Cautions syndromes

Caution Both glanders and melioidosis may occur in an acute localized form, as an acute pulmonary infection, or as an acute fulminant, rapidly fatal, sepsis. Combinations of these syndromes may occur in human cases. In addition, melioidosis may remain asymptomatic after initial acquisition, and remain quiescent for decades, but these patients may display active melioidosis years later which is often associated with an immune-compromising state. Aerosol infection produced by a biological weapon containing either glanders (B. mallei) or melioidosis (B. pseudomallei) could produce any of these syndromes... 

A concern with the administration of lamotrigine is that it has the potential to induce the Stevens-Johnson syndrome (exfoliative dermatitis). The incidence of a serious rash in clinical trials appears to be about 0.08% with monotherapy and 0.13% with combination therapy. The rash usually resolves when lamotrigine is stopped, but all patients starting lamotrigine should be cautioned to be vigilant for the development of a rash, especially during the first 6 months of treatment. 

Buscopan contains hyoscine butylbromide, which is a quaternary ammonium compound with antimuscarinic properties. It is used as an antispasmodic and therefore may be useful in irritable bowel syndrome. Hyoscine butylbromide, as with all antimuscarinics, must be used with caution in patients with prostatic hypertrophy, as they may lead to urinary retention. 

Some authors believe that neuropathic effects of vincristine are greatly exacerbated in patients with underlying neuropathy, such as in those with Marie-Charcot syndrome. This is based on experience with one patient who developed bulbar paralysis following vincristine injection. Some authors believe this reaction to have been idiosyncratic and report successful treatment of patients with underlying neuropathies with vincristine without untoward effects. At the least, extreme caution and careful consideration of alternate therapies seems reasonable in such patients (31,32). In either case, the neurologic symptoms are so common they should not limit the use of this agent, which in early studies was well tolerated at a weekly dose of 3.5 mg. 

Speciai risk Use with caution in the following situations Nonspecific ulcerative colitis if there is a probability of impending perforation, abscess, or other pyogenic infection diverticulitis fresh intestinal anastomoses hypertension CHF thromboembolitic tendencies thrombophlebitis osteoporosis exanthema Cushing syndrome antibiotic-resistant infections convulsive disorders metastatic carcinoma myasthenia gravis vaccinia varicella diabetes mellitus hypothyroidism, cirrhosis (enhanced effect of corticosteroids). 

Autoimmune polyglandular syndrome-Chron c autoimmune thyroiditis may occur in association with other autoimmune disorders. Treat patients with concomitant adrenal insufficiency with replacement glucocorticoids prior to initiation of treatment. Failure to do so may precipitate an acute adrenal crisis when thyroid hormone therapy is initiated. Patients with diabetes mellitus may require upward adjustments of their antidiabetic therapeutic regimens. Nontoxic diffuse goiter or nodular thyroid disease Use caution when administering levothyroxine to patients with nontoxic diffuse goiter or nodular thyroid disease in order to prevent precipitation of thyrotoxicosis. If the serum TSH is already suppressed, do not administer levothyroxine. 

Conduction abnormalities Use caution in patients with sick sinus syndrome, Wolff-Parkinson-White syndrome or bundle branch block. 

Sick sinus syndrome Use only with extreme caution the drug may cause sinus bradycardia, sinus pause, or sinus arrest. The frequency probably increases with higher trough plasma levels. 

Oral- Amiodarone may cause a clinical syndrome of cough and progressive dyspnea accompanied by functional, radiographic, gallium scan, and pathological data consistent with pulmonary toxicity. The frequency varies from 2% to 17% fatalities occur in about 10% of cases. However, in patients with life-threatening arrhythmias, discontinuation of amiodarone therapy due to suspected drug-induced pulmonary toxicity should be undertaken with caution. 

Pregnancy Category B (ethacrynic acid, torsemide) Category C (furosemide, bumetanide). Since furosemide may increase the incidence of patent ductus arteriosus in preterm infants with respiratory-distress syndrome, use caution when administering before delivery. 

Promethazine is not recommended in children younger than 2 years of age. Exercise caution when administering promethazine to children because of the potential for fatal respiratory depression. Limit antiemetics to prolonged vomiting of known etiology. Avoid use in children whose signs and symptoms may suggest Reye syndrome or other hepatic diseases. In children with dehydration, there is an increased susceptibility to dystonias with the use of promethazine. 

Phenytoin Use with caution in hypotension and severe myocardial insufficiency. Hypersensitivity reactions Phenytoin hypersensitivity reactions are not typical they may present as one of many different syndromes (eg, lymphoma, hepatitis, Stevens-Johnson syndrome) and may include such symptoms as fever, rash, arthralgias, or lymphadenopathy. 

Prescribers should exercise caution when discontinuing entacapone treatment. When considered necessary, withdrawal should proceed slowly. Consider this syndrome in the differential diagnosis for any patient who develops a high fever or severe rigidity. 

