Warfarin: PreOperative Procedure

<div class="MsoNormal"><b><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">Discontinuation </span></span></b></div><span style="font-family: Verdana, sans-serif;"> </span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">typically discontinue warfarin five days before elective surgery<span style="mso-spacerun: yes;">  </span>and, when possible, check the PT/INR on the day before surgery</span></span></li><li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">If the INR is >1.5, administer low dose oral <a href="https://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_link">vitamin K</a> (eg, 1 to 2 mg) to hasten normalization of the PT/INR and recheck the following day.</span></span></li><li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">proceed with surgery when the INR is ≤1.4. An INR in the normal range is especially important in patients undergoing surgery associated with a high bleeding risk (eg, intracranial, spinal, urologic) or if neuraxial anesthesia is to be used</span></span></li><li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">This timing of <a href="https://www.uptodate.com/contents/warfarin-drug-information?source=see_link">warfarin</a> discontinuation is based on the biological half-life of warfarin (36 to 42 hours) and the observed time for the PT/INR to return to normal after stopping warfarin (eg, two to three days for the INR to fall to below 2.0; four to six days to normalize)</span></span></li><li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">Normalization of the INR may take longer in patients receiving higher-intensity anticoagulation (INR 2.5 to 3.5), and in elderly individuals</span></span></li><li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">For a procedure that requires more rapid normalization of the INR, additional interventions may be needed to actively reverse the anticoagulant.</span></span></li><li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">This discontinuation schedule will produce a period of several days with subtherapeutic anticoagulation. As an example, it is estimated that if <a href="https://www.uptodate.com/contents/warfarin-drug-information?source=see_link">warfarin</a> is withheld for five days before surgery and is restarted as soon as possible afterwards, patients would have a subtherapeutic INR for approximately eight days (four days before and four days after surgery)</span></span></li><li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">Thus, for patients at very high or high thromboembolic risk, bridging may be appropriate.</span></span></li></ul><span style="font-family: Verdana, sans-serif;"> </span><div class="MsoNormal"><b><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">Use of bridging preoperatively </span></span></b></div><span style="font-family: Verdana, sans-serif;"> </span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">generally reserve bridging for individuals considered at very high or high risk of thromboembolism (eg, recent stroke, mechanical heart valve, CHA₂DS₂-VASc score of 7 or 8, CHADS₂ score of 5 or 6) if they require interruption of warfarin</span></span></li><li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">In these cases, the bridging agent (eg, therapeutic dose subcutaneous low molecular weight [LMW] heparin) is started three days before surgery</span></span></li><li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">A bridging agent may also be appropriate if there is a prolonged period during which the patient cannot take oral medications (eg, postoperative ileus).</span></span></li></ul><span style="font-family: Verdana, sans-serif;"> </span><div class="MsoNormal"><b><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">Restarting warfarin and postoperative bridging </span></span></b></div><span style="font-family: Verdana, sans-serif;"> </span><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l0 level1 lfo3; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">resume warfarin 12 to 24 hours after surgery, typically the evening of the day of surgery or the evening of the day after surgery, assuming there were no unexpected surgical issues that would increase bleeding risk and the patient is taking adequate oral fluids</span></span></li><li class="MsoNormal" style="mso-list: l0 level1 lfo3; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">use the same dose the patient was receiving preoperatively</span></span></li><li class="MsoNormal" style="mso-list: l0 level1 lfo3; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">After <a href="https://www.uptodate.com/contents/warfarin-drug-information?source=see_link">warfarin</a> is restarted in the perioperative setting, it takes 5 to 10 days to attain a full anticoagulant effect as measured by an INR above 2.0.</span></span></li><li class="MsoNormal" style="mso-list: l0 level1 lfo3; tab-stops: list 36.0pt;"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">Thus, treat individuals at very high risk and some individuals with a high risk of thromboembolism with a heparin bridging agent during this period.</span></span></li></ul><span style="font-family: Verdana, sans-serif;"> </span><div class="MsoNormal"><b><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">Reference:</span></span></b></div><span style="font-family: Verdana, sans-serif;"> </span><div class="MsoNormal"><span style="font-family: Verdana, sans-serif;"><span style="mso-bidi-font-weight: bold;">www.uptodate.com </span></span></div>

other Warfarin: PreOperative Procedure

Discontinuation typically discontinue warfarin five days before elective surgery   and, when possible, check the PT/INR on the day before s...

