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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

In addition to allergy shots once a week cheap desloratadine 5mg with amex the risks from Hepatitis B some parents may be aware of risks of Hepatitis C allergy symptoms for spring buy desloratadine 5mg line. Although the incidence of Hepatitis C in drug abusers in this city is high (>50%) allergy testing wheal desloratadine 5mg visa, the rate of seroconversion after inoculation from a known source is low ~1% 3% allergy symptoms latex condoms cheap desloratadine 5 mg with amex. Occupational Health offer excellent support and risk assessment individuals as required and are able to offer prophylaxis (for which there is a tight window of opportunity for maximum protection) and index case testing with appropriate counselling where indicated. Beware facial fractures have an associated risk of significant head injury / skull fracture and cervical spine injury due to the nature of the mechanism of injury. Put patient in recovery position (no C spine concerns) using an oral airway if necessary or head down trolley position, if needed, with C spine control. A tongue stitch may be used to help pull the tongue forward if obstructing the airway. Orotracheal intubation may be necessary with impacted fractures or severe haemorrhage. Nasotracheal intubation is contraindicated in suspected base of skull fractures and this would be a significant concern with severe facial injury – if required due to obstruction to orotracheal intubation it should be performed by experienced anaesthetist only. In any circumstances intubation will be a procedure for an experienced anaesthetist as this represents a seriously compromised airway. Simple fractures such as isolated fractures of the zygoma do not need admission but discuss first with the maxillo-facial team to arrange appropriate follow up. If examination does not suggest a significant fracture, it is reasonable to discharge the patient. The pattern of injury is often dictated by the age of the child as deciduous teeth tend to be ‘looser’ and more easily displaced. The usual presentation is often a fall onto the face resulting in intruded or avulsed teeth (younger children), or a direct blow to the face. The treatment of injuries to deciduous teeth is different to that of the permanent teeth, so take into account the age of the child and the history. Emergency management of the dental injury requires the services of the maxillo-facial department. Dentists usually annotate teeth within grids, so that the patient’s upper right teeth are represented as, upper left as, lower right as, and lower left as. Deciduous teeth (n=20) incisal edge central incisor (A) -erupts 6 months lateral incisor (B) -erupts 8 months canine (C) -erupts 18 months maxillary buccal surface (upper) first molar (D) -erupts 12 months second molar (E) -erupts 24-30 months palatal surface lingual surface second molar (E) buccal surface mandibular first molar (D) (lower) canine (C) lateral incisor (B) central incisor (A) Permanent teeth (n=28-32) central incisor (1) -erupts 7-8 yrs lateral incisor (2) -erupts 8-9 yrs canine (3) -erupts 11-12 yrs first premolar (4) -erupts 10-11 yrs second premolar (5) -erupts 10-12 yrs upper first molar (6) -erupts 6-7 yrs second molar (7) -erupts 12-13 yrs third molar (8) -erupts 17-21 yrs third molar (8) -erupts 17-21 yrs second molar (7) -erupts 11-13 yrs lower first molar (6) -erupts 6-7 yrs second premolar (5) -erupts 11-12 yrs first premolar (4) -erupts 10-12 yrs canine (3) -erupts 9-10 yrs lateral incisor (2) -erupts 7-8 yrs central incisor (1) -erupts 6-7 yrs D. Between 09:00 and 17:00 hrs contact the paediatric dentistry clinic at the Charles Clifford Dental Hospital for advice and referral of patients if necessary (ext 17882 / 3). Get the child to bite on a piece of rolled up gauze until maxfax arrives and the tooth can then be splinted (If it has not been left dry for much over an hour). The risk to the younger child of aspirating a tooth that falls out again far outweighs the risk of any cosmetic problems for the short period before the permanent tooth erupts. Advise follow up with own general dental practitioner, and warn about the possibility of damage to the developing permanent successor. Permanent teeth Mature permanent teeth that have been intruded usually need to be surgically extruded, realigned and splinted. Deciduous teeth Primary teeth are usually very mobile when subluxed and this will not improve even if they are repositioned. Extraction is the treatment