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Brand name: Ultram, Ultram ER

Class of drug: Narcotic (opioid) analgesic.

Mechanism of action: Most likely produces analgesia by binding to opioid receptors. Also inhibits reuptake of norepinephrine and serotonin.

Indications/dosage/route: Oral only.

• Moderate to moderately severe pain

Adults: 50-100 mg q4-6h prn. Maximum: 400 mg/d.

Adjustment of dosage

• Kidney disease: Creatinine clearance <30 mL/min: 50-100 mg q12h. Maximum: 200 mg/d.
• Liver disease (cirrhosis): 50 mg q12h.
• Elderly: Maximum daily dose of 300 mg in patients >75 years.
• Pediatric: Safety and efficacy of tramadol have not been estab-
• lished in children <16 years.

Food: May take with food.

Pregnancy: Category C.

Lactation: Appears in breast milk. Best to avoid.

Contraindications: Hypersensitivity to tramadol or opioids; acute intoxication with alcohol; other analgesics, opioids, hypnotics, or psychotropic agents.

Warnings/precautions

• Use with caution in patients with increased cranial pressure, head injury, alcohol and drug withdrawal, respiratory depression, acute abdominal conditions, history of physical dependence on opioids, and in those concomitantly using (SSRIs), tricyclic antidepressants, neuroleptics, drugs decreasing seizure threshold, kidney or liver disease, elderly.
• Tramadol has been associated with seizures. There is an increased risk in patients with conditions that predispose to seizures, eg, head injury.
• Tramadol is not recommended for patients who have exhibited dependence on opioids or have received opioids previously for more than 1 week.
• Prolonged use of tramadol may result in physical or psychologic dependence although this is not as intense as with opioids.
• Do not give tramadol to patients with abdominal pain without adequate evaluation to rule out structural or pathophysiologic causes.
• Tramadol should be discontinued gradually after long-term use to avoid withdrawal symptoms.
• Patients who have exhibited a previous allergic reaction to opioids may experience seizures if given tramadol.
• It is recommended that tramadol be given on a regular basis rather than prn.

Advice to patient

• Avoid driving and other activities requiring mental alertness or that are potentially dangerous until response to drug is known.
• Change position slowly, in particular from recumbent to upright, to minimize orthostatic hypotension. Sit at the edge of the bed for several minutes before standing, and lie down if feeling faint or dizzy. Avoid hot showers or baths and standing for long periods. Male patients with orthostatic hypotension may be safer urinating while seated on the toilet rather than standing.
• Avoid alcohol.
• If experiencing constipation, increase intake of fluids and consume high-fiber foods (bran, whole-grain bread, raw vegetables and fruits).

Adverse reactions

• Common: dizziness, vertigo, headache, nausea, constipation, somnolence.
• Serious: CNS stimulation, seizures, anaphylaxis.

Clinically important drug interactions

• Drugs that increase effects/toxicity of tramadol: alcohol, antihistamines, opioids, sedatives, hypnotics, other psychotropic drugs, MAO inhibitors, tricyclic antidepressants, SSRIs, carbamazepine, quinidine.
• Tramadol increases effects/toxicity of digoxin, warafarin, MAO inhibitors.

Parameters to monitor: BP and respiratory rate before and periodically after drug administration.

Editorial comments

• This agent has proven to be highly beneficial for patients with chronic pain in whom other opioids and/or NSAIDs are to be avoided. It produces less respiratory depression than narcotic agents. In some clinical trials, tramadol was comparable or superior to adult dosages of codeine with/without acetaminophen.
• Abuse and dependence on tramadol have been reported; avoid overuse. Use caution if administering to individuals with a prior history of opioid dependence or abuse of other drugs.

About the study

Researchers from Cook County Hospital in Chicago, along with colleagues from the Universities of Pittsburgh and Iowa, studied 220 acute bronchitis patients from the screening clinic at Cook County Hospital. All patients were adults with a cough lasting 2 to 14 days and were diagnosed with acute bronchitis at the clinic between December 1999 and March 2000. Patients were excluded if they had a chronic lung disease, were pregnant, had another infectious disease that required medication, needed to be admitted to the hospital, or showed signs of pneumonia. Patients currently taking the following medications were also excluded: bronchodilators, glucocorticoids, ACE inhibitors (in last 4 weeks), and antibiotics (in last 2 weeks).

Participants were randomly assigned to receive either 250 mg of azithromycin once per day for five days or 250 mg of vitamin C once per day for five days. Vitamin C was used as a placebo because research shows that people won’t participate in this type of study if they might get a dummy pill, but a vitamin pill is considered acceptable. However, there is no evidence that 250 mg of vitamin C is effective in treating acute bronchitis or any other respiratory illness. All participants were also given dextromethorphan cough syrup and an albuterol inhaler for symptomatic relief of coughing.

This study was double-blind, meaning that neither the patients nor the interviewers knew what treatment each patient was receiving.

At the first doctor visit for bronchitis (day 1), participants were interviewed about their health-related quality of life and their activity limitations (such as missed work or reduced physical activity) due to their bronchitis. This interview was repeated by telephone on day 3 and day 7.

The researchers compared the health-related quality of life on day 7 reported by people taking azithromycin with that of people taking the placebo pill. In addition, they compared the time it took to return to normal activities-work, exercise, school, housework, etc.-between the two groups.

