Needle Stick Injury: HIV Prophylaxis

<div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b><span lang="EN-US">Risk of seroconversion</span></b></span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">Deep injury (odds ratio [OR] 15)</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">A device visibly contaminated with the patient's blood (OR 6.2)</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">Needle placement in a vein or artery (OR 4.3)</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">Terminal illness in the source patient (OR 5.6)</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">The majority of cases were injured by a hollow bore as opposed to a solid needle</span></span></li></ul><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>Initial actions following exposure</b></span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">immediate cleansing of the exposed site.</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">Small wounds and punctures may be cleansed with an antiseptic such as an alcohol-based hand hygiene agent, since alcohol is virucidal to HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV).</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">Other antiseptics such as iodophors, chloroxylenol (PCMX) and <a href="https://www.uptodate.com/contents/chlorhexidine-gluconate-drug-information?source=see_link">chlorhexidine</a> (CHG) also inactivate HIV</span></span></li></ul><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>Testing for HIV</b> </span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">Baseline and follow-up serologic testing for HIV should be performed in all HCP exposed to HIV to see if seroconversion occurred.</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">The majority of individuals who seroconvert will do so within the first three months.</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">Testing should be performed even among those who receive PEP</span></span></li></ul><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>Post Exposure Prophylaxis </b></span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">offer post-exposure prophylaxis (PEP) using a three-drug regimen to healthcare personnel (HCP) with a percutaneous, mucous membrane, or nonintact skin exposure to body fluids of concern (eg, blood or blood tinged fluids) if the source patient is, or is suspected to be, HIV-infected</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">PEP should be discontinued if testing shows that the source patient is HIV-negative, unless there is concern that the source is acutely infected with HIV</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">If the HIV status of the source patient is unknown, offer PEP while awaiting HIV testing if the source has risk factors for HIV infection (eg, injection drug users, men who have sex with men) or symptoms suggesting HIV infection.</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">If the source patient is unknown, do not administer PEP unless the exposure occurred in a setting where exposure to HIV is likely (eg, a needlestick from a sharps container in an HIV clinic</span></span></li></ul><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>Timing</b> </span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">PEP should be initiated as soon as possible.</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">The goal is to start within one to two hours (or earlier) after exposure, often using a "starter pack" with appropriate drugs that are immediately available.</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><span> </span>It is likely that a delay in initiating PEP can reduce efficacy</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">For most HCP, we do not initiate PEP if more than 72 hours have elapsed after the initial exposure; PEP is likely to be less effective when administered after that period of time.</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><span> </span>However, we offer three-drug PEP after a longer interval to patients with a very high-risk exposure (eg, sharps injuries from a needle that was in an artery or vein of an HIV-infected source patient).</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">For such HCP, The United States Public Health Services suggests that PEP can be offered up to one week after the exposure</span></span></li></ul><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>Selection of antiretroviral therapy</b></span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>Tenofovir-emtricitabine (300/200 mg once daily) plus <a href="https://www.uptodate.com/contents/raltegravir-drug-information?source=see_link">raltegravir</a> (400 mg twice daily)</b></span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">Tenofovir-emtricitabine (300/200 mg once daily) plus <a href="https://www.uptodate.com/contents/dolutegravir-drug-information?source=see_link">dolutegravir</a> (50 mg once daily)</span></span></li></ul><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>PEP during pregnancy</b></span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> For pregnant HCP who have an occupational exposure to HIV and choose to initiate post-exposure prophylaxis (PEP), we typically use the same regimen as noted above, namely tenofovir-emtricitabine (available as Truvada) plus <a href="https://www.uptodate.com/contents/raltegravir-drug-information?source=see_link">raltegravir</a></span></span></li></ul><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>Duration of therapy</b> </span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">The recommended duration of PEP is four weeks because a course of <a href="https://www.uptodate.com/contents/zidovudine-drug-information?source=see_link">zidovudine</a> for this duration appeared protective in some studies; however, the optimal duration of PEP is unknown</span></span></li><li class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">PEP should be discontinued if testing shows that the source patient is HIV-negative </span></span></li></ul><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"><b>Reference:</b></span></span></div><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormal"><span style="font-family: "Helvetica Neue", Arial, Helvetica, sans-serif;"><span style="font-size: small;">www.uptodate.com</span></span></div>

dose Indication other Needle Stick Injury: HIV Prophylaxis

Risk of seroconversion Deep injury (odds ratio [OR] 15) A device visibly contaminated with the patient's blood (OR 6.2) Needle placemen...