if very mobile or being traumatised by the occlusion, otherwise leave. Give supportive advice re soft diet, analgesia and chlorhexidine mouthwash / sponges. Permanent teeth If very mobile ask for dental help as teeth may need to be splinted. If not too mobile or displaced, advise soft diet, chlorhexidine mouthwash / sponges, analgesia and follow up with own dental practitioner. Minimal fractures just involving enamel can be left, but advise follow up with own dental practitioner. More extensive fractures into dentine can be sensitive and should be covered as soon as possible with a dental material. Complicated fractures these are fractures of the enamel and dentine that involve the tooth pulp. If the nerve is exposed immediate pulp coverage is indicated (otherwise the pulp may become contaminated and become non-vital). These therefore appear displaced but are not avulsed and remain (often firmly) within their sockets. It tends to affect the upper 2 incisor teeth and for the reasons given above these are not avulsions, and again do not represent a time critical condition. If unsuccessful, call max-fax, attempt packing of the socket or suture the socket yourself if able (see below). If the above does not control bleeding, and bleeding is from more than one socket, then a systemic cause should be suspected. Treat as above but if haemorrhage uncontrollable refer to the maxillo-facial team. Remember that infection can track as follows, and examine accordingly: Maxillary teeth spread into facial soft tissues (infraorbitally) intraoral swelling may be seen in the buccal sulcus Mandibular teeth spread submandibularly, and around angle of mandible intraoral swelling may be seen buccally or lingually D. Consider whether there is an infected dermoid cyst present (common in these positions. Notable facial swellings may also arise from infected lymph nodes – usually involving the submandibular region. The majority of acute facial swellings are due to dental abscess infection spreading from a non-vital tooth, which has a necrotic pulp (secondary to dental caries, trauma, or a recent deep filling). Sometimes an acute infection can occur around an erupting tooth (usually a wisdom tooth). Occasionally it is only a unilateral swelling to the face that raises concerns and prompts an attendance. Serious acute dental infection is one of the few indications for immediate intervention and removal of the offending tooth. The size is measured by feeling the defect underlying the umbilicus, not the size of the protuberant skin. Most (95%) resolve spontaneously before 5 years of age, with 90% closing before 3 years of age. The first symptoms begin during the second to third week of life when babies begin with “spitting up” which develops into projectile vomiting. A mass can often be felt in the right upper quadrant following a test feed, but this requires some experience and ultrasound is the definitive test. A history of projectile vomiting or a typical history of vomiting which is worsening over a few days should be sufficient to refer for surgical review. Half of all cases occur in children under 1 year of age, with males being three times more likely to be affected than females. The child usually presents between the ages of 6 months and 4 years with sudden onset of acute abdominal pain which may be accompanied by episodes of pallor. Stools may change to red colour with the consistency of jelly due to stool mixed with blood and mucus – this is a late sign. The diagnosis may be confirmed by air or barium enema, which may also be curative, by reducing the intussusception. More prolonged case may require surgery because of the risk of perforating an ischaemic or necrosed bowel. They present in similar fashion – vomiting often bilious, poor feeding, irritability/ unsettled, may have had bowel motion but that will reduce, abdominal distension, failure to thrive. It is one of the few medical (as opposed to traumatic) conditions that presents with severe pain and is often very emotive for both patient and parents. As such it may be difficult to get an accurate history and a satisfactory examination especially at first consultation. It is therefore important to come to a conclusion and give good advice about returning before discharging the patient. Many conditions including tonsillitis, pneumonia, urine infections, flu, glandular fever can all cause abdominal pain. If surgical causes and acute viral infection have been ruled out, constipation becomes a strong possibility and it may be difficult to get a classic history from a child.