The findings

There was no difference in the health-related quality of life reported by the two groups on day 7. In addition, there was no difference between the two groups in the number of days to return to usual activities. These findings indicate that taking azithromycin did not help acute bronchitis patients feel better or resume regular activities sooner than patients taking a placebo.

Although these results are interesting, there are limitations to this study.

The institutional review board stopped this study early, when only 220 people had participated rather than the planned 400 people, because the interim results clearly showed the ineffectiveness of azithromycin. However, this left too few people in the study to examine whether severity of symptoms or patient age affected recovery time-for example, severe versus moderate cough and elderly people versus younger adults. In addition, 17% of participants did not complete the study and were unavailable to be interviewed and included in the analysis. However, the percentage of people lost to follow-up was similar in both groups. Finally, although this study suggests that azithromycin is ineffective in treating chronic bronchitis, it does not identify a better treatment for the condition.

How does this affect you?

Do you need an antibiotic for acute bronchitis? Probably not. The majority of acute bronchitis cases are not caused by bacteria, so an antibiotic won’t help. And the findings of this study suggest that azithromycin, the most commonly prescribed antibiotic for acute bronchitis, is not effective in treating the condition. People who took a dummy pill in this study got better just as quickly as those who took azithromycin.

Taking antibiotics when you do not have a bacterial infection contributes to the development of bacteria that are resistant to antibiotics. The decision to prescribe an antibiotic is up to your health care provider, but you can help by not demanding an antibiotic when your health care provider feels it is unnecessary. And you can tell your health care provider that you do not want an antibiotic unless he or she suspects you have a bacterial infection. If your health care provider has reason to suspect a bacterial infection, he or she may prescribe an antibiotic.

Source: Evans AT, et al. Azithromycin for acute bronchitis: a randomised, double-blind, controlled trial. The Lancet . May 11, 2002;359:1648-1654.

Buy Azithromycin (Generic Zithromax) 500mg

Pronunciation
(az ith roe MYE sin)

U.S. Brand Names
Zithromax®

Synonyms
Azithromycin Dihydrate; Zithromax® TRI-PAK™; Zithromax® Z-PAK®

Generic Available
No

Canadian Brand Names
Zithromax®

Azithromycin Use
Treatment of acute otitis media due to H. influenzae , M. catarrhalis , or S. pneumoniae ; pharyngitis/tonsillitis due to S. pyogenes ; treatment of mild-to-moderate upper and lower respiratory tract infections, infections of the skin and skin structure, community-acquired pneumonia, pelvic inflammatory disease (PID), sexually-transmitted diseases (urethritis/cervicitis), pharyngitis/tonsillitis (alternative to first-line therapy), and genital ulcer disease (chancroid) due to susceptible strains of C. trachomatis , M. catarrhalis , H. influenzae , S. aureus , S. pneumoniae , Mycoplasma pneumoniae , and C. psittaci ; acute bacterial exacerbations of chronic obstructive pulmonary disease (COPD) due to H. influenzae, M. catarrhalis, or S. pneumoniae ; acute bacterial sinusitis

Azithromycin Use - Dental
Alternate antibiotic in the treatment of common orofacial infections caused by aerobic gram-positive cocci and susceptible anaerobes alternate antibiotic for the prevention of bacterial endocarditis in patients undergoing dental procedures

Azithromycin Use - Unlabeled/Investigational
Prevention of (or to delay onset of) or treatment of MAC in patients with advanced HIV infection; prophylaxis of bacterial endocarditis in patients who are allergic to penicillin and undergoing surgical or dental procedures

Pregnancy Risk Factor
B

Pregnancy Implications
Azithromycin has been shown to cross the placenta. It has been used as an alternative treatment of Chlamydia in late-term pregnancy. There are no adequate and well-controlled studies in pregnant women; use during pregnancy only if clearly needed.

Lactation
Enters breast milk/use caution

Azithromycin Contraindications
Hypersensitivity to azithromycin, other macrolide antibiotics, or any component of the formulation

Azithromycin Warnings/Precautions
Use with caution in patients with hepatic dysfunction; hepatic impairment with or without jaundice has occurred chiefly in older children and adults; it may be accompanied by malaise, nausea, vomiting, abdominal colic, and fever; discontinue use if these occur. May mask or delay symptoms of incubating gonorrhea or syphilis, so appropriate culture and susceptibility tests should be performed prior to initiating azithromycin. Pseudomembranous colitis has been reported with use of macrolide antibiotics; use caution with renal dysfunction. Prolongation of the QTc interval has been reported with macrolide antibiotics; use caution in patients at risk of prolonged cardiac repolarization. Safety and efficacy have not been established in children <6 months of age with acute otitis media, acute bacterial sinusitis, or community-acquired pneumonia, or in children <2 years of age with pharyngitis/tonsillitis.