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Methotrexate Treatment : Dose of Folic Acid

<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;"><b>Availability in Hospital Keningau:</b></div><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;">T. Methotrexate 2.5mg </li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;">T. Folic Acid 5mg</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;">T. Obimin (Contain 1mg FA)</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;">T. Zincofer (Contain 1mg FA)</li></ul><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;"><b>Need of Folate Supplementation</b></div><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt;"><b>Methotrexate is a first line</b> disease-modifying-anti-rheumatic-drug (DMARD) for <b>rheumatoid arthritis</b></li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt;">Administered in low doses, methotrexate <b>inhibits a number of folate dependent metabolic steps</b>, including a very potent inhibition of dihydrofolate reductase which reduces folic acid to dihydrofolic acid and to tetrahydrofolate thus causes a <b>depleted pool of reduced folates</b> and produces a state of <b>effective folate deficiency</b>.</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt;">The British Society for Rheumatology states that <b>regular folic acid supplements</b> are thought to <b>reduce toxicity of methotrexate</b></li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt;">But there has been much controversy regarding the dose of supplementation and whether it has benefit on toxicity <b>without being detrimental to methotrexate efficacy</b></li></ul><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;"><b>Dose Selection</b></div><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt;">Meta-analysis shown that concurrently supplementation of low dose folic acid (<5mg/week) in low dose methotrexate (<20mg/week) achieved a <b>79% reduction of mucosal and gastrointestinal side-effects</b> (p < 0.0001). </li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt;">There were <b>no major differences</b> between low and high doses of folic acid (p = 0.17).</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt;">Other studies have not found any significant difference in efficacy of methotrexate whether given with or without folate supplements.</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt;">The potential of folic acid interfering with the gastro-intestinal absorption of methotrexate is a matter of controversy, but this possibility may be overcome by <b>administration of folic acid 24 hours prior to the weekly methotrexate dose.</b></li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt;">The British Society for Rheumatology guidelines for disease modifying anti-rheumatic drug therapy recommends a typical <b>folic acid dose of 5mg once weekly</b>, preferably <b>the day after the methotrexate.</b></li></ul><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;"><b>Recommendation:</b></div><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l3 level1 lfo4; tab-stops: list 36.0pt;">Based on the evidence, <b>5mg of folic acid weekly</b> is sufficient enough to benefit on reducing methotrexate toxicity.</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l3 level1 lfo4; tab-stops: list 36.0pt;">Preferably not to consume on methotrexate day which may reduce the effectiveness and efficacy of methotrexate.</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l3 level1 lfo4; tab-stops: list 36.0pt;">In other hand, prescribing with 5mg folic acid weekly may reduce the cost of medication and improve the compliancy.</li></ul><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;"><b>References:</b></div><ol start="1" style="margin-top: 0cm;" type="1"><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l4 level1 lfo5; tab-stops: list 36.0pt;">Ortiz Z, Shea B, Suarez-Almazor ME, Moher D, Wells GA, Tugwell P.  Folic Acid and Folinic Acid for Reducing Side-Effects in Patients Receiving Methotrexate for Rheumatoid Arthritis (Review).  Cochrane Review 2009</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l4 level1 lfo5; tab-stops: list 36.0pt;">Ortiz Z, Shea B, Suarez-Almazor M E et al.  The Efficacy of Folic Acid and Folinic Acid in Reducing Methotrexate Gastrointestinal Toxicity in Rheumatoid Arthritis.  A Meta-analysis of Randomized Controlled Trials.  J Rheum 1998; 25 (1): 36 – 43</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l4 level1 lfo5; tab-stops: list 36.0pt;">https://www.sps.nhs.uk/articles/what-is-the-dose-of-folic-acid-to-use-with-methotrexate-therapy-for-rheumatoid-arthritis/</li><li class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l4 level1 lfo5; tab-stops: list 36.0pt;">https://academic.oup.com/rheumatology/article/43/3/267/1774685</li></ol>

dose Indication other supplement Methotrexate Treatment : Dose of Folic Acid

Availability in Hospital Keningau: T. Methotrexate 2.5mg  T. Folic Acid 5mg T. Obimin (Contain 1mg FA) T. Zincofer (Contain 1mg FA) Need of ...