Neuropathic disorders Administer with caution in individuals with peripheral motor neuropathic diseases (eg, amyotrophic lateral sclerosis, motor neuropathy) or neuromuscular junctional disorders (eg, myasthenia gravis, Lambert-Eaton syndrome). Patients with neuromuscular disorders may be at increased risk of clinically significant P.787... 

Chiidren Use with caution signs of atropinism may occur with recommended doses, particularly in Down syndrome patients. Use with caution in young children because of variable response. Not recommended in children less than 2 years of age. 

Children Use with caution and in reduced dosages in premature and full-term infants to avoid gray syndrome toxicity. Monitor drug serum levels carefully during therapy of the newborn. 

Use with caution Use with caution in patients with hypertension, hypotension, hypoglycemia, hyperglycemia, hypocalcemia, leukopenia, thrombocytopenia, anemia, hepatic or renal dysfunction, ventricular tachycardia, pancreatitis, and Stevens-Johnson syndrome. 

The triptans should be used with caution in patients on lithium, monoamine oxidase inhibitors or selective serotonin reuptake inhibitors, due to the rare occurrence of the serotonin syndrome. 

The first point is that treatment with steroids is generally palliative rather than curative, and only in a very few diseases, such as leukemia and nephrotic syndrome, do corticosteroids alter prognosis. One must also consider which is worse, the disease to be treated or possible induced hypercortisolism. The patient s age can be an important factor, since such adverse effects as hypertension are more apt to occur in old and infirm individuals, especially in those with underlying cardiovascular disease. Glucocorticoids should be used with caution during pregnancy. If steroids are to be employed, prednisone or prednisolone should be used, since they cross the placenta poorly. 

Caution when medication discontinued abruptly after long-term (>4 wk) use— may precipitate withdrawal syndrome... 

Use with caution in older patients with Parkinson s Disease (an atypical antipsychotic is recommended), seizure disorders, cardiovascular disease with conduction disturbance, hepatic encephalopathy, narrow-angleglaucoma, congenital prolonged O-T syndrome or drugs which prolong O-T interval. 

Apathy and frontal lobe-like syndromes. A reversible, dose-related frontal lobe-like syndrome characterized by apathy, indifference, loss of initiative, and/or disinhibition has been reported in adults on SSRI therapy (Hoehn-Saric et al.l990, 1991). Recently, five cases of amotivational syndrome in youths, 10 to 17 years of age, were reported (Garland Baerg, 2001). Symptoms had a delayed onset, were dose related, and were reversible. The authors caution that such presentation may go underrecognized or may be mistakenly attributed to residual depression or to avoidance rather than to a medication side effect. 

Loperamide and codeine are preferred to diphenoxylate in chronic diarrhoea, because they have less tendency to produce drug dependence. Long-term use of these drugs may aggravate irritable bowel syndrome. These drugs are used cautiously in attacks of colitis because there is increased risk of toxic megacolon. Also all these drugs should be used with caution in elderly because faecal impaction... 

Naltrexone is generally taken once a day in an oral dose of 50 mg for treatment of alcoholism. An extended-release formulation administered as an IM injection once every 4 weeks is also effective. The drug can cause dose-dependent hepatotoxicity and should be used with caution in patients with evidence of mild abnormalities in serum aminotransferase activity. The combination of naltrexone plus disulfiram should be avoided, since both drugs are potential hepatotoxins. Administration of naltrexone to patients who are physically dependent on opioids precipitates an acute withdrawal syndrome, so patients must be opioid-free before initiating naltrexone therapy. Naltrexone also blocks the therapeutic effects of usual doses of opioids. 

Gastrointestinal complaints (eg, nausea, diarrhea, vomiting, flatulence) are the most common adverse effects but rarely require discontinuation of therapy. Other potential adverse effects include headache and asthenia. Tenofbvir-associated proximal renal tubulopathy causes excessive renal phosphate and calcium losses and 1-hydroxylation defects of vitamin D, and preclinical studies in several animal species have demonstrated bone toxicity (eg, osteomalacia). Monitoring of bone mineral density should be considered with long-term use in those with risk factors for or with known osteoporosis, as well as in children. Reduction of renal function over time, as well as cases of acute renal failure and Fanconi s syndrome, have been reported in patients receiving tenofovir alone or in combination with emtricitabine. For this reason, tenofovir should be used with caution in patients at risk for renal dysfunction. Tenofovir may compete with other drugs that are actively secreted by the kidneys, such as cidofovir, acyclovir, and ganciclovir. 

When Qi, Yang, fire and wind are ascending in an acute pathological condition, herbs that move Qi, blood or Yang upwards and outwards should be used with caution. Relevant formulas here are those which treat Bi syndrome or exterior syndrome caused by wind, damp and cold, formulas that disperse and spread the Liver-Qi and formulas that treat headache caused by Qi and blood stagnation. 

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