Adverse Reactions
1% to 10%: Gastrointestinal: Diarrhea, nausea, abdominal pain, cramping, vomiting (especially with high single-dose regimens)

<1%: Agitation, allergic reaction, anemia, anorexia, candidiasis, chest pain, conjunctivitis, dermatitis (fungal), dizziness, dyspepsia, eczema, enteritis, facial edema, fatigue, flatulence, gastritis, headache, hyperkinesia, increased cough, insomnia, jaundice, leukopenia, malaise, nervousness, pain, pharyngitis, pleural effusion, pruritus, rash, rhinitis, urticaria

Postmarketing and/or case reports: Acute renal failure, aggressive behavior, anaphylaxis, angioedema, anxiety, arrhythmia (including ventricular tachycardia), arthralgia, cholestatic jaundice, deafness, edema, erythema multiforme (rare), hearing loss, hepatic necrosis (rare), hepatitis, hypertrophic pyloric stenosis, hypotension, interstitial nephritis, pancreatitis, paresthesia, pseudomembranous colitis, QTc prolongation (rare), seizure, somnolence, Stevens-Johnson syndrome (rare), syncope, taste abnormality, thrombocytopenia, tinnitus, tongue discoloration (rare), torsade de pointes (rare), vertigo, weakness

Azithromycin Overdosage/Toxicology
Symptoms of overdose include nausea, vomiting, diarrhea, and prostration. Treatment is supportive and symptomatic.

Drug Interactions
Substrate of CYP3A4 (minor); Inhibits CYP3A4 (weak)

Decreased peak serum levels: Aluminum- and magnesium-containing antacids by 24% but not total absorption

Increased effect/toxicity: Azithromycin may increase levels of tacrolimus, phenytoin, ergot alkaloids, alfentanil, bromocriptine, carbamazepine, cyclosporine, digoxin, disopyramide, and triazolam; azithromycin did not affect the response to warfarin or theophylline although caution is advised when administered together; nelfinavir may increase azithromycin serum levels (monitor for adverse effects)

Avoid use with pimozide due to significant risk of cardiotoxicity

Ethanol/Nutrition/Herb Interactions
Food: Rate and extent of GI absorption may be altered depending upon the formulation. Azithromycin suspension, not tablet form, has significantly increased absorption (46%) with food.

Stability
Injection: Store intact vials of injection at room temperature. Reconstitute the 500 mg vial with 4.8 mL of sterile water for injection and shake until all of the drug is dissolved. Each mL contains 100 mg azithromycin. Reconstituted solution is stable for 24 hours when stored below 30°C/86°F.

The initial solution should be further diluted to a concentration of 1 mg/mL (500 mL) to 2 mg/mL (250 mL) in 0.9% sodium chloride, 5% dextrose in water, or lactated Ringer’s. The diluted solution is stable for 24 hours at or below room temperature (30°C or 86°F) and for 7 days if stored under refrigeration (5°C or 41°F).

Other medications should not be infused simultaneously through the same I.V. line.

Suspension: Store dry powder below 30°C (86°F); following reconstitution, store suspension at 5°C to 30°C (41°F to 86°F).

Tablets: Store between 15°C to 30°C (59°F to 86°F).

Compatibility
Other medications should not be infused simultaneously through the same I.V. line.

Mechanism of Action
Inhibits RNA-dependent protein synthesis at the chain elongation step; binds to the 50S ribosomal subunit resulting in blockage of transpeptidation

Pharmacodynamics/Kinetics

Absorption: Rapid

Distribution: Extensive tissue; distributes well into skin, lungs, sputum, tonsils, and cervix; penetration into CSF is poor

Protein binding (concentration dependent): 7% to 50%

Metabolism: Hepatic

Bioavailability: 37%; variable effect with food (increased with oral suspension, unchanged with tablet)

Half-life elimination: Terminal: 68 hours

Time to peak, serum: 2.3-4 hours

Excretion: Feces (50% as unchanged drug); urine (~5% to 12%)

Azithromycin Dosage

Oral:

Children 6 months:

Community-acquired pneumonia: 10 mg/kg on day 1 (maximum: 500 mg/day) followed by 5 mg/kg/day once daily on days 2-5 (maximum: 250 mg/day)

Bacterial sinusitis: 10 mg/kg once daily for 3 days (maximum: 500 mg/day)

Otitis media:

1-day regimen: 30 mg/kg as a single dose (maximum dose: 1500 mg)

3-day regimen: 10 mg/kg once daily for 3 days (maximum: 500 mg/day)

5-day regimen: 10 mg/kg on day 1 (maximum: 500 mg/day) followed by 5 mg/kg/day once daily on days 2-5 (maximum: 250 mg/day)

Children 2 years: Pharyngitis, tonsillitis: 12 mg/kg/day once daily for 5 days (maximum: 500 mg/day)

Children:

M. avium -infected patients with acquired immunodeficiency syndrome (unlabeled use): 5 mg/kg/day once daily (maximum dose: 250 mg/day) or 20 mg/kg (maximum dose: 1200 mg) once weekly given alone or in combination with rifabutin

Treatment and secondary prevention of disseminated MAC (unlabeled use): 5 mg/kg/day once daily (maximum dose: 250 mg/day) in combination with ethambutol, with or without rifabutin

Prophylaxis for bacterial endocarditis (unlabeled use): 15 mg/kg 1 hour before procedure

Uncomplicated chlamydial urethritis or cervicitis (unlabeled use): Children 45 kg: 1 g as a single dose

Adolescents 16 years and Adults:

Respiratory tract, skin and soft tissue infections: 500 mg on day 1 followed by 250 mg/day on days 2-5 (maximum: 500 mg/day)