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By means of Molybdan compositum allergy symptoms wheat intolerance order desloratadine from india, therefore allergy medicine mold spores generic 5 mg desloratadine free shipping, an influence is exerted on the mineral equilibrium and allergy forecast kingston ontario cheap desloratadine 5mg without a prescription, indeed allergy medicine zantac order discount desloratadine, on deficient enzyme regulation and enzyme blocking. This effect is intensified by the mutual amplification of the individual constituents according to Burgi’s principle, i. The action of Molybdan compositum is strengthened by preparations which act upon enzymes, such as Coenzyme compositum and Ubichinon compositum, also by Composita-Heel, etc. The action of all biotherapeutic agents is intensified to some extent by regulation of the trace element level and, in accordance with Burgi’s principle, in the combination effect, many favourable side effects are produced. The dosage is adjusted according to the disease, the clinical picture and the stage of the illness. Molybdan compositum can be administered as trace element preparation both in the short term in daily doses and in general, in rarer doses: 1 tablet about every 2nd or 3rd day. One starts with 1 tablet daily (for 3 to 4 days; when well tolerated and there are no unfavourable side effects, also for a longer period, of about 8 to 10 days). Then 1 tablet is administered, only 2 to 3 times weekly and later, possibly only once weekly. Trace elements, however, should not be given in overdoses, as they can then have a toxic effect. If any undesirable or unexplained symptoms appear, it is beneficial to suspend medication for 3 to 5 days, followed by a reduction in dosage. However, interactions with other preparations, including biotherapeutic agents, cannot always be excluded, when a mutual intensification occurs according to Burgi’s principle, with possibly excessive reactions. In serious dyscrasia, however, at least temporarily for 1 to 3 weeks, daily doses may be beneficial (and possibly necessary). As the organism suffering from cancer is deficient in molybdenum, in certain cases, provided that it is well tolerated, 1 tablet daily can even be administerd through many weeks. Indications: Pancreatic affections and epigastric complaints; regulative antihomotoxic effect in cases of pancreatitis and dysfunctions of the pancreas. Pharmacological and clinical notes Momordica balsamina (balsam apple) Gripping, colicky pains in the epigastrium, gastrocardiac syndrome, pancreopathy. Jodum (iodine) Emaciation accompanied by a good appetite (lycorexia), hunger pains, pancreopathy. Mercurius solubilis Hahnemanni (mixture containing essentially mercuroamidonitrate) Acute and chronic inflammation of the whole lymphatic apparatus, dysentery, hepatitis, cholangitis. Ceanothus americanus (New Jersey tea) “Tangled” sensation in the left side of the epigastrium, diabetes, splenic disorders. Carbo vegetabilis (wood charcoal) Flatulent colic, slow digestion (disorders start half an hour after a meal), conditions of collapse. Lycopodium clavatum (club-moss) Disturbed digestion, meteorism, dyspepsia, disorders of the hepatic and cystic duct. Lachesis mutus (bushmaster) Sensation of globus; every time nourishment is taken disorders follow; sensitivity of the area of the liver, (clothes feel too tight), inflated abdomen. Argentum nitricum (silver nitrate) Gastritis, ventricular ulcers, intestinal colic, flatulence. Veratrum album (white hellebore) Gastroenteritis acuta, colic, tendency to collapse. Based on the individual homoeopathic constituents of Momordica compositum, therapeutical possibilities result for the treatment of disturbances of the pancreatic function and to produce a regulatory antihomotoxic effect in pancreatitis. Momordica compositum, due to its composition, is aimed specifically at the symptoms present in pancreas affections, it being recommended, in the case of somewhat obscure disorders, to combine the injections in alternation with Injeel-Chol and Hepeel; in chronic conditions, also with Hepar compositum, Coenzyme compositum and Ubichinon compositum. Also interpolated injections of Mucosa compositum are advantageous in the case of a duodenal contributory cause of a pancreatic affection; for diabetes also Syzygium compositum (orally); for accompanying coronary disorders