4th$YEAR$Professional$Pharmacy$ Placement$Semester$1:$DRUG$LIST$2013$$

Transcription

1 4th$YEAR$Prfessinal$Pharmacy$ Placement$Semester$1:$RUG$LIST$2013$$ Guide:Majrityfthedruglistremainsthesameeachyear,withusuallynlynertwdrugsbeing different.itisimprtanttknwtheindicatin,dse,adverseeffects,mdeftheactin(briefly), precautins(smepints),interactinsandcunsellingpints.hspitalplacementfcusesmren mnitringanddsesfrcmmnindicatins,whilethecmmunityplacementwillfcusmren cunselling. Cntents Alendrnate Page24 Allpurinl Page56 Amidarne Page711 Amldipine Page1213 Celecxib Page1417 Clpidgrel Page1819 abigatran Page2022 igxin Page2326 iltiazem Page2729 Enxaparin Page3032 Fluticasne Page3335 Frusemide Page3638 Gliclazide Page3940 Glyceryltrinitrate Page4143 Heparin Page4447 Hydrcrtisne Page4853 Insulin Page5458 Irbesartan Page5960 IssrbidemnnitratePage6162 Mesalazine Page6367 Metfrmin Page6870 Metprll Page7174 Methtrexate Page7579 Prednislne Page8081 Ramipril Page8285 Salmeterl Page8688 Simvastatin Page8992 Titrpium Page9395 Verapamil Page9699 Warfarin Page100103

2 Terms: Pagetsdisease=iswheretheremdellingprcess(breaking&buildingfbne)isdisturbedcausing excessivebneresrptinbysteclastsandadisrganisedcmpensatryincreaseinbnefrmatin. Gettingweakdefrmbnesintheskeletn,leadingtbnepain ONJ(stenecrsisfthejaw)=getbnenecrsisduetbldvesselsaredestryede.gprral hygieneandbac.theischaemicbnedesn tgetridfbysteclastasthebisphsphnateinhibitsit,s itkeepsgrwing. Bisphsphnates Alendrnate Tx: Pagetsdiseasefbne1 st lineisbisphsphnaterelievesthepain&breakdwn Preventinandtreatmentfsteprsis(incpstmenpausal&crticsteridinduced)=1 st line sagefrm:tab:adrnat,alendr,ensate,fsamax,ossmax Cmb:(alendrnate70mg,clecalciferl(vitamin3)70/140mg):rnalenPlus,FsaamaxPlus se: Pagetsdisease=40mgd(frupt6mnths) TxsteprsisinM&pstmenpausalF=10mgdr70mgnceawk Preventinfpstmenpausalsteprsis=5mgd. txandpreventinfcrticsteridinducedsteprsis=5mgd;10mgdfrpstmenpausalwmen ntreceivingestrgen MOA:slwsdwnbnebreakdwn(byinhibitsteclast)andallwsbnetrebuildintnrmalbnes a/e; Cmmn:NVH,+hypcalcaemia,musculskeletalpain(rarelybesevere) IV:allergicrxn,flulikesx Infreq:(quiteirritatinghencewhentakeralgetSI:esphagitis,ersin/ulcerinesphageal Rare:renalimpairment,ONJ ONJ:needbecarefulfhxdentalsurgery,prdentalhygiene.It sriskislwerinral PK:givenralaftervernightfastrIV.Haslngt1/2inbneTyrsasenzymeresistant Needvernightfastasithaslwabsrptalready&fd/drinks itmre ShuldgiveCa2+&vitsupplementswithuseifdietinadequateasneedCatbuildthematrixfirst Precautin: ONJ:OstenecrsisfthejawCnsiderdentalassessmentbefreuse,espifhaveriskfactrslike cancer,chemtherapy.prralhygiene, CancausedeteriratinfrenalfunctasitsExcretedunchangedmainlyviathekidney Aviduseinsevererenalimpaired UpperGIcnditins(egdysphagia,gastritis),usewithNSAIs increaseriskfesphagealadverse effects. C/i: hypcalcaemia asa/eduetinhibitsteclastsca2+cantbereplacedinbldfrmbne Inabilitytstandrsituprightfratleast30minutes Oesphagealdisrders(activeesphagitis,esphagealulceratin,swallwingdifficulty) Preg&b/faviduseasndata.CatB3.Tx:useCalciumtab Interactins:

