Category Prednisone Dosage

BUY ELDEPRYL ONLINE USA ~ BUY ELDEPRYL FREE SHIPPING

<h1>BUY ELDEPRYL ONLINE USA ~ BUY ELDEPRYL FREE SHIPPING</h1>

BUY ELDEPRYL ONLINE USA ~ BUY ELDEPRYL FREE SHIPPING

Easy to Buy FDA Approved ELDEPRYL ELDEPRYL online no prescription. ELDEPRYL online with next day shipping. ELDEPRYL overnight cod Buy ELDEPRYL with cod. ELDEPRYL deliver to uk fedex overnight. ELDEPRYL cash delivery. Buy ELDEPRYL ELDEPRYL ELDEPRYL ELDEPRYL Online Pharmacy Reviews ~ Buy ELDEPRYL Online Overnight
ELDEPRYL: ELDEPRYL Online In Usa ~ Order ELDEPRYL Online Overnight
What is ELDEPRYL?
INDICATIONS
Eldepryl is indicated as an adjunct in the management of Parkinsonian patients being treated with levodopa/carbidopa who exhibit deterioration in the quality of their response to this therapy.
INSTRUCTIONS
Take this medicine only as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered.
It is best to take this medicine before breakfast and without liquids.
If you are using the disintegrating tablet, make sure your hands are dry before you handle the tablet. Do not open the blister pack that contains the tablet until you are ready to take it. Remove the tablet from the blister pack by peeling back the foil, then taking the tablet out. Do not push the tablet through the foil. Do not break or split the tablet. Place the tablet on the top of your tongue, where it will melt quickly. Do not eat food or drink liquids for 5 minutes before or after taking this medicine.
If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.
DOSAGE
The dose of this medicine will be different for different patients. Follow your doctor’s orders or the directions on the label. The following information includes only the average doses of this medicine. If your dose is different, do not change it unless your doctor tells you to do so.
The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.
For oral dosage form (tablets):
For Parkinson’s disease:
Adults—At first, 1.25 milligrams (mg) once a day for at least 6 weeks. After 6 weeks, your doctor may increase your dose to 2.5 mg once a day.
Children—Use and dose must be determined by your doctor. Use and dose must be determined by your doctor.
STORAGE
Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.
Keep out of the reach of children.
Do not keep outdated medicine or medicine no longer needed.
MORE INFO:
Eldepryl is a levorotatory acetylenic derivative of phenethylamine. It is commonly referred to in the clinical and pharmacological literature as l-deprenyl.
SAFETY INFORMATION
It is very important that your doctor check your progress at regular visits to allow for changes in your dose and to check for any unwanted effects.
Do not take selegiline if you have used meperidine (e.g., Demerol®) or an MAO inhibitor (MAOI) (e.g., isocarboxazid, phenelzine, tranylcypromine, Marplan®, Nardil®, or Parnate®) within the past 14 days. If you do, you may develop agitation, confusion, restlessness, stomach or intestinal symptoms, sudden high body temperature, extremely high blood pressure, or severe convulsions.
Do not take cough medicines (e.g., dextromethorphan, Robitussin®, Pediacare®) or pain medicines (e.g., methadone, propoxyphene, tramadol, Darvon®, Dolophine®, Ultram®) while you are using this medicine. Using these medicines together can cause unwanted effects.
Selegiline may cause serious side effects when used together with some antidepressants. Tell your doctor if you have used amitriptyline, doxepin, fluoxetine, fluvoxamine, nortriptyline, paroxetine, sertraline, Elavil®, Luvox®, Pamelor®, Paxil®, Prozac®, or Zoloft® within the past 14 days.
When selegiline is taken at doses of 10 mg or less per day for the treatment of Parkinson’s disease, there are no restrictions on food or beverages you eat or drink. However, the chance exists that dangerous reactions, such as sudden high blood pressure, may occur if doses higher than those used for Parkinson’s disease are taken with certain foods, beverages, or other medicines. These foods, beverages, and medicines include:
Foods that have a high tyramine content (most common in foods that are aged or fermented to increase their flavor), such as cheeses; fava or broad bean pods; yeast or meat extracts; smoked or pickled meat, poultry, or fish; fermented sausage (bologna, pepperoni, salami, summer sausage) or other fermented meat; sauerkraut; or any overripe fruit. If a list of these foods and beverages is not given to you, ask your doctor to provide one.
Alcoholic beverages or alcohol-free or reduced-alcohol beer and wine.
Large amounts of caffeine-containing food or beverages such as coffee, tea, cola, or chocolate.
Any other medicine unless approved or prescribed by your doctor. This especially includes nonprescription (over-the-counter [OTC]) medicine, such as that for colds (including nose drops or sprays), cough, asthma, hay fever, and appetite control; “keep awake” products; or products that make you sleepy.
Also, for at least 2 weeks after you stop taking this medicine, these foods, beverages, and other medicines may continue to react with selegiline if it was taken in doses higher than those usually used for Parkinson’s disease.
Check with your doctor or hospital emergency room immediately if severe headache, stiff neck, chest pains, fast heartbeat, or nausea and vomiting occur while you are taking this medicine. These may be symptoms of a serious side effect that should have a doctor’s attention.
Dizziness, lightheadedness, or fainting may occur, especially when you get up from a lying or sitting position. Getting up slowly may help. If the problem continues or gets worse, check with your doctor.
Selegiline may cause dryness of the mouth. For temporary relief, use sugarless candy or gum, melt bits of ice in your mouth, or use a saliva substitute. However, if your mouth continues to feel dry for more than 2 weeks, check with your medical doctor or dentist. Continuing dryness of the mouth may increase the chance of dental disease, including tooth decay, gum disease, and fungus infections.
It is important that your doctor check your skin for melanoma (tumor) regularly if you have Parkinson’s disease.
Do not stop taking this medicine without first checking with your doctor. Your doctor may want you to reduce gradually the amount you are taking before stopping completely.
Hallucinations may occur in some patients. This is more common with elderly patients. If you have hallucinations, check with your doctor.
Some people who have used this medicine had unusual changes in their behavior. Talk with your doctor if you start having problems with gambling or increased sex drive while using this medicine.
SIDE EFFECTS
Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.
Check with your doctor immediately if any of the following side effects occur:
More common
Chest pain (severe)
enlarged pupils
fast or slow heartbeat
headache (severe)
increase in unusual movements of the body
increased sensitivity of the eyes to light
increased sweating (possibly with fever or cold, clammy skin)
mood or other mental changes
nausea and vomiting (severe)
stiff or sore neck
Less common or rare
Bloody or black, tarry stools
bruising
convulsions (seizures)
decreased urine
difficult or frequent urination
difficulty with breathing
difficulty with speaking
difficulty with swallowing
dizziness or lightheadedness, especially when getting up from a lying or sitting position
dry mouth
hallucinations (seeing, hearing, or feeling things that are not there)
increased thirst
irregular heartbeat
large, flat, blue, or purplish patches in the skin
lip smacking or puckering
loss of appetite
loss of balance control
muscle pain or cramps
nausea or vomiting
numbness or tingling in the hands, feet, or lips
puffing of the cheeks
rapid or worm-like movements of the tongue
restlessness or desire to keep moving
severe stomach pain
shakiness in the legs, arms, hands, or feet
shortness of breath
swelling of the feet or lower legs
swelling or inflammation of the mouth
tightness in the chest
trembling or shaking of the hands or feet
twisting movements of the body
uncontrolled chewing movements
uncontrolled movements of the face, neck, back, arms, or legs
unusual tiredness or weakness
vomiting of blood or material that looks like coffee grounds
wheezing
Get emergency help immediately if any of the following symptoms of overdose occur:
Symptoms of overdose
Agitation or irritability
chest pain
difficulty opening the mouth or lockjaw
dizziness (severe) or fainting
fast or irregular pulse (continuing)
high fever
high or low blood pressure
severe spasm where the head and heels are bent backward and the body arched forward
troubled breathing
Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:
More common
Abdominal or stomach pain
dizziness or feeling faint
runny nose
sneezing
stuffy nose
trouble with sleeping
Less common or rare
Anxiety
back or leg pain
blurred or double vision
body aches or pain
burning of the lips, mouth, or throat
chills
constipation
cough
diarrhea
drowsiness
dryness or soreness of the throat
frequent urge to urinate
headache
heartburn
inability to move
increased sweating
irritability (temporary)
memory problems
nervousness
pounding or fast heartbeat
rash
red, raised, or itchy skin
ringing or buzzing in the ears
slow or difficult urination
slowed movements
taste changes
uncontrolled closing of the eyelids
unusual feeling of well-being
unusual weight loss
voice changes
Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.
buy ELDEPRYL on craigslist
ELDEPRYL No Prescription To Buy
ELDEPRYL For Sale Cod
Cheap ELDEPRYL Saturday Delivery
ELDEPRYL No Prescription Cod . ELDEPRYL Sale No Prescription Required
paginas para comprar ELDEPRYL
can i buy ELDEPRYL over the counter
BUY ELDEPRYL WITH NO PRESCRIPTION ~ ~ ELDEPRYL BUY FEDEX
Free Consultation – Fastest Shipping
ELDEPRYL Shipped By Ups
Order ELDEPRYL Er Without Rx
Buy Codest ELDEPRYL
ELDEPRYL cod no prescription required
Is ELDEPRYL Hcl A Narcotic
prescription! BuyING CheaP ELDEPRYL ! Guaranteed CheaPest ELDEPRYL! Buy generic ELDEPRYL!
Buy ELDEPRYL No Script
comprar provigrax ELDEPRYL natural españa
Buy ELDEPRYL Cod, ELDEPRYL For Sale Online No Prescription Required
No Rx ELDEPRYL Cod Delivery
Lowest Price And Best Quality Guaranteed
ELDEPRYL No Prescription Cod . ELDEPRYL Sale No Prescription Required
comprar ELDEPRYL en farmacia fisica
Cheap ELDEPRYL Cod Free Fedex :: ELDEPRYL Buy Onliine Without Prescription
ELDEPRYL Order
ELDEPRYL Overnight No Script ~ ELDEPRYL On Line Cash On Delivery ~ ELDEPRYL Xr Buy Online Cheap
Cash On Delivery ELDEPRYL
BUY CHEAP ELDEPRYL OVERNIGHT SHIPPING ONLINE ~ BUY ELDEPRYL COD OVERNIGHT
buy ELDEPRYL citrate powder
Fedex Online ELDEPRYL, Buy Online ELDEPRYL, Cheap ELDEPRYL No Pres
I Want To Purchase ELDEPRYL Without A Prescription
Order ELDEPRYL Without Script
doxycycline Online #Buy zovirax Online #Buy prednisone Online #Buy kamagra polo Online #Buy keftab Online #Buy periactin Online #Buy elavil Online #Buy fucidin Online #Buy calan Online #Buy acticin Online #Buy aricept Online #Buy inderal Online #Buy chloramphenicol Online #Buy zebeta Online #Buy tetracycline Online #Buy tadora Online #Buy adalat Online #Buy malegra dtx Online #Buy doxycycline Online #Buy abana Online #Buy fosamax Online #Buy metformin Online #Buy brahmi Online #Buy antabuse Online #Buy vasodilan Online #Buy viagra super active Online #Buy synthroid Online #Buy wellbutrin Online #Buy anacin Online