Strophanthus compositum and possibly Cor compositum. It is attempted to make as precise as possible a diagnosis in respect of the “storm centre”, the epigastrium, whereby the improvement through Momordica compositum can also provide an indication that the pancreas is or was participating. In this connection, Momordica compositum can also prove useful in certain cases of duodenal ulcers as intermediate injection (to Erigotheel and Anacardium-Homaccord). An important alternating remedy is Leptandra compositum, especially in pancreatic affections, but also in hepatitis as well as in diseases of the bile duct (in alternation with Chelidonium-Homaccord and Injeel-Chol). The dosage is adjusted according to the disease, the symptoms and the stage of the illness: in acute disorders 1 ampoule daily, otherwise 1 ampoule 1-3 times weekly i. Orally, in addition, Cardiacum-Heel, and further, Duodenoheel and Chelidonium-Homaccord, have proved effective in disorders which radiate to the heart; also Cralonin and Glonoin-Homaccord and the other auxiliary remedies. Indications: Stimulation of the bodily defences in diseases of the mucous membranes and catarrhs of various types and localisations. Pharmacological and clinical notes Ventriculus suis (stomach) Stimulating effect in dysfunctions and retoxic damage. Mucosa nasalis suis (nasal mucosa) Stimulating effect specific to the mucous membrane in dysfunctions and retoxic damage. Mucosa oris suis (oral mucosa) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa pulmonis suis (mucosa of the small bronchi) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa oculi suis (conjunctiva) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa vesicae felleae suis (mucosa of the gall bladder) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa vesicae urinariae suis (mucosa of the bladder) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa pylori suis (mucosa of the pyloric region) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa duodeni suis (mucosa of the duodenum) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa oesophagi suis (mucosa of the oesophagus) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa jejuni suis (mucosa of the upper segment of the small intestine) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa ilei suis (mucosa of the lower segment of the small intestine) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa coli suis (mucosa of the colon) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa recti suis (mucosa of the rectum) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Mucosa ductus cholidochi suis (mucosa of the bile duct) Stimulating effect specific to the mucosa in dysfunctions and retoxic damage. Argentum nitricum (silver nitrate) Inflamed and ulcerated mucosa, gastroenteritis, splinter pains. Atropa belladonna (deadly nightshade) Localized reaction phase, dryness of the mucosa, conditions of irritation with cramp and stabbing pains, biliary colic. Oxalis acetosella (wood sorrel) Gastritis, ventricular and duodenal ulcers, diarrhoea, hepatopathy with dyspepsia, stomatitis aphthosa. Phosphorus (phosphorus) Remedy for affections of the parenchyma and mucosa, tendency towards diffuse haemorrhages of the mucosa. Lachesis mutus (bushmaster) Sensation of globus, each ingestion of food brings disorders, sensitive hepatic region, feeling that clothes are too tight, inflated abdomen, angina tonsillaris, bluish-red swelling. Ipecacuanha (ipecacuanha) Nausea and vomiting, coughs with nausea, gushes of blood, conjunctivitis, chemosis, epiphora. Nux vomica (vomit-nut) Remedy for affections of the stomach, intestine and liver; consequences of the misuse of stimulants (alcohol, nicotine); vomitus matutinus, spasmodic constipation, haemorrhoids. Veratrum album (white hellebore) All highly feverish affections and those starting feverishly. Pulsatilla pratensis (wind flower) Remedy for affections of the mucosa, heartburn, gastro-intestinal colic, conjunctivitis. Sulfur (sulphur) Reagent, cellular activity is influenced catalytically, scrofulous glandular swelling, hepatopathy, catarrh of the upper part of the respiratory tract. Natrium diethyloxalaceticum (sodium oxalacetate) Active factor of the citric acid cycle and of redox systems, weakness of the defensive system. Bacterium coli-Nosode (Escherichia coli nosode) Coli infection, meteorism, cholangitis, cholelithiasis, cystitis.