3 Ca,Fe,Mge.gantacid,supp it absrptinfralbisphsphnates.tx:dnttakewithin2hursf takingabisphsphnate(atleast30minutesafteralendrnateribandrnicacid). alendrnate+nsais: gastriculcerwithnsai.tx:avidcmbrmnitr Mnitring; Efficacy:Bne&a/e:BM,Ca2+lvls,Vit,Xrays, alkalinephsphatase(frpagetsdisasisbnemarkerfrbnefrmatin)=madebysteblast. ALP, bneturnver.e.ginpagetdis ALP a/e:crclascauserenalimpairment " dentalassessment:onj " heartburn,dysphagia(painnswallw)=esphagitis Cunselling:IARL :Swallwwhletabletinthemrningwithafullglassfplainwaternanemptystmach,sb/fany fdrdrink,andstayuprightfratleast30minduringthistime.uringthis30mindnteat/drink, nlytapwater.(caneatafter30min) Plainwaterntmineralwaterasdrink/fdcan absrptasitcaninteractwithaltfthings. Swallwwhlesdesn tcausemuthulcerandwatertmakesureitdesn tgetstuck Stayupright tensureitdesn tgetstuckncauseirritatintthrat (I) nttakeantacids,calcium,irnrmineralsupplementswithin30minutesfalendrnateas theymayinterferewithitsabsrptin.(asprabsrptin.nbtherbisphsphnateiswait 2hrsb/ftakesupplements) A: Tellyurdentistandhealthprfessinalyuaretakingthisdrugasthereareraredental cmplicatinsitmaycause.henceimprtantthavegdralhygiene Tellyurdctrifyuhaveseverepaininyurbnes,jintsrmuscleswhiletakingthis medicine.includingjawpainrdentalprblemse.gtthache R:Stptabletsandseeyurdctrimmedifyuhavepainnswallwing,rnewrwrsening heartburngiirritatin L: NOTES Lwweightbearingexercises MakesureuhaveadequatecalciumindietifntenughgiveCa,vitsupplements(tbe takenatadifferenttimefdaytralbisphsphnatee.gatnightandalendrnateinmrning) " AdeqdietintakefCa2+:1300mgfrmen>70y,pstmenpausalF,teenage12T18y 1000mgfralltheradultes(incpreg/bf),child9T11y Bisphsphnatesmay AF.Alendrantewasassciatedwithitbutneedfurtherresearch Lwenergyfemral(thigh)fracturenlngtermuse(asptentiallymakebnesbrittleeventhu BM)butrareandntsureifcause.Hweverbenefitfdrug>risk (BM) T-screis the # f S away frm the mean BM f an adult aged 30 years T-scre Interpretatin -1 r higher nrmal between -1 and -2.5 stepenia -2.5 r lwer steprsis

4 AspirinAVOIASPIRININGOUTaswrsensitduetsalicylatecntentinhibitskidneytsecreteurate. Occursevenatanalgesicdses. Ifatlwdseasanticagcntuseasbenefitsutweighrisk FASTING,HYPOTHYROIISM,ALCOHOL= Urateexcretin (MstAlchl(excludingwine)hashighpurinecntentduettheyeast) Cyclsprineinhibitstransprterfuricacidusedfrexchangeinkidneyfrexcretin&als breakdwnfcells. Nictinicacid(niacin/vitb3)Thighdsecauseskidneytexcreteitratherthanuricacid rug_drug: Amxycillin(Pc)/ampicillin+allpurinl:riskfskinrash AzathiprineandmercaptpurineAllpurinlwill theirmetablismbyinhibitingxanthinexidase, itscncentratinbmsuppressin(severebmtxicity).txaviduseifpssiblerreduce Azathiprine/mercaptpurinedset1/4r1/3fnrmal allpurinl+thephylline:highdseallpurinlwill thephyllinecnc riska/e.tx:mnitr thephyllinecncentratinandfradverseeffects;decreasethephyllinedseasneeded. Mnitring #gutattacks,#jintsaffected Uricacidlvls:nteHyperuricaemiaisaRISKFACTORbutOESNOTmeanthatpatientwith hyperuricaemiawillhavegut rug:fbc,lft Gis/e,allergicrxn Renalfx:tadjustAllpurinldse cunselling Takethismedicineshrtlyafterfdtreducethepssibilityfstmachupset.(labelBtakewith fd) AThismedicinemaymakeyufeeldizzyrdrwsy;dntdriverperatemachineryifyuare affected.(label12) R_Ifyudevelparash,swllenlipsrmuth,persistentfeverrsrethrat,stptakingallpurinl andtellyurdctrimmediately. Rash,swllenlip=allergicrxn. stillreferifgetrashasculdbeallergicrxn persistentfeverrsrethrat= WBCfrmBMsupp L Makesurethatyudrinkltsffluidsduringtreatment(atleast2Lperday) ReducealchlintakeESPECIALLYBEER,iet:(decrease)highpurinecntente.gSeafdAnimal liver,kidney,pancreas,weightlss Practicepints: IfrenalfailurereduceallpurinldseandPROBENECIEISINEFFECTIVE stpallpurinlifrashdevelps,therearethersignsfallergy,liverfunctinisabnrmal,rbld dyscrasiasccur Ntes: prbenecidislesseffectivethanallpurinlbutcanbeaddedtallpurinlifntwrking/severe