Read More…

Highly recommended Dog Training Tip site

<h1>Highly recommended Dog Training Tip site</h1>

Highly recommended Dog Training Tip site

0 6.2 Post-Marketing Experiences The following adverse reactions have been identified from clinical trials and/or post-marketing surveillance. Because they are reported from a population of unknown size, precise estimates of frequency cannot be made.
Body as a whole : diffuse pain, chest pain, radiation recall phenomenon.
Cardiovascular : atrial fibrillation, deep vein thrombosis, ECG abnormalities, thrombophlebitis, pulmonary embolism, syncope, tachycardia, myocardial infarction.
Cutaneous : very rare cases of cutaneous lupus erythematosus and rare cases of bullous eruptions such as erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, and Scleroderma-like changes usually preceded by peripheral lymphedema. In some cases multiple factors may have contributed to the development of these effects. Severe hand and foot syndrome has been reported. Cases of permanent alopecia have been reported.
Gastrointestinal : abdominal pain, anorexia, constipation, duodenal ulcer, esophagitis, gastrointestinal hemorrhage, gastrointestinal perforation, ischemic colitis, colitis, intestinal obstruction, ileus, neutropenic enterocolitis and dehydration as a consequence to gastrointestinal events have been reported.
Hematologic : bleeding episodes. Disseminated intravascular coagulation (DIC), often in association with sepsis or multiorgan failure, has been reported. Cases of acute myeloid leukemia and myelodysplasic syndrome have been reported in association with TAXOTERE when used in combination with other chemotherapy agents and/or radiotherapy.
Hypersensitivity : rare cases of anaphylactic shock have been reported. Very rarely these cases resulted in a fatal outcome in patients who received premedication.
Hepatic : rare cases of hepatitis, sometimes fatal primarily in patients with pre-existing liver disorders, have been reported.
Neurologic : confusion, rare cases of seizures or transient loss of consciousness have been observed, sometimes appearing during the infusion of the drug.
Ophthalmologic : conjunctivitis, lacrimation or lacrimation with or without conjunctivitis. Excessive tearing which may be attributable to lacrimal duct obstruction has been reported. Rare cases of transient visual disturbances (flashes, flashing lights, scotomata) typically occurring during drug infusion and in association with hypersensitivity reactions have been reported. These were reversible upon discontinuation of the infusion. Cases of cystoid macular edema (CME) have been reported in patients treated with TAXOTERE.
Hearing : rare cases of ototoxicity, hearing disorders and/or hearing loss have been reported, including cases associated with other ototoxic drugs.
Respiratory : dyspnea, acute pulmonary edema, acute respiratory distress syndrome/pneumonitis, interstitial lung disease, interstitial pneumonia, respiratory failure, and pulmonary fibrosis have rarely been reported and may be associated with fatal outcome. Rare cases of radiation pneumonitis have been reported in patients receiving concomitant radiotherapy.
Renal : renal insufficiency and renal failure have been reported, the majority of these cases were associated with concomitant nephrotoxic drugs.
Metabolism and nutrition disorders : cases of hyponatremia have been reported. BACK TO TOP 7. DRUG INTERACTIONS Docetaxel is a CYP3A4 substrate. In vitro studies have shown that the metabolism of docetaxel may be modified by the concomitant administration of compounds that induce, inhibit, or are metabolized by cytochrome P450 3A4.
In vivo studies showed that the exposure of docetaxel increased 2.2-fold when it was coadministered with ketoconazole, a potent inhibitor of CYP3A4. Protease inhibitors, particularly ritonavir, may increase the exposure of docetaxel. Concomitant use of TAXOTERE and drugs that inhibit CYP3A4 may increase exposure to docetaxel and should be avoided. In patients receiving treatment with TAXOTERE, close monitoring for toxicity and a TAXOTERE dose reduction could be considered if systemic administration of a potent CYP3A4 inhibitor cannot be avoided [see Dosage and Administration (2.7) and Clinical Pharmacology (12.3) ] . 8. USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category D [see ‘ Warnings and Precautions ‘ section ]
Based on its mechanism of action and findings in animals, TAXOTERE can cause fetal harm when administered to a pregnant woman. If TAXOTERE is used during pregnancy, or if the patient becomes pregnant while receiving this drug, the patient should be apprised of the potential hazard to the fetus. Women of childbearing potential should be advised to avoid becoming pregnant during therapy with TAXOTERE.
TAXOTERE can cause fetal harm when administered to a pregnant woman. Studies in both rats and rabbits at doses ≥0.3 and 0.03 mg/kg/day, respectively (about 1/50 and 1/300 the daily maximum recommended human dose on a mg/m 2 basis), administered during the period of organogenesis, have shown that TAXOTERE is embryotoxic and fetotoxic (characterized by intrauterine mortality, increased resorption, reduced fetal weight, and fetal ossification delay). The doses indicated above also caused maternal toxicity. 8.3 Nursing Mothers It is not known whether docetaxel is excreted in human milk. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions in nursing infants from TAXOTERE, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. 8.4 Pediatric Use The alcohol content of TAXOTERE Injection should be taken into account when given to pediatric patients [see Warnings and Precautions (5.11) ] .
The efficacy of TAXOTERE in pediatric patients as monotherapy or in combination has not been established. The overall safety profile of TAXOTERE in pediatric patients receiving monotherapy or TCF was consistent with the known safety profile in adults.
TAXOTERE has been studied in a total of 289 pediatric patients: 239 in 2 trials with monotherapy and 50 in combination treatment with cisplatin and 5-fluoruracil (TCF). TAXOTERE Monotherapy
TAXOTERE monotherapy was evaluated in a dose-finding phase 1 trial in 61 pediatric patients (median age 12.5 years, range 1–22 years) with a variety of refractory solid tumors. The recommended dose was 125 mg/m 2 as a 1-hour intravenous infusion every 21 days. The primary dose limiting toxicity was neutropenia.
The recommended dose for TAXOTERE monotherapy was evaluated in a phase 2 single-arm trial in 178 pediatric patients (median age 12 years, range 1–26 years) with a variety of recurrent/refractory solid tumors. Efficacy was not established with tumor response rates ranging from one complete response (CR) (0.6%) in a patient with undifferentiated sarcoma to four partial responses (2.2%) seen in one patient each with Ewing Sarcoma, neuroblastoma, osteosarcoma, and squamous cell carcinoma. TAXOTERE in Combination
TAXOTERE was studied in combination with cisplatin and 5-fluorouracil (TCF) versus cisplatin and 5-fluorouracil (CF) for the induction treatment of nasopharyngeal carcinoma (NPC) in pediatric patients prior to chemoradiation consolidation. Seventy-five patients (median age 16 years, range 9 to 21 years) were randomized (2:1) to TAXOTERE (75 mg/m 2 ) in combination with cisplatin (75 mg/m 2 ) and 5-fluorouracil (750 mg/m 2 ) (TCF) or to cisplatin (80 mg/m 2 ) and 5-fluorouracil (1000 mg/m 2 /day) (CF). The primary endpoint was the CR rate following induction treatment of NPC. One patient out of 50 in the TCF group (2%) had a complete response while none of the 25 patients in the CF group had a complete response. Pharmacokinetics:
Pharmacokinetic parameters for docetaxel were determined in 2 pediatric solid tumor trials. Following docetaxel administration at 55 mg/m 2 to 235 mg/m 2 in a 1-hour intravenous infusion every 3 weeks in 25 patients aged 1 to 20 years (median 11 years), docetaxel clearance was 17.3±10.9 L/h/m 2 .
Docetaxel was administered in combination with cisplatin and 5-fluorouracil (TCF), at dose levels of 75 mg/m 2 in a 1-hour intravenous infusion day 1 in 28 patients aged 10 to 21 years (median 16 years, 17 patients were older than 16). Docetaxel clearance was 17.9±8.75 L/h/m 2 , corresponding to an AUC of 4.20±2.57 μg.h/mL.
In summary, the body surface area adjusted clearance of docetaxel monotherapy and TCF combination in children were comparable to those in adults [see Clinical Pharmacology (12.3) ] . 8.5 Geriatric Use In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy in elderly patients. Non-Small Cell Lung Cancer
In a study conducted in chemotherapy-naïve patients with NSCLC (TAX326), 148 patients (36%) in the TAXOTERE+cisplatin group were 65 years of age or greater. There were 128 patients (32%) in the vinorelbine+cisplatin group 65 years of age or greater. In the TAXOTERE+cisplatin group, patients less than 65 years of age had a median survival of 10.3 months (95% CI: 9.1 months, 11.8 months) and patients 65 years or older had a median survival of 12.1 months (95% CI: 9.3 months, 14 months). In patients 65 years of age or greater treated with TAXOTERE+cisplatin, diarrhea (55%), peripheral edema (39%) and stomatitis (28%) were observed more frequently than in the vinorelbine+cisplatin group (diarrhea 24%, peripheral edema 20%, stomatitis 20%). Patients treated with TAXOTERE+cisplatin who were 65 years of age or greater were more likely to experience diarrhea (55%), infections (42%), peripheral edema (39%) and stomatitis (28%) compared to patients less than the age of 65 administered the same treatment (43%, 31%, 31% and 21%, respectively).
When TAXOTERE was combined with carboplatin for the treatment of chemotherapy-naïve, advanced non-small cell lung carcinoma, patients 65 years of age or greater (28%) experienced higher frequency of infection compared to similar patients treated with TAXOTERE+cisplatin, and a higher frequency of diarrhea, infection and peripheral edema than elderly patients treated with vinorelbine+cisplatin. Prostate Cancer
Of the 333 patients treated with TAXOTERE every three weeks plus prednisone in the prostate cancer study (TAX327), 209 patients were 65 years of age or greater and 68 patients were older than 75 years. In patients treated with TAXOTERE every three weeks, the following treatment emergent adverse reactions occurred at rates ≥10% higher in patients 65 years of age or greater compared to younger patients: anemia (71% vs. 59%), infection (37% vs. 24%), nail changes (34% vs. 23%), anorexia (21% vs. 10%), weight loss (15% vs. 5%) respectively. Breast Cancer
In the adjuvant breast cancer trial (TAX316), TAXOTERE in combination with doxorubicin and cyclophosphamide was administered to 744 patients of whom 48 (6%) were 65 years of age or greater. The number of elderly patients who received this regimen was not sufficient to determine whether there were differences in safety and efficacy between elderly and younger patients. Gastric Cancer
Among the 221 patients treated with TAXOTERE in combination with cisplatin and fluorouracil in the gastric cancer study, 54 were 65 years of age or older and 2 patients were older than 75 years. In this study, the number of patients who were 65 years of age or older was insufficient to determine whether they respond differently from younger patients. However, the incidence of serious adverse reactions was higher in the elderly patients compared to younger patients. The incidence of the following adverse reactions (all grades, regardless of relationship): lethargy, stomatitis, diarrhea, dizziness, edema, febrile neutropenia/neutropenic infection occurred at rates ≥10% higher in patients who were 65 years of age or older compared to younger patients. Elderly patients treated with TCF should be closely monitored. Head and Neck Cancer
Among the 174 and 251 patients who received the induction treatment with TAXOTERE in combination with cisplatin and fluorouracil (TPF) for SCCHN in the TAX323 and TAX324 studies, 18 (10%) and 32 (13%) of the patients were 65 years of age or older, respectively.
These clinical studies of TAXOTERE in combination with cisplatin and fluorouracil in patients with SCCHN did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. Other reported clinical experience with this treatment regimen has not identified differences in responses between elderly and younger patients. 8.6 Hepatic Impairment Patients with bilirubin >ULN should not receive TAXOTERE. Also, patients with AST and/or ALT >1.5 × ULN concomitant with alkaline phosphatase >2.5 × ULN should not receive TAXOTERE [see Boxed Warning , Warnings and Precautions (5.2) , Clinical Pharmacology (12.3) ] .
The alcohol content of TAXOTERE Injection should be taken into account when given to patients with hepatic impairment [see Warnings and Precautions (5.11) ] . BACK TO TOP 10. OVERDOSAGE There is no known antidote for TAXOTERE overdosage. In case of overdosage, the patient should be kept in a specialized unit where vital functions can be closely monitored. Anticipated complications of overdosage include: bone marrow suppression, peripheral neurotoxicity, and mucositis. Patients should receive therapeutic G-CSF as soon as possible after discovery of overdose. Other appropriate symptomatic measures should be taken, as needed.
In two reports of overdose, one patient received 150 mg/m 2 and the other received 200 mg/m 2 as 1-hour infusions. Both patients experienced severe neutropenia, mild asthenia, cutaneous reactions, and mild paresthesia, and recovered without incident.
In mice, lethality was observed following single intravenous doses that were ≥154 mg/kg (about 4.5 times the human dose of 100 mg/m 2 on a mg/m 2 basis); neurotoxicity associated with paralysis, non-extension of hind limbs, and myelin degeneration was observed in mice at 48 mg/kg (about 1.5 times the human dose of 100 mg/m 2 basis). In male and female rats, lethality was observed at a dose of 20 mg/kg (comparable to the human dose of 100 mg/m 2 on a mg/m 2 basis) and was associated with abnormal mitosis and necrosis of multiple organs. BACK TO TOP 11. DESCRIPTION Docetaxel is an antineoplastic agent belonging to the taxoid family. It is prepared by semisynthesis beginning with a precursor extracted from the renewable needle biomass of yew plants. The chemical name for docetaxel is (2R,3S)-N-carboxy-3-phenylisoserine,N- tert -butyl ester, 13-ester with 5β-20-epoxy-1,2α,4,7β,10β,13α-hexahydroxytax-11-en-9-one 4-acetate 2-benzoate, trihydrate. Docetaxel has the following structural formula:
Docetaxel is a white to almost-white powder with an empirical formula of C 43 H 53 NO 14 • 3H 2 O, and a molecular weight of 861.9. It is highly lipophilic and practically insoluble in water. One-vial TAXOTERE (Injection Concentrate)
TAXOTERE (docetaxel) Injection Concentrate is a sterile, non-pyrogenic, pale yellow to brownish-yellow solution at 20 mg/mL concentration.
Each mL contains 20 mg docetaxel (anhydrous) in 0.54 grams polysorbate 80 and 0.395 grams dehydrated alcohol solution.
TAXOTERE is available in single use vials containing 20 mg (1 mL) or 80 mg (4 mL) docetaxel (anhydrous).
TAXOTERE Injection Concentrate requires NO prior dilution with a diluent and is ready to add to the infusion solution. 12. CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Docetaxel is an antineoplastic agent that acts by disrupting the microtubular network in cells that is essential for mitotic and interphase cellular functions. Docetaxel binds to free tubulin and promotes the assembly of tubulin into stable microtubules while simultaneously inhibiting their disassembly. This leads to the production of microtubule bundles without normal function and to the stabilization of microtubules, which results in the inhibition of mitosis in cells. Docetaxel’s binding to microtubules does not alter the number of protofilaments in the bound microtubules, a feature which differs from most spindle poisons currently in clinical use. 12.3 Human Pharmacokinetics Absorption: The pharmacokinetics of docetaxel have been evaluated in cancer patients after administration of 20 mg/m 2 to 115 mg/m 2 in phase 1 studies. The area under the curve (AUC) was dose proportional following doses of 70 mg/m 2 to 115 mg/m 2 with infusion times of 1 to 2 hours. Docetaxel’s pharmacokinetic profile is consistent with a three-compartment pharmacokinetic model, with half-lives for the α, β, and γ phases of 4 min, 36 min, and 11.1 hr, respectively. Mean total body clearance was 21 L/h/m 2 . Distribution: The initial rapid decline represents distribution to the peripheral compartments and the late (terminal) phase is due, in part, to a relatively slow efflux of docetaxel from the peripheral compartment. Mean steady state volume of distribution was 113 L. In vitro studies showed that docetaxel is about 94% protein bound, mainly to α 1 -acid glycoprotein, albumin, and lipoproteins. In three cancer patients, the in vitro binding to plasma proteins was found to be approximately 97%. Dexamethasone does not affect the protein binding of docetaxel. Metabolism: In vitro drug interaction studies revealed that docetaxel is metabolized by the CYP3A4 isoenzyme, and its metabolism may be modified by the concomitant administration of compounds that induce, inhibit, or are metabolized by cytochrome P450 3A4 [see Drug Interactions (7) ] . Elimination: A study of 14 C-docetaxel was conducted in three cancer patients. Docetaxel was eliminated in both the urine and feces following oxidative metabolism of the tert -butyl ester group, but fecal excretion was the main elimination route. Within 7 days, urinary and fecal excretion accounted for approximately 6% and 75% of the administered radioactivity, respectively. About 80% of the radioactivity recovered in feces is excreted during the first 48 hours as 1 major and 3 minor metabolites with very small amounts (less than 8%) of unchanged drug. Effect of Age: A population pharmacokinetic analysis was carried out after TAXOTERE treatment of 535 patients dosed at 100 mg/m 2 . Pharmacokinetic parameters estimated by this analysis were very close to those estimated from phase 1 studies. The pharmacokinetics of docetaxel were not influenced by age. Effect of Gender: The population pharmacokinetics analysis described above also indicated that gender did not influence the pharmacokinetics of docetaxel. Hepatic Impairment: The population pharmacokinetic analysis described above indicated that in patients with clinical chemistry data suggestive of mild to moderate liver impairment (AST and/or ALT >1.5 times ULN concomitant with alkaline phosphatase >2.5 times ULN), total body clearance was lowered by an average of 27%, resulting in a 38% increase in systemic exposure (AUC). This average, however, includes a substantial range and there is, at present, no measurement that would allow recommendation for dose adjustment in such patients. Patients with combined abnormalities of transaminase and alkaline phosphatase should not be treated with TAXOTERE. Patients with severe hepatic impairment have not been studied . [see Warnings and Precautions (5.2) and Use in Specific Populations (8.6) ] Effect of Race: Mean total body clearance for Japanese patients dosed at the range of 10 mg/m 2 to 90 mg/m 2 was similar to that of European/American populations dosed at 100 mg/m 2 , suggesting no significant difference in the elimination of docetaxel in the two populations. Effect of Ketoconazole: The effect of ketoconazole (a strong CYP3A4 inhibitor) on the pharmacokinetics of docetaxel was investigated in 7 cancer patients. Patients were randomized to receive either docetaxel (100 mg/m 2 intravenous) alone or docetaxel (10 mg/m 2 intravenous) in combination with ketoconazole (200 mg orally once daily for 3 days) in a crossover design with a 3-week washout period. The results of this study indicated that the mean dose-normalized AUC of docetaxel was increased 2.2-fold and its clearance was reduced by 49% when docetaxel was co-administration with ketoconazole [see Dosage and Administration (2.7) and Drug-Drug Interactions (7) ] . Effect of Combination Therapies: Dexamethasone: Docetaxel total body clearance was not modified by pretreatment with dexamethasone. Cisplatin: Clearance of docetaxel in combination therapy with cisplatin was similar to that previously observed following monotherapy with docetaxel. The pharmacokinetic profile of cisplatin in combination therapy with docetaxel was similar to that observed with cisplatin alone. Cisplatin and Fluorouracil: The combined administration of docetaxel, cisplatin and fluorouracil in 12 patients with solid tumors had no influence on the pharmacokinetics of each individual drug. Prednisone: A population pharmacokinetic analysis of plasma data from 40 patients with hormone-refractory metastatic prostate cancer indicated that docetaxel systemic clearance in combination with prednisone is similar to that observed following administration of docetaxel alone. Cyclophosphamide and Doxorubicin: A study was conducted in 30 patients with advanced breast cancer to determine the potential for drug-drug-interactions between docetaxel (75 mg/m 2 ), doxorubicin (50 mg/m 2 ), and cyclophosphamide (500 mg/m 2 ) when administered in combination. The coadministration of docetaxel had no effect on the pharmacokinetics of doxorubicin and cyclophosphamide when the three drugs were given in combination compared to coadministration of doxorubicin and cyclophosphamide only. In addition, doxorubicin and cyclophosphamide had no effect on docetaxel plasma clearance when the three drugs were given in combination compared to historical data for docetaxel monotherapy.

Read More…

<h1></h1>

k1002 said…
iPoop, partlycloudy:
The GI at the hospital decided that I should start Inflectra after a failed transition from IV steroids to Prednisone which caused me to faint after 2 days of bloody BMs. My first dose was at what I believe is the normal dosage at 5mg/kg. One week later, I was still having bloody mucus so the GI told me that they are going to be more aggressive and give me another dose at 10mg/kg (one week after the first one). Two weeks after my second dose, I got a third dose at 5mg/kg. My fourth dose four weeks later, and fifth six weeks after that (both at 5mg/kg).
I was symptom free half a week after my second dose (aside from some pain during BMs for the first week) and remained symptom free for four weeks while tapering Prednisone. Then I started seeing a bit of blood just before my fourth dose and halfway through my course of Prednisone, then things started going downhill again. Long story short, I ended up in the hospital again (two months and a half since I got discharged), that’s when the GI decided to push my fifth dose forward by two weeks, try to max out inflectra/check levels, and check to see if I can take Aza with inflectra.
No results on any of the blood tests yet. I do have an appointment with my GI before my next dose of inflectra (8 weeks after the fifth dose) and hopefully I’ll get some answers then because I haven’t been so lucky this time (got discharged from the hospital okay, got my fifth dose the next day, got a bit of bloody mucus with my once per day normal BM that progressed into bloody (not horribly) BMs roughly 3 times a day, and I’ve just begun my Prednisone taper).
Personally I’d drop inflectra if it’s not doing anything (less meds to be on and save money) rather than be on both inflectra and Aza. My GI also said that I shouldn’t be on so many immune suppressors at a time (Prednisone, inflectra, Aza) anyway. And if TNF-alpha is not the thing causing my UC, then inflectra really isn’t helping.
Have you had stool tests done to rule out superimposed infections?
Are you still on prednisone? If so, what dose?

Read More…

Phase I Study of the Investigational Aurora A Kinase Inhibitor Alisertib plus Rituximab or Rituximab/Vincristine in Relapsed/Refractory Aggressive B-cell Lymphoma

<h1>Phase I Study of the Investigational Aurora A Kinase Inhibitor Alisertib plus Rituximab or Rituximab/Vincristine in Relapsed/Refractory Aggressive B-cell Lymphoma</h1>

Phase I Study of the Investigational Aurora A Kinase Inhibitor Alisertib plus Rituximab or Rituximab/Vincristine in Relapsed/Refractory Aggressive B-cell Lymphoma

Purpose: The aurora A kinase inhibitor alisertib demonstrated single-agent clinical activity and preclinical synergy with vincristine/rituximab in B-cell non-Hodgkin lymphoma (B-NHL). This phase I study aimed to determine the safety and recommended phase II d…

Read More…

Pulmicort Respules (Budesonide Inhalation Suspension) – updated on RxList

<h1>Pulmicort Respules (Budesonide Inhalation Suspension) – updated on RxList</h1>