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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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Types of Hemodialysis

<div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXVCNImtIkhI7pkHEumZ1kwYjg0X1x0jkzwDRzhCNA4Zsd_QCoXtFi3gygUnlUb-mfezZ7D18zweg8nREbTlHhmQPKhu1W5RhAKEhEV-Q2Z3oVp8NZnGifefCYmc7OtpUI8OxSyOX3p6b8/s1600/dialysis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="693" data-original-width="1281" height="345" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXVCNImtIkhI7pkHEumZ1kwYjg0X1x0jkzwDRzhCNA4Zsd_QCoXtFi3gygUnlUb-mfezZ7D18zweg8nREbTlHhmQPKhu1W5RhAKEhEV-Q2Z3oVp8NZnGifefCYmc7OtpUI8OxSyOX3p6b8/s640/dialysis.jpg" width="640" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgw-lTrsek47P8CurRX95xXfp04OiS5Miqn5IdFpMb3YVB8nxyXz-wZ37aZXCxgVtrsH-n560y9aeYja5-Kcvjh6SUKOaQczsYHYgCgwxSALLF5sCrFSKtbDVFJZAKhaG2ADFAWO6Q6bbTl/s1600/hemodialysis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="349" data-original-width="748" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgw-lTrsek47P8CurRX95xXfp04OiS5Miqn5IdFpMb3YVB8nxyXz-wZ37aZXCxgVtrsH-n560y9aeYja5-Kcvjh6SUKOaQczsYHYgCgwxSALLF5sCrFSKtbDVFJZAKhaG2ADFAWO6Q6bbTl/s640/hemodialysis.jpg" width="640" /></a></div><div class="separator" style="clear: both; text-align: center;"><b>PERITONEAL DIALYSIS </b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyF85dnLcdFn_AJrewJ3hnmosvrz2GRwqnCraILydyNayHAndP5A2c9hroVtt2EfinvPDXuNWtZTOb5cvjcinW5oZ08w9IGGWDn2N_MkeXor0psNW0o4bkmQ07HJibBnu94XfUbXVNoRlJ/s1600/CAPD.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="273" data-original-width="1107" height="155" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyF85dnLcdFn_AJrewJ3hnmosvrz2GRwqnCraILydyNayHAndP5A2c9hroVtt2EfinvPDXuNWtZTOb5cvjcinW5oZ08w9IGGWDn2N_MkeXor0psNW0o4bkmQ07HJibBnu94XfUbXVNoRlJ/s640/CAPD.jpg" width="640" /></a></div><br /><div style="text-align: center;"> <strong>Continuous ambulatory peritoneal dialysis (CAPD)</strong></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgP3A8nReDH7KaECH8malcmmsSczr1qbTX2_W92b_j5g1o4OUe_MszAR_-PeWAepcctrpq55rsrKU5v4HkowZjFSLILkBxVInm3l8L0kvKoQQ1ntaQDyxuA98hmosXb66bnP8nyKg5YG7iE/s1600/capd2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="616" data-original-width="1600" height="244" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgP3A8nReDH7KaECH8malcmmsSczr1qbTX2_W92b_j5g1o4OUe_MszAR_-PeWAepcctrpq55rsrKU5v4HkowZjFSLILkBxVInm3l8L0kvKoQQ1ntaQDyxuA98hmosXb66bnP8nyKg5YG7iE/s640/capd2.png" width="640" /></a></div><ul><li>Manual PD is termed continuous ambulatory peritoneal dialysis (CAPD)</li><li>standard CAPD regimen consisting of 4-5, 2-L exchanges/day (Figure 1). The procedure involves the infusion of the solution (approximately 10 min), a dwell period (3-6 hours) and drainage of the dialysate (10 - 20 min)</li><li><span style="text-align: justify;">Due to variation in patient size and body composition, they might not be able to achieve enough solute clearance per day with the standard CAPD prescription. They may thus require more, frequent exchanges or larger infusion volumes</span></li><li><span style="text-align: justify;"><span style="text-align: justify;">The simplicity of CAPD, its low cost, and the associated freedom from machines made CAPD a very popular form of chronic PD. In addition, CAPD can maintain a steady physiological state, control fluid volume and blood pressure in most patients</span> </span></li></ul><div style="text-align: center;"><span style="text-align: justify;"><strong>Intermittent peritoneal dialysis (IPD)</strong> </span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEP69PGWEw0GrL0qldd_lIZF358xp3KTVx0QmR4FteoDdXF4c1TilhDfILYgBWXP9I0YDcnDwCcdtJ7OjcGTJgFTiXXWYIEAdIteRgg98q29gXM_MLv-EhLYt-DMLCD_A64DMlOJFNVnit/s1600/capd1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="616" data-original-width="1600" height="123" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEP69PGWEw0GrL0qldd_lIZF358xp3KTVx0QmR4FteoDdXF4c1TilhDfILYgBWXP9I0YDcnDwCcdtJ7OjcGTJgFTiXXWYIEAdIteRgg98q29gXM_MLv-EhLYt-DMLCD_A64DMlOJFNVnit/s320/capd1.png" width="320" /></a></div><ul><li>IPD is an automated peritoneal dialysis</li><li>generally consists of frequent, short cycles performed over 8 - 10 hours per session, three times weekly<strong> </strong></li><li>If IPD is practiced on a nightly basis only, it is referred to as nocturnal IPD (NIPD)</li><li>NIPD is mostly reserved for patients with high solute transport and limited ultrafiltration, since the short cycles of NIPD can achieve better ultrafiltration than the longer cycles of CAPD or CCPD. The total volume of dialysis fluid exchanged per treatment ranges between 8 L and 12 L</li></ul><b>References:</b><br /><ol><li>http://advancedrenaleducation.com/content/modalities-therapy-1</li><li>www.uptodate.com</li></ol><br /><br /><br /><br /><br /><br /><br />

other Types of Hemodialysis

PERITONEAL DIALYSIS   Continuous ambulatory peritoneal dialysis (CAPD) Manual PD is termed continuous ambulatory peritoneal dialysis (CAPD) ...

