Antibiotic Regimens for Sexually Transmitted Infections: A Comprehensive Guide for Healthc, Exams of Nursing

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Antibiotic Regimens for Sexually

Transmitted Infections

Advanced Pharmacology - Care of the Family

Sexually Transmitted Infections (STIs)/Sexually

Transmitted Diseases (STDs)

Chlamydia

Among Adolescents and Adults: - First-line treatment for non-pregnant adolescents and adults with uncomplicated chlamydial infections at urethral, cervical, rectal, and oropharyngeal sites: - Doxycycline 100 mg orally twice daily for 7 days - Alternative options: - Azithromycin 1 gram orally in a single dose - Levofloxacin 500 mg orally given daily for 7 days

Children: - Less than 45 kg: Erythromycin base/ethylsuccinate - Greater than 45 kg but less than 8 years old: Azithromycin - Greater than 8 years old: Azithromycin, Doxycycline

Pregnant Women: - Azithromycin 1 gram orally in a single dose

Newborns: - Ophthalmia or pneumonia: Erythromycin base/ethylsuccinate

Lymphogranuloma Venereum

Doxycycline

Uncomplicated Gonococcal Urethritis

Ceftriaxone 250 mg intramuscularly in a single dose For persons who weigh less than 150 kg, the single intramuscular ceftriaxone dose has been increased from 250 mg to 500 mg For persons who weigh 150 kg or greater, the dose should be increased to 1 gram When chlamydia is ruled out, monotherapy without the use of oral azithromycin/doxycycline is better to reduce the risk of resistance If someone has signs and symptoms of gonorrhea and chlamydia, the treatment is: Ceftriaxone 500 mg intramuscularly in a single dose plus oral doxycycline 100 mg twice daily for 7 days

Disseminated Gonococcal Infection (DGI) and Conjunctivitis in Adults: - Ceftriaxone 1g plus azithromycin 1 g

DGI with Meningitis and DGI with Endocarditis: - Ceftriaxone 1-2 g plus azithromycin 1 g

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Newborns: - Ophthalmia neonatorum-prophylaxis: Erythromycin 0.5% ophthalmic ointment in each eye at birth - Ophthalmia neonatorum: Ceftriaxone - Disseminated infection or scalp abscess: Ceftriaxone and Cefotaxime

Children: - Arthritis, bacteremia: Ceftriaxone - Vulvovaginitis, cervicitis, proctitis, pharyngitis, urethritis if under 45 kg and over 45 kg: Ceftriaxone

Bacterial Vaginosis

Metronidazole 500 mg orally twice a day for 7 days Metronidazole gel 0.75%, one full applicator (5 grams) intravaginally once daily for 5 days Clindamycin vaginal cream 2%, one full applicator (5 grams) inserted at bedtime for 7 days

Pregnancy: - Any of the recommended bacterial vaginosis treatments for nonpregnant women (oral metronidazole, metronidazole gel, and clindamycin cream) as well as certain alternative regimens (oral clindamycin and clindamycin ovules) can be used to treat women with symptomatic bacterial vaginosis during pregnancy.

Breastfeeding Mothers: - Metronidazole can be used.

Herpes Simplex Virus (First Clinical Episode)

Acyclovir 400 mg PO TID 7-10 days Acyclovir 200 mg PO 5 times a day 7-10 days Valacyclovir 1g OR BID 7-10 days Famciclovir 250 mg TID PO 7-10 days

Severe Infection: - Acyclovir

Recurrent Episodes: - Acyclovir 800 mg 2 or 3 times per day - Acyclovir 400 mg - Famciclovir 125 mg, 1g or 500 mg - Valacyclovir 500 mg or 1g

Pelvic Inflammatory Disease (PID) (IM or Oral Regimens)

Ceftriaxone 1 g IV every 24 hours Plus doxycycline 100 mg orally or IV every 12 hours Plus metronidazole 500 mg orally or IV every 12 hours

Syphilis

Primary syphilis, secondary syphilis, and early latent syphilis: Adults: Benzathine penicillin G Children: Benzathine penicillin G Late latent syphilis or latent syphilis of unknown duration: Benzathine penicillin G Tertiary syphilis: Benzathine penicillin G

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Neurosyphilis and congenital syphilis: Aqueous crystalline penicillin G

Pharmacology Concepts

Doxazosin

Side effects: Hypotension, dizziness, and nasal congestion

Dutasteride

Patient teaching: It may take up to one month for the effects of dutasteride to take effect.