Pulmicort Respules (Budesonide Inhalation Suspension) – updated on RxList

Skin and subcutaneous tissue disorders contact dermatitis , eczema , pustular rash, pruritus ,
The incidence of reported adverse events was similar between the 447 PULMICORT RESPULES-treated (mean total daily dose 0.5 to 1 mg) a
Endocrine disorders : symptoms of hypocorticism and hypercorticism [see WARNINGS AND PRECAUTIONS
Eye disorders : cataracts, glaucoma, increased intraocular pressure [see WARNINGS AND PRECAUTIONS
General disorders and administration site conditions fever ,
Immune system disorders : immediate and delayed hypersensitivity reactions including, anaphylaxis, angioedema , bronchospasm, rash, contact dermatitis , and urticaria [see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS
Infection and Infestation sinusitis , pharyngitis ,
Musculoskeletal and connective tissue disorders avascular necrosis of the femoral head, osteoporosis
Nervous system disorders :
Psychiatric disorders : psychiatric symptoms including psychosis , depression , aggressive reactions, irritability, nervousness, restlessness, and
Respiratory, thoracic, and mediastinal disorders cough
Skin and subcutaneous tissue disorders :
Cases of growth suppression have been reported for inhaled corticosteroids including post-marketing reports for PULMICORT RESPULES [see WARNINGS AND PRECAUTIONS and Use In Specific Populations , Pediatric Use Inhibitors of Cytoch
The main route of metabolism of corticosteroids, including budesonide, is via cytochrome P450 (CYP) isoenzyme 3A4 (CYP3A4). After oral administration of ketoconazole , a strong inhibitor of CYP3A4, the mean plasma concentration of orally administered budesonide increased. Concomitant administration of a CYP3A4 inhibitor may inhibit the metabolism of, and increase the systemic exposure to, budesonide. Caution should be exercised when considering the coadministration of PULMICORT RESPULES (budesonide inhalation suspension) with long-term ketoconazole and other known strong CYP3A4 inhibitors (e.g., ritonavir, atazanavir, clarithromycin , indinavir, itraconazole, nefazodone, nelfinavir, saquinavir, telithromycin) [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY , Pharmacokinetics Warnings &
Included as part of the PRECAUTIONS
In clinical trials with PULMICORT RESPULES (budesonide inhalation suspension) , localized infections with Candida albicans occurred in the mouth and pharynx in some patients. The incidences of localized infections of Candida albicans were similar between the placebo and PULMICORT RESPULES (budesonide inhalation suspension) treatment groups. If these infections develop, they may require treatment with appropriate local or systemic antifungal
Hypersensitivity reactions including anaphylaxis, rash , contact dermatitis , urticaria , angioedema , and bronchospasm have been reported with use of PULMICORT RESPULES. Discontinue PULMICORT RESPULES if such reactions occur [see CONTRAINDICATIONS
Patients who are on drugs that suppress the immune system are more susceptible to infection than healthy individuals. Chicken pox and measles , for example, can have a more serious or even fatal course in susceptible children or adults using corticosteroids. In children or adults who have not had these diseases, or been properly immunized, particular care should be taken to avoid exposure. How the dose, route, and duration of corticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If exposed to chicken pox, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If exposed to measles, prophylaxis with pooled immunoglobulin ( IG ) may be indicated. (See the respective package inserts for complete VZIG and IG prescribing information .) If chicken pox develops, treatment with antiviral
The clinical course of chicken pox or measles infection in patients on inhaled corticosteroids has not been studied. However, a clinical study has examined the immune responsiveness of asthma patients 12 months to 8 years of age who were treated with PULMICORT RESPULES (budesonide inhalation suspension) . An open-label non-randomized clinical study examined the immune responsiveness of varicella vaccine in 243 asthma patients 12 months to 8 years of age who were treated with PULMICORT RESPULES (budesonide inhalation suspension) 0.25 mg to 1 mg daily (n=151) or noncorticosteroid asthma therapy (n=92) (ie, beta2-agonists, leukotriene receptor antagonists, cromones). The percentage of patients developing a seroprotective antibody titer of ≥ 5.0 (gpELISA value) in response to the vaccination
Inhaled corticosteroids should be used with caution, if at all, in patients with active or tuberculosis infection of the respiratory tract, untreated systemic fungal, bacterial, viral, or parasitic infections; or ocular
Particular care is needed for patients who are transferred from systemically active corticosteroids to inhaled corticosteroids because deaths due to adrenal insufficiency have occurred in asthmatic patients during and after transfer from systemic corticosteroids to less systemically available inhaled corticosteroids. After withdrawal from systemic corticosteroids, a number of months are required for recovery of hypothalamic- pituitary -adrenal (HPA)- axis
Patients who have been previously maintained on 20 mg or more per day of prednisone
During this period of HPA-axis suppression, patients may exhibit signs and symptoms of adrenal insufficiency when exposed to trauma , surgery, infection (particularly gastroenteritis ) or other conditions associated with severe electrolyte loss. Although PULMICORT RESPULES (budesonide inhalation suspension) may provide control of asthma symptoms duri
During periods of stress
Lung function (FEV 1 or PEF ), beta-agonist use, and asthma symptoms should be carefully monitored during withdrawal of oral corticosteroids. In addition to monitoring asthma signs and symptoms, patients should be observed for signs and symptoms of adrenal insufficiency such as fatigue, lassitude , weakness, nausea and vomiting, and hypotension
Transfer of patients from systemic corticosteroid therapy to PULMICORT RESPULES (budesonide inhalation suspension) may unmask allergic or other immunologic conditions previously suppressed by the systemic corticosteroid therapy, e.g., rhinitis , conjunctivitis , eosinophilic conditions, eczema, and arthritis [see DOSAGE AND ADMINISTRATION
During withdrawal from oral corticosteroids, patients may experience symptoms of systemically active corticosteroid withdrawal (e.g., joint and/or pain , lassitude, depression
PULMICORT RESPULES (budesonide inhalation suspension) , will often help control asthma symptoms with less suppression of HPA function than therapeutically equivalent oral doses of prednisone. Since individual sensitivity to effects on cortisol production exists, physicians should consider this information when prescribing PULMICORT RESPULES (budesonide inhalation suspension) . Because of the possibility of systemic absorption of inhaled corticosteroids, patients treated with PULMICORT RESPULES (budesonide inhalation suspension) should be observed carefully for any e
Decreases in bone mineral density (BMD) have been observed with long-term administration of products containing inhaled corticosteroids. The clinical significance of small changes in BMD with regard to long-term outcomes is unknown. Patients with major risk factors for decreased bone mineral content, such as prolonged immobilization, family history of osteoporosis , poor nutrition
Orally inhaled corticosteroids, including budesonide, may cause a reduction in growth velocity when administered to pediatric patients. Monitor the growth of pediatric patients receiving PULMICORT RESPULES (budesonide inhalation suspension) routinely (e.g., via stadiometry). To minimize the systemic effects of orally inhaled corticosteroids, including PULMICORT RESPULES (budesonide inhalation suspension) , each patient should be titrated to his/her lowest effective dose [see Use In Specific Populations, Pediatric Use
Glaucoma, increased intraocular pressure
As with other inhaled asthma medications, bronchospasm, with an immediate increase in wheezing
In rare cases, patients on inhaled corticosteroids may present with systemic eosinophilic conditions. Some of these patients have clinical features of vasculitis consistent with Churg- Strauss syndrome, a condition that is often treated with systemic corticosteroids therapy. These events usually, but not always, have been associated with the reduction and/or withdrawal of oral corticosteroid therapy following the introduction of inhaled corticosteroids. Healthcare providers should be alert to eosinophilia , vasculitis rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. A causal relationship betw
Caution should be exercised when considering the coadministration of PULMICORT RESPULES with ketoconazole, and other known strong CYP3A4 inhibitors (e.g., ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, saquinavir, telithromycin) because adverse effects related to increased systemic exposure to budesonide may occur [see DRUG INTERACTIONS and CLINICAL PHARMACOLOGY , Clinical Pharmacokinetics
Patients should be advised that PULMICORT RESPULES (budesonide inhalation suspension) should be administered with a jet nebulizer connected to a compressor with an adequate air flow, equipped with a mouthpiece or suitable face mask. Ultrasonic nebulizers are not suitable for the adequate administration of PULMICORT RESPULES (budesonide inhalation suspension) and, therefore, are not recommended. The effects of mixing PULMICORT RESPULES (budesonide inhalation suspension) with other nebulizable medications have not been adequately assessed. PULMICORT RESPULES (budesonide inhalation suspension) should be administered separately in the nebulizer [see DOSAGE AND ADMINISTRATION
Patients should be advised that localized infections with Candida albicans occurred in the mouth and pharynx in some patients. If oropharyngeal candidiasis develops, it should be treated with appropriate local or systemic (i.e. oral) antifungal therapy while still continuing therapy with PULMICORT RESPULES (budesonide inhalation suspension) , but at times therapy with PULMICORT RESPULES (budesonide inhalation suspension) may need to be temporarily interrupted under close medical supervision. Rinsing the mouth after inhalation is advised [see WARNINGS AND PRECAUTIONS
PULMICORT RESPULES (budesonide inhalation suspension) is not meant to relieve acute asthma symptoms and extra doses should not be used for that purpose. Acute symptoms should be treated with an inhaled, short-acting beta2- agonist such as albuterol
Patients should not stop therapy with PULMICORT RESPULES (budesonide inhalation suspension) without physician/provider guidance since symptoms may recur after discontinuation [see WARNINGS AND PRECAUTIONS
Hypersensitivity reactions including anaphylaxis, rash, contact dermatitis, urticaria, angioedema, and bronchospasm have been reported with use of PULMICORT RESPULES. Discontinue PULMICORT RESPULES if such reactions occur [see CONTRAINDICATIONS ; WARNINGS AND PRECAUTIONS
Patients who are on immunosuppressant doses of corticosteroids should be warned to avoid exposure to chickenpox or measles and, if exposed, to consult their physician without delay. If exposure to such a person occurs, and the child has not had chicken pox or been properly vaccinated, a physician should be consulted without delay. Patients should be informed of potential worsening of existing tuberculosis, fungal, bacterial, viral, or parasitic infections, or ocular herpes simplex [see WARNINGS AND PRECAUTIONS
Patients should be advised that PULMICORT RESPULES (budesonide inhalation suspension) may cause systemic corticosteroid effects of hypercorticism and adrenal suppression. Additionally, patients should be instructed that deaths due to adrenal insufficiency have occurred during and after transfer from systemic corticosteroids. Patients should taper slowly from systemic corticosteroids if transferring to PULMICORT RESPULES (budesonide inhalation suspension) [see WARNINGS AND PRECAUTIONS
Patients who are at an increased risk for decreased BMD should be advised that the use of corticosteroids may pose an additional risk [see WARNINGS AND PRECAUTIONS
Patients should be informed that orally inhaled corticosteroids, including PULMICORT RESPULES (budesonide inhalation suspension) , may cause a reduction in growth velocity when administered to pediatric patients. Healthcare professionals should closely follow the growth of children and adolescents taking corticosteroids by any route [see WARNINGS AND PRECAUTIONS
Long-term use of inhaled corticosteroids may increase the risk of some eye problems (cataracts or glaucoma); regular eye examinations should be considered [see WARNINGS AND PRECAUTIONS
See accompanying PATIENT INFORMATION
In a two-year study in Sprague-Dawley rats, budesonide caused a statistically significant increase in the incidence of gliomas in male rats at an oral dose of 50 mcg/kg (approximately 0.4 and 0.1 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mcg/m² basis). No tumorigenicity was seen in male rats at oral doses up to 25 mcg/kg (approximately 0.2 and 0.06 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mcg/m² basis) and in female rats at oral doses up to 50 mcg/kg (approximately 0.4 and 0.1 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mcg/m² basis). In two additional two-year studies in male Fischer and Sprague-Dawley rats, budesonide caused no gliomas at an oral dose of 50 mcg/kg (approximately 0.4 and 0.1 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mcg/m² basis). However, in the male Sprague-Dawley rats, budesonide caused a statistically significant increase in the incidence of hepatocellular tumors at an oral dose of 50 mcg/kg (approximately 0.4 and 0.1 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mcg/m² basis). The concurrent reference corticosteroids ( prednisolone and triamcinolone
In a 91-week study in mice, budesonide caused no treatment-related carcinogenicity at oral doses up to 200 mcg/kg (approximately 0.8 and 0.2 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mcg/m²
Budesonide was not mutagenic or clastogenic in six different test systems: Ames Salmonella /microsome plate test, mouse micronucleus test, mouse lymphoma test, chromosome aberration test in human lymphocytes, sex-linked lethal test in Drosophila melanogaster , and DNA repair
In rats, budesonide had no effect on fertility at subcutaneous doses up to 80 mcg/kg approximately 0.6 times the maximum recommended daily inhalation dose in adults on a mcg/m² basis. However, it caused a decrease in prenatal viability and viability in the pups at birth and during lactation, along with a decrease in maternal body-weight gain, at subcutaneous doses of 20 mcg/kg and above approximately 0.2 times than the maximum recommended daily inhalation dose in adults on a mcg/m² basis. No such effects were noted at 5 mcg/kg (approximately 0.04 times the maximum recommended daily inhalation dose in adults on a mcg/m²
– Studies of pregnant women, have not shown that inhaled budesonide increases the risk of abnormalities when administered during pregnancy. The results from a large population-based prospective cohort epidemiological study reviewing data from three Swedish registries covering approximately 99% of the pregnancies from 1995-1997 (ie, Swedish Medical Birth Registry; Registry of Congenital Malformations; Child Cardiology Registry) indicate no increased risk for congenital malformations from the use of inhaled budesonide during early pregnancy. Congenital malformations were studied in 2014 infants born to mothers reporting the use of inhaled budesonide for asthma in early pregnancy (usually 10-12 weeks after the last menstrual period
These s
As with other corticosteroids, budesonide was teratogenic and embryocidal in rabbits and rats. Budesonide produced fetal loss, decreased pup weights, and skeletal abnormalities at a subcutaneous dose in rabbits that was approximately 0.4 times the maximum recommended daily inhalation dose in adults on a mcg/m² basis and at subcutaneous dose that was approximately 4 times the maximum recommended daily inhalation dose in adults on a mcg/m² basis. In another study in rats, no teratogenic or embryocidal effects were seen at inhalation doses up to approximately 2 times the maximum recommended daily inhalation dose in adults on a mcg/m²
Experience with oral corticosteroids since their introduction in pharmacologic, as opposed to physiologic , doses suggests that rodents are more prone Nursing
Budesonide, like other corticosteroids, is secreted in human milk. Data with budesonide delivered via dry powder inhaler indicates that the total daily oral dose of budesonide in breast milk to the infant is approximately 0.3% to 1% of the dose inhaled by the mother [see CLINICAL PHARMACOLOGY , Pharmacokinetics, and Use In Specific Populations, Nursing Mothers
Safety and effectiveness in children six months to 12 months of age has been evaluated but not established. Safety and effectiveness in children 12 months to 8 years of age have been established [see CLINICAL PHARMACOLOGY , Pharmacodynamics, and ADVERSE REACTIONS , Clinical Trials Experience
A 12-week study in 141 pediatric patients 6 to 12 months of age with mild to moderate asthma or recurrent /persistent wheezing was conducted. All patients were randomized to receive either 0.5 mg or 1 mg of PULMICORT RESPULES (budesonide inhalation suspension) or placebo once daily. Adrenal-axis function was assessed with an ACTH stimulation test at the beginning and end of the study, and mean changes from baseline in this variable did not indicate adrenal suppression in patients who received PULMICORT RESPULES versus placebo. However, on an individual basis, 7 patients in this study (6 in the PULMICORT RESPULES (budesonide inhalation suspension) treatment arms and 1 in the placebo arm) experienced a shift from having a normal baseline stimulated cortisol level to having a subnormal level at Week 12 [see CLINICAL PHARMACOLOGY , Pharmacodynamics ]. Pneumonia
Controlled clinical studies have shown that inhaled corticosteroids may cause a reduction in growth velocity in pediatric patients. In these studies, the mean reduction in growth velocity was approximately one centimeter per year (range 0.3 to 1.8 cm per year) and appears to be related to dose and duration of exposure. This effect has been observed in the absence of laboratory evidence of hypothalamic-pituitary-adrenal (HPA)-axis suppression, suggesting that growth velocity is a more sensitive indicator of systemic corticosteroid exposure in pediatric patients than some commonly used tests of HPA-axis function. The long-term effects of this reduction in growth velocity associated with orally inhaled corticosteroids, including the impact on final adult height, are unknown. The potential for “catch up”
The growth of pediatric patients receiving inhaled corticosteroids, including PULMICORT RESPULES (budesonide inhalation suspension) , should be monitored routinely (e.g., via stadiometry). The potential growth effects of prolonged treatment should be weighed against clinical benefits obtained and the risks and benefits associated with alternative therapies. To minimize the systemic effects of inhaled corticosteroids, including PULMICORT RESPULES, each patient should be titrated to his/her lowest effective dose [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS Overdosage &
The potential for acute toxic effects following overdose of PULMICORT RESPULES (budesonide inhalation suspension) is low. If inhaled corticosteroids are used at excessive doses for prolonged periods, systemic corticosteroid effects such as hypercorticism or growth suppression may occur [see WARNINGS AND PRECAUTIONS , Hypercorticism and Adrenal Suppression
In mice, the minimal lethal inhalation dose was 100 mg/kg (approximately 410 and 120 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mg/m² basis). In rats there were no deaths at an inhalation dose of 68 mg/kg (approximately 550 and 160 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mg/m² basis). In mice, the minimal oral lethal dose was 200 mg/kg (approximately 810 and 240 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mg/m² basis). In rats, the minimal oral lethal dose was less than 100 mg/kg (approximately 810 and 240 times, respectively, the maximum recommended daily inhalation dose in adults or and children 12 months to 8 years of age on a mg/m² Hypersensitivity to budesonide or any of the ingredients of PULMICORT RESPULES [see WARNINGS AND PRECAUTIONS , DESCRIPTION and ADVERSE REACTIONS , Post-marketing Experience CLINICAL PHARMACOLOGY Mechanism of Action
Budesonide is an anti-inflammatory corticosteroid that exhibits potent glucocorticoid in vitro and animal models, budesonide has approximately a 200-fold higher affinity for the glucocorticoid receptor and a 1000-fold higher topical anti-inflammatory potency than cortisol thymus assay. The clinical significance of these findings is unknown.
The activity of PULMICORT RESPULES is due to the parent drug, budesonide. In glucocorticoid receptor affinity studies, the 22R form was two times as active as the 22S epimer. In vitro studies indicated that the two forms of budesonide do not interconvert.
The precise mechanism of corticosteroid actions on inflammation in asthma is not well known. Inflammation is an important component in the pathogenesis of asthma. Corticosteroids have been shown to have a wide range of inhibitory activities against multiple cell types (e.g., mast cells, eosinophils, neutrophils, macrophages, and lymphocytes) and mediators (e.g., , eicosanoids, leukotrienes, and cytokines) involved in allergic- and non-allergic-mediated inflammation. The anti-inflammatory actions of corticosteroids may contribute to their efficacy in asthma.
Studies in asthmatic patients have shown a favorable ratio between topical anti-inflammatory activities and systemic corticosteroid effects over a wide dose range of inhaled budesonide in a variety of formulations and delivery systems including an inhalation-driven, multi-dose dry powder inhaler and the inhalation suspension for nebulization. This is explained by a combination of a relatively high local antiinflammatory effect, extensive first pass hepatic degradation of orally absorbed drug (85-95%) and the low potency of metabolites (see ). Pharmacodynamics
The therapeutic effects of conventional doses of orally inhaled budesonide are largely explained by its direct local action on the respiratory tract. To confirm that systemic absorption is not a significant factor in the clinical efficacy of inhaled budesonide, a clinical study in adult patients with asthma was performed comparing 400 mcg budesonide administered via a pressurized metered dose inhaler with a tube spacer to 1400 mcg of oral budesonide and placebo. The study demonstrated the efficacy of inhaled budesonide but not orally administered budesonide, even though systemic budesonide exposure was comparable for both treatments, indicating that the inhaled treatment is working locally in the lung. Thus, the therapeutic effect of conventional doses of orally inhaled budesonide are largely explained by its direct action on the respiratory tract.
reatment, although maximum benefit may not be achieved for 4-6 weeks.
Budesonide administered via a dry powder inhaler has been shown in various challenge models (including histamine, methacholine, sodium metabisulfite, and monophosphate) to decrease bronchial hyperresponsiveness in asthmatic patients. The clinical relevance of these models is not certain.
Pre-treatment with budesonide administered as 1600 mcg daily (800 mcg twice daily) via a dry powder inhaler for 2 weeks reduced the acute (early-phase reaction) and delayed (late-phase reaction) decrease in FEV 1 following inhaled challenge. HPA Axis Effects
The effects of PULMICORT RESPULES (budesonide inhalation suspension) on the hypothalamic-pituitary-adrenal (HPA) axis were studied in three, 12-week, double-blind, placebo-controlled studies in 293 pediatric patients, 6 months to 8 years of age, with persistent asthma. For most patients, the ability to increase cortisol production in response to stress, as assessed by the short cosyntropin (ACTH) stimulation test, remained intact with PULMICORT RESPULES (budesonide inhalation suspension) treatment at recommended doses. In the subgroup of children age 6 months to 2 years (n=21) receiving a total daily dose of PULMICORT RESPULES equivalent to 0.25 mg (n=5), 0.5 mg (n=5), 1 mg (n=8), or placebo (n=3), the mean change from baseline in ACTH-stimulated cortisol levels showed a decline in peak stimulated cortisol at 12 weeks compared to an increase in the placebo group. These mean differences were not statistically significant compared to placebo. Another 12-week study in 141 pediatric patients 6 to 12 months of age with mild to moderate asthma or recurrent/persistent wheezing was conducted. All patients were randomized to receive either 0.5 mg or 1 mg of PULMICORT RESPULES (budesonide inhalation suspension) or placebo once daily. A total of 28, 17, and 31 patients in the PULMICORT RESPULES (budesonide inhalation suspension) 0.5 mg, 1 mg, and placebo arms respectively, had an evaluation of serum cortisol levels post-ACTH stimulation both at baseline and at the end of the study. The mean change from baseline to Week 12 ACTH-stimulated minus basal plasma cortisol levels did not indicate adrenal suppression in patients treated with PULMICORT RESPULES versus placebo. However, 7 patients in this study (4 of whom received PULMICORT RESPULES (budesonide inhalation suspension) 0.5 mg, 2 of whom received PULMICORT RESPULES (budesonide inhalation suspension) 1 mg and 1 of whom received placebo) showed a shift from normal baseline stimulated cortisol level ( ≥ 500 nmol/L) to a subnormal level ( 500 nmol/L) at Week 12. In 4 of these patients receiving PULMICORT RESPULES (budesonide inhalation suspension) , the cortisol values were near the cutoff value of 500 nmol/L.
tatistically significantly reduced urinary cortisol excretion compared to the run-in period.
PULMICORT RESPULES (budesonide inhalation suspension) , like other inhaled corticosteroid products, may impact the HPA axis, especially in susceptible individuals, in younger children, and in patients given high doses for prolonged periods [see WARNINGS AND ]. Pharmacokinetics Absorption
In asthmatic children 4-6 years of age, the total absolute bioavailability (ie, lung + oral) following administration of PULMICORT RESPULES (budesonide inhalation suspension) via jet nebulizer was approximately 6% of the labeled dose.
In children, a peak plasma concentration of 2.6 nmol/L was obtained approximately 20 minutes after nebulization of a 1 mg dose. Systemic exposure, as measured by AUC and Cmax, is similar for young children and adults after inhalation of the same dose of PULMICORT RESPULES (budesonide inhalation suspension) . Distribution
In asthmatic children 4-6 years of age, the volume of distribution at steady-state of budesonide was 3 L/kg, approximately the same as in healthy adults. Budesonide is 85-90% bound to plasma proteins, the degree of binding being constant over the concentration range (1-100 nmol/L) achieved with, and exceeding, recommended doses. Budesonide showed little or no binding to corticosteroid-binding globulin. Budesonide rapidly equilibrated with in a concentration independent manner with a blood/plasma ratio of about 0.8. Metabolism
In vitro studies with human liver homogenates have shown that budesonide is rapidly and extensively metabolized. Two major metabolites formed via cytochrome P450 (CYP) isoenzyme 3A4 (CYP3A4) catalyzed biotransformation have been isolated and identified as 16α-hydroxyprednisolone and 6β-hydroxybudesonide. The corticosteroid activity of each of these two metabolites is less than 1% of that of the parent compound. No qualitative difference between the and in vivo metabolic patterns has been detected. Negligible metabolic inactivation was observed in human lung and serum preparations. Excretion/Elimination
Budesonide is primarily cleared by the liver. Budesonide is excreted in urine and feces in the form of metabolites. In adults, approximately 60% of an intravenous radiolabeled dose was recovered in the urine. No unchanged budesonide was detected in the urine.
In asthmatic children 4-6 years of age, the terminal half-life of budesonide after nebulization is 2.3 hours, and the systemic clearance is 0.5 L/min, which is approximately 50% greater than in healthy adults after adjustment for differences in weight. Special Populations
No differences in pharmacokinetics due to race, gender, or age have been identified. Hepatic Insufficiency
Reduced liver function may affect the elimination of corticosteroids. The pharmacokinetics of budesonide were affected by compromised liver function as evidenced by a doubled systemic availability after oral ingestion. The intravenous pharmacokinetics of budesonide were, however, similar in cirrhotic patients and in healthy adults. Nursing Mothers
The disposition of budesonide when delivered by inhalation from a dry powder inhaler at doses of 200 or 400 mcg twice daily for at least 3 months was studied in eight lactating women with asthma from 1 to 6 months postpartum . Systemic exposure to budesonide in these women appears to be comparable to that in non-lactating women with asthma from other studies. Breast milk obtained over eight hours post-dose revealed that the maximum concentration of budesonide for the 400 and 800 mcg doses was 0.39 and 0.78 nmol/L, respectively, and occurred within 45 minutes after dosing. The estimated oral daily dose of budesonide from breast milk to the infant is approximately 0.007 and 0.014 mcg/kg/day for the two dose regimens used in this study, which represents approximately 0.3% to 1% of the dose inhaled by the mother. Budesonide levels in plasma samples obtained from five infants at about 90 minutes after breast-feeding (and about 140 minutes after drug administration to the mother) were below quantifiable levels ( < 0.02 nmol/L in four infants and < 0.04 nmol/L in one infant) [see Use In Specific Populations ]. Drug-Drug Interactions Inhibitors of cytochrome P450 enzymes
Ketoconazole : Ketoconazole, a strong inhibitor of cytochrome P450 (CYP) isoenzyme 3A4 (CYP3A4), the main metabolic enzyme for corticosteroids, increased plasma levels of orally ingested budesonide [see WARNINGS AND PRECAUTIONS and ].
Cimetidine : At recommended doses, , a nonspecific inhibitor of CYP enzymes, had a slight but clinically insignificant effect on the pharmacokinetics of oral budesonide. Animal Toxicology Reproductive Toxicology
As with other corticosteroids, budesonide was teratogenic and embryocidal in rabbits and rats. Budesonide produced fetal loss, decreased pup weights, and skeletal abnormalities at a subcutaneous dose of 25 mcg/kg in rabbits (approximately 0.4 times the maximum recommended daily inhalation dose in adults on a mcg/m² basis) and at a subcutaneous dose of 500 mcg/kg in rats (approximately 4 times the maximum recommended daily inhalation dose in adults on a mcg/m² basis). In another study in rats, no teratogenic or embryocidal effects were seen at inhalation doses up to 250 mcg/kg (approximately 2 times the maximum recommended daily inhalation dose in adults on a mcg/m²
Three double-blind, placebo-controlled, parallel group, randomized U.S. clinical trials of 12-weeks duration each were conducted in 1018 pediatric patients, 6 months to 8 years of age, 657 males and 361 females (798 Caucasians, 140 Blacks, 56 Hispanics, 3 Asians, 21 Others) with persistent asthma of varying disease duration (2 to 107 months) and severity. Doses of 0.25 mg, 0.5 mg, and 1 mg administered either once or twice daily were compared to placebo to provide information about appropriate dosing to cover a range of asthma severity. A Pari-LC-Jet Plus Nebulizer (with a face mask or mouthpiece) connected to a Pari Master compressor was used to deliver PULMICORT RESPULES (budesonide inhalation suspension) to patients in the 3 U.S. controlled clinical trials . The co-primary endpoints were nighttime and daytime asthma symptom scores (0-3 scale). Improvements were addressed in terms of the primary efficacy variables of changes from baseline to the double-blind treatment period in nighttime and daytime asthma symptom scores (scale 0-3) as recorded in the patient diaries. Baseline was defined as the mean of the last seven days prior to randomization
Results of the 3
Improvements in lung function were associated with PULMICORT RESPULES (budesonide inhalation suspension) in the subgroup of patients capable of performing lung function testing. Statistically significant increases were seen in FEV 1
Patients Not Receiving Inhaled Corticosteroid Therapy
The efficacy of PULMICORT RESPULES (budesonide inhalation suspension) at doses of 0.25 mg, 0.5 mg, and 1 mg once daily was evaluated in 344 pediatric patients, 12 months to 8 years of age, with mild to moderate persistent asthma (mean baseline nighttime asthma symptom scores of the treatment groups ranged from 1.07 to 1.34) who were not well controlled by bronchodilators alone. The changes from baseline to Weeks 0-12 in nighttime asthma symptom scores are shown in Figure 1. Nighttime asthma symptom scores showed statistically significant decreases in the patients treated with PULMICORT RESPULES compared to placebo. Similar decreases were also observed for daytime asthma symptom scores.
Changes from baseline to the double-blind phase for the budesonide treatment groups compared to placebo were made using analysis of variance techniques. The model included terms for the respective changes from baseline as the dependent variable and terms for treatment, center and treatment by center interaction as exploratory variables. (See Figures 1-3 ). Figure 1: A 12-Week Trial in Pediatric Patients Not on Inhaled Corticosteroid Therapy Prior to Study Entry. Nighttime Asthma Change from Baseline
Patients Previously Maintained on Inhaled Corticosteroids
The efficacy of PULMICORT RESPULES (budesonide inhalation suspension) at doses of 0.25 mg and 0.5 mg twice daily was evaluated in 133 pediatric asthma patients, 4 to 8 years of age, previously maintained on inhaled corticosteroids (mean FEV 1 79.5% predicted; mean baseline nighttime asthma symptom scores of the treatment groups ranged from 1.04 to 1.18; mean baseline dose of beclomethasone dipropionate of 265 mcg/day, ranging between 42 to 1008 mcg/day; mean baseline dose of triamcinolone acetonide of 572 mcg/day, ranging between 200 to 1200 mcg/day). The changes from baseline to Weeks 0-12 in nighttime asthma symptom scores are shown in Figure 2. Nighttime asthma symptom scores showed statistically significant decreases in patients treated with PULMICORT RESPULES (budesonide inhalation suspension) compared to placebo. Similar decreases were also observed for daytime asthma symptom scores.
Statistically significant increases in FEV 1 compared to placebo were observed with PULMICORT RESPULES (budesonide inhalation suspension) at a dose of 0.5 mg twice daily and in morning PEF for both doses (0.25 mg and 0.5 mg twice daily). Figure 2: A 12-Week Trial in Pediatric Patients Previously Maintained on Inhaled Corticosteroid Therapy Prior to Study Entry. Nighttime Asthma Change from Baseline
Patients Receiving Once-Daily or Twice-Daily Dosing
The efficacy of PULMICORT RESPULES (budesonide inhalation suspension) at doses of 0.25 mg once daily, 0.25 mg twice daily, 0.5 mg twice daily, and 1 mg once daily, was evaluated in 469 pediatric patients 12 months to 8 years of age (mean baseline nighttime asthma symptom scores of the treatment groups ranged from 1.13 to 1.31). Approximately 70% were not previously receiving inhaled corticosteroids. The changes from baseline to Weeks 0-12 in nighttime asthma symptom scores are shown in Figure 3. PULMICORT RESPULES at doses of 0.25 mg and 0.5 mg twice daily, and 1 mg once daily, demonstrated statistically significant decreases in nighttime asthma symptom scores compared to placebo. Similar decreases were also observed for daytime asthma symptom scores.
PULMICORT RESPULES (budesonide inhalation suspension) at a dose of 0.5 mg twice daily resulted in statistically significant increases compared to placebo in FEV 1 , and at doses of 0.25 mg and 0.5 mg twice daily and 1 mg once daily statistically significant increases in morning PEF.
The evidence supports the efficacy of the same nominal dose of PULMICORT RESPULES (budesonide inhalation suspension) administered on either a once-daily or twice-daily schedule. However, when all measures are considered together, the evidence is stronger for twice-daily dosing (see DOSAGE AND ADMINISTRATION ). Figure 3: A 12-Week Trial in Pediatric Patients Either Maintained on Bronchodilators Alone or Inhaled Corticosteroid Therapy Prior to Study Entry. Nighttime Asthma Change from Baseline Medication Guide OVERDOSE
The potential for acute toxic effects following overdose of PULMICORT RESPULES (budesonide inhalation suspension) is low. If inhaled corticosteroids are used at excessive doses for prolonged periods, systemic corticosteroid effects such as hypercorticism or growth suppression may occur [see WARNINGS AND PRECAUTIONS , Hypercorticism and Adrenal Suppression
In mice, the minimal lethal inhalation dose was 100 mg/kg (approximately 410 and 120 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mg/m² basis). In rats there were no deaths at an inhalation dose of 68 mg/kg (approximately 550 and 160 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mg/m² basis). In mice, the minimal oral lethal dose was 200 mg/kg (approximately 810 and 240 times, respectively, the maximum recommended daily inhalation dose in adults and children 12 months to 8 years of age on a mg/m² basis). In rats, the minimal oral lethal dose was less than 100 mg/kg (approximately 810 and 240 times, respectively, the maximum recommended daily inhalation dose in adults or and children 12 months to 8 years of age on a mg/m² Hypersensitivity to budesonide or any of the ingredients of PULMICORT RESPULES [see WARNINGS AND PRECAUTIONS , DESCRIPTION and ADVERSE REACTIONS , Post-marketing Experience

