In response the pituitary gland reduces its own release of adrenocorticotrophic hormone. ACTH normally stimulates the adrenal glands to release their natural corticosteroids, but with reduced levels of ACTH this does not happen. With prolonged use of anti-inflammatory corticosteroids, the adrenal glands atrophy and lose their ability to synthesize their natural corticosteroids. If the corticosteroid drugs are stopped and the adrenal glands are no longer able to produce sufficient natural corticosteroids, the body will be unable to withstand every day stresses, a situation that can be life threatening. Anti-inflammatory corticosteroids depress the immune system.

Alternatively, a doctor may have referred the patient. However the patient presents, the health care professional working within the PGD is responsible for assessing that the patient fits the criteria set out in the PGD. In general, a PGD is not meant to be a long-term means of managing a patients clinical condition. This is best achieved by a health care professional prescribing for an individual patient on a one-to-one basis. An example of a service using PGDs, which was cited in the Crown Report (Department of Health, a podiatric surgeon can use a PGD to give a patient a supply of NSAIDs for post-operative pain.

All health care professionals who are involved in prescribing, andor administration of medicines have to abide by standards set out by their respective professional bodies. For podiatrists, radiographers and physiotherapists, this is the Health Professions Council. Health care professionals have a responsibility to consult documentation produced by the professional bodies and be accountable for prescribing and administering drugs. All members of health care professions have a responsibility to reduce the risk of errors in prescribing, must assess and appraise their own practice and show a commitment to continuing professional development. This is essential not least because information about drugs and associated legislation is constantly changing.

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Other drugs act as false substrates for the enzyme so that an abnormal product is made instead of the normal one. The abnormal product then brings about the action of the original drug. Methyldopa can be used again as an example here.

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These recommended doses should not be exceeded. As clearance and metabolism of zolpidem is reduced in hepatic impairment, dosage should begin at 5 mg in these patients with particular caution being exercised in elderly patients. In adults under 65 years dosage may be increased to 10 mg only where the clinical response is inadequate and the drug is well tolerated. Zolpidem must not be used in patients with severe hepatic impairment as it may contribute to encephalopathy see section 4.

In the absence of data, zolpidem should not be prescribed for children or patients with psychotic illness. The cause of insomnia should be identified wherever possible and the underlying factors treated before a hypnotic is prescribed. The failure of insomnia to remit after a 7 — 14 day course of treatment may indicate the presence of a primary psychiatric or physical disorder, and the patient should be carefully re-evaluated at regular intervals.

The risk of next-day psychomotor impairment, including impaired driving ability, is increased if Zolpidem should be taken in a single intake immediately at bedtime and not be re-administered during the same night. As hypnotics have the capacity to depress respiratory drive, precautions should be observed if zolpidem is prescribed to patients with compromised respiratory function. Concomitant use of zolpidem and opioids may result in sedation, respiratory depression, coma and death.

If a decision is made to prescribe zolpidem concomitantly with opioids, the lowest effective dose should be used, and the duration of treatment should be as short as possible see also general dose recommendation in section 4. Extreme caution should be exercised when prescribing for patients with a history of drug or alcohol abuse. These patients should be under careful surveillance when receiving zolpidem tartrate or any other hypnotic, since they are at risk of habituation and psychological dependence.

Some epidemiological studies suggest an increased incidence of suicidal ideation, suicide attempt and suicide in patients with or without depression, and treated with benzodiazepines and other hypnotics, including zolpidem. However, a causal relationship has not been established. Suicidal tendencies may be present therefore the least amount of zolpidem that is feasible should be supplied to these patients to avoid the possibility of intentional overdose by the patient. Pre-existing depression may be unmasked during use of zolpidem.

Since insomnia may be a symptom of depression, the patient should be re-evaluated if insomnia persists. Some loss of efficacy to the hypnotic effects of short-acting benzodiazepines and benzodiazepine-like agents like zolpidem may develop after repeated use for a few weeks. The risk of dependence increases with dose and duration of treatment. Zolpidem should be used with extreme caution in patients with current or a history of alcohol, substance or drug abuse or dependence.