5 Terms Refractryperidamuntftimeittakesfranexcitablemembranetbereadyfrasecndstimulus Intrpe=cntractinsfheart +veintrpiceffect= frcefcntractin Chrntrpic=HeartRate,+veChrntrpiceffect= HR SVT:atrialtachycardiaandarrhythmiasarisingfrmtheatriventricular(AV)junctin sicksinussyndrme=allheartrhythmdisrdersthatisduetsinusnde(pacemaemaker)malfunctine.gsinus bradycardia,sinuspausesrarrest(whenthepacemakerstpswrkingfrperidsftime) 2 nd /3 rd degreeblcks=(aavblcksimpulsegeneratedinthesandeintheatriumdesntprpagatetthe ventricle) Heartblckisaprblemthatccurswiththeheartselectricalsystem.Thissystemcntrlstherateandrhythm fheartbeats.heartblckccursiftheelectricalsignalisslwedrdisruptedasitmvesthrughtheheart. Firstdegreeheartblckmayntcauseanyseveresymptms. Secnddegreeheartblckmayresultintheheartskippingabeatrbeats.Thistypefheartblckalscanmake yufeeldizzyrfaint. Thirddegreeheartblck(cmpleteblck)limitstheheartsabilitytpumpbldttherestfthebdy.This typefheartblckmaycausefatigue(tiredness),dizziness,andfainting.thirddegreeheartblckrequires prmpttx,e.gapacemaker,becauseitcanbefatal. Amidarne(likethyridhrmnestructure) Tx Treatment&Prphylaxisfseveretachyarrythmias(fastirregularheartbeat)refractry(can tbe managed)tthertxe.gaf,ventriculartachycardia,andsvt atrialfibrillatin(af) " cardiversin=useasmaintenanceafternsr 2 nd lineduetit sa/e.1 st line=flecainide " rhythmcntrl=cnvertthearrhythmiatnrmalsinusrhythm(nsr)bydrug 1 st lineis flecainidenamidarane ventriculartachycardia parxysmalsupraventriculartachycardia(svt)prphylaxis.itisregularfasthrthatbeginsand endssuddenly&riginatesfrmmycardium(hearttissue)ratherthanventricles acutecardigenicpulmnaryedema=ifthepatientisinafwithrapidventricularrateanditis thughttbeacntributingfactrtprcardiacutput,useit(iv) sagefrms tablets(arataccrdarnerithmikcardinrm) IV(Crdarne) se(trytuselwestdsenecessarytcntrlarrhythmia) Adult Oral(nnurgentcasesstartwithmaintenancedse.Omitladingdse) " Lading:200mgtdsfr1weekfllwedby200mgbdfr1week " Maintenance:100_400mg1d IV(seekspecialistadvice) " Emergency:150T300mgver1T3minutes(mnitrclinicalsigns+ECGclsely) " Lading:5mg/kgver20minT2hurs " Maintenance:15$20mg/kgver24hurs(max1.2gin24hrs). BeginraltreatmentASAPverlappingralandIVtreatmentbyupt2days MOA:Itactsbyblckingptassiumrectifiercurrents(IK)thatreplarisetheheartprlngingAP& refractryperid.apcannlybegeneratedncesdiumchannelahsreturedtrestingstatenceslws cnductinslwshr. ecreases sinus nde autmaticity,ecreases ventricularcnductin ClassIIIantiarrhythmicagent ecreasesaandavcnductin Prlngsphase3fthecardiacactinptential(thereplarizatinphasewherethereisnrmally decreasedcalciumpermeabilityandincreasedptassiumpermeability)