Read More…

Pulmicort Turbuhaler (Budesonide) – updated on RxList

<h1>Pulmicort Turbuhaler (Budesonide) – updated on RxList</h1>

Pulmicort Turbuhaler (Budesonide) – updated on RxList

Copyright © 2018 by RxList Inc. RxList does not provide medical advice, diagnosis or treatment. See additional information . Pulmicort Turbuhaler
(budesonide) Inhalation Powder 200 mcg
For Oral Inhalation Only. DESCRIPTION
Budesonide, the active component of PULMICORT TURBUHALER (budesonide) 200 mcg, is a corticosteroid designated chemically as (RS)-11β, 16α, 17,21-Tetrahydroxypregna-1,4-diene-3,20-dione cyclic 16,17-acetal with butyraldehyde. Budesonide is provided as a mixture of two epimers (22R and 22S). The empirical formula of budesonide is C 25 H 34 O 6 and its molecular weight is 430.5. Its structural formula is:
Budesonide is a white to off-white, tasteless, odorless powder that is practically insoluble in water and in heptane, sparingly soluble in ethanol, and freely soluble in chloroform . Its partition coefficient between octanol and water at pH 7.4 is 1.6 x 10 3 .
PULMICORT TURBUHALER (budesonide) is an inhalation-driven multi-dose dry powder inhaler that contains only micronized budesonide. Each actuation of PULMICORT TURBUHALER provides 200 mcg budesonide per metered dose, which delivers approximately 160 mcg budesonide from the mouthpiece (based on in vitro testing at 60 L/min for 2 sec).
In vitro testing has shown that the dose delivery for PULMICORT TURBUHALER (budesonide) is substantially dependent on airflow through the device. Patient factors such as inspiratory flow rates will also affect the dose delivered to the lungs of patients in actual use (see Patient’s Instructions for Use ). In adult patients with asthma (mean FEV 1 2.9 L [0.8 – 5.1 L]) mean peak inspiratory flow (PIF) through PULMICORT TURBUHALER (budesonide) was 78 (40-111) L/min. Similar results (mean PIF 82 [43-125] L/min) were obtained in asthmatic children (6 to 15 years, mean FEV 1 2.1 L [0.9 – 5.4 L]). Patients should be carefully instructed on the use of this drug product to assure optimal dose delivery. Indications & Dosage INDICATIONS
PULMICORT TURBUHALER (budesonide) is indicated for the maintenance treatment of asthma as prophylactic therapy in adult and pediatric patients six years of age or older. It is also indicated for patients requiring oral corticosteroid therapy for asthma. Many of those patients may be able to reduce or eliminate their requirement for oral corticosteroids over time.
PULMICORT TURBUHALER (budesonide) is NOT indicated for the relief of acute bronchospasm. DOSAGE AND ADMINISTRATION
PULMICORT TURBUHALER (budesonide) should be administered by the orally inhaled route in asthmatic patients age 6 years and older. Individual patients will experience a variable onset and degree of symptom relief. Generally, PULMICORT TURBUHALER (budesonide) has a relatively rapid onset of action for an inhaled corticosteroid. Improvement in asthma control following inhaled administration of PULMICORT TURBUHALER (budesonide) can occur within 24 hours of initiation of treatment, although maximum benefit may not be achieved for 1 to 2 weeks, or longer. The safety and efficacy of PULMICORT TURBUHALER (budesonide) when administered in excess of recommended doses have not been established.
The recommended starting dose and the highest recommended dose of PULMICORT TURBUHALER (budesonide) , based on prior asthma therapy, are listed in the following table.
200 to 400 mcg twice daily 400 mcg twice daily 200 to 400 mcg twice daily 800 mcg twice daily 400 to 800 mcg twice daily 800 mcg twice daily Oral Corticosteroids The highest recommended dose in children is 400 mcg twice daily
*In patients with mild to moderate asthma who are well controlled on inhaled corticosteroids, dosing with PULMICORT TURBUHALER (budesonide) 200 mcg or 400 mcg once daily may be considered. PULMICORT TURBUHALER (budesonide) can be administered once daily either in the morning or in the evening.
If the once-daily treatment with PULMICORT TURBUHALER (budesonide) does not provide adequate control of asthma symptoms, the total daily dose should be increased and/or administered as a divided dose. Patients Maintained on Chronic Oral Corticosteroids
Initially, PULMICORT TURBUHALER (budesonide) should be used concurrently with the patient’s usual maintenance dose of systemic corticosteroid. After approximately one week, gradual withdrawal of the systemic corticosteroid is started by reducing the daily or alternate daily dose. The next reduction is made after an interval of one or two weeks, depending on the response of the patient. Generally, these decrements should not exceed 2.5 mg of prednisone or its equivalent. A slow rate of withdrawal is strongly recommended. During reduction of oral corticosteroids, patients should be carefully monitored for asthma instability, including objective measures of airway function, and for adrenal insufficiency (see WARNINGS ). During withdrawal, some patients may experience symptoms of systemic corticosteroid withdrawal, eg, joint and/or muscular pain, lassitude , and depression , despite maintenance or even improvement in pulmonary function. Such patients should be encouraged to continue with PULMICORT TURBUHALER (budesonide) but should be monitored for objective signs of adrenal insufficiency. If evidence of adrenal insufficiency occurs, the systemic corticosteroid doses should be increased temporarily and thereafter withdrawal should continue more slowly. During periods of stress or a severe asthma attack, transfer patients may require supplementary treatment with systemic corticosteroids.
NOTE: In all patients it is desirable to titrate to the lowest effective dose once asthma stability is achieved. Directions for Use
Illustrated Patient’s Instructions for Use accompany each package of PULMICORT TURBUHALER (budesonide) .
Patients should be instructed to prime PULMICORT TURBUHALER (budesonide) prior to its initial use, and instructed to inhale deeply and forcefully each time the unit is used. Rinsing the mouth after inhalation is also recommended. HOW SUPPLIED
PULMICORT TURBUHALER (budesonide) consists of a number of assembled plastic details, the main parts being the dosing mechanism, the storage unit for drug substance and the mouthpiece. The inhaler is protected by a white outer tubular cover screwed onto the inhaler. The body of the inhaler is white and the turning grip is brown. The following wording is printed on the grip in raised lettering, “Pulmicort™ 200 mcg”. The TURBUHALER inhaler cannot be refilled and should be discarded when empty.
PULMICORT TURBUHALER (budesonide) is available as 200 mcg/dose, 200 doses (NDC 0186-0915-42) and has a target fill weight of 104 mg.
When there are 20 doses remaining in PULMICORT TURBUHALER (budesonide) , a red mark will appear in the indicator window. If the unit is used beyond the point at which the red mark appears at the bottom of the window, the correct amount of medication may not be obtained. The unit should be discarded.
Store with the cover tightened in a dry place at controlled room temperature 20-25°C (68-77°F) [see USP]. Keep out of the reach of children. All trademarks are the property of the AstraZeneca group of companies. ©AstraZeneca 2001, 2006. Manufactured for: AstraZeneca LP, Wilmington, DE 19850 By: AstraZeneca AB, Sodertalje, Sweden 33020-00. Rev. 10/06. FDA Rev date: 8/20/2007 Side Effects SIDE EFFECTS
The following adverse reactions were reported in patients treated with PULMICORT TURBUHALER (budesonide) .
The incidence of common adverse events is based upon double-blind , placebo-controlled US clinical trials in which 1116 adult and pediatric patients age 6-70 years (472 females and 644 males) were treated with PULMICORT TURBUHALER (budesonide) (200 to 800 mcg twice daily for 12 to 20 weeks) or placebo .
The following table shows the incidence of adverse events in patients previously receiving bronchodilators and/or inhaled corticosteroids in US controlled clinical trials. This population included 232 male and 62 female pediatric patients (age 6 to 17 years) and 332 male and 331 female adult patients (age 18 years and greater). Adverse Events with ≥ 3% Incidence reported by Patients on PULMICORT TURBUHALER (budesonide)
Average Duration of Exposure (days) 59 80 80
The table above includes all events (whether considered drug-related or non-drug-related by the investigators) that occurred at a rate of ≥3% in any one PULMICORT TURBUHALER (budesonide) group and were more common than in the placebo group. In considering these data, the increased average duration of exposure for PULMICORT TURBUHALER (budesonide) patients should be taken into account.
The following other adverse events occurred in these clinical trials using PULMICORT TURBUHALER (budesonide) with an incidence of 1 to 3% and were more common on PULMICORT TURBUHALER (budesonide) than on placebo.
Resistance Mechanisms: infection
Special Senses: taste perversion
In a 20-week trial in adult asthmatics who previously required oral corticosteroids, the effects of PULMICORT TURBUHALER (budesonide) 400 mcg twice daily (N=53) and 800 mcg twice daily (N=53) were compared with placebo (N=53) on the frequency of reported adverse events. Adverse events, whether considered drug-related or non-drug-related by the investigators, reported in more than five patients in the PULMICORT TURBUHALER (budesonide) group and which occurred more frequently with PULMICORT TURBUHALER (budesonide) than placebo are shown below (% PULMICORT TURBUHALER (budesonide) and % placebo). In considering these data, the increased average duration of exposure for PULMICORT TURBUHALER (budesonide) patients (78 days for PULMICORT TURBUHALER (budesonide) vs. 41 days for placebo) should be taken into account.
Body As A Whole: asthenia (9% and 2%) headache (12% and 2%) pain (10% and 2%) Digestive: dyspepsia (8% and 0%)nausea (6% and 0%)oral candidiasis (10% and 0%) Musculoskeletal: arthralgia (6% and 0%) Respiratory: cough increased (6% and 2%) respiratory infection (32% and 13%) rhinitis (6% and 2%) sinusitis (16% and 11%) Patients Receiving PULMICORT TURBUHALER (budesonide) Once Daily
The adverse event profile of once-daily administration of PULMICORT TURBUHALER (budesonide) 200 mcg and 400 mcg, and placebo, was evaluated in 309 adult asthmatic patients in an 18-week study. The study population included both patients previously treated with inhaled corticosteroids, and patients not previously receiving corticosteroid therapy. There was no clinically relevant difference in the pattern of adverse events following once-daily administration of PULMICORT TURBUHALER (budesonide) when compared with twice-daily dosing.
Pediatric Studies: In a 12-week placebo-controlled trial in 404 pediatric patients 6 to 18 years of age previously maintained on inhaled corticosteroids, the frequency of adverse events for each age category (6 to 12 years, 13 to 18 years) was comparable for PULMICORT TURBUHALER (budesonide) (at 100, 200 and 400 mcg twice daily) and placebo. There were no clinically relevant differences in the pattern or severity of adverse events in children compared with those reported in adults.
Adverse Event Reports From Other Sources: Rare adverse events reported in the published literature or from worldwide marketing experience with any formulation of inhaled budesonide include: immediate and delayed hypersensitivity reactions including rash , contact dermatitis , urticaria , angioedema and bronchospasm; symptoms of hypocorticism and hypercorticism; glaucoma , cataracts; psychiatric symptoms including depression , aggressive reactions, irritability, anxiety and psychosis . Drug Interactions DRUG INTERACTIONS
In clinical studies, concurrent administration of budesonide and other drugs commonly used in the treatment of asthma has not resulted in an increased frequency of adverse events. The main route of metabolism of budesonide, as well as other corticosteroids, is via cytochrome P450 (CYP) isoenzyme 3A4 (CYP3A4). After oral administration of ketoconazole , a potent inhibitor of CYP3A4, the mean plasma concentration of orally administered budesonide increased. Concomitant administration of other known inhibitors of CYP3A4 (eg, itraconazole, clarithromycin , erythromycin , etc.) may inhibit the metabolism of, and increase the systemic exposure to, budesonide. Care should be exercised when budesonide is coadministered with long-term ketoconazole and other known CYP3A4 inhibitors. Warnings WARNINGS
Particular care is needed for patients who are transferred from systemically active corticosteroids to PULMICORT TURBUHALER (budesonide) because deaths due to adrenal insufficiency have occurred in asthmatic patients during and after transfer from systemic corticosteroids to less systemically available inhaled corticosteroids. After withdrawal from systemic corticosteroids, a number of months are required for recovery of hypothalamic- pituitary -adrenal (HPA) function.
Patients who have been previously maintained on 20 mg or more per day of prednisone (or its equivalent) may be most susceptible, particularly when their systemic corticosteroids have been almost completely withdrawn. During this period of HPA suppression, patients may exhibit signs and symptoms of adrenal insufficiency when exposed to trauma , surgery , or infection (particularly gastroenteritis ) or other conditions associated with severe electrolyte loss. Although PULMICORT TURBUHALER (budesonide) may provide control of asthma symptoms during these episodes, in recommended doses it supplies less than normal physiological amounts of glucocorticoid systemically and does NOT provide the mineralocorticoid activity that is necessary for coping with these emergencies.
During periods of stress or a severe asthma attack, patients who have been withdrawn from systemic corticosteroids should be instructed to resume oral corticosteroids (in large doses) immediately and to contact their physicians for further instruction. These patients should also be instructed to carry a medical identification card indicating that they may need supplementary systemic corticosteroids during periods of stress or a severe asthma attack.
Patients requiring oral corticosteroids should be weaned slowly from systemic corticosteroid use after transferring to PULMICORT TURBUHALER (budesonide) . Lung function (FEV 1 or AM PEF ), beta-agonist use, and asthma symptoms should be carefully monitored during withdrawal of oral corticosteroids. In addition to monitoring asthma signs and symptoms, patients should be observed for signs and symptoms of adrenal insufficiency such as fatigue , lassitude , weakness, nausea and vomiting, and hypotension .
Transfer of patients from systemic corticosteroid therapy to PULMICORT TURBUHALER (budesonide) may unmask allergic conditions previously suppressed by the systemic corticosteroid therapy, eg, rhinitis , conjunctivitis , arthritis , eosinophilic conditions, and eczema (see DOSAGE AND ADMINISTRATION ).
Patients who are on drugs that suppress the immune system are more susceptible to infection than healthy individuals. Chicken pox and measles , for example, can have a more serious or even fatal course in susceptible pediatric patients or adults on immunosuppressant doses of corticosteroids. In pediatric or adult patients who have not had these diseases, particular care should be taken to avoid exposure. How the dose, route, and duration of corticosteroid administration affects the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If exposed, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin ( IG ) may be indicated. (See the respective package inserts for complete VZIG and IG prescribing information.) If chicken pox develops, treatment with antiviral agents may be considered.
PULMICORT TURBUHALER (budesonide) is not a bronchodilator and is not indicated for rapid relief of bronchospasm or other acute episodes of asthma.
As with other inhaled asthma medications, bronchospasm, with an immediate increase in wheezing , may occur after dosing. If bronchospasm occurs following dosing with PULMICORT TURBUHALER (budesonide) , it should be treated immediately with a fast-acting inhaled bronchodilator. Treatment with PULMICORT TURBUHALER (budesonide) should be discontinued and alternate therapy instituted.
Patients should be instructed to contact their physician immediately when episodes of asthma not responsive to their usual doses of bronchodilators occur during treatment with PULMICORT TURBUHALER (budesonide) . During such episodes, patients may require therapy with oral corticosteroids. Precautions PRECAUTIONS General
During withdrawal from oral corticosteroids, some patients may experience symptoms of systemically active corticosteroid withdrawal, eg, joint and/or muscular pain, lassitude, and depression , despite maintenance or even improvement of respiratory function (see DOSAGE AND ADMINISTRATION ).
In responsive patients, PULMICORT TURBUHALER (budesonide) may permit control of asthma symptoms with less suppression of HPA- axis function than therapeutically equivalent oral doses of prednisone. Since budesonide is absorbed into the circulation and can be systemically active, the beneficial effects of PULMICORT TURBUHALER (budesonide) in minimizing HPA dysfunction may be expected only when recommended dosages are not exceeded and individual patients are titrated to the lowest effective dose . Since individual sensitivity to effects on cortisol production exists, physicians should consider this information when prescribing PULMICORT TURBUHALER (budesonide) .
Because of the possibility of systemic absorption of inhaled corticosteroids, patients treated with PULMICORT TURBUHALER (budesonide) should be observed carefully for any evidence of systemic corticosteroid effects. Particular care should be taken in observing patients postoperatively or during periods of stress for evidence of inadequate adrenal response.
It is possible that systemic corticosteroid effects such as hypercorticism, reduced bone mineral density , and adrenal suppression may appear in a small number of patients, particularly at higher doses. If such changes occur, PULMICORT TURBUHALER (budesonide) should be reduced slowly, consistent with accepted procedures for management of asthma symptoms and for tapering of systemic steroids.
Orally inhaled corticosteroids, including budesonide, may cause a reduction in growth velocity when administered to pediatric patients. A reduction in growth velocity may occur as a result of inadequate control of asthma or from use of corticosteroids for treatment. The potential effects of prolonged treatment on growth velocity should be weighed against the clinical benefits obtained and the risks associated with alternative therapies. To minimize the systemic effects of orally inhaled corticosteroids, including PULMICORT TURBUHALER (budesonide) , each patient should be titrated to his/her lowest effective dose (see PRECAUTIONS, Pediatric Use ).
Although patients in clinical trials have received PULMICORT TURBUHALER (budesonide) on a continuous basis for periods of 1 to 2 years, the long-term local and systemic effects of PULMICORT TURBUHALER (budesonide) in human subjects are not completely known. In particular, the effects resulting from chronic use of PULMICORT TURBUHALER (budesonide) on developmental or immunological processes in the mouth, pharynx , trachea , and lung are unknown.
In clinical trials with PULMICORT TURBUHALER (budesonide) , localized infections with Candida albicans occurred in the mouth and pharynx in some patients. These infections may require treatment with appropriate antifungal therapy and/or discontinuance of treatment with PULMICORT TURBUHALER (budesonide) .
Inhaled corticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculosis infection of the respiratory tract, untreated systemic fungal , bacterial , viral or parasitic infections, or ocular herpes simplex.
Rare instances of glaucoma , increased intraocular pressure , and cataracts have been reported following the inhaled administration of corticosteroids. Information for Patients
Patients being treated with PULMICORT TURBUHALER (budesonide) should receive the following information and instructions. This information is intended to aid the patient in the safe and effective use of the medication. It is not a disclosure of all possible adverse or intended effects. For proper use of PULMICORT TURBUHALER (budesonide) and to attain maximum improvement, the patient should read and follow the accompanying Patient’s Instructions for Use carefully. Patients should use PULMICORT TURBUHALER (budesonide) at regular intervals as directed since its effectiveness depends on regular use. The patient should not alter the prescribed dosage unless advised to do so by the physician. Patients should be advised that PULMICORT TURBUHALER (budesonide) is not a bronchodilator and is not intended to treat acute or life-threatening episodes of asthma. Patients should be advised that the effectiveness of PULMICORT TURBUHALER (budesonide) depends on proper use of the device and inhalation-administering technique: 1. PULMICORT TURBUHALER (budesonide) must be in the upright position (mouthpiece on top) during loading in order to provide the correct dose. 2. PULMICORT TURBUHALER (budesonide) must be primed when the unit is used for the very first time. To prime the unit, it must be held in an upright position and the brown grip turned fully to the right, then turned fully to the left until it clicks. Repeat. 3. To load the first dose, the grip must be turned fully to the right and fully to the left until it clicks. 4. After the first dose, it is not necessary to prime the unit. However, it must be loaded in the upright position immediately prior to use as described above. 5. Patients should be advised not to shake the inhaler. Patients should place the mouthpiece between the lips and inhale forcefully and deeply. The powder is then delivered to the lungs . Patients should not exhale through PULMICORT TURBUHALER (budesonide) . Due to the small volume of powder, the patient may not taste or sense the presence of any medication entering the lungs when inhaling from the TURBUHALER inhaler. This lack of sensation does not indicate that the patient is not receiving benefit from PULMICORT TURBUHALER (budesonide) . Patients should be advised that rinsing the mouth with water without swallowing after each dosing may decrease the risk of the development of oral candidiasis . Patients should be instructed that they will receive a new PULMICORT TURBUHALER (budesonide) unit each time they refill their prescription. Patients should be advised to discard the whole device after the labelled number of inhalations has been used. When there are 20 doses remaining in PULMICORT TURBUHALER (budesonide) , a red mark will appear in the indicator window. PULMICORT TURBUHALER (budesonide) should not be used with a spacer. The mouthpiece should not be bitten or chewed. The cover should be replaced securely after each opening. Patients should keep PULMICORT TURBUHALER (budesonide) clean and dry at all times. Patients should be advised that improvement in asthma control following inhalation of PULMICORT TURBUHALER (budesonide) can occur within 24 hours of beginning treatment although maximum benefit may not be achieved for 1 to 2 weeks, or longer. If symptoms do not improve in that time frame, or if the condition worsens, the patient should be instructed not to increase the dosage, but to contact the physician. Patients whose systemic corticosteroids have been reduced or withdrawn should be instructed to carry a warning card indicating that they may need supplemental systemic corticosteroids during periods of stress or an asthma attack that does not respond to bronchodilators. Patients should be advised not to stop the use of PULMICORT TURBUHALER (budesonide) abruptly. Patients should be warned to avoid exposure to chicken pox or measles and if they are exposed, to consult their physicians without delay. Long-term use of inhaled corticosteroids, including budesonide, may increase the risk of some eye problems (cataracts or glaucoma). Regular eye examinations should be considered. Women considering the use of PULMICORT TURBUHALER (budesonide) should consult with their physician if they are pregnant or intend to become pregnant, or if they are breast-feeding a baby. Patients considering use of PULMICORT TURBUHALER (budesonide) should consult with their physician if they are allergic to budesonide or any other orally inhaled corticosteroid. Patients should inform their physician of other medications they are taking as PULMICORT TURBUHALER (budesonide) may not be suitable in some circumstances and the physician may wish to use a different medicine. Carcinogenesis, Mutagenesis, Impairment of Fertility
Long-term studies were conducted in rats and mice using oral administration to evaluate the carcinogenic potential of budesonide.
In a 104-week oral study in Sprague-Dawley rats, a statistically significant increase in the incidence of gliomas was observed in male rats receiving an oral dose of 50 mcg/kg/day (less than the maximum recommended daily inhalation dose in adults and children on a mcg/m 2 basis). No tumorigenicity was seen in male and female rats at respective oral doses up to 25 and 50 mcg/kg (less than the maximum recommended daily inhalation dose in adults and children on a mcg/m 2 basis). In two additional two-year studies in male Fischer and Sprague-Dawley rats, budesonide caused no gliomas at an oral dose of 50 mcg/kg (less than the maximum recommended daily inhalation dose in adults and children on a mcg/m 2 basis). However, in the male Sprague-Dawley rats, budesonide caused a statistically significant increase in the incidence of hepatocellular tumors at an oral dose of 50 mcg/kg (less than the maximum recommended daily inhalation dose in adults and children on a mcg/m 2 basis). The concurrent reference corticosteroids (prednisone and triamcinolone acetonide) in these two studies showed similar findings.