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Conversion : Novomix to Mixtard

<span style="font-family: Verdana,sans-serif;"></span><br /><ul><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">A more rapid onset-of-action means that the newer analogue premixed insulins are more effective at lowering post-prandial rises in glucose. </span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Rapid-acting analogues have a shorter duration of action than human insulin, there is a much lower risk of hypoglycaemia, especially in the hours prior to the next meal. </span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">In a meta-analysis, Davidson et al (2009) found that premixed insulin containing the analogue aspart was associated with 50% reduced rates of nocturnal hypoglycaemia and 65% less major hypoglycaemia than human premixed insulin.</span></span><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgrr2tEfGwM47SHcQsk38sujO350Q1s8Oe8yjs9lod_BuOzCq3uqNvIFt4HZ7KGjlPIvyOl3ld2C6-TvdZ7hbkGDpQ6hAxBAvZ1W9ZOfFN0QzLdPD8lB5p4pKbpXVGwPiPcA8ho_SdKgJ7/s1600/mixtard+conversion2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="324" data-original-width="1076" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgrr2tEfGwM47SHcQsk38sujO350Q1s8Oe8yjs9lod_BuOzCq3uqNvIFt4HZ7KGjlPIvyOl3ld2C6-TvdZ7hbkGDpQ6hAxBAvZ1W9ZOfFN0QzLdPD8lB5p4pKbpXVGwPiPcA8ho_SdKgJ7/s640/mixtard+conversion2.png" width="640" /></a></span></span></li></ul><b><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Dose Equivalence</span></span></b><br /><ul><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Unit to unit equivalent</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">However, Novomix (analgoues) have a faster onset of reactions </span></span><b><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"> </span></span></b></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Ensure patients are counselled, especially on the importance of initial blood glucose monitoring following the switch and monitored for compliance and adverse events.</span></span><b><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"> </span></span></b></li></ul><div class="separator" style="clear: both; text-align: center;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgoVaEmo3Px3HogVctS5HugsbSMJR0qIg3hAGQCNkfpAhoz2eGO62r92ReDuZp8zjbJdo7KnRVDus4y6xQEL7JhENZofld9CtngMD-H1bKGvOml_LqnOoel4YH5herZ2O39BHyg4fOAWHmO/s1600/mixtard+conversion.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="157" data-original-width="1111" height="90" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgoVaEmo3Px3HogVctS5HugsbSMJR0qIg3hAGQCNkfpAhoz2eGO62r92ReDuZp8zjbJdo7KnRVDus4y6xQEL7JhENZofld9CtngMD-H1bKGvOml_LqnOoel4YH5herZ2O39BHyg4fOAWHmO/s640/mixtard+conversion.png" width="640" /></a></span></span></div><b><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"></span></span></b><br /><div class="separator" style="clear: both; text-align: center;"><b><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhUhB0v9_UceZqNBAOs0WzWD4TNf9uHtEwwT7NwldTieDjTwkJKOU5j39Nk8siDI-25N_lpMJNZu6w9LWp3ITTCgNWQjXvwI9GXw7ChYz0ImpNTlPkplgDkOXT2eQprGvbJZSu60elibyB/s1600/mixtard+conversion3.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="568" data-original-width="1040" height="349" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhUhB0v9_UceZqNBAOs0WzWD4TNf9uHtEwwT7NwldTieDjTwkJKOU5j39Nk8siDI-25N_lpMJNZu6w9LWp3ITTCgNWQjXvwI9GXw7ChYz0ImpNTlPkplgDkOXT2eQprGvbJZSu60elibyB/s640/mixtard+conversion3.png" width="640" /> </a></span></b></div><div class="separator" style="clear: both; text-align: center;"><br /></div><b><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"> </span></span></b><br /><b><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Premixed-Insulin as TDS Dosing</span></span></b><br /><ul><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">not recommended by manufacturer or guides</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">however a study </span></span><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">on thrice daily biphasic human insulin regimen showed it is non-inferior to the basal bolus insulin analogue regimen in terms efficacy and safety in patients with poorly controlled T2DM (dose split by 40:20:40) </span></span><b><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"> </span></span></b></li></ul><b><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">References:</span></span></b><br /><ol><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Wu T (2016) Premixed insulin analogues: A new look at an established option. Diabetes & Primary Care Australia 1: 129–33</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Clinical Resource, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes. Pharmacist’s Letter/Prescriber’s Letter. March 2017 </span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307189/</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20160214160507771435</span></span></li></ol>

dose other Conversion : Novomix to Mixtard

A more rapid onset-of-action means that the newer analogue premixed insulins are more effective at lowering post-prandial rises in glucose. ...