Terazosin

How to know it's working: Terazosin relaxes the smooth muscles of the bladder and neck to improve urinary symptoms associated with BPH, but it does not decrease the size of the prostate.

Estrogen Therapy

Routes of administration: Oral: Estradiol alone or in combination with progestins Transdermal: Emulsion, spray, gels, and patches Intravaginal: Inserts, creams, and vaginal rings Parenteral: IV and IM, but rarely used

Progesterone (Progestin) Therapy

Indications: Cessation of hemorrhage, establishing a regular monthly cycle, counteracting endometrial hypoplasia, management of dysfunctional uterine bleeding, amenorrhea, endometriosis, and supporting pregnancy. Contraindications: Undiagnosed abnormal vaginal bleeding, active thrombophlebitis or history of thromboembolic disorders, active liver disease, and carcinoma of the breast. Side effects: Breakthrough bleeding, spotting, and amenorrhea.

Progestin-Only Oral Contraceptives

Side effects: Breakthrough bleeding, spotting, amenorrhea, increased appetite, weight gain, depression, tiredness, fatigue, hypomenorrhea, breast regression, monilial vaginitis, acne, oily scalp, hair loss, and hirsutism.

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Medroxyprogesterone Acetate

Benefits: Protects against pregnancy for 3 months or longer by inhibiting the secretion of gonadotropins. Not having to remember to take pills and not as invasive as the Nexplanon or IUD.

Testosterone Therapy

Routes of administration: Oral: Not first-line due to erratic androgenic effects. Transdermal patch: Indicated for male hypogonadism, applied once daily to the upper arm, thigh, back, or abdomen. Topical gel: Applied once daily (preferably in the morning) to clean, dry skin of the shoulders, upper arms, or abdomen but not the genitalia. Topical solution (Axiron): Formulated for application to the axilla. Patient education: Proper handwashing, covering application site with clothing, avoiding skin-to-skin contact, and avoiding swimming or bathing for 2 hours after application.

Transdermal Drug Administration

Skin-to-Skin Contact

Drugs can be transferred to others through skin-to-skin contact, posing a risk to women and children. The same guidelines noted previously to prevent drug transfer should be followed.

Nasal Gel Administration

Patient Eligibility

Patients with nasal disorders or abnormalities (e.g., chronic sinusitis, a severely deviated nasal septum) should not take this drug.

Side Effects

Common side effects include rhinorrhea, epistaxis, and nasopharyngitis, but these tend to be modest effects.

Patient Education

The pump should be primed before use, and excess gel should be removed. The patient should blow their nose before administration. The pump is inserted into the nostril with the tip aimed toward the lateral nostril wall. The pump should be depressed slowly until it stops.

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As the tip is withdrawn, it should be wiped against the lateral nostril wall to ensure that any remaining gel is distributed to the nostril. After administration in both nostrils, the nose should be lightly massaged below the nasal bridge. The patient should avoid blowing or sniffing for at least 1 hour after administration.

Implantable Pellets

Testosterone Pellets (Testopel)

Testosterone pellets are long-acting formulations indicated for male hypogonadism and delayed puberty. They are implanted into the hip subdermal or in the umbilical wall close to the umbilicus.

Buccal Tablets

Striant

Buccal tablets are applied to the gum area just above the incisor tooth and are designed to stay in place until removed. To ensure good adhesion, tablets should be held in place (with a finger over the lip) for 30 seconds. The recommended dosage is 1 tablet every 12 hours, alternating sides of the mouth with each dose. If a tablet falls out before 8 hours, it should be replaced with a new one for the remainder of the dosing interval. If a tablet falls out after 8 hours, it should be replaced with a new one, and the next scheduled dose should be skipped (i.e., the replacement tablet should remain in place for 16 hours or so). The tablets are not affected by eating, drinking, chewing gum, or brushing teeth. Adverse effects include local irritation, bitter taste, and taste distortion. Treatment for up to 1 year has not caused serious gum changes.