There was no evidence of a carcinogenic effect when budesonide was administered orally for 91 weeks to mice at doses up to 200 mcg/kg/day (less than the maximum recommended daily inhalation dose in adults and children on a mcg/m 2 basis).
Budesonide was not mutagenic or clastogenic in six different test systems: Ames Salmonella /microsome plate test, mouse micronucleus test, mouse lymphoma test, chromosome aberration test in human lymphocytes, sex-linked recessive lethal test in Drosophila melanogaster , and DNA repair analysis in rat hepatocyte culture.
In rats, budesonide had no effect on fertility at subcutaneous doses up to 80 mcg/kg (less than the maximum recommended human daily inhalation dose on a mcg/m 2 basis).
At 20 mcg/kg/day (less than the maximum recommended human daily inhalation dose on a mcg/m 2 basis), decreases in maternal body weight gain, prenatal viability, and viability of the young at birth and during lactation were observed. No such effects were noted at 5 mcg/kg (less than the maximum recommended human daily inhalation dose in adults on a mcg/m 2 basis). Pregnancy: Teratogenic Effects
Pregnancy Category B: As with other glucocorticoids, budesonide produced fetal loss, decreased pup weight, and skeletal abnormalities at subcutaneous doses of 25 mcg/kg/day in rabbits (less than the maximum recommended human daily inhalation dose on a mcg/m 2 basis) and 500 mcg/kg/day in rats (approximately 3 times the maximum recommended human daily inhalation dose on a mcg/m 2 basis).
No teratogenic or embryocidal effects were observed in rats when budesonide was administered by inhalation at doses up to 250 mcg/kg/day (equivalent to the maximum recommended human daily inhalation dose on a mcg/m 2 basis).
Experience with oral corticosteroids since their introduction in pharmacologic as opposed to physiologic doses suggests that rodents are more prone to teratogenic effects from corticosteroids than humans.
Studies of pregnant women, however, have not shown that PULMICORT TURBUHALER (budesonide) increases the risk of abnormalities when administered during pregnancy. The results from a large population-based prospective cohort epidemiological study reviewing data from three Swedish registries covering approximately 99% of the pregnancies from 1995-1997 (i.e., Swedish Medical Birth Registry; Registry of Congenital Malformations; Child Cardiology Registry) indicate no increased risk for congenital malformations from the use of inhaled budesonide during early pregnancy. Congenital malformations were studied in 2,014 infants born to mothers reporting the use of inhaled budesonide for asthma in early pregnancy (usually 10-12 weeks after the last menstrual period ), the period when most major organ malformations occur. The rate of recorded congenital malformations was similar compared with the general population rate (3.8 % vs. 3.5%, respectively). In addition, after exposure to inhaled budesonide, the number of infants born with orofacial clefts was similar to the expected number in the normal population (4 children vs. 3.3, respectively).
These same data were utilized in a second study bringing the total to 2,534 infants whose mothers were exposed to inhaled budesonide. In this study, the rate of congenital malformations among infants whose mothers were exposed to inhaled budesonide during early pregnancy was not different from the rate for all newborn babies during the same period (3.6%).
Despite the animal findings, it would appear that the possibility of fetal harm is remote if the drug is used during pregnancy. Nevertheless, because the studies in humans cannot rule out the possibility of harm, PULMICORT TURBUHALER (budesonide) should be used during pregnancy only if clearly needed. Nonteratogenic Effects
Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Such infants should be carefully observed. Nursing Mothers
Corticosteroids are secreted in human milk. Because of the potential for adverse reactions in nursing infants from any corticosteroid, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother. Actual data for budesonide are lacking. Pediatric Use
Safety and effectiveness of PULMICORT TURBUHALER (budesonide) in pediatric patients below 6 years of age have not been established.
In pediatric asthma patients the frequency of adverse events observed with PULMICORT TURBUHALER (budesonide) was similar between the 6- to 12-year age group (N=172) compared with the 13- to 17-year age group (N=124).
Controlled clinical studies have shown that orally inhaled corticosteroids may cause a reduction in growth velocity in pediatric patients. This effect has been observed in the absence of laboratory evidence of hypothalamic-pituitary-adrenal (HPA) axis suppression, suggesting that growth velocity is a more sensitive indicator of systemic corticosteroid exposure in pediatric patients than some commonly used tests of HPA-axis function. The long-term effects of this reduction in growth velocity associated with orally inhaled corticosteroids including the impact on final adult height are unknown. The potential for “catch up” growth following discontinuation of treatment with orally inhaled corticosteroids has not been adequately studied.
In a study of asthmatic children 5-12 years of age, those treated with PULMICORT TURBUHALER (budesonide) 200 mcg twice daily (n=311) had a 1.1- centimeter reduction in growth compared with those receiving placebo (n=418) at the end of one year; the difference between these two treatment groups did not increase further over three years of additional treatment. By the end of four years, children treated with PULMICORT TURBUHALER (budesonide) and children treated with placebo had similar growth velocities. Conclusions drawn from this study may be confounded by the unequal use of corticosteroids in the treatment groups and inclusion of data from patients attaining puberty during the course of the study.
The growth of pediatric patients receiving orally inhaled corticosteroids, including PULMICORT TURBUHALER (budesonide) , should be monitored routinely (eg, via stadiometry). The potential growth effects of prolonged treatment should be weighed against clinical benefits obtained and the risks and benefits associated with alternative therapies. To minimize the systemic effects of inhaled corticosteroids, including PULMICORT TURBUHALER (budesonide) , each patient should be titrated to his/her lowest effective dose. Geriatric Use
One hundred patients 65 years or older were included in the US and non-US controlled clinical trials of PULMICORT TURBUHALER (budesonide) . There were no differences in the safety and efficacy of the drug compared with those seen in younger patients.
In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic , renal , or cardiac function, and of concomitant disease or other drug therapy. Overdosage & Contraindications OVERDOSE
The potential for acute toxic effects following overdose of PULMICORT TURBUHALER (budesonide) is low. If used at excessive doses for prolonged periods, systemic corticosteroid effects such as hypercorticism may occur (see PRECAUTIONS ). PULMICORT TURBUHALER at twice the highest recommended dose (3200 mcg daily) administered for 6 weeks caused a significant reduction (27%) in the plasma cortisol response to a 6-hour infusion of ACTH compared with placebo (+1%). The corresponding effect of 10 mg prednisone daily was a 35% reduction in the plasma cortisol response to ACTH.
The minimal inhalation lethal dose in mice was 100 mg/kg (approximately 320 times the maximum recommended daily inhalation dose in adults and approximately 380 times the maximum recommended daily inhalation dose in children on a mcg/m 2 basis). There were no deaths following the administration of an inhalation dose of 68 mg/kg in rats (approximately 430 times the maximum recommended daily inhalation dose in adults and approximately 510 times the maximum recommended daily inhalation dose in children on a mcg/m 2 basis). The minimal oral lethal dose was 200 mg/kg in mice (approximately 630 times the maximum recommended daily inhalation dose in adults and approximately 750 times the maximum recommended daily inhalation dose in children on a mcg/m 2 basis) and less than 100 mg/kg in rats (approximately 630 times the maximum recommended daily inhalation dose in adults and approximately 750 times the maximum recommended daily inhalation dose in children based on a mcg/m 2 basis).
Post-marketing experience showed that patients experiencing acute overdose of inhaled budesonide commonly remained asymptomatic . The use of excessive doses (up to 6400 mcg daily) for prolonged periods showed systemic corticosteroid effects such as hypercorticism. CONTRAINDICATIONS
PULMICORT TURBUHALER (budesonide) is contraindicated in the primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.
Hypersensitivity to budesonide contraindicates the use of PULMICORT TURBUHALER (budesonide) . Clinical Pharmacology CLINICAL PHARMACOLOGY Mechanism of Action
Budesonide is an anti-inflammatory corticosteroid that exhibits potent glucocorticoid activity and weak mineralocorticoid activity. In standard in vitro and animal models, budesonide has approximately a 200-fold higher affinity for the glucocorticoid receptor and a 1000-fold higher topical anti-inflammatory potency than cortisol (rat croton oil ear edema assay). As a measure of systemic activity, budesonide is 40 times more potent than cortisol when administered subcutaneously and 25 times more potent when administered orally in the rat thymus involution assay.
The activity of PULMICORT TURBUHALER is due to the parent drug, budesonide. In glucocorticoid receptor affinity studies, the 22R form was two times as active as the 22S epimer. In vitro studies indicated that the two forms of budesonide do not interconvert.
The precise mechanism of corticosteroid actions on inflammation in asthma is not known. Inflammation is an important component in the pathogenesis of asthma. Corticosteroids have been shown to have a wide range of inhibitory activities against multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, and lymphocytes) and mediators (eg, histamine , eicosanoids, leukotrienes, and cytokines) involved in allergic and non-allergic-mediated inflammation. These anti-inflammatory actions of corticosteroids may contribute to their efficacy in asthma.
Studies in asthmatic patients have shown a favorable ratio between topical anti-inflammatory activity and systemic corticosteroid effects over a wide range of doses from PULMICORT TURBUHALER (budesonide) . This is explained by a combination of a relatively high local anti-inflammatory effect, extensive first pass hepatic degradation of orally absorbed drug (85-95%), and the low potency of formed metabolites (see below). Pharmacokinetics Absorption: After oral administration of budesonide, peak plasma concentration was achieved in about 1 to 2 hours and the absolute systemic availability was 6-13%. In contrast, most of budesonide delivered to the lungs is systemically absorbed. In healthy subjects, 34% of the metered dose was deposited in the lungs (as assessed by plasma concentration method) with an absolute systemic availability of 39% of the metered dose. Pharmacokinetics of budesonide do not differ significantly in healthy volunteers and asthmatic patients. Peak plasma concentrations of budesonide occurred within 30 minutes of inhalation from PULMICORT TURBUHALER.
In asthmatic patients, budesonide showed a linear increase in AUC and Cmax with increasing dose after both a single dose and repeated dosing from PULMICORT TURBUHALER (budesonide) . Distribution: The volume of distribution of budesonide was approximately 3 L/kg. It was 85-90% bound to plasma proteins. Protein binding was constant over the concentration range (1-100 nmol/L) achieved with, and exceeding, recommended doses of PULMICORT TURBUHALER. Budesonide showed little or no binding to corticosteroid binding globulin. Budesonide rapidly equilibrated with red blood cells in a concentration independent manner with a blood/plasma ratio of about 0.8. Metabolism: In vitro studies with human liver homogenates have shown that budesonide is rapidly and extensively metabolized. Two major metabolites formed via cytochrome P450 (CYP) isoenzyme 3A4 (CYP3A4) catalyzed biotransformation have been isolated and identified as 16α-hydroxyprednisolone and 6β-hydroxybudesonide. The corticosteroid activity of each of these two metabolites is less than 1% of that of the parent compound. No qualitative differences between the in vitro and in vivo metabolic patterns have been detected. Negligible metabolic inactivation was observed in human lung and serum preparations. Excretion/Elimination: The 22R form of budesonide was preferentially cleared by the liver with systemic clearance of 1.4 L/min vs. 1.0 L/min for the 22S form. The terminal half-life, 2 to 3 hours, was the same for both epimers and was independent of dose. Budesonide was excreted in urine and feces in the form of metabolites. Approximately 60% of an intravenous radiolabelled dose was recovered in the urine. No unchanged budesonide was detected in the urine. Special Populations: No pharmacokinetic differences have been identified due to race, gender or advanced age. Pediatric: Following intravenous dosing in pediatric patients age 10-14 years, plasma half-life was shorter than in adults (1.5 hours vs. 2.0 hours in adults). In the same population following inhalation of budesonide via a pressurized metered-dose inhaler , absolute systemic availability was similar to that in adults. Hepatic Insufficiency: Reduced liver function may affect the elimination of corticosteroids. The pharmacokinetics of budesonide were affected by compromised liver function as evidenced by a doubled systemic availability after oral ingestion. The intravenous pharmacokinetics of budesonide were, however, similar in cirrhotic patients and in healthy subjects. Drug-Drug Interactions: Ketoconazole, a potent inhibitor of cytochrome P450 (CYP) isoenzyme 3A4 (CYP3A4), the main metabolic enzyme for corticosteroids, increased plasma levels of orally ingested budesonide. At recommended doses, cimetidine had a slight but clinically insignificant effect on the pharmacokinetics of oral budesonide. Pharmacodynamics
To confirm that systemic absorption is not a significant factor in the clinical efficacy of inhaled budesonide, a clinical study in patients with asthma was performed comparing 400 mcg budesonide administered via a pressurized metered-dose inhaler with a tube spacer to 1400 mcg of oral budesonide and placebo . The study demonstrated the efficacy of inhaled budesonide but not orally ingested budesonide despite comparable systemic levels. Thus, the therapeutic effect of conventional doses of orally inhaled budesonide are largely explained by its direct action on the respiratory tract.
Generally, PULMICORT TURBUHALER (budesonide) has a relatively rapid onset of action for an inhaled corticosteroid. Improvement in asthma control following inhalation of PULMICORT TURBUHALER (budesonide) can occur within 24 hours of beginning treatment although maximum benefit may not be achieved for 1 to 2 weeks, or longer.
PULMICORT TURBUHALER (budesonide) has been shown to decrease airway reactivity in various challenge models, including histamine, methacholine, sodium metabisulfite, and adenosine monophosphate in patients with hyperreactive airways. The clinical relevance of these models is not certain.
Pretreatment with PULMICORT TURBUHALER (budesonide) 1600 mcg daily (800 mcg twice daily) for 2 weeks reduced the acute (early-phase reaction) and delayed (late-phase reaction) decrease in FEV 1 following inhaled allergen challenge.
The effects of PULMICORT TURBUHALER (budesonide) on the hypothalamic-pituitary-adrenal (HPA) axis were studied in 905 adults and 404 pediatric patients with asthma. For most patients, the ability to increase cortisol production in response to stress, as assessed by cosyntropin (ACTH) stimulation test, remained intact with PULMICORT TURBUHALER (budesonide) treatment at recommended doses. For adult patients treated with 100, 200, 400, or 800 mcg twice daily for 12 weeks, 4%, 2%, 6%, and 13% respectively, had an abnormal stimulated cortisol response (peak cortisol <14.5 mcg/dL assessed by liquid chromatography following short-cosyntropin test) as compared with 8% of patients treated with placebo. Similar results were obtained in pediatric patients. In another study in adults, doses of 400, 800 and 1600 mcg budesonide twice daily via PULMICORT TURBUHALER (budesonide) for 6 weeks were examined; 1600 mcg twice daily (twice the maximum recommended dose) resulted in a 27% reduction in stimulated cortisol (6-hour ACTH infusion) while 10 mg prednisone resulted in a 35% reduction. In this study, no patient on PULMICORT TURBUHALER (budesonide) at doses of 400 and 800 mcg twice daily met the criterion for an abnormal stimulated cortisol response (peak cortisol <14.5 mcg/dL assessed by liquid chromatography) following ACTH infusion. An open-label , long-term follow-up of 1133 patients for up to 52 weeks confirmed the minimal effect on the HPA axis (both basal and stimulated plasma cortisol) of PULMICORT TURBUHALER (budesonide) when administered at recommended doses. In patients who had previously been oral steroid -dependent, use of PULMICORT TURBUHALER (budesonide) in recommended doses was associated with higher stimulated cortisol response compared with baseline following 1 year of therapy.
The administration of budesonide via PULMICORT TURBUHALER (budesonide) in doses up to 800 mcg/day (mean daily dose 445 mcg/day) or via a pressurized metered-dose inhaler in doses up to 1200 mcg/day (mean daily dose 620 mcg/day) to 216 pediatric patients (age 3 to 11 years) for 2 to 6 years had no significant effect on statural growth compared with non-corticosteroid therapy in 62 matched control patients. However, the long-term effect of PULMICORT TURBUHALER (budesonide) on growth is not fully known. Clinical Trails
The therapeutic efficacy of PULMICORT TURBUHALER (budesonide) has been evaluated in controlled clinical trials involving more than 1300 patients (6 years and older) with asthma of varying disease duration (20 years) and severity.
Double-blind , parallel, placebo-controlled clinical trials of 12 weeks duration and longer have shown that, compared with placebo, PULMICORT TURBUHALER (budesonide) significantly improved lung function (measured by PEF and FEV 1 ), significantly decreased morning and evening symptoms of asthma, and significantly reduced the need for as-needed inhaled β2- agonist use at doses of 400 mcg to 1600 mcg per day (200 mcg to 800 mcg twice daily) in adults and 400 mcg to 800 mcg per day (200 mcg to 400 mcg twice daily) in pediatric patients 6 years of age and older.
Improved lung function (morning PEF) was observed within 24 hours of initiating treatment in both adult and pediatric patients 6 years of age and older, although maximum benefit was not achieved for 1 to 2 weeks, or longer, after starting treatment. Improved lung function was maintained throughout the 12 weeks of the double-blind portion of the trials. Patients Not Receiving Corticosteroid Therapy
In a 12-week clinical trial in 273 patients with mild to moderate asthma (mean baseline FEV 1 2.27 L) who were not well controlled by bronchodilators alone, PULMICORT TURBUHALER (budesonide) was evaluated at doses of 200 mcg twice daily and 400 mcg twice daily versus placebo. The FEV 1 results from this trial are shown in the figure below. Pulmonary function improved significantly on both doses of PULMICORT TURBUHALER (budesonide) compared with placebo.
A 12-Week Trial in Patients Not on Corticosteroid Therapy Prior to Study Entry
In a 12-month controlled trial in 75 patients not previously receiving corticosteroids, PULMICORT TURBUHALER (budesonide) at 200 mcg twice daily resulted in improved lung function (measured by PEF) and reduced bronchial hyperreactivity compared with placebo. Patients Previously Maintained on Inhaled Corticosteroids
The safety and efficacy of PULMICORT TURBUHALER (budesonide) was also evaluated in adult and pediatric patients (age 6 to 18 years) previously maintained on inhaled corticosteroids (adults: N=473, mean baseline FEV 1 2.04 L, baseline doses of beclomethasone dipropionate 126-1008 mcg/day; pediatrics : N=404, mean baseline FEV 1 2.09 L, baseline doses of beclomethasone dipropionate 126-672 mcg/day or triamcinolone acetonide 300-1800 mcg/day). The FEV 1 results of these two trials, both 12 weeks in duration, are presented in the following figures. Pulmonary function improved significantly with all doses of PULMICORT TURBUHALER (budesonide) compared with placebo in both trials.
Adult Patients Previously Maintained on Inhaled Corticosteroids
Pediatric Patients Age 6 to 18 Years Previously Maintained on Inhaled Corticosteroids Patients Receiving PULMICORT TURBUHALER (budesonide) Once Daily
The efficacy and safety of once-daily administration of PULMICORT TURBUHALER (budesonide) 200 mcg and 400 mcg and placebo were also evaluated in 309 adult asthmatic patients (mean baseline FEV 1 2.7 L) in an 18-week study. Compared with placebo, patients receiving Pulmicort 200 or 400 mcg once daily showed significantly better asthma stability as assessed by PEF and FEV 1 over an initial 6-week treatment period, which was maintained with a 200 mcg daily dose over the subsequent 12 weeks. Although the study population included both patients previously treated with inhaled corticosteroids, as well as patients not previously receiving corticosteroid therapy, the results showed that once-daily dosing was most clearly effective for those patients previously maintained on orally inhaled corticosteroids (see DOSAGE AND ADMINISTRATION ). Patients Previously Maintained on Oral Corticosteroids
In a clinical trial in 159 severe asthmatic patients requiring chronic oral prednisone therapy (mean baseline prednisone dose 19.3 mg/day) PULMICORT TURBUHALER (budesonide) at doses of 400 mcg twice daily and 800 mcg twice daily was compared with placebo over a 20-week period. Approximately two-thirds (68% on 400 mcg twice daily and 64% on 800 mcg twice daily) of PULMICORT TURBUHALER (budesonide) -treated patients were able to achieve sustained (at least 2 weeks) oral corticosteroid cessation (compared with 8% of placebo-treated patients) and improved asthma control. The average oral corticosteroid dose was reduced by 83% on 400 mcg twice daily and 79% on 800 mcg twice daily for PULMICORT TURBUHALER (budesonide) -treated patients vs. 27% for placebo. Additionally, 58 out of 64 patients (91%) who completely eliminated oral corticosteroids during the double-blind phase of the trial remained off oral corticosteroids for an additional 12 months while receiving PULMICORT TURBUHALER (budesonide) . Medication Guide PATIENT INFORMATION
Patient’s Instructions For Use
Please read this leaflet carefully before you start to take your medicine. It provides a summary of information on your medicine. Following these instructions helps to ensure that you are inhaling the medication correctly.
FOR FURTHER INFORMATION ASK YOUR DOCTOR OR PHARMACIST.
WHAT YOU SHOULD KNOW ABOUT PULMICORT TURBUHALER (budesonide)
Your doctor has prescribed PULMICORT TURBUHALER 200 mcg. It contains a medication called budesonide, which is a synthetic corticosteroid . Corticosteroids are natural substances found in the body that help fight inflammation . They are used to treat asthma because they reduce the swelling and irritation in the walls of the small air passages in the lungs and ease breathing problems. When inhaled regularly, corticosteroids also help to prevent attacks of asthma.
PULMICORT TURBUHALER (budesonide) treats the inflammation—the “quiet part” of asthma that you cannot hear, see, or feel. When inflammation is left untreated, your asthma symptoms and attacks can increase. PULMICORT TURBUHALER (budesonide) works to prevent and reduce your asthma symptoms and attacks.
IMPORTANT POINTS TO REMEMBER ABOUT PULMICORT TURBUHALER (budesonide)
MAKE SURE that this medicine is suitable for you (see “BEFORE USING YOUR PULMICORT TURBUHALER (budesonide) ”).
It is important that you inhale each dose as your doctor has advised.
Use your Turbuhaler as directed by your doctor. DO NOT STOP TREATMENT OR REDUCE YOUR DOSE EVEN IF YOU FEEL BETTER, unless told to do so by your doctor.
DO NOT inhale more doses or use your Turbuhaler more often than instructed by your doctor.
This medicine is NOT intended to provide rapid relief of your breathing difficulties during an asthma attack. It must be taken at regular intervals as recommended by your doctor, and not as an emergency measure.
Your doctor may prescribe additional medication (such as bronchodilators) for emergency relief if an acute an asthma attack does not respond to the additional medication, you require more of the additional medication than usual.
If you also use another medicine by inhalation, you should consult your doctor for instructions on when to use it in relation to using your PULMICORT TURBUHALER (budesonide) .
BEFORE USING YOUR PULMICORT TURBUHALER (budesonide)
TELL YOUR DOCTOR BEFORE STARTING TO TAKE THIS MEDICINE IF YOU: are pregnant (or intending to become pregnant), are breast-feeding a baby, are allergic to budesonide or any other orally inhaled corticosteroid, have any infections,

