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By B. Hamlar. Central Methodist College.

The regulatory authority might not have enough inspectors to monitor all drug shops on the prescribed timetable (Goodman et al purchase antivert 25 mg online symptoms brain tumor. The Ghanaian Pharmacy Council cheap antivert 25mg with mastercard medications without doctors prescription, for example, inspects only about 20 percent of all drug sellers annually (Segrè and Tran, 2008). Inspectors commonly fnd the shops selling restricted medicines, the products that bring in about half of the stores’ total revenues (Segrè and Tran, 2008). The low likelihood of being caught in a violation and the social and fnancial in- centives to ignore regulations outweigh the threat of punishment for many shopkeepers (Segrè and Tran, 2008). When infrequent inspection does identify violations, regulators are loath to enforce the rules, as this would remove from many communities their only medicine store (Goodman et al. People in rural areas use these shops for more than just retail; the shopkeepers are a source, sometimes the sole source, of health advice in their communities (Anderson et al. In some parts of the world, so-called pharmacy assistants may have less than a middle-school education (Goel et al. These shopkeepers are not properly trained for medicines retail, let alone patient counseling. Shortage of Trained Pharmacy Staff Poor supervision of medicines retail allows falsifed and substandard products to circulate. Pharmacists oversee the responsible purchase of drugs from legitimate wholesalers. They watch for suspicious products in the licit supply chain, educate patients on warning signs of problem drugs, and are Copyright © National Academy of Sciences. Too few people are trained to do this job in the parts of the world where falsifed and sub- standard medicines are a systemic problem. In general, the region has a pharmacist for every 23,375 people; 75 percent of these pharmacists live in Nigeria or South Africa (Kome and Fieno, 2006). After excluding these countries, the ratio is closer to 1:64,640 (Kome and Fieno, 2006). National estimates in Malaysia (1:6,207) and Pakistan (≈ 1:19,748) also suggest serious problems (Azhar et al. The world distribution of pharmacists shown in Figure 5-5 indicates a dearth of pharmacy professionals in sub-Saharan Africa and Southeast Asia. This map fails to capture the relative privation of rural areas, where far fewer pharmacists per person work (Hawthorne and Anderson, 2009). In India, for example, most pharmacists work in the country’s drug manu- facturing sector (Mohanta et al. So, although the national average ratio of pharmacists to population is 1:1,785, this number masks regional disparities (Basak et al. Few pharmacists work outside of cities, and almost none works in remote areas (Basak et al. Pharmacy schools are in cit- ies and therefore attract urban students who have little interest in working in the countryside or reason to move there after graduation (Anderson et al. Furthermore, pharmacy training in many low- and middle- income countries, especially in Asia, qualifes people to work in industry (Azhar et al. A critic of the Indian pharmacy education system observed, “Community pharmacy practice does not exist in its true sense, only drug selling” (Mohanta et al. Improvements to the practice of community pharmacy would curtail Copyright © National Academy of Sciences. How- ever, having practicing community pharmacists oversee all pharmacies is an unrealistic solution in the parts of the world most hurt by falsifed and substandard pharmaceuticals. Viable short-term solutions should aim to increase the reach of legal drug shops staffed by sellers with appropriate minimal training. The committee believes that governments and the private sector both have important roles in assuring a safe medicine supply in un- derserved areas. Recommendation 5-3: Governments in low- and middle-income coun- tries should provide an environment conducive to the private sector establishing high-quality medicines retail in underserved areas. To the same end, governments, the World Health Organization, and the International Pharmaceutical Federation should support national pharmacy councils and education departments to train tiers of pharmaceutical personnel. The committee recognizes two main problems with medicines retail in low- and middle-income countries. First, there are not enough high-quality vendors, driving customers to street markets and unlicensed shops. Second, there are not enough trained staff to oversee the responsible purchasing and Copyright © National Academy of Sciences.