Intramuscular Testosterone Formulations

Testosterone Cypionate (Depo-Testosterone) and

Testosterone Enanthate (Delatestryl)

These formulations vary in their dosage and release in the blood, resulting in significant variations in libido, energy, and mood for patients.

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Androgen Therapy

Therapeutic Goal

To manage hypogonadism and subsequent testosterone deficiency through testosterone supplementation.

Evaluating Therapeutic Effects

Development of secondary sex characteristics and restoration of energy, libido, and other symptoms of testosterone deficiency.

When is Androgen Therapy Not Needed?

For sports enhancements to increase muscle mass. Drugs commonly used by athletes include nandrolone, stanozolol, and methenolone.

Common Side Effects

Salt and water retention can lead to hypertension. Suppression of LH and FSH release can result in testicular shrinkage, sterility, and gynecomastia when administered in high doses used by athletes. Acne is common. Reduction of HDL cholesterol and elevation of LDL cholesterol may theoretically accelerate the development of atherosclerosis. Hepatotoxicity (cholestatic hepatitis, jaundice, hepatocellular carcinoma) is an ever-present risk due to the use of 17-α-alkylated compounds. Kidney damage has been linked to androgen use. In females, androgens can cause menstrual irregularities and virilization. In boys and girls, androgens may reduce attainable adult height. Psychological effects include depression, manic episodes, and aggressiveness. Abuse syndrome may develop.

Alprostadil for Erectile Dysfunction

Administration Routes

Intraurethral administration has fewer side effects than intracavernosal injection, but both routes lead to increased arterial blood flow to the penis.

Alprostadil Pellets (MUSE)

Erection develops 5 to 10 minutes after drug insertion and lasts 30 to 60 minutes.

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The response is rapid, and the injections are relatively painless. The dosing end point is an erection that is sufficient for intercourse but does not last for more than 1 hour.

Contraception

Carbamazepine and Oral Contraceptives

Carbamazepine induces hepatic cytochrome P450 enzymes and thus accelerates the metabolism of oral contraceptives. Reducing or increasing the dose of carbamazepine may lead to subtherapeutic or toxic doses. A pregnancy test should be obtained to rule out pregnancy before administering medroxyprogesterone acetate or prescribing oral contraceptives.

Etonogestrel Subdermal Implant (Nexplanon)

One of the most effective birth control methods. Etonogestrel diffuses slowly and continuously, providing blood levels sufficient for contraception for 3 years, after which the rod is removed. It is associated with little to no menstrual bleeding and is safe for breastfeeding.

Papaverine Plus Phentolamine for Erectile

Dysfunction

These vasodilator and α-adrenergic antagonist agents provide tumescence (engorgement due to vascular congestion) when injected directly into the corpus cavernosum. Erection develops within 10 minutes and lasts 2 to 4 hours.

Patient Education

Priapism occurs in about 10% of patients. Development of painless fibrotic nodules in the corpus cavernosum is common. Other adverse effects include orthostatic hypotension with dizziness, transient paresthesias, ecchymosis (extravasation of blood into subcutaneous tissue), and difficulty in achieving orgasm or ejaculation.

Migraine Management

Abortive Therapy

The objective of abortive therapy is to eliminate headache pain and suppress associated nausea and vomiting.

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It is used at the earliest sign of a migraine attack, before the onset of gastrointestinal disturbances, to allow for medication administration without vomiting. Non-specific analgesics or aspirin-like drugs, opioid analgesics, and migraine-specific drugs (e.g., serotonin 1B/1D agonists, ergot alkaloids) are used. Antiemetics (e.g., metoclopramide, prochlorperazine) are also used.