6 Mildbetablckereffects **A/e cmmn: GI:NV,anrexia,tastedisturbances(lssftast,metallictase),cnstipatin, Pulmnarytxicity.E.gdrypersistentcugh,SOB.(canturnintpneumnitis,brnchitisinfect)2 types: " Acuteinflameflungs=(Canccurearlyrlate)isReversibleifdrugiswithdrawnearly.May respndtcrticsterids " Chrnicfibrsisflungs=excessfibruscnnectivetissue(fibrsis)inthelungs,duet prlngedexpsure&islessreversible Skin:phtsensitivityBlue_Greyskindiscluratin, hyper/hypthyridismduetidinecntentfdrugcancause " Occurmainlyinfirst2years.Canccurevenwhenhavestppedamidarnefrmnthsdue tlngt½ Visualprblems:Crnealdepsits,blurredvisin " Reversiblebenignmicrdepsitsncrneaccurinmstpatientsbutrarelyaffectvisin (phtphbia,visualhalesmayccur) " Stpamidarneifpticneurpathyrneuritis(inflamfnervese.gpain)ccurs Neurtxicity(tremr,ataxia(lackfmusclecrdiantine.gdrunk),paraesthesia(pins&needles), peripheralneurpathy,limbweakness) Sleepdisturbances:nightmares,vivddreams Transientelevatinfliverenzymes Infreq: AVblck,arrhythmia bradycardia Rare Allergicrxn,alpecia Hepattxicity(aswhereitisstredandmetablised)e.ghepatits Thrmbcytpenia Heartfailure Opticneurpathy **Txicity:Blue_Greyskindiscluratin,eyetxicity,lungtxicity,heart_severebradycardia, hepattxicity Amidarne txicity frm prlnged use f the medicine. Amidarne is a fat sluble drug, it gets distributed t and stred in many different tissues f the bdy and has lng t ½. Strage is primarily in fat, muscle, liver, lungs, and skin, while its effects are als seen n thyrid and eyes in additin t heart. Its txicities als affect these rgans. Precautins Thyriddysfunctinincreaseriskfhyprhyperthyridism Lungdiseaseifgetpulmnarytxicityitisharderfrthemtrecver Electrlytedisturbances(hyper/hypkalaemia,hypmagnesaemia)increaseriskfarrhythmia, crrectbefrestartingtreatment *Hepaticimpairmentdecreasedmetablismaccumulatinandhepattxicity.itismetablisedby liver

7 Eplerenne(aldsterneantagnist)andriskfitsadverseeffectse.g.hyperkalaemia;TxLimit eplerennedset25mgdandmnitrptassiumcncentratinandclinicalsignsandadjustdse Chlestyramine BindstamidarneinGITdecreasingitsabsrptin Takeamidarne>1hrbefrechlestyraminer4T6hursafter Mnitramidarnecncentratinandclinicalrespnseandadjustdse Simvastatin Amidarneincreasesriskfmypathyrrhabdmylysiswithsimvastatin Usealternativestatinifpssible(e.gpravastatin) Ifcmbinatincanntbeavided,uselwesteffectivedsefsimvastatin(nt>20mgdaily) Mnitrfradverseeffectsandmeasurecreatinekinase(CK) **Mnitr Therapeuticmnitring:TRis12.5mg/L(1.64micrml/L). Maxeffectfdsagechangeisn tseenfr13mnthsrmre.cuzfitslngt½(13mnths) Befrestarting(thendq6mnts) Baselineclinicalstatus Serumelectrlyese.gK+riskfarrthymia Thyridfx,Liverfx(causehepattxicity),Lungfx(includingchestXray) Riskfthyridfunctinabnrmalitiesandliverdamagepersistfruptayearafter stppingtreatment;cntinuemnitring ECG Other: FBP:causethrmbcytpenia Eyeexam Ifdyspnea(SOB)rnnprductivecughdevelp(indicatepulmnarytxicity)perfrm chestxrayandlung(pulmnary)fxtestsasapandmnitrclsely Cunsel takewithfdtmingia/e A TelldctrifdevelpSOB,drycugh,prblemswithvisin,weightlss,muscleweaknessr wrseningfheartprblems (label8)avidsunexpsure,whereprtectiveclthingandsunscreen(spf30+) " asamidarnecausesphtsensitivity (label18)avidgrapefruitjuiceandtelldctriftakinganytherdrugs " Grapefruitjuiceinhibitmetablismfamidarnetxicity (label5)askurdcrpharmacistb/fusingthermedincotcrhealthprducts yu llneedregularbldtests,ecg,chestxrayswhiletakingthisdrug Extrainf Amidarneistheleastnegativelyintrpicantiarrhythmicandisusuallywelltleratedinheart failure Amidarnehasseriusadverseeffectsincludingptentialtwrsenarrhythmia;theseareslwt reslveafteritisstpped(verylnghalflife). Fatslublewithlnghalflife Resemblesthyrxinecancausethyridprblems.EachAmidarne200mgtabhas75mgf idine