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Rate control in Atrial Fibrilation

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<br /><div class="MsoNormal"></div><ul><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">If LVEF<40% or any sign of CHF, smallest dose of <b style="mso-bidi-font-weight: normal;">beta-blocker</b> is recommended to achieve rate control.</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Amiodarone</b> is an option to patient with haemodynamic instability or severely reduced LVEF.</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">If LVEF>40%, <b style="mso-bidi-font-weight: normal;">beta-blocker or diltiazem or verapamil</b> are recommended because of its rapid onset of action and effectiveness at high sympathetic tone compared to digoxin.</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">In both condition, <b style="mso-bidi-font-weight: normal;">digoxin</b> may be added to achieve initial resting heart rate target which is <110bpm.</span></span></li></ul><table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: medium none;"> <tbody><tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Therapy</b></span></span></div></td> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Acute Intravenous rate control</b></span></span></div></td> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Long-term oral rate control</b></span></span></div></td> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 191.55pt;" valign="top" width="255"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Comments</b></span></span></div></td> </tr><tr style="mso-yfti-irow: 1;"> <td colspan="4" style="border: 1pt solid; padding: 0in 5.4pt; width: 6.65in;" valign="top" width="638"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Beta-Blocker</b></span></span></div></td> </tr><tr style="mso-yfti-irow: 2;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Bisoprolol</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Not available</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">1.25–20 mg once daily or split.</span></span></div></td> <td rowspan="5" style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 191.55pt;" valign="top" width="255"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Bronchospasm is rare – in cases of asthma, recommend beta-1 selective agents (avoid carvedilol).</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Contra-indicated in acute cardiac failure and a history of severe bronchospasm.</span></span></div></td> </tr><tr style="mso-yfti-irow: 3;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Carvedilol</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Not available</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">3.125–50 mg BD.</span></span></div></td> </tr><tr style="mso-yfti-irow: 4;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Metoprolol</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">2.5–10 mg intravenous bolus</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">(repeated as required)</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">100–200 mg total daily dose</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">(according to preparation)</span></span></div></td> </tr><tr style="mso-yfti-irow: 5;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Nebivolol</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Not available</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">2.5–10 mg once daily or split.</span></span></div></td> </tr><tr style="mso-yfti-irow: 6;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Esmolol</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">0.5 mg/kg intravenous bolus over</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">1 min; then 0.05–0.25 mg/kg/min.</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div></td> </tr><tr style="mso-yfti-irow: 7;"> <td colspan="4" style="border: 1pt solid; padding: 0in 5.4pt; width: 6.65in;" valign="top" width="638"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Calcium Channel Blockers</b></span></span></div></td> </tr><tr style="mso-yfti-irow: 8;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Diltiazem</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">15–25 mg intravenous bolus</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">(repeated as required)</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">60mg TDS up to 360mg total daily dose</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">(120-360mg OD modified release)</span></span></div></td> <td rowspan="2" style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 191.55pt;" valign="top" width="255"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Use with caution in combination with beta-blockers. Reduce dose with hepatic impairment and start with smaller dose in renal impairment. Contra-indicated in LV failure with pulmonary congestion or LVEF <40%.