If further reducton in intra-ocular pressure is required a miotc antivert 25mg online medicine used to treat chlamydia, a sympathomimetc or a systemic carbonic anhydrase inhibitor may be used with tmolol purchase 25 mg antivert medicine ball workouts. Since systemic absorpton can occur, an ophthalmic beta- blocker should be used with cauton in certain individuals. A miotc such as pilocarpine, through its parasympatho- mimetc acton, contracts the iris sphincter muscle and the ciliary muscle, and opens the trabecular network. It is used in chronic open-angle glaucoma either alone or, if required, with a beta-blocker, epinephrine or a systemic carbonic anhydrase inhibitor. Pilocarpine is used with systemic acetazolamide in an acute atack of angle-closure glaucoma prior to surgery; however, it is not advisable to use pilocarpine afer surgery because of a risk of posterior forming. Systemic absorpton of topically applied pilocarpine can occur producing muscarinic adverse efects. Epinephrine is usually used with a miotc, a beta-blocker or a systemic carbonic anhydrase inhibitor in the treatment of chronic open-angle glaucoma; however, because epinephrine is also a mydriatc, it is contraindicated for angle-closure glau- coma unless an iridectomy has been carried out. Acetazolamide, by reducing carbonic anhydrase in the eye, reduces the producton of aqueous humour and so reduces intra-ocular pressure. It is used systemically as an adjunct in chronic open-angle glaucoma unresponsive to treatment with topically applied antglaucoma drugs. Prolonged therapy with acetazolamide is not normally recommended, but if treatment is unavoidable blood count and plasma electrolyte concentra- ton should be monitored. Acetazolamide is also used as part of emergency treatment for an acute atack of angle-closure glaucoma; however it should not be used in chronic angle-clo- sure glaucoma as it may mask deterioraton of the conditon. Acetazolamide* Pregnancy Category-C Schedule H Indicatons As an adjunct in the treatment of chronic open-angle glaucoma; secondary glaucoma; as part of pre-operatve treatment of acute angle-closure glaucoma. Contraindicatons Hypersensitvity to sulfonamides; chronic angle-closure glaucoma (may mask dete- rioraton); hypokalaemia, hyponatraemia, hyperchloraemic acidosis; renal impairment (Appendix 7d), severe hepatc impairment; renal hyperchloremic acidosis, addison’s dis- ease. Precautons Elderly; lactaton; diabetes mellitus; pulmonary obstructon; monitor blood count and electrolytes if used for long periods; interactons (Appendix 6b, 6c); pregnancy (Appendix 7c); severe respiratory acidosis. May impair ability to perform skilled tasks, for example operatng machinery, driving. Contraindicatons Systemic absorpton may follow topical applicaton to the eyes, therefore they are contraindicated in patents with bradycardia, heart block, or uncontrolled heart failure; hypersensitvity. Precautons Avoid in asthma, poor cardiac reserve, hepatc impairment; not for injecton; pregnancy (Appendix 7c). Adverse Efects Ocular stnging, burning, pain, itching, erythema, dry eyes and allergic reactons including anaphylaxis and blepharoconjunctvits; occasionally corneal disorders have been reported; crusty taste, photophobia, corneal punctuate staining, decreased corneal sensitvity, keratts, anisocoria; headache; sleep disturbances. Precautons Patents with coronary insufciency; interactons (Appendix 6a, 6c), pregnancy (Appendix 7c). Latanoprost Pregnancy Category-C Schedule H Indicatons To lower intraocular pressure in open angle glaucoma or ocular hypertension. Precautons Patents with a history of intraocular infammaton (irits/uveits) or actve intraocular infammaton, with torn posterior lens capsule, britle or severe asthma, infammatory, angle closure or congenital glaucoma, pregnancy (Appendix 7c), lactaton, interactons (Appendix 6c). Adverse Efects Conjunctval hyperaemia, iris pigmentaton; upper respiratory tract infecton; cold, fu; darkening and thickening of eyelashes, eyelid skin darkening; intraocular infammaton, ocular irritaton and pain; exacerbaton of asthma; blepharits. Physostgmine Pregnancy Category-C Schedule H Indicatons Glaucoma in conjuncton with other drugs and not alone (as it is very potent). Adverse Efects Twitching lids, myopia, ocular and periorbital pain, cilliary and conjuctval congeston. Dose Instllaton into the eye Adult- Chronic open-angle glaucoma before surgery: 1 drop (2% or 4 %) up to 4 tmes daily. Acuteangle closure glaucoma before surgery: 1 drop (2%) every 10 min for 30 to 60 min, then 1 drop every 1 to 3 h untl intra-ocular pressure subsides. Contraindicatons Acute irits, acute uveits, anterior uveits, some forms of secondary glaucoma; acute infammaton of anterior segment; not advisable afer angle-closure surgery (risk of posterior synechiae). Precautons Retnal disease, conjunctval or corneal damage; monitor intra-ocular pressure in chronic open-angle glaucoma and in long-term treatment; cardiac disease, hypertension; asthma; peptc ulceraton; urinary-tract obstructon; Parkinson’s disease; stop treatment if symptoms of systemic toxicity develop; ulcer; hyperthyroidism; seizures. Do not carry out skilled tasks, for example operatng machinery or driving untl vision is clear, pregnancy (Appendix 7c).