Drug Selection for Abortive Therapy

The choice of medication depends on the severity of the migraine attacks. Migraine-specific drugs, such as serotonin 1B/1D agonists, are the first- line choice. Ergot alkaloids are used less frequently, and opioid analgesics are used as a last resort.

First-Line Treatment for Migraine Prevention

Beta-blockers, such as propranolol and metoprolol, are the first-line preventive medications for migraine.

First-Line Treatment for Acute, Mild to Moderate Migraine

without Nausea or Vomiting

NSAIDs, such as aspirin, naproxen, and diclofenac, can provide adequate relief. Serotonin 1B/1D receptor agonists (triptans) are also first-line drugs for terminating a migraine attack.

Appropriate Candidates for Preventive Therapy

Patients who have three or more severe migraine attacks per month that do not respond to abortive agents are candidates for preventive therapy.

Opioid Analgesics for Severe Migraines

Butorphanol nasal spray (1 mg) may be used as a rescue medication for severe migraines that do not respond to first-line medications.

Triptans

Mechanism of Action

Triptans relieve pain by constricting intracranial blood vessels and suppressing the release of inflammatory neuropeptides.

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Contraindications

Triptans are contraindicated in patients with ischemic heart disease, prior myocardial infarction, or uncontrolled hypertension. Sumatriptan can cause birth defects and should not be used during pregnancy. Interactions with ergot alkaloids, SSRIs/SNRIs, and MAOIs should be considered.

Precautions

The first dose of any triptan should be administered under direct supervision to monitor for any unknown underlying cardiac disease.

Alzheimer's Disease Management

Rivastigmine (Exelon)

Patient Teaching

Most adverse effects (e.g., nausea, diarrhea, insomnia) are dose-related and can be decreased by starting with lower doses and increasing gradually. Falls are more likely to occur due to bradycardia and other cardiac changes, so fall precautions should be initiated if hospitalized, and patients and families should be taught how to prevent falls at home. To prevent weight loss, nutritional supplements and snacks between meals should be encouraged, and a registered dietitian should be consulted. The rivastigmine transdermal patch needs to be changed daily, and the application site should not be reused for 14 days.

Donepezil (Aricept)

Dose Increase

Donepezil is approved to treat moderate to severe Alzheimer's disease at a 23 mg/day dose, but there is minimal improvement in cognitive functioning when compared to a 10 mg/day dose. The higher dose has a higher incidence of adverse effects.

Cholinesterase Inhibitors

Side Effects

Gastrointestinal effects (nausea, vomiting, dyspepsia, diarrhea) are common. Dizziness and headache are also common.

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Increased activation of cholinergic receptors in the heart can cause symptomatic bradycardia, leading to fainting, falls, fall-related fractures, and pacemaker placement.

Medication Management

When symptoms increase while on medications for Alzheimer's disease, it is better to increase the Alzheimer's medication than to add herbal medications, vitamins, or NSAIDs.

Parkinson's Disease Management

Pramipexole

Most Common Adverse Effects

When used alone, the most common adverse effects are nausea, dizziness, daytime somnolence, insomnia, constipation, weakness, and hallucinations. When combined with levodopa, about 50% of patients experience orthostatic hypotension and dyskinesias. Sleep attacks (overwhelming and irresistible sleepiness that comes on without warning) and impulse control disorders (e.g., compulsive gambling, shopping, binge eating, hypersexuality) can occur. Cimetidine can inhibit the renal excretion of pramipexole, thereby increasing its blood level.

Appropriate Use in Parkinson's Disease

Levodopa is the most effective drug for Parkinson's disease, and if a patient fails to respond, the diagnosis of Parkinson's disease should be questioned. For patients with mild symptoms, treatment can begin with an MAO-B inhibitor, which confers mild symptomatic benefit and may have neuroprotective effects.

Parkinson's Disease Treatment

Levodopa and Dopamine Agonists

For patients with more severe symptoms, treatment should begin with either levodopa (combined with carbidopa) or a dopamine agonist. Improving motor function is the priority, but dopamine agonists have a high risk for disabling dyskinesias.