</span></span></div></td> </tr><tr style="mso-yfti-irow: 9;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Verapamil</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">2.5–10 mg intravenous bolus</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">(repeated as required)</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">40-120mg TDS</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">(120-480mg OD modified release)</span></span></div></td> </tr><tr style="mso-yfti-irow: 10;"> <td colspan="4" style="border: 1pt solid; padding: 0in 5.4pt; width: 6.65in;" valign="top" width="638"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Cardiac glycosides</b></span></span></div></td> </tr><tr style="mso-yfti-irow: 11;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Digoxin</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">0.5 mg intravenous bolus</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">(0.75–1.5 mg over 24 hours in</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">divided doses)</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">0.0625–0.25 mg daily dose</span></span></div></td> <td rowspan="2" style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 191.55pt;" valign="top" width="255"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">High plasma levels associated with increased risk of death. Check renal function before starting and adapt dose in patients with CKD. Contra-indicated in patients with accessory pathways, ventricular tachycardia and hypertrophic cardiomyopathy with outflow tract obstruction.</span></span></div></td> </tr><tr style="mso-yfti-irow: 12;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Digitoxin</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">0.4–0.6 mg intravenous bolus.</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">0.05–0.3 mg daily dose.</span></span></div></td> </tr><tr style="mso-yfti-irow: 13;"> <td colspan="4" style="border: 1pt solid; padding: 0in 5.4pt; width: 6.65in;" valign="top" width="638"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b style="mso-bidi-font-weight: normal;">Specific Indications</b></span></span></div></td> </tr><tr style="mso-yfti-irow: 14; mso-yfti-lastrow: yes;"> <td style="border: 1pt solid; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small; mso-spacerun: yes;">    </span><span style="font-size: small;">Amiodarone</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">300mg intravenously diluted in 250mL 5% dextrose over 30-60 minutes via central venous cannula.</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">*If ongoing requirement, 900mg diluted in 500-1000mL for over 24 hours.</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 95.75pt;" valign="top" width="128"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">200mg daily</span></span></div></td> <td style="border-color: -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 191.55pt;" valign="top" width="255"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Suggested as adjunctive therapy in patients where heart rate control cannot be achieved using combination therapy.</span></span></div></td> </tr></tbody></table><div class="MsoNormal" style="tab-stops: 328.1pt;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b>References:</b></span></span></div><ol><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">2016 ESC Guidelines for the management of atrial fibrillation</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">https://www.nice.org.uk/guidance/cg180/resources/atrial-fibrillation-management-pdf-35109805981381 </span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Pharmacologic Management of Newly Detected Atrial Fibrillation by AAFP, 2017</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Lexicomp</span></span></li></ol>