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All patents with invasive amoebiasis require treatment with a systemically actve compound such as metronidazole buy antivert 25mg with amex ok05 0005 medications and flying, ornidazole and tnidazole followed by a luminal amoebicide in order to eliminate any surviving organisms in the colon order antivert 25mg visa medications medicaid covers. In severe cases of amoebic dysentery, tetracycline given in combinaton with a systemic amoebicide lessens the risk of superinfecton, intestnal perforaton and peritonits. Giardiasis: Giardiasis is caused by Giardia intestnalis and is acquired by oral ingeston of Giardia cysts. Larger epidemics are difcult to eradicate because of the high proporton of sympto mless carriers and because excreted cysts can survive for long periods outside the human host. Trichomoniasis: Trichomoniasis is an infecton of the genito-urinary tract caused by Trichomonas vaginalis and transmission is usually sexual. Patents and their sexual partners should be treated with metronidazole or other nitroimidazole. Diloxanide Furoate* Schedule H Indicatons Amoebiasis (asymptomatc carriers in non- endemic areas; eradicaton of residual luminal amoebae afer treatment of invasive disease with other drugs). Adverse Efects Flatulence; occasionally vomitng, pruritus and urtcaria; furred tongue. Child- 35 to 50 mg/kg body weight in amoebiasis and 10 to 15 mg/kg body weight in giardiasis. Contraindicatons Chronic alcohol dependence; neurological disease, blood dyscrasias, frst trimester of pregnancy. Precautons Disulfram-like reacton with alcohol; hepatc impairment and hepatc encephalopathy (Appendix 7a); pregnancy (Appendix 7c); see also notes above); lactaton (Appendix 7b); clinical and laboratory monitoring in courses lastng longer than 10 days; interactons (Appendix 6a, 6c, 6d); prolonged use may result in fungal or bacterial superinfecton, phenobarbitones, history of seizure disorder. Adverse Efects Nausea, vomitng, unpleasant metallic taste, furred tongue and gastrointestnal distur- bances; rarely, headache, drowsiness, dizzi- ness, ataxia, darkening of urine, erythema multforme, pruritus, urtcaria, angioedema and anaphylaxis; abnormal liver functon tests, hepatts, jaundice; thrombocytope- nia, aplastc anaemia; myalgia, arthralgia; peripheral neuropathy, epileptform seizures; leukopenia on prolonged or high dosage reg- imens; anorexia, glossits, dryness of mouth. Tinidazole Pregnancy Category-C Schedule H Indicatons Amoebiasis, trichomoniasis and giardiasis, anaerobic infectons, necrotsing ulceratve gingivits, bacterial vaginosis, H. Parenteral Bacterial vaginosis and ulceratve gingivits: Adult- 2g as a single dose parenterally. Contraindicatons Hypersensitvity to nitroimidazole derivatves, frst trimester of pregnancy (Appendix 7c), lactaton, blood dyscrasias, porphyria; interactons (Appendix 6a). Benzylpenicillin and phenoxymethylpenicillin are actve against susceptble strains of Gram-positve bacteria and Gram-negatve bacteria, spirochaetes and actnomycetes, but are inactvated by penicillinase and other beta-lactamases. Benzathine benzylpenicillin and procaine benzylpenicillin are long-actng preparatons which slowly release benzylpenicillin on injecton. A range of penicillins with improved stability to gastric acid and penicillinases have been produced by substtuton of the 6-amino positon of 6-aminopenicillanic acid. Cloxacillin is an isoxazoyl penicillin which is resistant to staphylococcal penicillinase. Broad-spectrum penicillins such as ampicillin are acid-stable and actve against Gram-positve and Gram-negatve bacteria, but are inactvated by penicil- linase. Beta-lactamase inhibitors such as clavulanic acid are ofen necessary to provide actvity against beta-lactamases produced by a wide range of both Gram-negatve and Gram- positve bacteria. Cephalosporins are classifed by generaton, with the frst generaton agents having Gram-positve and some Gram- negatve actvity; the second generaton drugs have improved Gram-negatve actvity and the third generaton cephalosporin have a wider spectrum of actvity, although may be less actve against Gram-positve bacteria than frst generaton drugs, but they are actve against Gram-negatve Enterobacteriaceae and Pseudomonas aeruginosa. This rare, but serious adverse