He encontrado que alguna farmacia puede tener existencias limitadas de ciertos medicamentos, mientras que otras pueden tener casi cualquier formato que se le ocurra y el habitual de dosis habitualidad apareció. En resumen, siempre se contiene el almacén de corroborar. Al mismo tiempo que el producto que más que gustaba ha resultado no estaba disponible en stock otro distinto por las Buenas costumbres también debe buscarse jefe no asн parezca. Por eso es importante disponer de un Plan B para actuar cuandod ello no ocurra. Ventaja de tomar un genérico en lugar de Asix Un genérico es más barato que el nombre de marca Uno de los mayores incentivos para someterse al Dónde comprar Lasix genérico en lugar de pagar la marca es que usted puede obtener un ahorrando importantes Lasix genérico. Por lo tanto, un Lasix genérico es en general mucho más barato que el homólogo de marca, así que una denominación genérica se hace posible para las personas que usan este medicamento con frecuencia. Un ejemplo: La compra de lurosemida en lugar de Lasix es una considerable ahorro para el presupuesto mensual de medicamentos.

Physician assistant protocols

HYPERTENSION MANAGEMENT
When using any protocol, always fol ow the Guidelines of Proper Use (page Definitions
● In adults ≥ 18 years of age, hypertension classifications are the following with 2 or more averaged seated BP measurements over 2 or more office visits (initial BP may be elevated due to anxiety) • Some controversy exists if this label should be given to patients without diabetic, cardiac Considerations
● SBP > 140 mm Hg in age > 50 years is more important cardiovascular disease (CVD) risk factor ● Risk doubles for CVD for each SBP/DBP increase of 20/10 mm Hg starting at 115/75 mm Hg blood ● Thiazide diuretics should be used initially or in combination with other antihypertensive medications ● Most patients will require 2 or more antihypertensive medications to achieve target blood pressure of < 140/90 mm Hg in patients without diabetes or chronic renal disease, or < 130/80 mm Hg for diabetic or ● If blood pressure is > 20/10 mm Hg over target BP, consideration should be given to initiating 2 antihypertensive drugs, one of which should be a ● Clinician’s judgment remains paramount in using ● Self-measured averaged blood pressures at home > 135/85 mm Hg are considered hypertensive High risk conditions that have indications for
initiation of other antihypertensive medications
besides a diuretic
● Recurrent stroke prevention in patients with Evaluation
● Auscultation for carotid, abdominal and femoral bruits ● Abdominal examination for masses and abdominal ● Check legs for edema and arterial pulses Goals of Therapy
● Target blood pressure of < 140/90 mm Hg in patients without diabetes or chronic renal disease, or <130/80 mm Hg for diabetic or chronic renal disease patients with focus on lowering SBP in both groups Treatment Options without High Risk
Conditions
Prehypertension
• Weight loss diet rich in potassium and calcium Stage 1 hypertension
• Angiotensin converting enzyme inhibitor Stage 2 hypertension
● Two drug combination of stage 1 hypertension medications usually (caution if risk of orthostatic Treatment Options with High Risk
Conditions
Prehypertension
● Drugs as applicable in condition below Heart failure
● If asymptomatic give ≥ 1 medication • Angiotensin converting enzyme inhibitor ● If symptomatic give ≥ 1 medication with a loop diuretic ― Lasix (furosemide) or Bumex • Angiotensin converting enzyme inhibitor Ischemic heart disease (stable angina)
● Long acting calcium channel blocker such as Post myocardial infarction options
High risk for coronary disease options
Diabetic hypertension options
Combination of ≥ drugs usual y needed
• Angiotensin converting enzyme inhibitor • ACEI or ARB (reduces diabetic nephropathy) Chronic renal disease options
Definition of chronic renal disease
• Glomerular filtration rate (GFR) < 60 cc/min • Creatinine > 1.5 mg/dL in men and • Albuminuria > 300 mg/day or 200 mg of Medications
• Loop diuretic such as Lasix (furosemide) may be needed with creatinine > 2.5 mg/dL • Limited rise of up to 35% of creatinine with ACEI or ARB therapy is acceptable as long as Recurrent stroke prevention options
● Low dose aspirin (160–325 mg PO qd) if African Americans
● Thiazide diuretics or CCB more effective than ● ACEI induced angioedema occurs 2–4 times more Elderly patients
● Initial lower drug doses may be needed, though standard doses and multiple drugs are needed eventually in the majority to achieve BP control ● They are at risk of postural hypotension due to the frequent use of multiple medications Follow Up and Achieving Blood Pressure
● Monthly follow up till blood pressure control is ● Follow up every 3–6 months when blood control is ● Serum creatinine and potassium should be checked 1– ● Heart failure, diabetes and other comorbidities influence frequency of visits and tests needed ● Addition of a second drug should be in a different class if a single drug regimen was started initially and failed ● Do not use 2 drugs in the same class at the same time (exception is Maxzide or Dyazide which are Consult Criteria
● Unable to achieve target blood pressure reductions ● Blood pressure ≥ 180/110 mm Hg on 2 or more ● Symptomatic high risk conditions or comorbidities (CHF, progressive renal insufficiency, hyperkalemia, Antihypertensive Medications (Refer to
PDR or Inserts)
Thiazide diuretics
● Chorothiazide (Diuril) 125–250 mg PO qd-bid ● Hydrochlorothiazide (HCTZ) 12.5–50 mg PO qd Loop diuretics
● Lasix (furosemide) 20–40 mg PO bid ● Bumex (bumetanide) 0.5–1 mg PO bid Potassium sparing diuretics
Aldosterone receptor blockers
Beta-blockers
● Toprol XL (metoprolol) 50–100 mg PO qd Beta-blockers with intrinsic sympathomimetic
activity
● Sectral (acebutolol) 200–400 mg PO bid Combined alpha and beta-blockers
● Coreg (carvedilol) 6.25–25 mg PO bid increase every 1–2 weeks as tolerated and needed up to Angiotension converting enzyme inhibitors (ACEI)
● Accupril (quinapril) 10–80 mg PO qd Angiotensin receptor blockers
● Atacand (candesartan) 8–32 mg PO qd ● Cozaar (losartan) 25–50 mg PO qd-bid ● Diovan (valsartan) 80–320 mg PO qd Calcium channel blockers―non-Dihydropyridines
● Cardizem CD (diltiazem) 180–420 mg PO qd ● Cardizem LA (diltiazem) 120–540 mg PO qd ● Calan (verapamil) SR 120–240 mg PO qd-bid Calcium channel blockers―Dihydropyridines
● Norvasc (amlodipine) 2.5–10 mg PO qd ● Procardia XL (nifedipine) 30–60 mg PO qd Alpha-1 blockers (not first line drugs)
● Cardura (doxazosin) XL 4–8 mg PO qd ● Minipres (prazosin) 1–5 mg PO bid-tid ● Caution for orthostatic hypotension — give first Central alpha-2 agonists
● Catapres –TTS (clonidine) patch 0.1–0.3 mg Combination drugs
● ACEI+CCB (Lotrel) amlodipine and benazepril ● ACEI+HCTZ (Zestoretic) Lisinopril and HCTZ ● ARBs+diuretic (Diovan-HCT) valsartan and HCTZ ● BETABLOCKER+diuretic (Tenoretic) atenolol and ● Diuretic and diuretic (Aldactazide) 25/25 to 50/50
Reference:
http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf JNC 7 ― The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and

Source: http://clinician1.com/images/book_guide_pdfs/HYPERTENSION_MANAGEMENT.pdf