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Washing machines may be considered allergy meds for babies discount desloratadine 5 mg mastercard, but they require constant water pressure and their consumption of electricity is high allergy symptoms with dizziness purchase desloratadine overnight delivery. Don’t underestimate the hot and cold water consumption of the hospital laundry allergy medicine benadryl buy desloratadine 5 mg line, or the capacity of the waste water system required allergy juice generic 5mg desloratadine with mastercard. Ironing: Provide large tables for ironing and folding linen, shelves for storage and electric or stove-heated irons as appropriate. The tailor’s room should be large enough to accommodate a cutting table and sewing machines, and space should be allowed for storing material and maintaining an emergency stock. Set up a simple system of ordering, storing, and distributing all kinds of supplies at an early stage. Outside working hours, the nurse in charge should keep a key to the store in case additional supplies are needed. The storage system, the stock cards and the order forms should all correspond to the categories of non-medical and medical supplies outlined in Chapter 1. The arrival of requests from all the different departments at the same time should be avoided, as should multiple small requests. All departments should keep enough stocks for two to three days routine work, and for emergencies. Standard forms should be used for orders and receipts, which should be signed by the person in charge of the department. This person’s responsibilities also include the maintenance of specialized medical equipment and emergency access to the pharmacy store. They should also be familiar with the generic and trade names of all medical supplies and know how to handle drugs and medical supplies. The aim is to give each individual appropriate care whether the wounded arrive one by one or in large numbers at once. The management of war-wounded is based on well-established surgical principles (adequate primary wound excision followed by delayed closure). Likewise, nursing management relies on a framework of standard hospital policies and procedures within a well-organized system under strong leadership; this frame work helps medical personnel with different backgrounds, training and experience to work together as a team in difficult or unfamiliar situations. Such management does not require any special nursing techniques, but rather an open-minded, flexible, professional attitude and plenty of common sense. A standardized approach to the management of patients ensures continuity of care and maintains quality when there is a rapid turnover of staff, whether personnel from aid agencies or inexperienced local employees. He or she should have the authority to implement the decisions made by the team and to ensure that hospital policies and standard procedures are followed. This person must be experienced in the management of war-wounded and have proven leadership and management skills. He or she provides the ‘‘memory’’ of the project, has an overview of all hospital activities and ensures continuity in every aspect of hospital and patient management. Other roles involve acting as a clinical adviser and a point of reference and support for everyone. Because of this central role, the head nurse must be prepared to delegate administrative tasks. The system should be flexible enough to cope with the admission of large numbers of wounded (see Chapter 3. If the hospital has the specific task of treating war-wounded, admission criteria may be needed. Other medical and surgical emergencies should go to other health facilities if they exist. In such a case, all patients should be seen at the hospital entrance by a member of the medical team. Admission criteria are always difficult to establish and maintain and should be flexible to allow for changes in the situation. Never refuse treatment for true medical or surgical emergencies; they should be given first aid or emergency treatment and, where possible, referred to the appropriate facility. It may also serve as an area for outpatient treatment or surgical consultations, but during an influx of wounded these activities should be suspended. A list of all empty beds in the hospital allows the nurse in charge of admissions to allocate a bed to each new patient. Thus the number of available beds and the whereabouts of each patient are always known. Check equipment regularly to ensure that it is working properly and ready for use. Examination beds should be no wider than a stretcher, have a firm, washable mattress and be of a suitable height (50-60cm) to allow easy assessment and treatment of the patient. There should be enough space around each bed to manoeuvre stretchers and for medical staff to work. Wires or ropes at a height of 2 metres are better than stands for suspension of intravenous infusions. Sphygmomanometers Stethoscopes Thermometers For treatment: Intravenous