dose general other Rate control in Atrial Fibrilation

If LVEF<40% or any sign of CHF, smallest dose of beta-blocker is recommended to achieve rate control. Amiodarone is an option to patie...

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Dosing in Obesity : Tab Augmentin 625mg

<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;"><ul><li>very little information regarding dosing of penicillin antibiotics in obese patients. </li><li>oral penicillin absorption is also largely unaffected by obesity. </li><li>UKCPA guidance suggest dosing for penicillins in critically ill obese patients should be at the upper end of the recommended treatment ranges, taking into account the patient’s renal function, particularly in morbidly obese patients with more severe infections. <o:p></o:p></li></ul></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;"><b>Dosing:</b></div><br /><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-autospace: none;"><b>Adults</b> <b>and Children 40kg and over</b>:<br /><ul><li>1 AUGMENTIN 500 Tablet twice daily - mild to moderate infections. </li><li>1-2 AUGMENTIN 500 Tablet three times daily - lower respiratory tract infections, complicated urinary tract infections or severe infections at other sites, <b><i><o:p></o:p></i></b></li></ul></div><span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt;"><br /></span><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWo5VkSj8ufVOaNCPBZ4rcctFlbAAaH9tmoCf1NjL9UWyNEcbrIEC1xAFZMhzdXA5Il1f7Sa9NeB9jtffVifj2k0Pz6ew4XXx6LzQWj66vHLuwGxCtM0U3KItH1fKD-ZEGOBATZETMfMY/s1600/abx+2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="490" data-original-width="878" height="355" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWo5VkSj8ufVOaNCPBZ4rcctFlbAAaH9tmoCf1NjL9UWyNEcbrIEC1xAFZMhzdXA5Il1f7Sa9NeB9jtffVifj2k0Pz6ew4XXx6LzQWj66vHLuwGxCtM0U3KItH1fKD-ZEGOBATZETMfMY/s640/abx+2.jpg" width="640" /></a></div><div style="text-align: center;"> <b style="text-align: center;"><i>Table 1: </i></b><b style="text-align: center;"><i>Effects of obesity on the pharmacokinetics and pharmacodynamics of hydrophilic and lipophilic antibiotics</i></b></div><div style="text-align: center;"><b style="text-align: center;"><i><br /></i></b></div><div align="center" class="MsoNormal" style="text-align: center;"><b><i><o:p></o:p></i></b></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKKHU47s7e9V7kyERzDGMCsABeQx4jptRIi3XP9gXg1IarBhMjh9Y4P4nyx_gMfl_sMzGIMk6StIU6y5edIZK33Qdhhh0xyPPxAtaE8sxKdTTya8_ZE3pIMW_sTWuDsvV1NdgO0P2RFV8/s1600/abx.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="176" data-original-width="1174" height="92" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKKHU47s7e9V7kyERzDGMCsABeQx4jptRIi3XP9gXg1IarBhMjh9Y4P4nyx_gMfl_sMzGIMk6StIU6y5edIZK33Qdhhh0xyPPxAtaE8sxKdTTya8_ZE3pIMW_sTWuDsvV1NdgO0P2RFV8/s640/abx.jpg" width="640" /></a></div><div style="text-align: center;"> <b style="text-align: center;"><i>Table 2: Recommendation for dosing of antibiotics in obese patients</i></b></div><div style="text-align: center;"><b style="text-align: center;"><i><span style="font-family: "advp4aa440"; font-size: 9.0pt;"><br /></span></i></b></div><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: center; text-autospace: none;"><b><i><span style="font-family: "advp4aa440"; font-size: 9.0pt;"><o:p></o:p></span></i></b></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMgZIDPYEpducu-pbXnk9Kz0_lddF5zSGV4nZH8uxK5FtUgx7pdxjHdovtE7HvFaBRbewlulSbKZP2EiLZ0uwSKz_y0pIDt0UmFD8Y59quNUaiIe4c_hb2G38KAOIJmrpAmukJn7ahr5U/s1600/abx+3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="451" data-original-width="660" height="436" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMgZIDPYEpducu-pbXnk9Kz0_lddF5zSGV4nZH8uxK5FtUgx7pdxjHdovtE7HvFaBRbewlulSbKZP2EiLZ0uwSKz_y0pIDt0UmFD8Y59quNUaiIe4c_hb2G38KAOIJmrpAmukJn7ahr5U/s640/abx+3.jpg" width="640" /></a></div><br /><span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt;"><br /></span><br /><div class="MsoNormal"><b>*Availability at HKGU Tab. Augmentin 625mg <o:p></o:p></b></div><div class="MsoNormal"><b><br /></b></div><div class="MsoNormal"><b>REFERENCES <o:p></o:p></b></div><ol><li><b><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940399/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940399/</a><o:p></o:p></b></li><li><b><a href="https://link.springer.com/chapter/10.1007/978-3-319-44034-7_2">https://link.springer.com/chapter/10.1007/978-3-319-44034-7_2</a><o:p></o:p></b></li><li><b><a href="https://www.ncbi.nlm.nih.gov/pubmed/23041773">https://www.ncbi.nlm.nih.gov/pubmed/23041773</a></b></li><li><b><a href="http://www.medsafe.govt.nz/profs/Datasheet/a/Augmentintabsusp.pdf">http://www.medsafe.govt.nz/profs/Datasheet/a/Augmentintabsusp.pdf</a></b></li></ol>

dose Dosing in Obesity : Tab Augmentin 625mg

very little information regarding dosing of penicillin antibiotics in obese patients.  oral penicillin absorption is also largely unaffected...