Once physical dependence has developed, abrupt termination of treatment will be accompanied by withdrawal symptoms. These may consist of headaches or muscle pain, extreme anxiety and tension, restlessness, confusion and irritability. It may be accompanied by other reactions including mood changes, anxiety and restlessness. It is important that the patient should be aware of the possibility of rebound phenomena, thereby minimising anxiety over such symptoms should they occur when the medicinal product is discontinued.

There are indications that, in the case of benzodiazepines and benzodiazepine-like agents with a short duration of action, withdrawal phenomena can become manifest within the dosage interval, especially when the dosage is high. Benzodiazepines or benzodiazepine-like agents such as zolpidem may induce anterograde amnesia. The condition occurs most often several hours after ingesting the product and therefore to reduce the risk patients should ensure that they will be able to have an uninterrupted sleep of 8 hours see section 4.

Other psychiatric and paradoxical reactions like restlessness, exacerbated insomnia, agitation, irritability, aggression, delusion, anger, nightmares, hallucinations, psychosis, abnormal behaviour and other adverse behavioural effects are known to occur when using benzodiazepines or benzodiazepine-like agents.

Drugs used to treat anxiety and insomnia are often the same and because these conditions are common, the drugs are widely prescribed. Drug therapy is not the only possibility. Psychotherapy therapy techniques such as relaxation, cognitive behavioural therapy and counselling can benefit some patients. Drug therapy of anxiety is mainly with a group of drugs called benzodiazepines. Benzodiazepines are commonly used anxiolytics and hypnotics.

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Because cardiac failure results in hypertension and leads to oedema, diuretics are used in both cases because they encourage water loss and therefore produce a reduction in circulating blood volume. This lowers blood pressure, reduces the work the heart has to do and improves oedema by encouraging the movement of fluid from the tissues into the circulation. Of the different types of diuretics, the ones used in cardiac failure and hypertension are thiazide diuretics and loop diuretics. Thiazide diuretics work by inhibiting sodium and chloride ion transport in the distal convoluted tubule of the kidney and therefore limit water reabsorption.

Broader professional latitude is required so as to be more sensitive to patients on a serialchronic basis. Supplementary prescribing would be appropriate in these situations. Independent prescribing would grow out of supplementary prescribing for specific conditions and particular patient groups. Nuclear medicine is worthy of special mention for three reasons: Medicines for Human Use Miscellaneous Amendments Order, While working within zolpidem tevagen 10mg medicine, technicians and radiographers often have similar responsibilities.

Examples of PGDs are accessible on the internet and they follow a similar format to those given for podiatric surgery in Appendix C. Following amendments to the legislation in to become zolpidem tevagen 10mg prescribers, further changes to the NHS Regulations in April ( be treated by supplementary prescribers under an agreed CMP. Supplementary prescribing is best suited to the management of chronic conditions and includes the prescribing of general sales list medicines, pharmacy medicines and prescription-only medicines.

Adverse reactions are nausea and vomiting and bleeding. Anaemia results when, for whatever reason, there is not enough haemoglobin in the blood to carry sufficient oxygen around to the tissues. Typical symptoms of anaemia are fatigue due to anoxia and intolerance to cold and paleness due to low levels of haemoglobin. Haemorrhagic anaemia can be caused by large wounds, stomach ulcers or heavy menstrual bleeding. Sudden great loss of blood causes acute anaemia but slow prolonged bleeding can produce chronic anaemia.

The pleural membranes also ensure that the chest cavity is airtight. This is essential for the lungs to be able to expand as the ribs move. The hard and soft palates divide the nose from the throat and mouth. Air enters the nose through two openings, the nostrils. The nasal passages are lined with a moist hairy mucous membrane that traps dust, dirt and bacteria breathed in with air.

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