COMT Inhibitors

COMT inhibitors enhance the effects of levodopa by blocking its degradation. They are used when there is a gradual loss of effects (wearing

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off near the end of the dosing interval) or an abrupt loss of effect (on-off phenomenon).

Gradual loss indicates the drug levels have declined to a sub- therapeutic value. This can be addressed by shortening the dosing interval or using a drug that prolongs levodopa's plasma half-life, such as tolcapone or entacapone. Abrupt loss of effect (on-off phenomenon) can occur at any time during the dosing interval, even while drug levels are high. Off periods may last from minutes to hours and are likely to increase in both intensity and frequency over the course of treatment. A COMT inhibitor is the best drug to use in this situation.

Bromocriptine

Bromocriptine is a drug that increases the beneficial effects of levodopa (an ergot derivative). The most common dose-limiting effects are psychological reactions (confusion, nightmares, agitation, hallucinations, paranoid delusions), dyskinesias, and postural hypotension. Nausea can be helped by taking the medication with food.

Rarely, bromocriptine can cause retroperitoneal fibrosis, pulmonary infiltrates, a Raynaud-like phenomenon, and erythromelalgia (vasodilation in the feet and sometimes hands, resulting in swelling, redness, warmth, and burning pain).

Levodopa/Carbidopa

In the initial treatment of Parkinson's disease, for patients with more severe symptoms, treatment should begin with either levodopa (combined with carbidopa) or a dopamine agonist.

Seizure Disorders

Phenytoin

Phenytoin is the most widely used antiseizure drug, despite having tricky kinetics and troublesome side effects. Phenytoin causes selective inhibition of sodium channels.

Common Side Effects and Patient Education

Black box warning: severe hypotension and cardiac dysrhythmias Central nervous system effects: sedation, ataxia (staggering gait), diplopia (double vision), and cognitive impairment Gingival hyperplasia (excessive growth of gum tissue) - supplemental folic acid is often recommended Morbilliform (measles-like) rash, Stevens-Johnson syndrome (SJS), or toxic epidermal necrolysis (TEN) - strongly associated with HLA-B*

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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) - associated with HLA-B* Hirsutism (overgrowth of hair in unusual places)

Use with Oral Contraceptives

Phenytoin can decrease the effectiveness of oral contraceptives. The provider may need to increase the contraceptive dosage or switch to an alternative form of contraception.

Monitoring Antiepileptic Drugs

For all antiseizure drugs, ongoing monitoring includes evaluating frequency and type of seizures, degree of CNS change, and depression, suicidality, or behavior change.

Gabapentin

Gabapentin is the only FDA-approved drug for use in epilepsy and adjunctive therapy of partial seizures with or without secondary generalization.

Dementia

Memantine

Dosage adjustment is required for patients with renal impairment having a creatinine clearance of less than 30 mL/min. Discontinue with severe impairment.

Panic Disorder

First-Line Treatment Options

Owing to better tolerability, SSRIs are generally preferred for the treatment of panic disorder. Only three SSRIs—fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft)—are approved for this condition.

Performance Anxiety

First-Line Treatment Options

SSRIs are the first-line treatment options for performance anxiety, a subclass of seasonal affective disorder (SAD).

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General Anxiety Disorder

First-Line Treatment Options

Current US Food and Drug Administration approved first-line choices for general anxiety disorder include SSRIs, SNRIs, and buspirone. Benzodiazepines can be used for acute/severe symptoms but have a high potential for abuse.

Depression

Treatment Options

Treatment options for depression include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and atypical antidepressants.

Approach When First Drug Doesn't Seem to Be Working

Initial responses to antidepressants develop in 1 to 3 weeks, but maximal responses may not be seen until 12 weeks. A therapeutic trial should not be considered a failure until a drug has been taken for at least 1 month without success. After a drug has been selected for initial treatment, it should be used for 4 to 8 weeks to assess efficacy. If the initial drug is not effective, options include increasing the dosage, switching to another drug in the same class, switching to another drug in a different class, or adding a second drug, such as an atypical antidepressant.

Suicide Risks

There is a Black Box Warning regarding the increased risk of suicide with antidepressant drugs, especially in children, adolescents, and adults younger than 25 years. Patients should be monitored closely, especially during the first 4 weeks of treatment.