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Cloxacillin : Serum Level

<div class="MsoNormalCxSpFirst" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><b>Recommended Plasma Concentration</b></span></span></div><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><span>According to the European Committee on Antimicrobial Susceptibility Testing (EUCAST), the MIC threshold to determine the strain sensitivity is 2 mg/L for cloxacillin. </span></span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><span>Until now, the optimal plasma concentration target in order to achieve the best cure rate remains undefined, but as oxa- and cloxacillin are time-dependent antibiotics, a time of 100% above the minimum inhibitory concentration (MIC) was considered to be optimal for efficacy. </span></span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><span>Considering that oxa- and cloxacillin are highly bound to albumin and that their unbound fraction—the available fraction for antibiotic efficacy—in healthy patients is known to be 10%,</span></span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><span>Previous study indicated that a dosing regimen of 1 g dicloxacillin every 6 hours should be effective for <i>S</i>. <i>aureus</i> infections with a mean MIC value of 0.125 µg·mL⁻¹ (achieving 67%T > MIC) (higher bioavailability compared to cloxacillin, 48.8% versus 36.9%)</span></span></span></li></ul><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><b>Population: </b><b><span lang="EN">severe infections treated in ICU</span></b></span></span></div><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Defined a target range of total antibiotic concentration of 20–50 mg/L to reach the 100% <i>T</i> > MIC</span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">At a Median Daily Dosing of 105.5mg/kg [75; 150] produced a median plasma concentration of 134.3mg/L<span>  </span>[65.3; 201].</span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Using a percentage of 10% to estimate the unbound fraction of oxa- or cloxacillin, all patients would have had a trough unbound fraction concentration superior or equal to the maximum MIC for oxa- or cloxacillin sensitivity, i.e. 2 mg/L</span></span></li></ul><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><ol start="1" style="margin-top: 0cm;" type="1"><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><i><a href="https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-017-0255-8">https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-017-0255-8</a></i></span></span></li></ol><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><b>Oral Cloxacillin</b></span></span></div><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">At a dose of 2g, average calculated dose based on serum concentration was 649mg (32.9%).</span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Oral dose of 500mg cloxacillin produced a peak serum level of 8mcg/ml in adults</span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">After an oral dose of 500 mg, a peak plasma concentration of 7 to 14 μg per mL is attained in fasting subjects in 1 to 2 hours.</span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">After an oral dose of 500mg cloxacillin, a peak serum level of about 8 micrograms/mL is reached in about 1 hour.</span></span></li></ul><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><ol start="1" style="margin-top: 0cm;" type="1"><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><i>PHARMACOKINETICS OF FLUCLOXACILLIN AND CLOXACILLIN IN HEALTHY SUBJECTS AND PATIENTS ON CHRONIC INTERMITTENT HAEMODIALYSIS. Br. J. clin. Pharmac. (1975), 2, 111-121</i></span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><i>Infectious Diseases of the Female Genital Tract<b>. </b>By Richard L. Sweet, Ronald S. Gibbs</i></span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><i>Cloxigen Product Information Leaflet</i></span></span></li></ol><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><b>Intramuscular</b></span></span></div><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">serum level after i.m. cloxacillin is approximately twice that obtained when the same dose is given orally to fasting adults</span></span></li></ul><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><b>Concentration in Synovial tissue</b></span></span></div><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">After a 30 min i.v. infusion of 1 g cloxacillin, the concentrations of this antibiotic were measured in plasma and synovial tissue samples from 11 patients undergoing total hip replacement.</span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The concentration of free drug in synovial tissue was estimated to be 77% of the total tissue concentration.</span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The maximum tissue drug concentration after an i.v. bolus dose is predicted to occur at about 37 min.</span></span></li><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">it can be predicted that after an i.v. bolus injection of 1 g cloxacillin the maximum synovial tissue concentration will be reached at 37 min after administration. At this time the estimated free drug concentrations in plasma and tissue should be 0.9 mg/l.</span></span></li></ul><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span><ol start="1" style="margin-top: 0cm;" type="1"><li class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 0.0001pt;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><i>Diffusion of cloxacillin into synovial tissue. Br. J. clin. Pharmac. (1992), 34, 275-277</i></span></span></li></ol>

dose Indication Others Cloxacillin : Serum Level

Recommended Plasma Concentration According to the European Committee on Antimicrobial Susceptibility Testing (EUCAST), the MIC threshold to...