fluids (Ringer’s lactate) Compresses sterile and clean Plasma expander (macromolecules) Bandages Giving sets for intravenous fluids Adhesive tape Blood giving sets Intravenous cannulae (different sizes) Cotton wool Syringes/tubes for collecting blood Splints samples Plaster of Paris Syringes for drugs Needles Vaseline gauze Nasogastric tubes (different sizes) Triangular bandages Urine catheters (different sizes) Surgical blades Urine bags Antibiotics intravenous and oral Artery forceps/tubing clamps Thoracic drains (different sizes) Analgesics intravenous/ Chest drain bottles, tubing and Heimlich intramuscular and oral valves Tetanus Toxoid Gloves latex disposable and Human antitetanus immunoglobulin surgical sterile Kidney dishes, forceps, disinfectant for Water for injection dressings Skin-cleaning disinfectant In addition, trays may be prepared with equipment ready for the following procedures. Observe the patient’s general condition, check Airway, Breathing and Circulation, and then make a systematic, thorough examination. It covers essential investigations, treatment, operation and post operative orders for the first 24 hours. Patients presenting with injuries to the head, face or neck may arrive fully concious and should remain in the position in which they feel most comfortable often sitting up or kneeling. Look for wounds: Turn the patient over and examine the back and both sides of the body. Pressure dressings, those on traumatically amputated limbs or very large wounds may be left in place, as the extent of injury and the necessity for operation are evident. If the patient’s condition permits and there is no active bleeding, remove the dressings to allow a careful assessment of the wounds. Note abdominal distension or tenderness in injuries of the abdomen, chest or buttocks. Check for tourniquets on injured limbs: the decision to remove a tourniquet or to leave it in place depends on the patient’s condition, how long the tourniquet has been in place and its position. The removal of a tourniquet is often best done in the operating theatre under controlled conditions. Type of injury: Note the cause of the injury, whether by bullet, metallic fragments, or blast from bombs or mines,(patients do not always know what caused their injuries). The longer the delay between injury and surgery, the greater risk of complications. Ask the patient when he/she last ate or drank: If this cannot be determined accurately, presume that it was just before the time of injury. Take blood for haematocrit/ haemoglobin: Carry out grouping and crossmatching if necessary. Give benzylpenicillin 5 million units intravenously: this may be given directly in the infusion write the drug and dose on the infusion bottle (paediatric doses are calculated according to the age and weight of the patient). Give tetanus toxoid: Presume that the population is unvaccinated unless there is clear evidence to the contrary. Re-dress wounds and splint fractures: Following initial inspection, wounds are covered by bulky, dry gauze and bandages and any fractures are immobilised with splints prior to transfer of the patient to the X-ray department or operating theatre. The head operating theatre nurse needs to plan the inclusion of any new patients on the operating list. The ward: Allocate a bed and make sure that the nurses are prepared to receive the patient post-operatively. A surgeon’s assessment is helpful before the patient goes to the operating theatre. In any event, sending patients who do not need surgery to the operating theatre should be avoided. Wounded patients, especially those who have been injured by anti-personnel mines, usually arrive covered with mud, dust and other material. If the patient’s condition allows, and if there is time before transfer to the operating theatre, he/ she should be washed and be provided with clean clothing or sheets. Keep a patient’s clothing and personal property in a labelled bag which is transferred to the ward with the patient. The admission book may contain information which is considered to be of military significance (for example, the provenance and names of patients); the information it contains is sensitive and is therefore is confidential.

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Syndromes

  • Medicines to help your bladder contract and empty. These are called anticholinergic drugs. Possible side effects include slowed heart rate, low blood pressure, increased thirst, and constipation.
  • Low bone density, as measured by dual x-ray absorptiometry (DEXA)
  • Seizures
  • Physical disabilities
  • Agitation
  • Reactions to medicines
  • Removal of both ovaries and fallopian tubes (bilateral salpingo-oophorectomy)
  • Another method is to make a small surgical cut on the left side of the chest. The surgeon finds the PDA and then ties off or clips the ductus arteriosus, or divides and cuts it. Tying off the ductus arteriosus is called ligation. This procedure may be done in the neonatal intensive care unit (NICU).