efect may result from very high doses or in severe renal failure. Penicillins should not be given by intrathecal injecton because they can cause encephalopathy which may be fatal. Hypersensitvity: The most important adverse efect of penicillins is hypersensi- tvity which causes rashes and, occasionally anaphylaxis, which can be fatal. Allergic reactons to penicillins occur in 1-10% of exposed individuals, while anaphylactc reactons occur in fewer than 0. Individuals with a history of anaphylaxis, urtcaria or rash immediately afer peni- cllin administraton are at risk of immediate hypersensitvity to penicillin. These individuals should not receive penicillin, rather a cephalosporins or another beta-lactam antbiotc may be used. Patents who are allergic to one penicillin will be allergic to them all because the hypersensitvity is related to the basic penicillin structure and about 10% of penicillin-sensitve patents will be allergic to cephalosporins and other beta-lactams. Individuals with a history of a minor rash (a non-confuent rash restricted to a small area of the body) or a rash occurring more than 72 h afer penicillin administraton are possibly not allergic to peni- cillin and in these individuals a penicillin should not be withheld unnecessarily for a serious infecton; however, the possibility of an allergic reacton should be borne in mind and facilites should be available for treatng anaphylaxis.

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The inital phase (2 months) involves the concurrent use of at least 3 drugs to reduce the bacterial populaton rapidly and prevent drug-resistant bacteria emerging buy 25mg antivert overnight delivery medications list form. The second contnuaton phase (4-6 months) involves fewer drugs and is used to eliminate any remaining bacteria and prevent recur- rence purchase 25mg antivert free shipping treatment yeast in urine. Direct observaton of therapy is considered essental to ensure compliance in the inital phase and also useful in the contnuaton phase if patents are receiving rifampicin. Unsupervised and alternatve regimens as set out in the following tables may be administered as specifed. Chemoprophylaxis with isoniazid can prevent the devel- opment of clinically apparent disease in persons in close contact with infectous patents and also prevent the reac- tvaton of previously dormant disease in other persons at high risk partcularly those who are immunodefcient. Dose Intramuscular or intravenous injecton or infusion Adult- 15 mg/kg body weight daily in two divided doses, increased to 22. Neonates- loading dose is 10 mg/kg body weight followed by 15 mg/kg body weight in two divided doses. Precautons Pregnancy (Appendix 7c), renal impairment (Appendix 7d); neonates, infants and elderly; cross allergenicity. Adverse Efects Vestbular and auditory damage, nephrotoxicity; rarely, hypomagnesaemia on prolonged therapy, antbiotc-associated colits, stomatts; also reported, nausea, vomitng, rash, blood disorders; acute muscular paralysis; albuminuria; azotemia. Capreomycin Pregnancy Category-C Schedule H Indicatons Tuberculosis, in combinaton with other frst line drugs for tuberculosis. Dose Deep intramuscular injecton Adult- 1g daily for 2 to 4 months (not more than 20 mg/kg body weight). Then 1 to 2g 2 to 3 tmes each week, in case of renal impairment reduce the dose in accordance with creatnine clearance. Precautons Renal impairment; hepatc impairment; auditory impairment; monitor renal, hepatc, auditory and vestbular functon and electrolytes; pregnancy (teratogenic in animals; Appendix 7c) and lactaton; interactons (Appendix 6c). Adverse Efects Hypersensitvity reactons including urtcaria and rashes; eosinophilia; leucocytosis or leucopenia, rarely, thrombocytopenia; changes in liver functon tests; nephrotoxicity, electrolyte disturbances; hearing loss with tnnitus and vertgo; neuromuscular block afer large doses, pain and induraton at injecton site. Cycloserine Pregnancy Category-C Schedule H Indicatons Tuberculosis resistant to frst-line drugs. Dose Oral Adult-Initally 250 mg every 12 h for 2 weeks, increase according to blood concentraton and response to 500 mg every 2 h. Child- Initally 10 mg/kg body weight daily adjusted to blood concentraton and response. Contraindicatons Severe renal