Read More…

Clinical outcomes of bortezomib-based therapy in myeloma

Clinical outcomes of bortezomib-based therapy in myeloma

Bortezomib, a first generation proteasome inhibitor, is used in both newly diagnosed and relapsed myeloma settings. Considerable differences exist in the usage of bortezomib therapy in the clinical practice setting in comparison to clinical trial setting as w…

Read More…

buy cheap Bimatoprost , buy Bimatoprost 50 mg, buy Bimatoprost ult

<h1>buy cheap Bimatoprost , buy Bimatoprost 50 mg, buy Bimatoprost ult</h1>

buy cheap Bimatoprost , buy Bimatoprost 50 mg, buy Bimatoprost ult

Buy Cheap Bimatoprost Online uk. Buy Cheap Bimatoprost Online.Buy Bimatoprost online australia. Buy Bimatoprost for cheap. Buy Cheap Bimatoprost Online, Buy Bimatoprost online australia. Buy Quinine for cheap usa.
BUY Bimatoprost ONLINE! -> CLICK HERE!
CLICK HERE TO ENTER, Lowest Prices!
buy Bimatoprost from india
buy Bimatoprost from india
buy Bimatoprost no prescription
buy cheap Bimatoprost online
buy Bimatoprost in europe
buy Bimatoprost in europe
buy generic Bimatoprost
buy generic Bimatoprost
buy Bimatoprost online europe
buy Bimatoprost no rx
buy Bimatoprost overnight
best buy Bimatoprost
best buy Bimatoprost
can you buy Bimatoprost in mexico
buy Bimatoprost online europe
buy Bimatoprost online europe
buy Bimatoprost pregabalin
buy liquid Bimatoprost
buy Bimatoprost usa
buy Bimatoprost online no prescription
buy Bimatoprost without prescription
buy Bimatoprost without prescription
how to buy Bimatoprost online
buy Bimatoprost uk
buy Bimatoprost rosin
buy Bimatoprost rosin
buy Bimatoprost in europe
buy Bimatoprost no prescription
buy Bimatoprost online mastercard overnight
buy Bimatoprost online canada
buy Bimatoprost online canada
where can i buy Bimatoprost online
buy cheapest Bimatoprost online
buy Bimatoprost online without prior prescription
can i buy Bimatoprost online
buy Bimatoprost online overnight
where to buy Bimatoprost cheap
where to buy Bimatoprost cheap
buy Bimatoprost canada
buy pregabalin Bimatoprost uk
pregabalin generic Bimatoprost buy
Bimatoprost tablets buy now pay
Bimatoprost tablets buy now pay
buy liquid Bimatoprost
buy Bimatoprost online without prescription
buy Bimatoprost tablets uk
Bimatoprost tablets buy one get free
Bimatoprost tablets buy
buy Bimatoprost mexico
buy Bimatoprost mastercard
buy Bimatoprost online usa
buy Bimatoprost online usa
buy Bimatoprost online without prior prescription
buy cheap Bimatoprost overnight
buy cheap Bimatoprost overnight
buy Bimatoprost tablets uk
Bimatoprost 150 mg buy
buy Bimatoprost 300mg
buy Bimatoprost 300mg
Bimatoprost 50mg buy online
where to buy Bimatoprost
buy discount Bimatoprost
where can i buy Bimatoprost
buy Bimatoprost online
buy Bimatoprost online
is it legal to buy Bimatoprost online
buy Bimatoprost 300 mg online
buy Bimatoprost 300 mg online
cheapest place to buy Bimatoprost
buy Bimatoprost online cod only
buy Bimatoprost in canada
where to buy Bimatoprost
where to buy Bimatoprost
buy Bimatoprost with
buy Bimatoprost online without prescription
buy Bimatoprost online no prescription
buy Bimatoprost
buy Bimatoprost
buy generic Bimatoprost online
buy generic Bimatoprost online
buy generic Bimatoprost online
Bimatoprost to buy uk
Bimatoprost to buy uk
buy Bimatoprost 75 mg online
buy Bimatoprost 75 mg online
buy Bimatoprost hcl
buy Bimatoprost from trusted pharmacy
buy 180 Bimatoprost online
buy Bimatoprost tablets uk
buy Bimatoprost tablets uk
buy Bimatoprost on line
buy Bimatoprost on line
buy Bimatoprost online uk
buy Bimatoprost online uk
best place to buy Bimatoprost online
how to buy Bimatoprost
how to buy Bimatoprost
buy Bimatoprost in mexico
buy Bimatoprost 75 mg
buy Bimatoprost in uk
buy Bimatoprost online cheap
buy Bimatoprost online cheap
buy Bimatoprost 200mg
Bimatoprost 150 mg buy online
where can i buy Bimatoprost online
Bimatoprost to buy uk
buy Bimatoprost rosin
buy Bimatoprost rosin
Bimatoprost to buy
buy pregabalin Bimatoprost online
Bimatoprost tablets buy one get free
buy Bimatoprost canada
Bimatoprost tablets buy
buy Bimatoprost fedex
where to buy Bimatoprost online
where to buy Bimatoprost
buy Bimatoprost in mexico
buy Bimatoprost in mexico
buy Bimatoprost overnight
is it legal to buy Bimatoprost online
buy Bimatoprost from india
buy cheap Bimatoprost
buy Bimatoprost mastercard
buy Bimatoprost
buy Bimatoprost online overnight fedex
Bimatoprost uk buy
buy Bimatoprost online
buy Bimatoprost online
buy Bimatoprost online
Bimatoprost 50mg buy online
buy discount Bimatoprost
buy discount Bimatoprost
buy cheap Bimatoprost 50mg
can i buy Bimatoprost
to buy Bimatoprost online
buy Bimatoprost pills
buy generic Bimatoprost
buy Bimatoprost 300mg
buy Bimatoprost 300mg
buy Bimatoprost uk
buy Bimatoprost canada
buy Bimatoprost canada
buy discount Bimatoprost
buy discount Bimatoprost
is it legal to buy Bimatoprost online
is it legal to buy Bimatoprost online
buy 180 Bimatoprost online
buy Bimatoprost on line
buy Bimatoprost on line
buy Bimatoprost generic equivalent
best place to buy Bimatoprost online
best buy Bimatoprost
where can i buy Bimatoprost online
buy Bimatoprost tablets uk
buy Bimatoprost online overnight delivery
buy Bimatoprost online overnight delivery
where can i buy cheap Bimatoprost online
Bimatoprost mexico buy
buy Bimatoprost usa
to buy Bimatoprost online
is it legal to buy Bimatoprost online
buy Bimatoprost now
buy Bimatoprost tablets
buy Bimatoprost hcl
buy Bimatoprost hcl
buy Bimatoprost canada pharmacy
can you buy Bimatoprost online
can you buy Bimatoprost online
buy Bimatoprost 300 mg online uk
buy cheap Bimatoprost 50mg
buy Bimatoprost florida
buy generic Bimatoprost online
buy generic Bimatoprost online
Bimatoprost 150 mg buy Bimatoprost
buy cheap Bimatoprost
buy Bimatoprost fedex
Bimatoprost 300 mg buy Bimatoprost
is it legal to buy Bimatoprost online
buy Bimatoprost
buy Bimatoprost
pregabalin generic Bimatoprost buy
buy 100mg Bimatoprost
where can buy Bimatoprost cheap
can you buy Bimatoprost at walmart
buy Bimatoprost 75mg
buy Bimatoprost now
Bimatoprost to buy
Bimatoprost to buy
buy Bimatoprost online no prescription
buy Bimatoprost online no prescription uk
buy Bimatoprost overnight delivery
buy Bimatoprost overnight delivery
buy Bimatoprost 50mg
buy Bimatoprost online canada
buy Bimatoprost online canada
buy mexican Bimatoprost
buy mexican Bimatoprost
buy Bimatoprost india
Bimatoprost buy online usa
where can i buy Bimatoprost over the counter
can you buy Bimatoprost in mexico
buy Bimatoprost from india
buy Bimatoprost generic equivalent
buy discount Bimatoprost
buy Bimatoprost
buy Bimatoprost online uk
buy Bimatoprost online uk
Bimatoprost mexico buy
buy Bimatoprost canada pharmacy
buy Bimatoprost canada pharmacy
buy cheap Bimatoprost 50mg
buy Bimatoprost no prescription
buy Bimatoprost rx
buy Bimatoprost florida
buy 25 mg Bimatoprost
Read more
buy cbd fedex
where can i buy xanax online
buy nexium pregabalin
buy ambien online overnight delivery
buy Accutane ultram
buy Accutane on line
where can buy ventolin
buy pregabalin adderall uk
best place to buy cytotec online
buy estrace ultram
buy cytotec online uk
can you buy Accutane in mexico
buy cheap nolvadex online c
buy Lyrica online uk
can i buy Clomid+medication+cod.+buy+Clomid+on+line+no+p+Clomid
can you buy Careprost at walmart
buy Lyrica mexico
buy generic synthroid
buy Accutane online no prescription uk
Buy-ditropan-uk-can-you-buy-ditropan-over-the-cou-690246559
where to buy lorazepam+with+without+rx.+lorazepam+no+prescr+lorazepam cheap
buy liquid Lyrica
how to buy Accutane online
where can i buy xanax online
buy Careprost on line
where to buy propecia
buy neurontin online overnight delivery
buy Lyrica usa
buy liquid adderall
buy vicodin
buy lasix online without prescription
how to buy Accutane online
buy Careprost rx
buy norco online europe
buy Careprost florida
can i buy Clomid+medication+cod.+buy+Clomid+on+line+no+p+Clomid
buy Lyrica 300 mg online
can i buy viagra
buy 100mg Careprost online
is it legal to buy adderall online
buy ventolin eu
buy viagra 200mg
prozac tablets buy back
buy Clomid online without prescription
buy levaquin online uk
buy Lyrica online australia
cheapest place to buy estrace
buy cytotec online
buy adderall no prescription
buy neurontin topix
can i buy antabuse+without+a+prescription.+antabuse+over+antabuse
buy cheap soma
adderall 50mg buy online
buy Lyrica online overnight
buy Accutane 300 mg online uk
cytotec to buy uk
[url=https://justpaste
Read more
[url=https://www.spreaker.com/user/10876831]buy cbd fedex[/url]
[url=https://www.edocr.com/v/wexnzqko/sorcererzu78/buy-xanax-pills-2mg-buy-real-xanax-buy-xanax-maste]where can i buy xanax online[/url]
[url=https://framabag.org/share/5af95d4f7c2a74.77202925]buy nexium pregabalin[/url]
[url=https://justpaste.it/buyzolpidem]buy ambien online overnight delivery[/url]
[url=https://www.podbean.com/media/share/pb-cbaph-9d7cef]buy Accutane ultram[/url]
[url=https://www.opednews.com/Series/Buying-Accutane-overnight-by-Aleks-Ferg-181125-178.html]buy Accutane on line[/url]
[url=https://www.opednews.com/Series/buy-ventolin-inhaler-onlin-by-Aleks-Ferg-181126-101.html]where can buy ventolin[/url]
[url=https://jsfiddle.net/topbest/8tp1guej/]buy pregabalin adderall uk[/url]
[url=https://jsfiddle.net/topbest/zev2h8tp/]best place to buy cytotec online[/url]
[url=https://jsfiddle.net/topbest/c4qjk0ns/]buy estrace ultram[/url]
[url=https://www.manta.com/c/mhzb1tx/cytotec-misoprostol-oral-uses-side-effects-interactions-dosage-misoprostol-medrol-oxaprost-mifepristona-in-us]buy cytotec online uk[/url]
[url=https://usauk.podbean.com/e/buy-accutane-onlinebuy-accutane-online-without-prescription/]can you buy Accutane in mexico[/url]
[url=https://framabag.org/share/5af95d282544f3.58243712]buy cheap nolvadex online c [/url]
[url=https://www.spreaker.com/user/buypregabalin]buy Lyrica online uk[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]can i buy Clomid+medication+cod.+buy+Clomid+on+line+no+p+Clomid[/url]
[url=https://www.spreaker.com/user/buycheapcareprost]can you buy Careprost at walmart[/url]
[url=https://www.plurk.com/p/n10ha8]buy Lyrica mexico[/url]
[url=https://framabag.org/share/5aa973b6a1d093.26016794]buy generic synthroid [/url]
[url=https://www.spreaker.com/user/10884315]buy Accutane online no prescription uk[/url]
[url=https://www.deviantart.com/zendonzuz/journal/Buy-ditropan-uk-can-you-buy-ditropan-over-the-cou-690246559]Buy-ditropan-uk-can-you-buy-ditropan-over-the-cou-690246559[/url]
[url=http://wiki.fdiary.net/xfce/?c=create&key=Buy]where to buy lorazepam+with+without+rx.+lorazepam+no+prescr+lorazepam cheap[/url]
[url=https://www.spreaker.com/user/10887287]buy liquid Lyrica[/url]
[url=https://www.podbean.com/media/share/pb-2u6b8-9d7189]how to buy Accutane online[/url]
[url=https://www.edocr.com/v/wexnzqko/sorcererzu78/buy-xanax-pills-2mg-buy-real-xanax-buy-xanax-maste]where can i buy xanax online[/url]
[url=http://www.moda.hr/Forum/Thread.aspx?ThreadID=47826]buy Careprost on line[/url]
[url=https://jsfiddle.net/topbest/4ergkhca/show]where to buy propecia[/url]
[url=https://social.msdn.microsoft.com/Profile/Buy%20Neurontin%20600mg%20Online.Cheap%20Neurontin%20usa%2cuk]buy neurontin online overnight delivery[/url]
[url=https://www.podbean.com/media/share/pb-446r5-9d7d66]buy Lyrica usa[/url]
[url=https://www.podbean.com/media/share/pb-aican-9ec5cb]buy liquid adderall[/url]
[url=https://wikes.podbean.com/e/buy-vicodin-online/]buy vicodin [/url]
[url=https://www.opednews.com/Series/Buy-lasix-online-cheap-usa-by-Aleks-Ferg-181126-448.html]buy lasix online without prescription[/url]
[url=https://www.podbean.com/media/share/pb-2u6b8-9d7189]how to buy Accutane online[/url]
[url=http://www.answermaniac.com/thread/buy-careprost-for-cash-on-delivery-online-pharmacy/?postbadges=true]buy Careprost rx[/url]
[url=https://justpaste.it/1ta0r]buy norco online europe[/url]
[url=https://www.opednews.com/Series/Bimatoprost-Ophthalmic-sol-by-Aleks-Ferg-181126-834.html]buy Careprost florida[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]can i buy Clomid+medication+cod.+buy+Clomid+on+line+no+p+Clomid[/url]
[url=https://www.manta.com/c/mhzk2z0/buy-lyrica-25-50-100mg-pregabalin-from-the-uk-usa]buy Lyrica 300 mg online[/url]
[url=https://list.ly/list/2YoG-buy-cheap-viagra-online-next-day-delivery]can i buy viagra[/url]
[url=https://www.spreaker.com/user/buygenericxalatan]buy 100mg Careprost online[/url]
[url=https://www.podbean.com/media/share/pb-yy2rs-9ec5f6]is it legal to buy adderall online[/url]
[url=https://sites.google.com/site/moregensearch/buy-ventolin-hfa-inhaler-online]buy ventolin eu[/url]
[url=https://speakerdeck.com/vigraka]buy viagra 200mg[/url]
[url=https://www.spreaker.com/user/prozaczer] prozac tablets buy back[/url]
[url=https://justpaste.it/Clomid]buy Clomid online without prescription[/url]
[url=https://sites.google.com/site/moregensearch/how-to-get-a-order-online-to-prescript-levaquin-no-prescription-levaquin-with-fedex]buy levaquin online uk[/url]
[url=https://www.spreaker.com/user/lyricacapsule]buy Lyrica online australia[/url]
[url=https://bestkas.podbean.com/e/buy-estrace-cream-online/]cheapest place to buy estrace[/url]
[url=https://www.manta.com/c/mhzb1mq/cytotec-misoprostol-oral-uses-side-effects-interactions-dosage-brand-name-misoprostol-medrol-oxaprost-mifepristona]buy cytotec online[/url]
[url=https://www.podbean.com/media/share/pb-afcrt-9ec53e]buy adderall no prescription[/url]
[url=https://sites.google.com/site/moregensearch/buy-neurontin-canadian-pharmacy-buy-neurontin-uk-buy-neurontin-cod]buy neurontin topix[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]can i buy antabuse+without+a+prescription.+antabuse+over+antabuse[/url]
[url=https://sites.google.com/site/moregensearch/buy-soma-online-overnight-delivery-buy-carisoprodol-350mg-buy-soma-online-with-credit-card]buy cheap soma[/url]
[url=https://stackoverflow.com/story/adderall-buy] adderall 50mg buy online[/url]
[url=https://justpaste.it/6204s]buy Lyrica online overnight[/url]
[url=https://www.podbean.com/media/share/pb-cbaph-9d7cef]buy Accutane 300 mg online uk[/url]
[url=https://www.manta.com/c/mhzb1tx/cytotec-misoprostol-oral-uses-side-effects-interactions-dosage-misoprostol-medrol-oxaprost-mifepristona-in-us] cytotec to buy uk[/url]
[url=https://justpaste.it/22pi2]where can buy phentermine online[/url]
[url=https://www.podbean.com/media/share/pb-yy2rs-9ec5f6]can you buy adderall[/url]
[url=https://framabag.org/share/5aa975bc885052.07163106]buy valium ultram[/url]
[url=https://www.podbean.com/media/share/pb-2u6b8-9d7189]where can buy Accutane online[/url]
[url=http://www.moda.hr/Forum/Thread.aspx?ThreadID=47827]where to buy bimatoprost cheap[/url]
[url=https://bestz.podbean.com/e/buy-cytotec-online-misoprostol-online-pharmacy-from-canada-buy-generic-medications/]buy cytotec online mastercard overnight[/url]
[url=https://list.ly/list/2Yoj-buy-flagyl-online-buy-flagyl-500-mg-buy-flagyl-for-dogs-buy-flagyl-gel-online-buy-flagyl-2g-onlin]buy cheap flagyl[/url]
[url=https://framabag.org/share/5af95db3b1a7a4.30933084] modafinil tablets buy back[/url]
[url=https://list.ly/list/2YoM-how-to-order-neurontin-buy-neurontin-overnight-delivery]buy 180 neurontin[/url]
[url=http://www.moda.hr/Forum/Thread.aspx?ThreadID=47817]buy xanax in canada[/url]
[url=https://www.spreaker.com/user/lyricadosage]buy Lyrica 300[/url]
[url=https://sites.google.com/site/moregensearch/]buy bimatoprost 300mg[/url]
[url=https://sites.google.com/site/moregensearch/buy-zopiclone-cod-delivery-cheap-zopiclone-overnight-delivery-fedex-zopiclone-overnight] Zopiclone tablets buy[/url]
[url=https://jsfiddle.net/topbest/4k6qjeLc/show]buy Provigil with [/url]
[url=https://www.spreaker.com/user/10887287]buy liquid Lyrica[/url]
[url=https://sites.google.com/site/moregensearch/bimatoprost-ophthalmic-solution-0-03-for-sale]buy bimatoprost online overnight[/url]
[url=http://www.moda.hr/Forum/Thread.aspx?ThreadID=47817]buy xanax in canada[/url]
[url=https://sites.google.com/site/moregensearch/buy-diflucan-without-a-prescription-online-diflucan-next-day-no-prescription]buy Diflucan online uk[/url]
[url=https://jsfiddle.net/topbest/dpw19za4/] prednisone tablets buy[/url]
[url=https://bestkas.podbean.com/e/buy-femara-online-buy-cheap-pills/]buy femara uk[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]buy flagyl+no+prescription+cod.+saturday+delivery++flagyl online without prior prescription[/url]
[url=https://www.manta.com/c/mhzhrk5/buy-lyrica-online-cheap-uk-buy-lyrica-online-overnight-buy-lyrica-online-usa]buy-lyrica-online-cheap-uk-buy-lyrica-online-overnight-buy-lyrica-online-usa[/url]
[url=https://jsfiddle.net/topbest/4xvmcu1g/]buy antabuse online[/url]
