Combined therapies complications

A 30-year-old type I diabetic with renal complications develops acute pyelonephritis F aeruginosa is found in urine cultures and blood cultures. Combined therapy is instituted with an aminoglycoside and which of the following ... 

For patients with complicated infection (e.g., extracardiac foci) or when the organism is relatively resistant (MIC = 0.12 to 0.5 mcg/mL), combination therapy with an aminoglycoside and penicillin (higher dose) or ceftriaxone for the first 2 weeks is recommended (Table 37-4). 

Cyclosporine has been approved for use in allogeneic kidney, liver, and heart transplant patients and is under study for use in pancreas, bone marrow, single lung, and heart-lung transplant procedures. It is recommended that corticosteroids, such as prednisone, be used concomitantly, although at half or less of their usual dose. Such combined therapy leads to fewer side effects, a decreased incidence of infectious complications, efficacy of lower doses of cyclosporine, and a better history of patient survival. 

Mefloquine is effective in treating most falciparum malaria. The drug is not appropriate for treating individuals with severe or complicated malaria, since quinine, quinidine, and artemisinins are more rapidly active, and since drug resistance is less likely with those agents. The combination of artesunate plus mefloquine showed excellent antimalarial efficacy in regions of Southeast Asia with some resistance to mefloquine, and this regimen is now one of the combination therapies recommended by the WHO for the treatment of uncomplicated falciparum malaria (Table 52-4). Artesunate-mefloquine is the first-line therapy for uncomplicated malaria in a number of countries in Asia and South America. 

As indicated earlier, the development of the newer antiseizure medications has advanced the strategy of using two drugs rather than a single agent. Because these newer drugs have relatively predictable pharmacokinetic and side-effect profiles, they can be added to traditional medications without excessive complications and risk to the patient.4,31 Combination therapy is therefore a more common approach to treating seizure disorders than it was in the past. 

Duda et al. prospectively studied 70 patients in the PROMPT trial of UK and abciximab versus UK alone. The trial showed the combination therapy resulted in a decreased infusion time, improved amputation free survival, and improved open surgery free survival at 90 days (46). Interestingly, a post hoc economic analysis of the PROMPT trial found an economic benefit to combination therapy at 90 days based on endpoints of amputation free survival, survival without open surgery, lack of major amputation and lack of major complications. The extra cost of abciximab was more than offset by the decreased costs through improved patient outcomes (47). 

It is clear from this discussion that although there is significant potential for the use of hypothermia in combination with additional neuroprotective agents, it is premature to consider this a viable option in the near future. Moreover, there are no adequate data on the safety of such combination therapy. In fact, there is some evidence suggesting that hypothermia could result in such adverse effects as reduced thrombolytic efficacy and increased susceptibility to infectious complications. 

Flutamide (EULEXIN, EUFLEX) Nonsteroidal LH increased T increased Monotherapy Combination therapy Potency spared Breast tenderness, nausea and vomiting, diarrhea, rectal bleeding, hot flashes, cystitis, increased appetite, sleep disturbances, hepatotoxicity, anemias, hemolysis, headache, dizziness, malaise, blurred vision, anxiety, depression, decreased libido, hypertension, complications in patients with cardiovascular disease... 

Combination therapy is often used when dealing with infections caused by both aerobic and anaerobic bacteria [50,80]. Combination of metronidazole with either gentamicin or ciprofloxacin appeared to be effective in preventing infection of abdominal trauma [101] when combined with ciprofloxacin, metronidazole was affective as a preoperative antibiotic in colorectal surgery and appeared equal in efficacy to impipenem/cilastin for the treatment of complicated intraabdominal infections [103]. Combination therapy is not always indicated for the treatment of polymicrobial infections. New antibiotics, whose spectrum includes multiple classes of microorganisms (e.g., imipenem), may often preclude combination therapy. 

It is obvious that the aim must be to use as few drugs as possible - this is an old lesson. On the other hand, we should aim for near-normalisation of blood glucose values, since a normalisation of HbAlc seems to reduce the risk of diabetic complications tremendously (Fig. 1). In that respect, the economy may be taken into account, since combination therapy may be expensive. It is, however, much more expensive to treat diabetic complications. 

Observational studies In a study of seven patients with lupus nephritis who failed on mycophenolate mofetil monotherapy, toxicity hmited the use of combination therapy with tacrolimus - - mycophenolate mofetil [84 ]. One patient achieved complete renal remission, and three achieved partial remission with reduced proteinuria. Four of seven patients stopped taking combination therapy because of diabetic ketoacidosis (n = 1), pneumonia ( = 1) and muscle pain (n = 2). Four patients had infectious complications, pneumonia (n = 2), herpes zoster (n = l), and septic arthritis ( = 1). There were no severe nephrotoxic adverse reactions, although there was a small increase in serum creatinine in two patients. 

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