  • Adapin

Indications 624 Drug Name: Savella (milnacipran) Fibromyalgia Is indicated for the management of fibromyalgia allergy forecast irvine ca order genuine desloratadine on-line. Criteria Product Name: Savella Approval Length 12 Month(s) Guideline Type Step Therapy Approval Criteria 1 Trial and failure allergy medicine you can drink with generic desloratadine 5 mg overnight delivery, contraindication allergy forecast denton tx purchase 5 mg desloratadine fast delivery, or intolerance to allergy testing columbus ohio order 5mg desloratadine otc one of the following: [A, B] • amitriptyline* • cyclobenzaprine* • duloxetine • gabapentin • Lyrica immediate-release Notes *Amitriptyline and cyclobenzaprine are recommended only for patients less than 65 years old. Safety and effectiveness of Savella in a fibromyalgia pediatric population below the age of 17 have not been established. Amitriptyline is part of the Beer’s Criteria for potentially inappropriate medication use in older adults (independent of diagnoses or condition) because of its strong anticholinergic and sedation properties while cyclobenzaprine is listed as most muscle relaxants and antispasmodic drugs are poorly tolerated by elderly patients, since these cause anticholinergic adverse effects, sedation, and weakness. Product Name: Sensipar [a] Approval Length 12 Month(s) Therapy Stage Reauthorization Guideline Type Prior Authorization Approval Criteria 1 Patient has experienced a reduction in serum calcium from baseline Notes [a] State mandates may apply. Medical management of primary hyperparathyroidism: proceedings of the fourth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism. Indications Drug Name: Farxiga (dapagliflozin) Type 2 Diabetes Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitation of Use: Farxiga is not recommended for patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. Empagliflozin is indicated to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease However, the effectiveness of Glyxambi on reducing the risk of cardiovascular death in adults with type 2 diabetes mellitus and cardiovascular disease has not been established. Limitation of use: Glyxambi is not recommended in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. It is unknown whether patients with a history of pancreatitis are at an increased risk for the development of pancreatitis while using Glyxambi. Drug Name: Invokamet (canagliflozin/metformin) Type 2 Diabetes Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are not adequately controlled on a regimen containing metformin or canagliflozin or in patients already being treated with canagliflozin and metformin. Limitation of use: Invokamet is not recommended in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. Limitations of Use: Not recommended in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis. Drug Name: Invokana (canagliflozin), Farxiga (dapagliflozin) Type 2 Diabetes Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitation of use: Invokana and Farxiga are not recommended in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. Drug Name: Jardiance (empagliflozin) Cardiovascular Disease Indicated to reduce the risk of cardiovascular death in adult patients with type 2 diabetes mellitus and established cardiovascular disease. Type 2 Diabetes Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitation of use: Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Limitations of Use: Qtern is not indicated for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Drug Name: Segluromet (ertugliflozin and metformin) Type 2 Diabetes Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are not adequately controlled on a regimen containing ertugliflozin or metformin, or in patients who are already treated with both ertugliflozin and metformin. Limitations of Use: Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Drug Name: Steglatro (ertugliflozin) Type 2 Diabetes Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitation of use: Steglatro is not recommended in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. Drug Name: Steglujan (ertugliflozin and sitagliptin) Type 2 Diabetes Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus when treatment with both ertugliflozin and sitagliptin is appropriate. Drug Name: Synjardy (empagliflozin/metformin) Type 2 Diabetes Indicated as adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are not adequately controlled on a regimen containing empagliflozin or metformin, or in patients already being treated with both empagliflozin and metformin. Empagliflozin is indicated to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease. However, the effectiveness of Synjardy on reducing the risk of cardiovascular death in adults with type 2 diabetes mellitus and cardiovascular disease has not been established. Limitation of use: Synjardy is not recommended for patients with type 1 diabetes or for the treatment of diabetic ketoacidosis. Exercise-Induced Bronchospasm Indicated for the prevention of exercise-induced bronchospasm in patients 4 years of age and older. Notes Authorization for cancer, end of life pain or palliative care pain or sickle cell anemia will be issued or a quantity of 9999 for 24 months to prevent further disruption in therapy if the patient’s dose is increased. Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage 642 criteria. Members age 20 years and older new to opioid therapy are restricted to up to a 7-day supply for initial fill. Indications Drug Name: Silenor (doxepin) Indications Insomnia [1] Is indicated for the treatment of insomnia characterized by difficulty with sleep maintenance. The clinical trials performed in support of efficacy were up to 3 months in duration. Criteria Product Name: Silenor (doxepin) Guideline Type Non Formulary Approval Criteria 1 History of failure, contraindication, or intolerance to both of the following: • Ambien (zolpidem) • Lunesta (eszopiclone) 3. A 3 mg once daily dose may be Recommended Dose appropriate for some patients, if clinically indicated; (2) Elderly (greater than or equal to 65 years old): 3 mg once daily. Criteria Product Name: Solaraze* Approval Length 3 Month(s) Guideline Type Notification Approval Criteria 1 Diagnosis of actinic keratosis Notes *Applies to brand and generic Solaraze 3. Background Benefit/Coverage/Program Information Background: the recommended duration of therapy is from 60 to 90 days. Indications Drug Name: Solosec (secnidazole) Indications bacterial vaginosis Indicated for the treatment of bacterial vaginosis. Criteria 655 Product Name: Solosec [a] Approval Length 1 Month Guideline Type Step Therapy Approval Criteria 1 History of failure, contraindication or intolerance to one of the following: • clindamycin capsules (generic Cleocin) • clindamycin vaginal cream (generic Cleocin, Clindesse) • clindamycin vaginal suppository (Cleocin) • metronidazole tablets (generic Flagyl) • metronidazole vaginal gel (Metrogel-Vaginal) • tinidazole tablets (generic Tindamax) Notes [a] State mandates may apply. Background Benefit/Coverage/Program Information Background: Solosec (secnidazole) is indicated for the treatment of bacterial vaginosis. Solosec is available as a two gram oral granule and should be taken as a single dose. Step therapy programs are intended to encourage the use of lower cost alternatives for certain therapeutic classes. This program requires a member to try an alternative antibacterial agent before providing coverage for Solosec. Drug Name: Grastek, Oralair 661 Indications Allergic rhinitis Indicated for patients with grass pollen-induced allergic rhinitis. Drug Name: Ragwitek Indications Allergic rhinitis Indicated for ragweed pollen-induced allergic rhinitis. Product Name: Grastek [a] Diagnosis grass pollen-induced allergic rhinitis Approval Length 12 Month Therapy Stage Reauthorization Guideline Type Prior Authorization Approval Criteria 1 Documentation of positive clinical response to Grastek therapy Notes [a] State mandates may apply. Product Name: Oralair [a] Diagnosis grass pollen-induced allergic rhinitis Approval Length 12 Month 666 Therapy Stage Reauthorization Guideline Type Prior Authorization Approval Criteria 1 Documentation of positive clinical response to Oralair therapy Notes [a] State mandates may apply. Product Name: Ragwitek [a] Diagnosis ragweed pollen-induced allergic rhinitis 668 Approval Length 12 Month Therapy Stage Reauthorization Guideline Type Prior Authorization Approval Criteria 1 Documentation of positive clinical response to Ragwitek therapy Notes [a] State mandates may apply. Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. Candidates for allergen immunotherapy are patients whose symptoms are not adequately controlled by medications, and avoidance measures have been ineffective. In addition, patients experiencing unacceptable adverse effects of medications or who wish to reduce the long term use of medications may also be candidates for immunotherapy. Use of automated approval and re-approval processes varies by program and/or therapeutic class • Supply limits and/or Notification may be in place. Treatment of seasonal allergic rhinitis: An evidence-based focused 2017 guideline update. Sublingual immunotherapy: A focused allergen immunotherapy practice parameter update. Indications Drug Name: Symlin (pramlintide acetate) Indications Type 1 Diabetes Mellitus Indicated for type 1 diabetes, as an adjunct treatment in patients who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy. Type 2 Diabetes Mellitus 673 Indicated for type 2 diabetes, as an adjunct treatment in patients who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy, with or without a concurrent sulfonylurea agent and/or metformin.

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