Sleep Disturbance

First-Line Treatment Options

The four major groups of sedative hypnotics are barbiturates, benzodiazepines, benzodiazepine-like drugs, and new agents with unique mechanisms of action. Benzodiazepines, along with the newer benzodiazepine receptor agonists, are drugs of first choice for anxiety and insomnia.

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Medications for Falling Asleep

Benzodiazepines (e.g., estazolam) and non-benzodiazepine drugs (e.g., eszopiclone, zolpidem, zaleplon, ramelteon, suvorexant) can help patients fall asleep if they don't have trouble staying asleep.

Lithium

Therapeutic Drug Level

Lithium levels should be measured every two to three days during initial therapy and every three to six months during maintenance.

Drug-Drug Interactions

Diuretics can increase the risk for lithium toxicity by promoting sodium loss and increasing renal reabsorption of lithium. Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase lithium levels by as much as 60% by increasing renal reabsorption of lithium. Aspirin and sulindac do not increase lithium levels. Anticholinergic drugs can cause urinary hesitancy.

First-Generation Antipsychotics (FGA)

Common Adverse Reactions

All FGAs produce a strong blockade of dopamine in the central nervous system, which can cause serious movement disorders known as extrapyramidal symptoms (EPSs), including acute dystonia, parkinsonism, akathisia (early), and tardive dyskinesia (late).

Patients should be informed about signs of hypotension (lightheadedness, dizziness) and advised to sit or lie down if these occur. Patients should also be warned against participating in hazardous activities until sedative effects diminish.

Selective Serotonin Reuptake Inhibitors

(SSRI)

Drug-Drug Interactions

Monoamine oxidase inhibitors and other drugs that increase the risk for serotonin syndrome. MAOIs should be discontinued at least 14 days prior to starting an SSRI. Use with antiplatelet or anticoagulation can increase the risk for GI bleeding. Monitor those on warfarin and fluoxetine closely. Fluoxetine can elevate plasma levels of tricyclic antidepressants and lithium.

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Baseline Data and Adverse Effects

Serum sodium should be checked in older adults and patients on diuretic therapy. Common adverse effects include sexual dysfunction, weight gain, and serotonin syndrome.

Strategies to Minimize Adverse Effects

Educate patients that abrupt cessation of these drugs is not recommended and that they should report thoughts of suicide or self-harm immediately.

Serotonin/Norepinephrine Reuptake

Inhibitors (SNRI)

Baseline Data and Strategies to Minimize Adverse Effects

Serum sodium should be checked in older adults and patients on diuretic therapy. Educate patients that abrupt cessation of these drugs is not recommended and that they should report thoughts of suicide or self- harm immediately.

Tricyclic Antidepressants (TCA)

Baseline Data and Patient Education

An ECG should be checked, especially in patients with known dysrhythmias or patients older than 40 years of age. Patients should be educated regarding orthostatic hypotension and anticholinergic effects, including dry mouth, blurred vision, constipation, and urinary hesitancy. Patients should be informed that they can minimize orthostatic hypotension by moving slowly when assuming an upright posture and that they should sit or lie down if symptoms (dizziness, lightheadedness) occur. Patients should also be informed about anticholinergic effects and diaphoresis.

Pharmacological Considerations

Tricyclic Antidepressants (TCAs)

TCAs can affect the heart in two ways: Decreasing vagal influence on the heart (secondary to muscarinic blockade) Acting directly on the bundle of His to slow conduction These effects increase the risk of dysrhythmias.

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TCAs also lower the seizure threshold, thereby increasing the risk of seizures.

Monoamine Oxidase Inhibitors (MAOIs)

Baseline blood pressure should be obtained before prescribing MAOIs. Patient education is needed regarding the potential for: Central nervous system stimulation (e.g., anxiety, insomnia, agitation, hypomania, mania) Orthostatic hypotension Hypertensive crisis from dietary tyramine (Hypertensive Crisis) Dietary restrictions are required to avoid the risk of hypertensive crisis.