Alternative regimen: Bacterial exacerbation of COPD: 500 mg/day for a total of 3 days

Bacterial sinusitis: 500 mg/day for a total of 3 days

Urethritis/cervicitis:

Due to C. trachomatis : 1 g as a single dose

Due to N. gonorrhoeae : 2 g as a single dose

Chancroid due to H. ducreyi : 1 g as a single dose

Prophylaxis of disseminated M. avium complex disease in patient with advanced HIV infection (unlabeled use): 1200 mg once weekly (may be combined with rifabutin)

Treatment of disseminated M. avium complex disease in patient with advanced HIV infection (unlabeled use): 600 mg daily (in combination with ethambutol 15 mg/kg)

Prophylaxis for bacterial endocarditis (unlabeled use): 500 mg 1 hour prior to the procedure

I.V.: Adults:

Community-acquired pneumonia: 500 mg as a single dose for at least 2 days, follow I.V. therapy by the oral route with a single daily dose of 500 mg to complete a 7-10 day course of therapy

Pelvic inflammatory disease (PID): 500 mg as a single dose for 1-2 days, follow I.V. therapy by the oral route with a single daily dose of 250 mg to complete a 7-day course of therapy

Dosage adjustment in renal impairment: Use caution in patients with Clcr<10 mL/minute

Dosage adjustment in hepatic impairment: Use with caution due to potential for hepatotoxicity (rare). Specific guidelines for dosing in hepatic impairment have not been established.

Administration
I.V.: Infusate concentration and rate of infusion for azithromycin for injection should be either 1 mg/mL over 3 hours or 2 mg/mL over 1 hour. Other medications should not be infused simultaneously through the same I.V. line.

Oral: Suspension and tablet may be taken without regard to food.

Monitoring Parameters
Liver function tests, CBC with differential

Dietary Considerations

Powder for oral suspension may be administered with or without food.

Tablet may be administered with food to decrease GI effects.

Sodium content:

Injection: 114 mg (4.96 mEq) per vial

Powder: 3.7 mg per 100 mg/5 mL of constituted solution; 7.4 mg per 200 mg/5 mL of constituted solution; 37 mg per 1 g single-dose packet

Tablet: 0.9 mg/250 mg tablet; 1.8 mg/500 mg tablet; 2.1 mg/600 mg tablet

Patient Education
Inform prescriber of all prescriptions, OTC medications, or herbal products you are taking, and any allergies you have. Do not take any new medication during therapy unless approved by prescriber. Take as directed. Take all of prescribed medication and do not discontinue until prescription is completed. Take capsule form 1 hour before or 2 hours after meals; suspension may be taken with or without food; tablet form may be taken with meals to decrease GI effects. Do not take with antacids that contain aluminum or magnesium. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. If taken to treat a sexually-transmitted disease, follow advice of prescriber related to sexual intercourse and preventing transmission. May cause transient abdominal distress, diarrhea, and headache. Report signs of additional infections (eg, sores in mouth or vagina, vaginal discharge, unresolved fever, severe vomiting, or diarrhea). Breast-feeding precaution: Consult prescriber if breast-feeding.

Additional Information
Capsules are no longer being produced in the United States.

Cardiovascular Considerations
The clinical implications of the association between infection ( Chlamydia and cytomegalovirus) and coronary artery disease (CAD) is unknown. A recent trial showed no difference in clinical events in azithromycin-treated patients who had CAD and positive C. pneumoniae antibodies.

Dental Health: Effects on Dental Treatment
No significant effects or complications reported

Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions

Mental Health: Effects on Mental Status
Macrolides have been reported to cause nightmares, confusion, anxiety, and mood lability; may rarely cause dizziness, agitation, nervousness, and insomnia

Mental Health: Effects on Psychiatric Treatment
Contraindicated with pimozide; may increase concentration of bromocriptine, carbamazepine and triazolam

Azithromycin Dosage Forms
Injection, powder for reconstitution, as dihydrate: 500 mg

Powder for oral suspension, as dihydrate: 100 mg/5 mL (15 mL); 200 mg/5 mL (15 mL, 22.5 mL, 30 mL) [cherry creme de vanilla and banana flavor]; 1 g [single-dose packet; cherry creme de vanilla and banana flavor]

Tablet, as dihydrate: 250 mg, 500 mg, 600 mg

Zithromax® TRI-PAK™ [unit-dose pack]: 500 mg (3s)

Zithromax® Z-PAK® [unit-dose pack]: 250 mg (6s)

References
“1997 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected With Human Immunodeficiency Virus. USPHS/IDSA Prevention of Opportunistic Working Group,” MMWR Recomm Rep , 1997, 46(RR-12):1-46.

American Thoracic Society, “Guidelines for the Initial Management of Adults With Community-Acquired Pneumonia: Diagnosis, Assessment of Severity, and Initial Antimicrobial Therapy,” Am Rev Respir Dis , 1993, 148(5):1418-26.

Amsden GW, “Erythromycin, Clarithromycin, and Azithromycin: Are the Differences Real?” Clin Ther , 1996, 18(1):56-72.

Bahal N and Nahata MC, “The New Macrolide Antibiotics: Azithromycin, Clarithromycin, Dirithromycin, and Roxithromycin,” Ann Pharmacother , 1992, 26(1):46-55.