8 BPlvls (NrmalBP=<120/80mmHg) +20/10(mild)HTN= 140/90 +20/10(mderate 160/100) +20/10(severe 180/110) Hyp=<90/60 Target: Pplw/diabetes,CV,kidneydis:<130/80( 10/10frmHTN) Pplw/severekidneydis(prteinuria> 1g/day)=<125/75(5/5frmabve) Everyneelse<140/90(HTN) Amldipine-:-Calciumchannelblcker Tx: Hypertensin pulmnaryhypertensin angina(stable) ACS(acutecrnarysyndrme)=recurrentepisdesf ischaemicchestpain Raynaudphenmenn=extremitiesffingers/tesBVIs cnstrictedcausingischemia sagefrm:tablets Aml,Nrdip,Nrvapine,Nrvasc,Ozldip amldipine/atrvastatin=caduet,cadatin se:all1d Adult,child>6years=initially2.5 5mgd,increasever1 2weekstamaxf10mg1d.i.e2.5_ 10mgd Child<6years,initially mg/kg1d,increasever1 2weekstamaxf0.4mg/kgr10mg1 difrequired.i.e0.1mg/kg_0.4mg/kg Elderly,hepaticimpairment=initially2.5mg1d MOA:inhibitsthevltageTgatedLTtypeCa2+channelinvascularSMarteriesblckingCa2+insentering causingvascularsmrelaxatin resultinvasdilatin aresabutmreptentscancausereflextachycardia$aslwbpactivatesbarrecepcausingcns activitywhich BPby HR a/e:cmmn:causesvasdilatinheadache,flushing,dizzy,fatigue peripheraledema duetvasdilate infreq:hyptensin,reflextachycardia,dyspepsia(gis/e),cnstipatin,pulmnaryedema rare:parkinsnism,cerebralandmycardialischaemia(fllwingexcessivefallinbp) interactins: drugsthat BPe.gSterids,NSAI,raldecngestants,COC, drugsthat BPlpdiuretic cyclsprin+amldipine=amldipinemay cyclsprincncriskftxicity;txmnitrcyclsprin cncandfra/e&decreasecyclsprindseifnecessary. mnitr: BP,HR(heartrate)frreflextachycardia LFT=frhepaticimpairment treducedse s/e=dizzy,headache,edema cunsel: : C&A:Label#9dn tstptakingitabruptly=causeafastheartrateangina.therefrereduceslwly ver12wks A C&A: Label12:thismedaffectmentalalertness ifaffecteddntdrive =cancausedizzy Cmmns/e:izzyflushingheadachetired,swllenankle(edema),thisisduetthedilatinfBV frmthemedicaitn izzy,headacheusuallygetsusetit.justtimefrbldtadjust