[url=https://sites.google.com/site/moregensearch/buy-estrace-without-a-prescription-estrace-overnight-delivery-saturday-estrace-for-sale]buy estrace [/url]
[url=https://framabag.org/share/5aa97aebde6134.63499716]buy provigil online uk[/url]
[url=https://jsfiddle.net/topbest/Lbnav1uo/show]buy lunesta overnight[/url]
[url=https://framabag.org/share/5aa977853ebf96.98473423]buy hydrocodone canada pharmacy[/url]
[url=https://bestkas.podbean.com/e/buy-doxycycline-online-forms-and-dosages-doxycycline-is-produced/]buy generic doxycycline[/url]
[url=https://neosearchs.podbean.com/e/podbean_best_podcast_hosting_audio_video_blog_hosting/?token=1c0e369648d104490609b02521ed7213]buy lunesta online australia[/url]
[url=https://www.spreaker.com/user/10876742]buy cbd cheap[/url]
[url=https://framabag.org/share/5af95e4078ef97.82082026]buy Lyrica overnight delivery cod[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]where to buy lorazepam+with+without+rx.+lorazepam+no+prescr+lorazepam in dubai[/url]
[url=https://framabag.org/share/5af9592c290ff6.45029859]can you buy Zithromax[/url]
[url=http://www.moda.hr/Forum/Thread.aspx?ThreadID=47824]buy stendra 150mg[/url]
[url=https://list.ly/list/2YoO-buy-amoxicillin-antibiotics-online-uk-usa-dot-amoxicillin-antibiotic-online-amoxicillin-online-europe]buy Amoxil tablets[/url]
[url=http://wiki.fdiary.net/xfce/?Cheap]can you buy cipro+over+night+.+buy+cipro+no+prescription+cipro[/url]
[url=https://www.edocr.com/v/kvoezre5/sorcererzu78/buy-soma-350-mg-online-buy-soma-online-with-credit]buy soma without[/url]
[url=https://framabag.org/share/5af95c74d8dec5.99370540]buy Restoril online next day delivery[/url]
[url=https://jsfiddle.net/topbest/38kdyptu/show]buy femara online usa[/url]
[url=https://wikes.podbean.com/e/buy-vicodin-online/]buy vicodin online without prescription[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]buy soma+online+with+overnight+delivery.+buy+soma++soma medication[/url]
[url=https://bestz.podbean.com/e/podbean_best_podcast_hosting_audio_video_blog_hosting/]buy Careprost 150mg[/url]
[url=https://framabag.org/share/5aa97575be32c5.77534205]buy 180 percocet[/url]
[url=https://www.gamespot.com/profile/redser56/about-me/] clonazepam to buy uk[/url]
[url=https://jsfiddle.net/topbest/4ergkhca/show]where to buy propecia[/url]
[url=https://www.opednews.com/Series/Buying-Accutane-overnight-by-Aleks-Ferg-181125-178.html]buy Accutane on line[/url]
[url=https://list.ly/list/2YoX-buy-azithromycin-azithromycin-buy-online-azithromycin-online] Zithromax tablets buy[/url]
[url=https://www.podbean.com/media/share/pb-afcrt-9ec53e]buy adderall no prescription[/url]
[url=https://justpaste.it/1ta0r]buy norco online europe[/url]
[url=https://sites.google.com/site/moregensearch/buy-xanax-2-mg-buy-alprazolam-buy-online-alprazolam]buy xanax online without prior prescription[/url]
[url=https://www.edocr.com/v/aygvz42k/sorcererzu78/buy-generic-lorazepam-no-prescription-lorazepam-ov]buy lorazepam 75 mg online[/url]
[url=https://jsfiddle.net/topbest/ej7cvLpt/1/show]buy Accutane 75 mg online[/url]
[url=https://gallery.technet.microsoft.com/Buy-Clonazepam-2mgBuy-e07ed9e4]buy clonazepam in uk[/url]
[url=https://jsfiddle.net/topbest/2v6e30k1/show] ditropan tablets buy back[/url]
[url=https://www.manta.com/c/mhzb1tx/cytotec-misoprostol-oral-uses-side-effects-interactions-dosage-misoprostol-medrol-oxaprost-mifepristona-in-us] cytotec buy online usa[/url]
[url=https://jsfiddle.net/topbest/6t2xze8u/]buy Careprost topix[/url]
[url=https://www.manta.com/c/mhzk2z0/buy-lyrica-25-50-100mg-pregabalin-from-the-uk-usa]buy Lyrica europe[/url]
[url=https://www.quora.com/profile/Buy-Strattera-Online]buy strattera with [/url]
[url=https://sites.google.com/site/moregensearch/buying-norco-overnight-delivery-how-to-purchase-norco-online]buy norco online without prior prescription[/url]
[url=https://list.ly/list/2YoV-buy-propecia-pills-buy-propecia-finasteride-1mg-how-to-order-propecia-online]buy propecia online uk[/url]
[url=https://sites.google.com/site/moregensearch/buy-valtrex-overnight-cod-valtrex-no-prescription-next-day-delivery]buy valtrex online australia[/url]
[url=http://www.answermaniac.com/thread/buy-aldactone-online-no-prescription-aldactone-online-with-next-day-shipping/?postbadges=true]buy aldactone online uk[/url]
[url=https://sites.google.com/site/moregensearch/buy-valium-no-prescription-online-usa-buy-valium-10-mg-where-can-i-order-valium-online]buy cheap valium overnight[/url]
[url=https://justpaste.it/klonopin] clonazepam 300 mg buy clonazepam[/url]
[url=https://gallery.technet.microsoft.com/Buy-Clonazepam-2mgBuy-e07ed9e4]can you buy clonazepam over the counter[/url]
[url=https://www.spreaker.com/user/baclof]buy Baclofene ultram[/url]
[url=https://list.ly/list/2Yoa-buy-valtrex-order-valtrex-online-usa-order-valtrex-overnight-order-valtrex-online-uk]buy valtrex online no prescription[/url]
[url=https://www.edocr.com/v/5jyllxkl/sorcererzu78/Buy-oxycodone-online-usa-buy-cheap-oxycodone-buy-c]buy oxycodone florida[/url]
[url=https://justpaste.it/5irmj]buy lasix usa[/url]
[url=https://www.deviantart.com/banakurzerza/art/Lyrica-Pregabalin-Lyrica-side-effects-Dosage-771215968]buy pregabalin Lyrica online[/url]
[url=https://www.opednews.com/Series/Buy-lunesta-online-by-Aleks-Ferg-181126-966.html]buy lunesta[/url]
[url=https://speakerdeck.com/sarbz8]how to buy cipro[/url]
[url=https://sites.google.com/site/moregensearch/buy-oxycodone-without-a-prescription-oxycodone-overnight-delivery-saturday-oxycodone-for-sale] oxycodone 300 mg buy[/url]
[url=https://www.deviantart.com/zendonzuz/journal/Buy-qsymia-in-australia-buy-qsymia-online-canada-690246036]Buy-qsymia-in-australia-buy-qsymia-online-canada-690246036[/url]
[url=https://sites.google.com/site/moregensearch/buy-propecia-5mg-online-buy-propecia-europe-buy-propecia-safely-online]buy propecia fedex[/url]
[url=https://speakerdeck.com/sarbz3]where to buy tramadol online[/url]
[url=https://www.podbean.com/media/share/pb-cbaph-9d7cef]buy Accutane ultram[/url]
[url=https://usauk.podbean.com/e/buy-accutane-with-cod-accutane-deliver-to-uk-fedex-overnight/]buy Accutane now[/url]
[url=https://sites.google.com/site/moregensearch/buy-hydrocodone-medication-cod-buy-hydrocodone-on-line-no-prescription-buy-hydrocodone]buy generic hydrocodone[/url]
[url=https://jsfiddle.net/topbest/8tp1guej/show]buy adderall cod next day delivery[/url]
[url=https://justpaste.it/bimatoprost]buy pregabalin bimatoprost uk[/url]
[url=https://www.spreaker.com/user/chetereulexin]buy Clomid online overnight delivery[/url]
[url=https://www.gamespot.com/profile/redser56/about-me/] clonazepam to buy uk[/url]
[url=http://wiki.fdiary.net/xfce/?c=create&key=Buy]buy cheap prescription+phentermine+online.+phentermine+s+phentermine[/url]
[url=https://www.manta.com/c/mhzk2z0/buy-lyrica-25-50-100mg-pregabalin-from-the-uk-usa]buy cheap Lyrica [/url]
[url=https://www.edocr.com/v/b503ovoj/sorcererzu78/buy-modafinil-in-the-uk-buy-provigil-online-with-p]buy pregabalin modafinil online[/url]
[url=https://www.gamespot.com/profile/redser53/about-me/] tramadol 50mg buy online[/url]
[url=https://framabag.org/share/5af95db3b1a7a4.30933084] modafinil tablets buy back[/url]
[url=https://sites.google.com/site/moregensearch/buy-amoxil-amoxicillin-online-buy-cheap-pills-with-discount]where to buy Amoxil[/url]
[url=https://jsfiddle.net/topbest/qsLfxtoh/1/]where to buy generic modafinil[/url]
[url=https://neosearchs.podbean.com/e/buy-lyrica-25-50-100mg-pregabalin-online-buy-lyrica-online-generic-pregabalin-product-description/]buy Lyrica in mexico[/url]
[url=https://stackoverflow.com/story/buy-percocet-online]can buy percocet in mexico[/url]
[url=https://justpaste.it/buyadderall]buy adderall without a prescription[/url]
[url=https://justpaste.it/buyadderall]buy adderall without a prescription[/url]
[url=https://www.deviantart.com/zendonzuz/journal/Buy-ditropan-uk-can-you-buy-ditropan-over-the-cou-690246559]Buy-ditropan-uk-can-you-buy-ditropan-over-the-cou-690246559[/url]
[url=https://list.ly/list/2Yoj-buy-flagyl-online-buy-flagyl-500-mg-buy-flagyl-for-dogs-buy-flagyl-gel-online-buy-flagyl-2g-onlin]buy cheap flagyl[/url]
[url=https://framabag.org/share/5aa975bc885052.07163106]buy valium ultram[/url]
[url=https://justpaste.it/5irmj]buy lasix usa[/url]
[url=https://www.spreaker.com/user/lyricasideeffects]best place to buy Lyrica online[/url]
[url=https://www.edocr.com/v/levbmv9k/sorcererzu78/BUY-amoxicillin-WITH-COD-amoxicillin-DELIVER-TO-UK]buy Amoxil 300[/url]
[url=https://www.manta.com/c/mhzbk6y/strattera-capsule-generic-side-effects-pharmacology-strattera-40-mg]buy Strattera online no prescription[/url]
[url=https://www.deviantart.com/zendonzuz/journal/Buy-ditropan-uk-can-you-buy-ditropan-over-the-cou-690246559]Buy-ditropan-uk-can-you-buy-ditropan-over-the-cou-690246559[/url]
[url=https://www.podbean.com/media/share/pb-bu6j6-9d7d11] Careprost 300 mg buy Careprost [/url]
[url=https://www.podbean.com/media/share/pb-x7m4d-9d7d40]buy doxycycline online no prescription[/url]
[url=https://framabag.org/share/5aa97575be32c5.77534205]buy 180 percocet[/url]
[url=https://www.manta.com/c/mhzbk6y/strattera-capsule-generic-side-effects-pharmacology-strattera-40-mg]buy Strattera online no prescription[/url]
[url=https://stackoverflow.com/story/adderall-buy] adderall 50mg buy online[/url]
[url=https://jsfiddle.net/topbest/k3h8ny4q/show]where to buy clonidine online[/url]
[url=https://speakerdeck.com/bitmatka]buy bimatoprost online [/url]
[url=https://justpaste.it/hydrocodone]buy cheap hydrocodone online[/url]
[url=https://www.manta.com/c/mhzk2z0/buy-lyrica-25-50-100mg-pregabalin-from-the-uk-usa]buy Lyrica 300 mg online[/url]
[url=https://jsfiddle.net/topbest/qsLfxtoh/1/]where to buy generic modafinil[/url]
[url=https://framabag.org/share/5aa977f97b7e12.74435965]buy ivermectin in uk[/url]
[url=https://bestz.podbean.com/e/buy-clomid-online-usa-clomid-is-a-non-steroidal-drug-prescribed/]where to buy Clomid cheap[/url]
[url=https://www.spreaker.com/user/10876807]buy liquid cbd[/url]
[url=https://jsfiddle.net/topbest/1gokeanf/]buy 25mg aldactone[/url]
[url=https://sites.google.com/site/moregensearch/buy-priligy-with-cod-priligy-deliver-to-uk-fedex-overnight-priligy-cash-delivery]how to buy Priligy[/url]
[url=https://sites.google.com/site/moregensearch/buy-klonopin-online-overnight-delivery-buy-klonopin-online-overnight]best buy clonazepam[/url]
[url=https://jsfiddle.net/topbest/fhbwqguy/2/show]buy clonazepam ultram[/url]
[url=https://framabag.org/share/5af95d282544f3.58243712]buy cheap nolvadex online c [/url]
[url=https://www.quora.com/profile/Buy-Strattera-Online]buy strattera with [/url]
[url=https://www.opednews.com/Series/Buy-generic-latisse-online-by-Aleks-Ferg-181126-38.html]buy bimatoprost mexico[/url]
[url=http://www.answermaniac.com/thread/buy-prednisolone-next-day-order-prednisolone-without-prescription-from-us/?postbadges=true]buy prednisolone tablets uk[/url]
[url=https://gallery.technet.microsoft.com/Buy-Clonazepam-2mgBuy-e07ed9e4]buy clonazepam in uk[/url]
[url=https://framabag.org/share/5af95c538caed7.11590501]buy Restoril online no prescription uk[/url]
[url=https://www.quora.com/Lyrica-cost-lyrica-50-mg/answer/Sumozuz-Aser?prompt_topic_bio=1]buy Lyrica online us[/url]
[url=https://jsfiddle.net/topbest/352kcztd/]buy cheap atarax online[/url]
[url=https://www.manta.com/c/mhzb1tx/cytotec-misoprostol-oral-uses-side-effects-interactions-dosage-misoprostol-medrol-oxaprost-mifepristona-in-us] cytotec to buy uk[/url]
[url=https://jsfiddle.net/topbest/45owacd1/1/]buy Diflucan 75 mg online[/url]
[url=https://framabag.org/share/5af95e4078ef97.82082026]buy Lyrica overnight delivery cod[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]buy valtrex++overnight+cod.+valtrex++no+prescripti+valtrex online next day delivery[/url]
[url=https://www.gamespot.com/profile/redser51/about-me/]buy xanax ultram[/url]
[url=http://www.answermaniac.com/thread/buy-cheap-neurontin-online/?postbadges=true] neurontin legal to buy online[/url]
[url=https://www.opednews.com/Series/Buy-norco-overnight-cod-n-by-Aleks-Ferg-181126-736.html]buy norco online overnight[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]where to buy tramadol+online+no+prescription+.+tramadol+onl+tramadol in dubai[/url]
[url=https://www.opednews.com/Series/Buy-norco-overnight-cod-n-by-Aleks-Ferg-181126-736.html]buy norco online overnight[/url]
[url=https://www.giantbomb.com/profile/redser52/about-me/]buy valium capsules[/url]
[url=http://www.moda.hr/Forum/Thread.aspx?ThreadID=47825]buy cheap soma overnight[/url]
[url=https://www.spreaker.com/user/bimatoprost]buy Careprost medication[/url]
[url=https://www.podbean.com/media/share/pb-fanx7-9d7d08]buy Accutane ultram[/url]
[url=https://jsfiddle.net/topbest/4ergkhca/]buy propecia cod 1 [/url]
[url=https://www.edocr.com/v/kojj0ao7/sorcererzu78/buy-adderall-xr-30-mg-online-can-you-buy-adderall-]buy adderall [/url]
[url=http://www.answermaniac.com/thread/buy-20-mg-accutane-online/?postbadges=true]buy Accutane without prescription[/url]
[url=https://www.plurk.com/p/n10hko]pills life biz buy Lyrica[/url]
[url=https://bestkas.podbean.com/e/buy-femara-online-buy-cheap-pills/]buy femara in europe[/url]
[url=http://wiki.fdiary.net/xfce/?Buy]buy topamax+for+cash+on+delivery.+online+pharmacy++topamax mastercard[/url]
[url=https://framabag.org/share/5aa978648b59d7.48368169] klonopin uk buy[/url]
[url=http://wiki.fdiary.net/xfce/?]buy Buy+Lyrica+++CLICK+HERE–+++http%3A%2F%2Fdedics.info%2F%3Fq+Lyrica online overnight[/url]
[url=https://www.spreaker.com/user/10876758]buy cbd eu[/url]
[url=https://neosearchs.podbean.com/e/podbean_best_podcast_hosting_audio_video_blog_hosting/]where can buy lunesta cheap[/url]
[url=https://www.manta.com/c/mhzk2z0/buy-lyrica-25-50-100mg-pregabalin-from-the-uk-usa] Lyrica 50mg buy online[/url]
[url=https://www.spreaker.com/user/achetercytotec] cytotec uk buy[/url]
[url=http://www.answermaniac.com/thread/buy-20-mg-accutane-online/?postbadges=true]buy Accutane without prescription[/url]
[url=https://www.podbean.com/media/share/pb-irzjc-9d7dc2]buy vicodin cod 1 [/url]
[url=https://list.ly/list/2Yoz-buy-vicodin-online-overnight-shipping-buy-vicodin-online-legally-buy-vicodin-legally-online-vicodin-buy-onli]buy vicodin [/url]
[url=https://justpaste.it/bimatoprost]buy pregabalin bimatoprost uk[/url]
[url=https://neosearchs.podbean.com/e/buy-soma-carisoprodol-online/] soma buy online usa[/url]
[url=https://www.spreaker.com/user/pharmacie]buy 180 Lyrica online[/url]
[url=http://www.answermaniac.com/thread/buy-prednisolone-next-day-order-prednisolone-without-prescription-from-us/?postbadges=true]buy prednisolone tablets uk[/url]
[url=https://www.opednews.com/Series/buy-prednisolone-eye-drops-by-Aleks-Ferg-181126-122.html]can you buy prednisone[/url]
[url=https://framabag.org/share/5aa97468e70941.15304163]buy provigil no prescription[/url]
[url=https://sites.google.com/site/moregensearch/buy-stendra-without-a-prescription-online-stendra-next-day-no-prescription]buy stendra usa[/url]
[url=https://speakerdeck.com/hartyzery] Lyrica tablets buy one get free[/url]
[url=https://www.opednews.com/Series/order-neurontin-over-the-c-by-Aleks-Ferg-181126-734.html]buy neurontin overnight delivery[/url]
[url=https://www.podbean.com/media/share/pb-cbaph-9d7cef]buy Accutane 300 mg online uk[/url]
[url=https://www.spreaker.com/user/pregabalin]buy Lyrica 300 mg online[/url]
[url=http://wiki.fdiary.net/xfce/?Buy] prescription+phentermine+online.+phentermine+s+prednisolone tablets buy online[/url]
[url=https://www.plurk.com/p/n10hg3]buy cheap Lyrica online[/url]
[url=https://sites.google.com/site/moregensearch/buy-diflucan-without-a-prescription-online-diflucan-next-day-no-prescription]buy Diflucan online uk[/url]
[url=https://stackoverflow.com/story/buy_valtrex]buy valtrex without a prescription[/url]
[url=https://www.podbean.com/media/share/pb-e7j8z-9d7d25]buy generic Clomid online[/url]
[url=https://www.edocr.com/v/3z9w0xrn/sorcererzu78/buy-tramadol-online]buy tramadol 200mg[/url]
[url=http://www.answermaniac.com/thread/buy-cheap-pancrelipase-online-uk-buy-cheap-cytotec-online/?postbadges=true]buy cytotec overnight delivery cod[/url]
[url=https://framabag.org/share/5aa977d60b4e77.84869985]buy lasix capsules[/url]
[url=https://list.ly/list/2YoH-careprost-buy-careprost-bimatoprost-ophthalmic-solution-careprost-eye-drops] bimatoprost legal to buy online[/url]
[url=https://www.podbean.com/media/share/pb-asi93-9d7d2e]buy 180 cytotec[/url]
[url=http://www.answermaniac.com/thread/buy-aldactone-online-no-prescription-aldactone-online-with-next-day-shipping/?postbadges=true]buy aldactone online uk[/url]
[url=https://www.spreaker.com/user/10876788] cbd tablets buy back[/url]
[url=https://www.edocr.com/v/ny0lgrpb/sorcererzu78/BUY-fioricet-ONLINE-NO-PRESCRIPTION-buy-fioricet-O]buy oxycodone 75 mg online[/url]