Bendayan R, Georgis W, and Rafi-Tari S, “Interaction of 3′-Azido-d’-Deoxythymidine With the Organic Base Transporter in a Cultured Renal Epithelium,” Pharmacotherapy , 1995, 15(3):338-44.

Clauzel AM, Visier S, and Michel FB, “Efficacy and Safety of Azithromycin in Lower Respiratory Tract Infections,” Eur Respir J , 1990, 3(Suppl 10):89.

Coates P, Daniel R, Houston AC, et al, “An Open Study to Compare the Pharmacokinetics, Safety, and Tolerability of a Multiple-Dose Regimen of Azithromycin in Young and Elderly Volunteers,” Eur J Clin Microbiol Infect Dis , 1991, 10(10):850-2.

Dajani AS, Taubert KA, Wilson W, et al, “Prevention of Bacterial Endocarditis Recommendations by the American Heart Association,” JAMA , 1997, 277(22):1794-801.

Drew RH and Gallis HA, “Azithromycin - Spectrum of Activity, Pharmacokinetics, and Clinical Applications,” Pharmacotherapy , 1992, 12(3):161-73.

Feldman RJ, Alcid DV, and Boruchoff SE, “Failure of Prolonged Azithromycin Therapy in Early Lyme Disease,” Infect Dis Clin Pract , 1995, 4(3):230-2.

Foulds G, Shepard RM, and Johnson RB, “The Pharmacokinetics of Azithromycin in Human Serum and Tissues,” J Antimicrob Chemother , 1990, 25(Suppl A):73-82.

Goldman MP and Longworth DL, “The Role of Azithromycin and Clarithromycin in Clinical Practice,” Cleve Clin J Med , 1993, 60(5):359-64.

Guay DR, “Pharmacokinetics of the New Macrolides,” Infect Med , 1992, 9:9-13.

Hammerschlag MR, Golden NH, Oh MK, et al, “Single Dose of Azithromycin for the Treatment of Genital Chlamydial Infections in Adolescents,” J Pediatr , 1993, 122(6):961-5.

Hoffler D, Koeppe P, and Paeske B, “Pharmacokinetics of Azithromycin in Normal and Impaired Renal Function,” Infection , 1995, 23(6):356-61.

Ljutic D and Rumboldt Z, “Possible Interaction Between Azithromycin and Cyclosporin: A Case Report,” Nephron , 1995, 70(1):130.

Nahata MC, Koranyi KI, Gadgil SD, et al, “Pharmacokinetics of Azithromycin After Oral Administration of Multiple Doses of Suspension,” Antimicrob Agents Chemother , 1993, 37(2):314-16.

Neu HC, “New Macrolide Antibiotics: Azithromycin and Clarithromycin,” Ann Intern Med , 1992, 116(6):517-9.

Peters DH, Friedel HA, and McTavish D, “Azithromycin: A Review of Its Antimicrobial Activity, Pharmacokinetic Properties and Clinical Efficacy,” Drugs , 1992, 44(5):750-99.

Rapeport WG, Dewland PM, Muirhead DC, et al, “Lack of Interaction Between Azithromycin and Carbamazepine,” Br J Clin Pharmacol , 1992, 30:551P.

Starke JR and Correa AG, “Management of Mycobacterial Infection and Disease in Children,” Pediatr Infect Dis J , 1995, 14(6):455-69.

Steingrimsson O, Olafsson JH, Thorarinsson H, et al, “Azithromycin in the Treatment of Sexually Transmitted Disease,” J Antimicrob Chemother , 1990, 25(Suppl A):109-14.

Tartaglione TA, “Therapeutic Options for the Management and Prevention of Mycobacterium avium Complex Infection in Patients With the Acquired Immunodeficiency Syndrome,” Pharmacotherapy , 1996, 16(2):171-82.

Wahlstrom E, Zamora JU, and Teichman S, “Improvement in Cyclosporin-Associated Gingival Hyperplasia With Azithromycin Therapy,” N Engl J Med , 1995, 332(11):753-4.

Wynn RL, “New Erythromycins,” Gen Dent , 1996, 44(4):304-7.

Zuckerman JM and Kaye KM, “The Newer Macrolides. Azithromycin and Clarithromycin,” Infect Dis Clin North Am , 1995, 9(3):731-45.