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Diabetes in Thalassaemia

<!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-MY</w:LidThemeOther> <w:LidThemeAsian>ZH-CN</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:DontVertAlignCellWithSp/> <w:DontBreakConstrainedForcedTables/> <w:DontVertAlignInTxbx/> <w:Word11KerningPairs/> <w:CachedColBalance/> <w:UseFELayout/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument></xml><![endif]--> <br /> <ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">It is believed to be due to damage of pancreatic b cells caused by iron overload. There is reduced insulin secretion in normoglycaemic <span lang="ZH-CN" style="font-family: SimSun; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: SimSun; mso-fareast-theme-font: minor-fareast; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">β</span><span lang="ZH-CN" style="mso-ansi-language: EN-US;"> </span>thalassaemia major patients.</span></span></li></ul><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">The appearance of DM in thalassaemia patients may be due to a combination of insulin resistance and insulin deficiency caused by either exhaustion of <span lang="ZH-CN" style="font-family: SimSun; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: SimSun; mso-fareast-theme-font: minor-fareast; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">β</span><span lang="ZH-CN"> </span>cells, iron deposition in islet cells or a combination of these factors.</span></span></li></ul><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">Overt DM in thalassaemia major patients is preceded by a long period of insulin resistance and hyperinsulinaemia.</span></span></li></ul><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">Understanding the underlying cause of diabetes in an individual is essential for logical treatment decisions</span></span></li></ul><div class="MsoNormal"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;"><b>Treatment</b></span></span></div><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">The early and adequate use of iron chelation can prevent DM and major endocrinopathies.</span></span></li></ul><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">In thalassaemias with IGT, the condition may improve with a strict diabetic diet, weight reduction where applicable and intensive iron chelation</span></span></li></ul><div class="MsoNormal"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;"><b>Insulin</b></span></span></div><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l2 level1 lfo3; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">In thalassaemia patients with DM, insulin treatment is normally required but metabolic control may be difficult to achieve.</span></span></li></ul><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l2 level1 lfo3; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">Insulin requirement (0.15 - 1.72 U/kg) varies due to a wide variation in pancreatic b cell function as determined by C-peptide level</span></span></li></ul><div class="MsoNormal"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;"><b>Oral Hypogycaemic agents</b></span></span></div><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">The role of oral hypoglycaemic agents remains to be fully determined</span></span></li></ul><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">Where hyperinsulinism is insufficiently managed by diet alone, acarbose may be a useful first-line therapy for glycaemic control</span></span></li></ul><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">There are reports on the successful use of sulphonylureas and acarbose. Sulphonylureas (e.g. glibenclamide, gliclazide, glimepiride) lower blood glucose by increasing insulin release from pancreatic <span lang="EN-US" style="mso-ansi-language: EN-US;">ß-cells.</span></span></span></li></ul><ul style="margin-top: 0cm;" type="disc"><li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;"><span lang="EN-US" style="mso-ansi-language: EN-US;">For type 2 diabetes, metformin is the first choice treatment but there is little research on its use in thalassaemia. </span></span></span></li></ul><div class="MsoNormal"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">References</span></b></span></span></div><ol start="1" style="margin-top: 0cm;" type="1"><li class="MsoNormal" style="mso-list: l3 level1 lfo5; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;"><a href="http://www.latunisiemedicale.com/article-medicale-tunisie.php?article=1277">http://www.latunisiemedicale.com/article-medicale-tunisie.php?article=1277</a></span></span></li><li class="MsoNormal" style="mso-list: l3 level1 lfo5; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">CPD Management of Transfusion Dependent Thalassaemia</span></span></li><li class="MsoNormal" style="mso-list: l3 level1 lfo5; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;">Guidelines for the Clinical Management of Thalassaemia, 2^nd edition.</span></span></li><li class="MsoNormal" style="mso-list: l3 level1 lfo5; tab-stops: list 36.0pt;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-family: "Trebuchet MS", sans-serif;"><span style="mso-bidi-font-weight: bold;">Endocrinological Problems in Adult Thalassemia Patients. Available on-line at web site <a href="http://medicaljournal.gazi.edu.tr/">http://medicaljournal.gazi.edu.tr/</a></span></span></span> </li></ol><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true" DefSemiHidden="true" DefQFormat="false" DefPriority="99" LatentStyleCount="267"> <w:LsdException Locked="false" Priority="0" SemiHidden="false" UnhideWhenUsed="false" QFormat="true" Name="Normal"/> <w:LsdException Locked="false" Priority="9" SemiHidden="false" UnhideWhenUsed="false" QFormat="true" Name="heading 1"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 4"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/> <w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/> <w:LsdException Locked="false" Priority="9" QFormat="true" 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Indication other Diabetes in Thalassaemia

It is believed to be due to damage of pancreatic b cells caused by iron overload. There is reduced insulin secretion in normogl...

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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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