impairment; epilepsy; depression, severe anxiety, psychotc states, alcohol dependence; porphyria; hypersensitvity. Dose Oral Adult- 15 mg/kg body weight as a single dose, retreatment with 25 mg/kg body weight as a single dose for two months, thereafer reduce to 15 mg/kg body weight. Contraindicatons Optc neurits; children under 5 years-unable to report symptomatc visual disturbances; severe renal impairment; hypersensitvity. Precautons Visual disturbances-ocular examinaton recommended before and during treatment (see note below); reduce dose in renal impairment (Appendix 7d) and monitor plasma concentraton; elderly; pregnancy (Appendix 7c) (not known to be harmful); lactaton. Note: Patents should report visual disturbances immediately and discontnue treatment; children who are incapable of reportng symptomatc visual changes accurately should be given alternatve therapy, as should, if possible, any patent who cannot understand warnings about visual adverse efects Adverse Efects Optc neurits-reduced visual acuity and red/ green colour blindness (early changes usually reversible, prompt withdrawal may prevent blindness); peripheral neurits-especially in legs; gout; rarely, rash, pruritus, urtcaria, thrombocytopenia; pulmonary infltrates gastrointestnal upset. Isoniazid* Pregnancy Category-C Schedule H Indicatons Tuberculosis, in combinaton with other drugs; tuberculosis prophylaxis also. Patents or their caretakers should be told how to recognize signs of liver disorder and advised to discontnue treatment and seek immediate medical atenton if symptoms such as nausea, vomitng, malaise or jaundice develop. Adverse Efects Gastrointestnal disorders including nausea and vomitng, diarrhoea and pain, also constpaton, dry mouth; hypersensitvity reactons including fever, rashes, joint pain, erythema multforme, purpura usually during frst weeks of treatment; peripheral neuropathy; blood disorders including agranulocytosis, haemolytc anaemia, aplastc anaemia; optc neurits, toxic psychoses and convulsions; hepatts (especially over age of 35 years and regular users of alcohol)-withdraw treatment; also reported systemic lupus erythematosus- like syndrome, pellagra, hyperrefexia, difculty with micturiton, hyperglycaemia and gynaecomasta; memory impairement, elevated serum transaminase, rheumatc syndrome, pyridoxine syndrome. Kanamycin Pregnancy Category-D Schedule H Indicatons Tuberculosis; hepatc coma; penicillin resistant gonorrhoea, chronic bacterial infectons. Contraindicatons Lactaton; pregnancy (Appendix 7c); hypersensitvity; renal impairment. Precautons Myasthenia gravis; renal impairment; elderly patents with neuromuscular disorder.

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Dose Slow intravenous injecton Adult- Conscious sedaton: approximately 2 mg/min; 5 to 10 min before procedure; initally 2 to 2 antivert 25mg generic symptoms 4 days before period. Intramuscular injecton Adult- Sedaton in combined anaesthesia: 30 to 100 µg/kg repeated as required by contnuous intravenous infusion 30 to 100 µg/ kg/h (lower doses in elderly) buy antivert 25 mg on line medicine news. Contraindicatons Acute narrow angle glaucoma; comatose patents; shock; acute alcohol intoxicaton; for intrathecal and epidural use; acute pulmonary insufciency; myasthenia gravis. Precautons Chronic renal failure; cardiac disease; open angle glaucoma; respiratory disorders; neonates; prolonged use and abrupt withdrawal should be avoided; hepatc impairment; pregnancy (Appendix 7c) and lactaton; interactons (Appendix 6a, 6c). Dose Subcutaneous or intramuscular injecton Adult- Preoperatve medicaton before procedure: up to 10 mg; 60 to 90 min before procedure; 20 to 30 mg per 12 h depending on patent weight. Child- (By intramuscular injecton) Preopera- tve medicaton before procedure: 150 µg/kg. Postoperatve analgesia: 8 to10 mg over 30 min (slow intravenous infusion); then 2 to 2. Child- Intra-operatve analgesia: 100 µg/kg; repeated every 40 to 60 min as required. Contraindicatons Patents with acute respiratory depression and when there is risk of paralytc ileus; conditons associated with raised intracranial pressure and in head injury (they interfere with pupilary responses vital for neurological assessment); comatose patents; acute asthma; acute liver disease; acute alcoholism; pulmonary oedema; interactons (Appendix 6a, 6c, 6d); lactaton (Appendix 7b); hepatc impairment (Appendix 7a). Precautons Patents with impaired respiratory functon (avoid in chronic obstructve pulmonary disease) and asthma (avoid during an acute atack); hypotension; myasthenia gravis; prostatc hypertrophy and hyperplasia; obstructve or infammatory bowel disorders; disease of the biliary tract and convulsive disorders; pancreatts; cardiac arrhythmias; hypothyroidism; head injury; circulatory shock; lactaton; pregnancy (Appendix 7c). Adverse Efects Nausea and vomitng (partcularly in inital stages); constpaton; dry mouth and biliary spasm; larger doses produce muscle rigidity; hypotension and respiratory depression; bradycardia; paralytc ileus; abdominal pain; anorexia; dyspepsia; exacerbaton of pancreatts; taste disturbance; hypertension; hypothermia; syncope; bronchospasm; inhibiton of cough refex; restlessness; seizures; paraesthesis; asthenia; malaise; disorientaton; excitaton; agitaton; delirium; raised intracranial pressure; amenorrhoea; myoclonus; muscle fasciculaton and rhabdomyolysis. Contraindicatons Child under 1 year; impaired consciousness due to cerebral depressants or of other origin; porphyria. Precautons Prostatc hypertrophy; urinary retenton; glaucoma; epilepsy; hepatc impairment (Appendix 7a); lactaton (Appendix 7b); interactons (Appendix 6a); pregnancy (Appendix 7c). Warn patent not to perform skilled tasks; for example operatng machinery, driving for 24 h. Adverse Efects Drowsiness (rarely, paradoxical stmulaton in children); headache; antcholinergic efects such as dry mouth; blurred vision; urinary retenton. Drugs for Infammatory Bowel Disease Ulceratve colits and Crohn’s disease are infammatory diseases of the intestnal tract. Ulceratve Colits: Acute atacks of ulceratve colits require treatment with local cortcosteroids such as hydrocortsone in the form of suppositories or retenton enemas. Because of the risk of intestnal perforaton, rectal administraton of hydrocort- sone must be used with extreme cauton in patents with severe ulceratve disease and should not be given to such patents without conductng a thorough proctological exami- naton. More extensive disease requires oral cortcosteroid treatment and severe extensive or fulminant disease needs hospital admission and intravenous cortcosteroid admin- istraton; other therapy may include intravenous fuid and electrolyte replacement, blood transfusion and possibly parenteral nutriton and antbiotcs. The aminosalicylate sulfasalazine is useful in the treatment of symptomatc disease. It also has value in the mainte- nance of remission in ulceratve colits for which cortcos- teroid treatment is unsuitable because of adverse efects. Antmotlity drugs such as codeine and antspasmodic drugs should not be used in actve ulceratve colits because they can precipitate para- lytc ileus and megacolon. Diarrhoea resultng from reduced bile salt absorpton may improve with cholestyramine. Irritable bowel syndrome during remission of ulceratve colits requires avoidance of a high-fbre diet and possibly treatment with an antspasmodic. Crohn’s Disease: Treatment of Crohn’s disease of the colon is similar to that of ulceratve colits. Symptoms and infammaton associated with disease exacerbaton are suppressed by oral cortcosteroids such as prednisolone. Other antbacterials should be given if specif- cally indicated (for example, sepsis associated with fstulas and perianal disease) and for managing bacterial overgrowth in the small bowel. Contraindicatons Glaucoma, refux oesophagits, myasthenia gravis, lactaton, intestnal obstructon. Adverse efects Dry mouth; nausea; vomitng; constpaton; taste loss; anorexia; dizziness; dyskinesia; lethargy, respiratory arrest; drowsiness; photophobia, blurred vision; increased ocular pressure; tachycardia; urinary retenton. Storage Injecton: Store protected from light, in single dose or multple dose containers. Dose Rectal (suppositories) Adult- Ulceratve colits, proctts: 25 mg twice daily for 2 weeks; may be increased to 25 mg 3 tmes daily or 50 mg twice daily in severe cases; in facttal proctts treatment may be required for 6 to 8 weeks. Contraindicatons Use of enemas in bowel obstructon, bowel perforaton, or extensive fstulas; untreated infectons.

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