International Brand Names
Abacten® (CL); Adefin® (HN); Artricina® (DO); Aruzilina® (CR, DO, GT, HN, PA, SV); Arzomicin® (AR, DO); Asipral® (CL); Atizor® (CL); Azacid® (TR); Azadose® (FR); Azalid® (CL); Azatek® (TR); Azatril® (BG); AZ® (BD); Azenil® (IL); Azi® (BR); Azicin® (BD); Azimax® (BR); Azimin® (CO); Azimix® (BR); Azin® (BD); Azithral® (IN); Azithrocin® (BD); Azitrax® (BR); Azitrix® (PT); Azitrocin® (IT, MX); Azitromax® (NO, SE); Azitrom® (CL, DO); Azitromicina® (CL, EC); Azitromicina Dupomar® (AR); Azitromicina Genfar® (EC); Azitromicina MK ® (CO, CR, DO, GT, HN, PA, SV); Azitromicina Northia® (AR); Azitromicina Richet® (AR); Azitromicina Rigar® (PA); Azitromin® (BR, EC); Azitro® (TR); Azitrox® (CZ); Azitroxil® (BR); Aziwok® (IN, RU, ZA); Azomax® (TR); Azro® (TR); Aztrin® (ID); Azyth® (BD); Biosine® (GT); Clearsing® (AR); Clindal AZ® (BR); Cronopen® (AR); Dinamicina® (CL); Donozyt® (GT, SV); Doyle® (AR); Eritrosima® (BR); Fabramicina® (AR); Farmiz® (PT); Fina-3® (AR); Forcin® (CL); Gigatrom® (PT); Goxil® (ES); Hemomycin® (YU); Kromicin® (CO); Macromax® (AR); Mazitrom® (BR); Misultina® (AR); Mixoterin® (AR); Neblic® (AR); Nifostin® (AR); Nor-Zimax® (SV); Novegam® (CR, DO, GT, PA); Novozitron® (AR); Odazyth® (BD); Orobiotic® (AR); Pediagesic® (DO); Ribotrex® (IT); Selimax® (BR); Sumamed® (CZ, HR, HU, PL, RO, RU, SI); Sumir® (AR); Tanezox® (AR); Tobil (EC); Tobyl® (CO); Toraseptol® (ES); Tremac® (TR); Trex® (CL, EC); Triamid® (AR); Tritab® (AR); Tromic® (DO); Tromix® (CO); Trozocina® (IT); Ultrabac® (EC); Ultreon® (DE); Unizitro® (PT); Vinzam® (ES); Zaret® (CO, GT); Zentavion® (ES); Zeto® (IL); Zibramax® (ID); Zifin® (ID); Zimax® (BD); Zimericina® (CO); Zistic® (ID); Zithrax® (ID); Zithromac® (JP); Zithromax® (AT, AU, CA, CH, CL, CY, DE, DO, EG, FI, FR, GB, ID, IE, IL, JO, KW, LB, NL, NZ, PT, SG, TH, ZA); Zithrox® (BD); Zitrim® (CO); Zitrobifan® (CO); Zitromax® (AR, BE, BR, CO, DK, ES, IT, LU, TR); Zitroneo® (BR); Zitrotek® (TR); Zomax® (EG, JO, KW, LB, SY); Zycin® (ID)

Buy Azithromycin (Generic Zithromax) 500mg

What is the most important information I should know about azithromycin?

Do not use azithromycin if you have ever had an allergic reaction to this medicine or similar drugs such as erythromycin (E-Mycin, Ery-Tab, E.E.S.), clarithromycin (Biaxin), or other macrolide antibiotics.

There are many other medicines that can interact with azithromycin. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

Take this medication for the entire length of time prescribed by your doctor. Your symptoms may get better before the infection is completely treated. Azithromycin will not treat a viral infection such as the common cold or flu. Take azithromycin on an empty stomach 1 hour before or 2 hours after meals. Do not take azithromycin at the same time as taking an antacid that contains aluminum or magnesium. This includes Rolaids, Maalox, Mylanta, Milk of Magnesia, Pepcid Complete, and others. These antacids can make azithromycin less effective when taken at the same time.

What is azithromycin?

Azithromycin is in a group of drugs called macrolide antibiotics. Azithromycin fights bacteria in the body.

Azithromycin is used to treat many different types of infections caused by bacteria, such as respiratory infections, skin infections, ear infections, and sexually transmitted diseases.

Azithromycin may also be used for purposes other than those listed in this medication guide.

What should I discuss with my healthcare provider before taking azithromycin?

Do not use azithromycin if you have ever had an allergic reaction to this medicine or similar drugs such as erythromycin (E-Mycin, Ery-Tab, E.E.S.), clarithromycin (Biaxin), or other macrolide antibiotics.

Before taking azithromycin, tell your doctor if you have:

• liver disease;
• kidney disease;
• a heart rhythm disorder; or
• a history of Long QT syndrome.

If you have any of these conditions, you may not be able to use azithromycin, or you may need a dosage adjustment or special tests during treatment.

FDA pregnancy category B. This medication is not expected to be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether azithromycin passes into breast milk or if it could harm a nursing baby. Do not take this medication without telling your doctor if you are breast-feeding a baby.

How should I take azithromycin?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. The dose and length of treatment with azithromycin may not be the same for every type of infection.

Take each tablet or capsule with a full glass (8 ounces) of water.

To use the oral suspension single dose packet: Open the packet and pour the medicine into 2 ounces of water. Stir this mixture and drink all of it right away. To make sure you get the entire dose, add a little more water to the same glass, swirl gently and drink right away.

Azithromycin capsules must be taken on an empty stomach. Take the capsule at least 1 hour before or 2 hours after eating a meal Azithromycin tablets or powder oral suspension may be taken with or without food. Take the tablet or oral suspension with food if the medicine upsets your stomach.

Do not take azithromycin at the same time as taking an antacid that contains aluminum or magnesium. This includes Rolaids, Maalox, Mylanta, Milk of Magnesia, Pepcid Complete, and others. These antacids can make azithromycin less effective when taken at the same time.
Shake the oral suspension (liquid) well just before you measure a dose. To be sure you get the correct dose, measure the liquid with a marked measuring spoon or medicine cup, not with a regular table spoon. If you do not have a dose-measuring device, ask your pharmacist for one. Take this medication for the entire length of time prescribed by your doctor. Your symptoms may get better before the infection is completely treated. Azithromycin will not treat a viral infection such as the common cold or flu.