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Comparison: Antiemetics

<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b>Selection Rationale</b></span></span><br /><ul><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">choice of antiemetic should be guided by the cause</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">multiple causes may necessitate antiemetic polypharmacy </span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"> If a patient is already taking oral antiemetics and still nauseated, they may benefit from a change in route of administration for a few days</span></span></li></ul><div class="separator" style="clear: both; text-align: center;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjbs2ai94CXpGZF_iZb4P4K1AA64QG91Gfgm_e904GDJjZtGPulIXNMff6z6cPka6WRxWWa-mOh3N_ZAgrf6G5-cBiU8XN_sIyu2RPTFR0j9au4dBJeLQFylD0n5Ekr8feFMyT8FuDCC-q/s1600/antiemetic3.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="500" data-original-width="380" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjbs2ai94CXpGZF_iZb4P4K1AA64QG91Gfgm_e904GDJjZtGPulIXNMff6z6cPka6WRxWWa-mOh3N_ZAgrf6G5-cBiU8XN_sIyu2RPTFR0j9au4dBJeLQFylD0n5Ekr8feFMyT8FuDCC-q/s640/antiemetic3.jpeg" width="486" /></a></span></span></div><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b>Comparison </b></span></span><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_pcluZpwhab8SggSxgkocWHFdh3gQ8SuraL6opBOGxxPSIeIhfHIU2Lu10jj0gZMqQlJg_i7FpH27dqQi1A5oi9ay4arvEPtTpYNp5WKzvL665q5rftDPxZFieeaVDNTUg0vECrlJWKkY/s1600/antiemetic1.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="873" data-original-width="1600" height="348" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_pcluZpwhab8SggSxgkocWHFdh3gQ8SuraL6opBOGxxPSIeIhfHIU2Lu10jj0gZMqQlJg_i7FpH27dqQi1A5oi9ay4arvEPtTpYNp5WKzvL665q5rftDPxZFieeaVDNTUg0vECrlJWKkY/s640/antiemetic1.jpeg" width="640" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2HPSOAoc60YywTBLTfmGo-dSAjA1cRUC8kfvgCVS933jdVS332mmJjx16IjNAKQNeCWHvPPNTpDHqrBdutgG38iYKGC1TJR9KP6_VofuOiLKUsAxz1L3cgmcenh5GyEXbwqzBv33SXSYY/s1600/antiemetic2.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="849" data-original-width="1432" height="378" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2HPSOAoc60YywTBLTfmGo-dSAjA1cRUC8kfvgCVS933jdVS332mmJjx16IjNAKQNeCWHvPPNTpDHqrBdutgG38iYKGC1TJR9KP6_VofuOiLKUsAxz1L3cgmcenh5GyEXbwqzBv33SXSYY/s640/antiemetic2.jpeg" width="640" /></a></div><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><b> References:</b></span></span><br /><ol><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">http://www.aafp.org/afp/2004/0301/p1169.html</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">https://basicmedicalkey.com/nausea-and-vomiting-4/</span></span></li><li><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">https://www.pharmacytoday.co.nz/events/palliative-care-resource/choosing-the-right-antiemetic-agent.aspx</span></span></li></ol>

dose Indication Comparison: Antiemetics

Selection Rationale choice of antiemetic should be guided by the cause multiple causes may necessitate antiemetic polypharmacy  If a patien...

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Lugol’s Solution : Colposcopy

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mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin-top:0cm; mso-para-margin-right:0cm; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0cm; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-fareast-language:EN-US;} </style><![endif]--> <br /><div class="MsoNormal"><b>Rationale</b></div><br /><ul><li>Lugol’s solution can be used to determine the need for biopsy of areas that are minimally abnormal</li><li>It binds to cells with high amounts of glycogen (normal squamous epithelium)</li><li>Lugol’s Positive (epithelium turns dark brown after application) – epithelium is mature squamous and does not need to be bipsied (unless suspicion is high)</li></ul><br /><div class="MsoNormal"><b>Procedure</b></div><br /><ul><li>application to the cervix using cotton-tipped bud </li><li>no specific volume indicated/minimal amount based on site</li><li>be done in a manner without abrading the surface epithelium, as HSIL lesions can detach from the underlying stroma relatively easily and peel away</li><li>Lesion margins, color, and vascular patterns are then assessed and graded, with biopsies taken from the areas that are judges as the most severe</li></ul><br /><div class="MsoNormal"><b>References:</b></div><br /><ol><li>2002-04 ASCCP Section on the Cervix</li><li><span style="mso-bidi-font-weight: bold;">STANDARDIZEDPROCEDURE COLPOSCOPY (Adult, Peds).<span style="mso-spacerun: yes;">  </span><i>UC San Diego Health</i></span> </li><li>http://screening.iarc.fr/colpochap.php?chap=5</li><li>https://www.glowm.com/section_view/heading/Colposcopy/item/19</li></ol>

dose Indication Lugol’s Solution : Colposcopy

Rationale Lugol’s solution can be used to determine the need for biopsy of areas that are minimally abnormal It binds to cells with hig...

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