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By D. Javier. Bowie State University.

Chromium absorption through the small intestine is very poor; so normally order 500mg cipro, a lot of it gets excreted in urine generic 750mg cipro otc. People with diabetes excrete even more chromium than healthy people; and the loss of this vital nutrient makes it harder for their bodies to respond to insulin discount cipro 250 mg mastercard. Studies show that chromium supplements can help both Type 1 and Type 2 diabetics control their blood sugar. The picolinate form of chromium called "chromium picolinate" is the most absorbable. It is a unique molecule that combines chromium with picolinic acid, a compound found in breast milk, which helps the body better absorb and process minerals. In addition, Chromax®; has demonstrated that it is significantly more bioactive than other forms of chromium. Vandium (vanadyl sulfate) is a trace element that exhibits a variety of significant insulin- mimetic properties. Clinical trials indicate that "in vitro", vanadium salts have most of the same major effects of insulin on insulin-sensitive tissues. Favorable results are seen, as well, in animal models of insulin deficiency, where vanadium significantly reduces blood glucose levels, and in insulin- resistant diabetic animals, where vanadium improves glucose homeostasis. In "in vivo" animal studies, examining the relationship between hyperinsulinemia, insulin resistance and hypertension, vanadium compounds produce significant, sustained decreases in both plasma insulin concentration and blood pressure. Clinical trials with vanadium compounds have produced benefits in both type 1 and type 2 diabetic patients. Six type 2 diabetic subjects treated with 100 milligrams of vanadyl sulfate daily for four weeks had significant reductions in fasting plasma glucose; beneficial effects on insulin sensitivity persisted for up to four weeks after vanadium treatment ended. Banaba Leaf Banaba (Lagerstroemia speciosa) is a plant native to India, Southeast Asia and the Philippines and has several medicinal uses. In many cultures the banaba leaf is brewed into a tea and used as a treatment for diabetes and as a weigh loss aid. Banaba Leaf Extract provides a blood sugar lowering effect similar to that of insulin in that it induces glucose transport from the blood into body cells. Recently, researchers have isolated an active ingredient in the banaba leaf called corosolic acid which was originally thought to be "the" blood sugar regulating substance in the leaf. Other researchers have found that corosolic acid may not be the only active ingredient in banaba leaves. A study published in the journal Planta Medica in 2001 compared a whole- leaf extract of banaba with insulin in cell cultures. Another study reported that banaba leaf extract contains at least three active ingredients that effect blood sugar. In animal studies, administration of banaba leaf extract resulted in a significant decrease of blood glucose. The same studies suggest that corosolic acid may stimulate glucose transport into tissue. In other animal studies, administration of banaba leaf extract resulted in reduced weight gain, reduced triglyceride accumulation and reduced adipose tissue, with no changes in diet. In noninsulin-dependent animals, administration of banaba leaf extract resulted in suppressed blood plasma glucose, lower serum insulin and lower urinary excretion of glucose. In clinical studies conducted by Dr William Judy and associates at the Southeastern Institute of Biomedical Research in Bradenton, Florida, a one per cent corosolic acid extract of banaba leaf reportedly reduced serum glucose 20-30% in people with type 2 diabetes, but did not reduce serum glucose in healthy individuals. In a prior study, some of the same researchers observed that individuals receiving the corosolic acid extract also had an increased tendency toward weight loss. Momordica Bitter melon is the common name for Momordica charantia, also known as African cucumber, balsam pear and bitter gourd. The plant is aptly named, as all parts of the plant, including the fruit, taste bitter. Widely sold in Asian groceries as a vegetable, bitter melon is employed as a folk remedy primarily for regulating blood sugar in cases of diabetes, as well as for colitis and dysentery, intestinal worms, jaundice and fevers. Current understanding of the phytochemicals in bitter melon suggests that these multiple uses are well founded. Among the constituents in bitter melon, charantin is identified as a primary agent for blood- sugar regulation. Charantin demonstrates hypoglycaemic (blood sugar lowering) or other actions of potential benefit in diabetes. The fruits also contain insulin-like peptides, including one known as polypeptide P, and alkaloids. It is likely that several substances in bitter melon contribute to its blood sugar-modifying effects. In human studies, bitter melon demonstrates significant blood-sugar control after food intake and overall blood sugar- lowering effects. In a study published in the journal Chemistry & Biology- March 2008, a research team, headed by Dr. Mon-Jia Tan of the Chinese Academy of Sciences in Shanghai, concluded that bitter melon has potent anti-diabetes effects. In their study, Tan and colleagues isolated and described several compounds from bitter melon known as cucurbitane triterpenoids, and tested their effects on glucose (sugar) and fat metabolism in cells and in mice. Tests in mice of two of the compounds found that they promoted both glucose tolerance and fat burning, and one was particularly effective in promoting glucose tolerance in animals consuming high fat diets. The researchers note that there may be as many as 70 active compounds in bitter melon. Momordica has also been found to be just as effective as glibenclamide in reducing blood sugar levels (J Ethnopharmacol 2003; 88(1): 107-111). In fact, a large study at Harvard University Medical School concluded that mormodica is one of the best natural remedies for diabetes (Diabetes Care 2003; 26(4): 1277-1294). It appears that mormodica contains compounds similar in structure to insulin, which have the same effects in regulating blood sugar levels. There is also evidence that mormodica can prevent the release of excess glucose into the bloodstream from the liver (Am J Health Syst Pharm 2003; 60(4): 356- 359). Gymnema Sylvestre Gymnema Sylvestre is another herb, whose traditional use in treating diabetes, has been backed up by recent medical research.