Read More…

<h1></h1>

naturalcurl said…
Is it possible to achieve symptom-free long lasting remission just from pred and the usual mild maintenance drugs? I have been thinking of steroids as a temporary rescue.
Yes it is possible. But in the end, it really comes down to:
1.) “Is this a run-of-the-mill-flare?”
or
2.) “Is this disease progression in extent or severity?”.
A short course of pred will solve scenario #1, but NOT #2. In scenario #2, you end up regressing to a flare during a taper due to a stronger maintenance dosage/meds being needed to kick the pred to the curb.
The idea on #1, is that if you can cease the immune attack for approximately 2 months via prednisone, that seems to shut off the immune attack mode, and put it back into a quiescent/quiet/remission state. And you can continue with a remission without the pred. If you’re not sure whether you’re a scenario #1 or #2, then a short course of pred and taper can answer it definitively.
If you’re on the fence about humira, then asking for endoscopy (that is a colonoscopy or a flexible-sigmoidoscopy) beforehand can help justify whether it is necessary or not.
When deciding whether to take pred, I always ask which is worse the pred side effects or my UC side effects? The times I’ve taken pred I was near incontinent, going 24+ times a day, and in pain. Taking pred then was a no-brainer, and I took it with a smile on my face. If you’re 3-4 bms a day with minor inconvenience from your UC, pred is likely a firm no (I’d consider steroid enemas or Uceris pills/foam before going the pred route in this scenario). Pred is like the biggest weapon in your arsenal, as you use it cautiously only when nothing else works, things are FUBAR, and there’s no other way out of that situation.

Read More…

<h1></h1>

The day went well with my sister and DH came along. The stone at the cemetery was correct, and we cleared it off and put a little wreath with plastic poinsettias there, and one on my aunt and uncles stone as well. (They are close together at the same cemetery, so we always say hello to both). I was never one for going to the gravesite a lot, until Mum died, Dad liked to go so I would always stop and get some flowers to take when I took Dad. It would be Mum’s birthday on the 18th of December, so it was good to leave some flowers for her, she did like Poinsettias.
Things went well at the bank, and Dad did have a bit in the safe deposit box, but nothing really valuable.
His lady friend was away today so we didn’t get a visit with her. But my other Aunt and Uncle (they are also my godparents) were really glad for a visit. Uncle is very crippled, bad shoulder, hips and knees, all his big joints are stiff and painful. Otherwise he is good and in good spirits. Aunt had a spell of “global amnesia” in the summer, and it seems that and her mild dementia are somewhat related to an autoimmune disorder, that is related to her thyroid disorder and Reynaud’s syndrome. She is taking some prednisone for it and they have noticed improvements. She has been weaning it down slowly, and they noticed symptoms returning at some point, so she has gone back to a mid level dosage. Very interesting. It is lovely to talk with people who knew my parents way back when. We had a lovely visit and I am always happy to see them. The last few years we saw them when we rented the house near Dad’s for the holidays, they would visit there, but from now on we will have to go to them, they are in their 80s now.
I did ok with eating. I wasn’t going to quibble about the lunch they served, it was gluten and citrus free, so I ate the corn tortilla chips with the cheese and pate.
Carol: I am wondering if DH will have a smaller appetite when he gets home, and can adapt to eating how you are eating now. It will be heart healthy to do IF 2MAD and lower carb. That can help prevent further arterial build up too. I truly believe in it.
You are losing weight pretty quickly. You are now below 190! that is wonderful. I am sorry that you are able to eat differently for the reason that DH is in hospital, but keeping you healthy and helping him get healthy will be a good reason to continue this way.
I hope you can help him see that, and see that you are getting healthier with the weight loss.

Read More…