9 Celecxib-- Tx RA=autimmunedisthatcauseschrnicsystemicinflam.Wheretissuesthatlinejints (synvialmem)areattackedbywnimmunesystemàcausesswelling,pain,stiffnessin jints&jintdamage OA=Ostearthritisisadegenerativejintdiseasewherethecartilageisbrkendwn Ankylsingspndylitis=diseasewhichcausesinflammatinandpaininthespine(spineals calledspndylitis).causesunknwnbutprbduetgenes Painduetinjury(pstperative,musculskeletalrsfttissuee.gjintpain)r dysmenrrhea(perid) sagefrms 100mgand200mgCapsules:Celebrex se(nte:riskfcardivasculara/eisdserelated;sntuse>200mgdlngterm riskf CVevents) OA,Ankylsingspndylitis=upt200mgdin12divideddses RA=100mgbd.(Maybeincreasedt200mgbd(shrtterm)) Peridpain,Pain(pstperative,musculskeletalrsfttissue)=400mgdnthefirst day,then200mgncertwicedailyifneeded;max5daystreatment. (ntefrpain(pstperative,musculskeletalrsfttissue)the400mgdhasbe giveninasingledsehileperispaincanbein10r2dses) 400mgdn1 st day,then200mgdrbdrpn.max5daystx Mderatehepaticimpairment Startathalftherecmmendeddse. MOA:IsselectiveCOX2inhibitr(cxib+melxicam(atlwdse)) painmediatrse.gpg A/e Cmmn:N,dyspepsia,GIulceratinrbleeding, saltandfluidretentinhyperkalaemia,hypertensin headache,dizzy(c&a12)duet BP raisedliverenzymes infreq=hyperkalaemia,hf(cvevent),brnchspasm(asinhibtpgsmreaaloxlt) rare:hypersensitivity,acuterenalfailure(renalimpairment),blddyscrasia anaemiafrm GIbleeding GI:gastriculcer+GIbleeding impifccurstx:replacensaiw/paracetaml+giveppi(thencantestfrh.plyri afterulcerhealasitbecausingit) " ButifhavetcntusingNSAITx:givePPIegmeprazle20mgdrH2antag e.granitidine300mgd+uselwdse/leasttxicnsaie.gibuprfen200mgqid selectivensailessgis/ebutadvislstwhenusewiththernsai ibuprfenhaslessgis/ebutadvislstwhenusedatfulldse(400mg qid) CauseTinhibitCOXT1needfrPGsynthesistinhibitsecretinfgastricacidandprtect gastricmucsasnsai acid.als TXA2 bleedingrisk CV: riskfcveventsby BPe.gMI,strke(espmrebyselectiveNSAI)

10 Cause: renalfunctby GFRandrenalbldflw sdiumandfluidretentin BP c/i:hf renal:wrsenrenalimpairment Mnitr:GIbleeding/ulcere.gdarkstls,cffeegrainsvmit,dyspepsia,painincreaseespn mealsasincreasegastricacid BP,painlvls ElectrlyteK+ sayifpatientgtgibleeding/ulcer Iwuldmnitrfrdarkstls,FBPfrbldlss FBP,creatinineandLFTbefrestartingtreatment,andrepeatatleastnceayearduring cntinuedtreatment Interactintx:avidnsaiduseparacetaml.Ifisn tpssibleusethelwestdsepssiblenshrtest timerchangetalwerstrengthnsaie.gibuprfen UsewiththerNSAIs(incaspirin)addictiveeffectsgastricbleeding/ulcer, BP,impair renalfx anticagulant(inhibittxa2) riskfbleedingwiththeranticagulante.gwarfarin GIs/e OralCS gastriculceratin,dyspepsia alendrnate+nsais=alendrnatemayincreaseriskfgastriculceratinwithnsais; avidcmbrmnitrcarefully. renalfx NSAIs+diuretics=NSAIs(includingselectiveCOX2inhibitrs)reducerenalfxandmay reducediureticeffectandincreaseriskfnephrtxicity;mnitrbp,renalfunctinand weight;increasediureticdseaccrdinglyifnsaiusecanntbeavided.lwdseaspirin isunlikelytbeaprblem. TRIPLEWHAMMYdiuretic+ACEi/ATRA+NSAI GFRrenalfailure NSAIs+lithium=NSAIs(includingselectiveCOX2inhibitrs)mayreduce renallithium excretinandincreaseriskflithiumtxicity;txavidcmbunlessclsemnitring (mnitrlithiumcnc,renalfxandclinicaleffects;reducelithiumdseifnecessary)lw dseaspirinissafetuse. NSAIs+methtrexate=NSAIinducedreductininrenalfunctinreducesrenalexcretin fmethtrexateandmayincreaseriskftxicity(unlikelywithmethtrexatedses<20 mg/week);avidcmbinatinifmethtrexateisusedinantineplasticdses.lwdse aspirinmaybeused. Hyperkalaemia:NSAI+ptassium=NSAIcancausehyperkalaemiaduetcasuing renalfx.tx mnitrk+lvls BP_B_blckers,acei,CCB:asitcunteractstheireffectsby BP WrsenHTN,MI,HF Cunsel Ifyudevelpswllenankles,difficultyinbreathing,blackstlsrdarkcffeeclured vmit,stptakingthemedicineandtellyurdctrimmediately. nttakeaspirinfrpainreliefasitwillincreasetheriskfsideeffectswiththismedicine (label10a)dnttakemrethanneaspirineachdaywhilebeingtreatedwiththismed