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Phenothiazides Phenothiazides are used for several medical indications (nausea purchase cipro 750mg fast delivery, vomiting buy cipro 500 mg free shipping, psychotic dis- orders discount 750 mg cipro visa, mild pain). Prochlorperazine, chlorpromazine, and promethazine are the most commonly used phenothiazine derivatives used to treat nausea and vomiting during pregnancy. Phenothiazine use during pregnancy may be associated with extrapyramidal symptoms in the mother as well as the fetus, but these adverse effects are uncommon (Hill et al. The phenothiazide class does not seem to be asso- ciated with an increased frequency of congenital anomalies when used during gestation. Promethazine Promethazine is sold under several proprietary names, but Phenergan is the known brand. Among over a hundred infants whose mothers took promethazine in the first trimester, the frequency of malformations was not increased (Heinonen et al. Neither was the frequency of malformations increased in two other studies that included several- hundred women who used the drug during their first trimester (Aselton et al. The frequency of malformations was also not increased in the offspring of animals exposed to this agent (King et al. Chlorpromazine The frequency of birth defects was not increased among infants of more than 400 women who took chlorpromazine during embryogenesis (Farkas and Farkas, 1971; Heinonen et al. The frequency of congenital anomalies was not increased among rodents whose mothers were given large doses of the drug during embryogenesis (Beall, 1972; Jones-Price et al. Prochlorperazine Published studies include over 3000 women who took prochlorperazine during preg- nancy, involving over 1000 exposed during the first trimester (Heinonen et al. The frequency of congenital anomalies was not increased in the offspring of women who took the drug in the first trimester. The frequency of cleft palate was increased in the offspring of pregnant animals given large doses of prochlorperazine during embryogenesis (Roux, 1959; Szabo and Brent, 1974). Gastrointestinal medications during pregnancy 227 Piperazine derivatives Cyclizine, buclizine, and meclizine are piperazine derivatives used for their antiemetic and anti- histamine properties. The frequency of congenital anomalies was not increased in association with the exposure to cyclizine or meclizine during the first trimester in the Collaborative Perinatal Project in more than 1000 infants (Heinonen et al. Among 111 infants whose mothers took cyclizine in the first trimester, no increase in congenital anomalies was found (Milkovich and van den Berg, 1976). Doxylamine-pyridoxine The combination of doxylamine–pyridoxine (Bendectin) has received considerable attention over the past decade as a possible teratogen. Until it was taken off the market, Bendectin was the most commonly prescribed antiemetic for hyperemesis during preg- nancy. There have been reports of an association of Bendectin use with diaphragmatic hernias (Bracken and Berg, 1983) and with congenital heart disease and pyloric steno- sis (Aselton et al. Among more than 1100 infants exposed to doxylamine (Bendectin) during the first trimester of pregnancy, the frequency of congenital anomalies was not increased (Heinonen et al. No statistically significant association was found between doxylamine and congenital heart disease in a large case–control study (Zierler and Rothman, 1985). Millions of women used Bendectin during the first trimester of pregnancy with no apparent epidemic of birth defects or adverse fetal effects. Therefore, it seems very unlikely that either doxylamine or pyridoxine is a significant human teratogen. It is generally accepted that neither Bendectin nor its components caused birth defects in human infants. It is most often utilized for severe nausea and vomiting associated with cancer chemotherapy. It has also been utilized for severe hyperemesis gravidarum (World, 1993; Guikontes et al. In unpublished studies, this agent was not teratogenic in animal studies (infor- mation provided by the manufacturer). Prokinetic agents Prokinetic agents stimulate upper gastrointestinal tract motility and are utilized prima- rily for the treatment of gastrointestinal reflux. Two agents are currently available in this 228 Nutritional and dietary supplementation during pregnancy class: cisapride (Propulsid) and metoclopramide (Reglan). Among 88 infants born to women who used cisapride during the first trimester, the frequency of