It is important to take azithromycin regularly to get the most benefit.

Store this medication at room temperature away from moisture and heat. Throw away any unused liquid medicine after 10 days.

What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine.

Symptoms of an azithromycin overdose may include nausea, vomiting, diarrhea, and stomach discomfort.

What should I avoid while taking azithromycin?

Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to.

Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Azithromycin can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.What are the possible side effects of azithromycin?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop using azithromycin and call your doctor at once if you have any of these serious side effects:

• diarrhea that is watery or bloody;
• chest pain, uneven heartbeats; or
• nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes).

Continue using azithromycin and talk with your doctor if you have any of these less serious side effects:

• mild nausea, vomiting, diarrhea, constipation, or stomach pain;
• dizziness, tired feeling, or headache;
• vaginal itching or discharge; or mild itching or skin rash.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

What other drugs will affect azithromycin?

Do not take antacids that contain aluminum or magnesium within 2 hours of taking azithromycin.

Before taking azithromycin, tell your doctor if you are using any of the following drugs:

• nelfinavir (Viracept);
• digoxin (Lanoxin, Lanoxicaps);
• ergot medicine such as methysergide (Sansert), ergotamine (Ergostat, Medihaler, Cafergot, Ercaf, Wigraine), dihydroergotamine mesylate (D.H.E., Migranal Nasal Spray);
• triazolam (Halcion);
• carbamazepine (Carbatrol, Tegretol);
• cyclosporine (Neoral, Sandimmune);
• phenytoin (Dilantin);
• cholesterol-lowering medicines such as lovastatin (Mevacor), atorvastatin (Lipitor), or cerivastatin (Baycol);
• a calcium channel blocker such as diltiazem (Cartia XT, Diltiazem, Tiazac), felodipine (Plendil), nicardipine (Cardene), nifedipine (Procardia, Adalat), nimodipine (Nimotop), verapamil (Calan, Covera-HS);
• HIV medicines such as indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase);
• alprazolam (Xanax), diazepam (Valium), midazolam (Versed), triazolam (Halcion);
• theophylline (Theo-Dur, Theolair, Theochron);
• warfarin (Coumadin);
• pimozide (Orap); or
• another antibiotic, especially clarithromycin (Biaxin) or erythromycin (E-Mycin, E.E.S, Ery-Tab).

If you are using any of these drugs, you may not be able to use azithromycin, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with azithromycin. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

Where can I get more information?

Your pharmacist has additional information about azithromycin written for health professionals that you may read.

What does my medication look like?

Azithromycin is available with a prescription under the brand name Zithromax. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

1. Use a therapeutic dose at the appropriate time: An adequate dose of aspirin or acetaminophen (say, 975 mg, especially taken in conjunction with a caffeinated beverage) administered early in a migraine attack may be more effective than a “powerful” opioid (narcotic) taken too late. When patients tell us that “simple” analgesics have failed in the past, we are careful to ask them what dosage was used and at what point in the attack the medication was taken. Especially with over-the-counter (OTC) medications, the “recommended” doses often are insufficient to terminate acute migraine.

2. Match drug to headache intensity: There is no single drug that is ideal for the treatment of migraine headache regardless of pain intensity. Some agents will work only-or at least consistently-if taken when the headache is mild to moderate in intensity, and others (e.g., injectable sumatriptan) ironically may have little effect on early headache but relieve excruciating head pain completely. Evidence is rapidly accumulating to suggest that the oral triptans (see Appendix 3) are most effective and most consistently effective-when taken early in an attack, when the pain is still relatively mild.

3. Treat early: This caveat serves to some extent as a corollary to #1 and #2. As an attack progresses, the pain pathways within the central nervous system become sensitized, resulting in reduced drug effectiveness and a higher incidence of drug-related side effects. If you have mild headaches that never progress, it is reasonable to have a different medication for that headache. However, if your attack is generally disabling, never “step up” to the most effective drug: treat with that agent early on.

4. Use the appropriate formulation: Use the appropriate formulation. It makes no sense to take an oral medication for acute migraine if you are experiencing associated nausea and vomiting; that situation calls for medication that is administered intranasally, rectally, subcutaneously (i.e., injection under the skin) or in some other fashion that will enable the drug to be absorbed by the body and do its job. If the nausea is experienced some time after the attack begins, the pills will probably suffice; if these symptoms are experienced early in the attack, then the agent will never be absorbed and it is doubtful that it will be effective.

5. Even when vomiting is not a problem, the oral administration of acute migraine medication may be complicated by erratic gastrointestinal absorption; acute migraine frequently produces gastric paresis (i.e., delayed stomach emptying), resulting in impaired absorption. A way to overcome this obstacle is to take caffeine along with any other orally administered medication; a more expensive alternative is to administer oral metoclopramide (Reglan), like caffeine an agent that promotes gastric emptying, about 20 minutes before taking another oral drug intended for acute migraine treatment. The newer migraine agents; triptans, all reduce nausea and vomiting in parallel with reduction in headache.