Benzodiazepines and Benzodiazepine-like Drugs

Examples of benzodiazepines and benzodiazepine-like drugs include zolpidem and ramelteon (a melatonin receptor agonist).

Serotonin Withdrawal Syndrome

Abrupt discontinuation of selective serotonin reuptake inhibitors (SSRIs) can cause a withdrawal syndrome. Symptoms include dizziness, headache, nausea, sensory disturbances, tremor, anxiety, and dysphoria. These symptoms begin within days to weeks of the last dose and persist for 1 to 3 weeks. Resumption of drug use will make the symptoms subside.

St. John's Wort

St. John's wort can induce CYP3A4 and accelerate the metabolism of many drugs, causing a loss of therapeutic effects. Allergic skin reactions may occur, especially in people allergic to ragweed and daisies. St. John's wort may also cause central nervous system effects (e.g., insomnia, vivid dreams, restlessness, anxiety, agitation, and irritability), as well as gastrointestinal discomfort, fatigue, dry mouth, and headache. High-dose therapy may pose a risk for phototoxicity.

Ginger Root

Excessive doses of ginger root may cause gastrointestinal disturbances. High-dose ginger is believed to stimulate the uterus and may theoretically cause spontaneous abortion.

Echinacea

Patients with autoimmune diseases such as lupus erythematosus or rheumatoid arthritis should not take echinacea.

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There is concern that long-term exposure to echinacea can suppress immune function, creating an immunosuppressive effect. Echinacea should be avoided in immunocompromised patients, including those with HIV infection, tuberculosis, and other chronic infections that require optimal immune function for cure.

Flaxseed

Flaxseed may reduce the absorption of conventional medications. Flaxseed should be taken 1 hour before or 2 hours after these drugs to avoid adverse gastrointestinal effects.

Coenzyme Q-10 (CoQ-10)

CoQ-10 is a potent antioxidant that participates in many metabolic pathways, most notably the production of adenosine triphosphate (ATP). CoQ-10 is used to treat heart failure, muscle injury caused by HMG- CoA reductase inhibitors (statins), and mitochondrial encephalomyopathies (i.e., muscle and nervous system injury caused by deranged mitochondrial metabolism).

Feverfew

Feverfew is primarily used for the prophylaxis of migraine. Feverfew's mechanisms of action include inhibition of vasoconstriction in the brain, suppression of serotonin release from platelets and leukocytes, and suppression of inflammation secondary to inhibition of arachidonic acid release. Feverfew may also be used for conditions associated with hypersensitivity and altered immune responses, such as allergies, asthma, rheumatoid arthritis, and psoriasis.

Regulatory Considerations

The Dietary Supplement Health and Education Act (DSHEA) of 1994 exempts supplements from the FDA approval process. The Dietary Supplement and Nonprescription Drug Consumer Protection Act of 2006 mandates reporting of serious adverse effects of nonprescription drugs and dietary supplements. The Current Good Manufacturing Practices (CGMP) ruling of 2007 regulates supplement manufacturing and labeling to ensure supplements are free of contaminants and prevent mislabeling.

Antibiotic Examples

Azithromycin

Indicated for infections, including uncomplicated gonococcal infections (2 g PO x1).

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Not a first-line agent for uncomplicated gonococcal infections; ceftriaxone plus azithromycin is the recommended regimen.

Erythromycin

Indicated for gram-positive cocci and gram-positive bacilli infections. Typical dosage: 1000 mg/day PO divided q6-12h (250 mg or 500 mg tabs). Maximum dose: 4 g/day. Consider giving on an empty stomach; duration varies with infection type and pathogen susceptibility.

Tinidazole

Indicated for the eradication of Helicobacter pylori. Available as 250- and 500-mg tablets, with a typical dosage of 1000 mg/ day PO.

Acyclovir

Indicated for the treatment of herpes simplex virus (HSV) and varicella- zoster virus (VZV) infections. Available as capsules (200 mg) and tablets (400 and 800 mg). Herpes zoster treatment: 800 mg five times daily for 7–10 days.

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