congenital anom- alies was not increased (Bailey et al. Metoclopramide is also used as an antiemetic, especially for postoperative nausea. Among 175 infants born to women who used metoclopramide during the first trimester, the frequency of congenital anomalies was 4. According to the manufacturer, metoclopramide was not teratogenic in rats or rabbits (unpublished data). Interestingly, cisapride is listed as a category C drug and metoclopramide as a category B drug. In view of the data, both prokinetic agents appear safe for use during pregnancy, keeping in mind that metoclopramide has a larger cohort size and more power. Anticholinergics Anticholinergics are mainly used as antispasmodics and in the therapy of gastrointesti- nal diseases (ulcer disease, irritable bowel disease). Some of these medications are uti- lized for other nongastrointestinal indications, such as cardiac arrhythmias or urologic disorders. The frequency of congenital anomalies was not increased among more than 450 women who received this agent in early pregnancy (Heinonen et al. Skeletal Gastrointestinal medications during pregnancy 229 anomalies were reported to be increased in one animal study (Arcuri and Gautieri, 1973). Such anomalies have not been reported to date in humans and the data suggest atropine is a safe drug for use during pregnancy. The frequency of congenital anomalies was no different from control in the offspring of the almost 400 women who received this medication in early preg- nancy (Heinonen et al. The frequency of birth defects was not increased among the offspring of rodents given doses much larger than the human dose during embryo- genesis (George et al. Among more than 500 infants born to women who took belladonna during the first trimester, the fre- quency of major congenital anomalies was not increased (Heinonen et al.

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Of the noncardiac adverse reac- tions effective cipro 250 mg, pulmonary toxicity is the most serious; in one study it occurred between 6 d and 60 mo of treatment in 33 of 573 patients order 750 mg cipro with visa, with three deaths buy cipro 1000 mg with mastercard. The mechanism is unclear but may relate to a hypersensitivity reaction and/or widespread phospholipidosis. Dys- pnea, nonproductive cough, and fever are common symptoms, with rales, hypoxia, a positive gallium scan, reduced diffusion capacity, and radiographic evidence of pul- monary infiltrates noted. Steroids can be tried, but no controlled studies have been done to support their use. A 10% mortality in patients with pulmonary inflammatory changes results, often in patients with unrecognized pulmonary involvement that is allowed to progress. Chest roentgenograms at 3-mo intervals for the first year and then twice a year for several years have been recommended. Although asymptomatic elevations of liver enzymes are found in most patients, the drug is not stopped unless values exceed two or three times normal in a patient with initially abnormal values. Neurological dysfunction, photosensitivity (perhaps minimized by sunscreens), bluish skin discolor- ation, corneal microdeposits (in almost 100% of adults receiving the drug more than 6 mo), gastroenterological disturbances, and hyperthyroidism (1–2%) or hypothyroidism (2–4%) can occur. Cardiac side effects include symptomatic bradycardias in about 2%, aggravation of ventricular tachyarrhythmias (with occasional development of torsades de pointes) in 1–2%, possibly higher in women, and worsening of congestive heart failure in 2%. Possibly due to interactions with anes- thetics, complications after open-heart surgery have been noted by some, but not all, investigators, including pulmonary dysfunction, hypotension, hepatic dysfunction, and 226 Auer low cardiac output. Important interactions with other drugs occur, and when given concomitantly with amiodarone, the dose of warfarin, digoxin, and other antiarrhythmic drugs should be reduced by one-third to one-half and the patient watched closely. Drugs with synergistic actions, such as beta-blockers or calcium channel blockers, must be given cautiously. Therapy with this drug in patients with renal disease should be extremely conservative. Overall, new or worsened ventricular tachyarrhythmias occur in about 4%, and this response is due to torsades de pointes in about 2. The incidence of torsades de pointes increases to 4% in patients with a history of sustained ventricular tachycardia and is dose related, report- edly only 1. Other adverse effects commonly seen