6. Avoid overuse: We will explore the issue of analgesic overuse headache in detail later in this chapter, but for now, medication intended for the acute treatment of migraine actually may promote headache if it is overused. Along with this, overuse of certain analgesics rapidly may lead to tolerance, wherein the pain killing effect of the drug progressively decreases with continued use. Tolerance may provoke a vicious cycle, enticing the patient to take more and more of an analgesic to obtain less and less pain relief and may lead to physical and psychological drug addition.

The abortive medications commonly used for migraine are listed and briefly described in Appendix 3. When you receive a prescription for such medication, be sure you understand how and when it is to be used, what side effects you may anticipate and what to do should the drug prove ineffective. To ensure that you do not receive a prescription for an abortive medication that might cause a serious side effect or interact adversely with other medications you are taking, provide your physician with a complete medical history (emphasizing any problems you may have had with blood pressure, heart disease, diabetes or gastrointestinal disorder such as peptic ulcer disease). Also, be sure to provide a complete listing of your medications and their current dosages.

The ideal abortive agent for headache is one that is inexpensive, easy to administer, exerts its therapeutic effect rapidly, invariably terminates the headache completely, does so without conveying side effects, is associated with a 0% chance of early headache recurrence and possesses no potential for producing analgesic overuse headache. Needless to say, no such agent yet exists, but in designing an acute headache treatment strategy, this is the ideal for which we should strive.

Despite the advances that have been made, pharmacologic treatment of migraine remains a process of educated trial and error. Come to one of one of our headache clinics, and you will find after a few weeks that although their personalities may vary dramatically, virtually all migraine patients offer one of surprisingly few histories in describing their headache syndromes. Despite the similarities
in the histories provided by migraineurs, there is no one abortive or prophylactic drug that is universally effective for all patients. Presumably this reflects the heterogeneous nature of migraine’s underlying biology; it well may be that there are dozens, hundreds or even thousands of genetic permutations that yield these relatively few clinical presentations, and each of those genetic
polymorphisms may produce a different type of neurochemical abnormality. The resulting biologic variation implies that only some proportion of migraineurs will respond to a drug that possesses a relatively specific mechanism of action, acting only to modify a certain type neurochemical abnormality.

What are the different subtypes of migraine? The majority of migraineurs have migraine without aura, but a significant minority (again, approximately 20%) have at least occasional aura with their attacks; a tiny percentage report migraine attacks that predominantly involve aura only. In terms of headache frequency, there are those patients who experience less than 15 days of headache per
month (episodic migraine), those who experience 15 or more headache days per month but not daily headache (frequent episodic migraine) and those whose headaches are daily (chronic daily headache/chronic migraine); the last group is subdivided into those who are aggravating their chronic daily headache (CDH) headache syndrome through overuse of acute medications and those who are not.

Drug therapy for migraine is divided into treatment that is abortive (ie, for acute headache only) versus treatment that is prophylactic (i.e., intended for prevention of attacks).

Toward the end of the 1800s, exploration of the causes of tension-type headache received particular attention from physicians. Victorian neurologists attributed these headaches to overintense mental concentration, hysteria, or hypochondria. Treatments ran the gamut from bed rest to vigorous exercise, and medicines included laudanum and hemp. Sigmund Freud, physician and founder of modern psychoanalysis, wrote that the logical center for migraine was the “trigeminal nucleus whose fibers supply the dura mater” and “may include spastic innervation of muscles of blood vessels in the reflex sphere of the ductal region.” This anticipated the current theory of Moskowitz, proposing that abnormally dilated menin-geal vessels (blood vessels on the outside of the brain) emit signals that stimulate trigeminovascular neurons to produce migraine.

The twentieth-century physician William Osler first introduced the idea that the muscles of the head were abnormally tense during headache. Wolff studied this and purported to show that involuntary contraction of scalp and neck muscles did cause headache; he called this “muscle-contraction” headache. More recent studies show no consistent correlation between “tension-type” headache and muscle contraction. While many individuals with “pure” tension-type headache are commonly found in the general population, the spectrum of head pain suffered by migraineurs runs the gamut from the mildest tension-type headache to functionally disabling, commode-hugging head pain of such miserable intensity that death may seem preferable. Interestingly, the tension-type headaches experienced by those with “pure” tension-type headache are typically unresponsive to medications designed for migraine, while those medications are effective for the tension-type headaches experienced by migraineurs. Thus, it may be that a single headache type may arise from very different biologic sources.

Misery loves company, and it may help the migraineur to feel less picked upon to know that many famous persons also suffered from headache. Among them are former U.S. presidents Ulysses S. Grant (Appendix I) and Thomas Jefferson; writers Guy de Maupassant, Edgar Allan Poe, Leo Tolstoy, Virginia Woolf, and Lewis Carroll; scientists Carl Linnaeus, Charles Darwin, and Sigmund Freud; philosophers Immanuel Kant and Karl Marx; Julius Caesar, Mary Todd Lincoln and Madame de Pompadour. The less noteworthy are, of course, often afflicted as well; of this book’s authors, Drs. Rothrock and Mark Green have migraine.

Research intended to reveal the origins of headache continues to advance, and the greater knowledge derived will help us to develop rational, safer, and more effective therapies. Regardless, the past has much to teach us; in attempting to subdue headache, one should not lose sight of the powerful effect of applying any remedies attempted to both mind and body.