucovorin ANTIMETABOLITES (citrovorum factor, folinic acid, 5-formyltetrahydrofo- late) is the agent commonly used for rescue. Folate Antagonists Absorption, Metabolism, and Excretion In general, antimetabolites used in cancer chemother- Methotrexate is well absorbed orally and at usual apy are drugs that are structurally related to naturally dosages is 50% bound to plasma proteins. The plasma occurring compounds, such as vitamins, amino acids, decay that follows an intravenous injection is triphasic, and nucleotides. These drugs can compete for binding with a distribution phase, an initial elimination phase, sites on enzymes or can themselves become incorpo- and a prolonged elimination phase. The last phase is rated into DNA or RNA and thus interfere with cell thought to reflect slow release of methotrexate from tis- growth and proliferation. The major routes of drug excretion are glomerular use include the folic acid analogue methotrexate, the filtration and active renal tubular secretion. These methotrexate polyglutamates are re- Methotrexate tained in the cell and are also potent inhibitors of dihy- Methotrexate competitively inhibits the binding of folic drofolate reductase. It is also useful in adjuvant therapy of breast car- cinoma; in the palliation of metastatic breast, head, neck, Tetrahydrofolate is in turn converted to N5,N10- cervical, and lung carcinomas; and in mycosis fungoides. Its routine use as pro- Cells in S-phase are most sensitive to the cytotoxic ef- phylactic intrathecal chemotherapy in acute lym- fects of methotrexate. RNA and protein synthesis also phoblastic leukemia has greatly reduced the incidence may be inhibited to some extent and may delay pro- of recurrences in the CNS and has contributed to the gression through the cell cycle, particularly from G1to S. Daily oral doses of methotrex- ate are used for severe cases of the nonneoplastic skin Resistance disease psoriasis (see Chapter 41), and methotrexate Mammalian cells have several mechanisms of resist- has been used as an immunosuppressive agent in severe ance to methotrexate. Gastrointestinal phate (dTGTP), which has been shown to be incorpo- toxicity may appear in the form of ulcerative mucositis rated into DNA. Nausea, alopecia, and dermatitis are com- thioguanine has been correlated with decreased activity mon with high-dose methotrexate.

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