with other beta-blockers also apply to sotalol. Adenosine Transient side effects occur in almost 40% of patients with supraventricular tachy- cardia given adenosine and are most commonly flushing, dyspnea, and chest pressure. Drug Interactions (Selection; Amiodarone Preferred) Drug interactions associated with amiodarone are pharmacodynamic and/or phar- macokinetic in nature. The pharmacodynamic interactions associated with amiodarone occur primarily with other antiarrhythmics and are a consequence of additive or syner- gistic electrophysiologic effects. As the pharmacologic effects of amiodarone are delayed by several days even with adequate loading doses, concomitant use of another antiarrhy- thmic is often necessary. Should this be the case, the dose of the secondary antiarrhy- thmic should, in general, be decreased by 30–50% after the first few days of initiating amiodarone therapy. Discontinuation of the second antiarrhythmic agent should be attempted as soon as the therapeutic effects of amiodarone are observed. Conversely, in patients requiring combination therapy, the dose of the second antiarrhythmic should, in general, be decreased by 50% until amiodarone eliminated from the body. Proarrhyth- mia, including torsade de pointes (Table 1) and monomorphic ventricular tachycardia can and has occurred when amiodarone was administered in combination with any num- 7. Caution should be exercised when amiodarone is administered with any drug with elec- trophysiologic effects. As a consequence, it has been reported to reduce the metabolism of cer- tain drugs. Of these drugs, the most significant interactions are reported with anticoag- ulants, antiarrhythmics, phenytoin, and cyclosporin. The anticoagulant effects of warfarin and nicoumalone are significantly increased when amiodarone is added. Concurrent use of amiodarone with cyclosporin need not be avoided but cyclo- sporin serum levels can be increased and must be monitored. Flecainide concentrations increase by an average of 60% with concomitant amio- darone therapy. Although the exact mechanism of the interaction is unknown, it is postu- lated that the hepatic metabolism and/or renal clearance of flecainide may be decreased. An empiric reduction of the flecainide dose by 50% is suggested 2–3 d following initiation of amiodarone therapy. Quinidine serum concentrations generally increase by about 33% in patients receiv- ing concomitant amiodarone therapy. Although the mechanism is unclear, it appears that hepatic and/or renal clearance may be diminished and quinidine may also be dis- placed from tissue- and protein-binding sites. An empiric reduction of the quinidine dose by 50% is suggested within 2 d following initiation of amiodarone therapy with consideration given to immedi- ately discontinuing quinidine once amiodarone therapy is begun. The precise pharmacokinetic mech- anism of this interaction has not been elucidated, although a reduction in the renal clearance of both parent and metabolite, as well as a reduction in hepatic metabolism seem likely. In general, it is recommended to discontinue completely or reduce the procainamide daily dose by 25% during the first week of initiating amio- darone therapy. Concomitant administration of b-blockers, or calcium-channel blockers with ami- odarone may result in additive electrophysiologic effects including bradycardia, sinus arrest, and atrioventricular block. In general these drugs should only be continued in patients at risk of significant bradycardia if a permanent artificial pacemaker is in place. In addi- tion, amiodarone can decrease the clearance of drugs eliminated by hepatic metabolism. Severe cardiovascular reactions were observed when amiodarone was coadministered with metoprolol and propranolol. Amiodarone increases serum levels of digoxin when given concomitantly, and an empiric 50% dosage reduction is advised upon initiation of amiodarone therapy. The degree to which digoxin serum concentrations will increase is not predictable and reassessment of the need for both drugs is prudent. The mechanism of the increase in digoxin serum concentration is complex and not well understood, but is thought to result from an amiodarone-induced displacement of digoxin from tissue-binding sites, an increase in bioavailability, and/or a decrease in renal or nonrenal clearance. Furthermore, amio- darone may induce changes in thyroid function and alter sensitivity to cardiac glycos- ides, and thyroid function should be monitored closely in patients receiving both drugs simultaneously.