By A. Yugul. William Carey University.

Figure 4: Downward shifted window and upward shifted curve Changes in window and curve in patient 20 Changes in both window and curve are also possible order 20 mg benicar free shipping, as illustrated in Patient 20 (depression) (see Figure 4) generic benicar 20 mg overnight delivery. Dosage schedules for antidepressant drugs in the elderly usually recommend that the dose be reduced to half the adult dose proven benicar 20 mg, for two reasons. First, in the elderly the therapeutic window of antidepressant drugs shifts downwards (a lower plasma concentration will suffice). At a full adult dose the plasma curve may rise above the therapeutic window, leading to side effects, especially 58 Chapter 8 Step 3: Verify the suitability of your P-drug anticholinergic and cardiac effects. Secondly, metabolism and renal clearance of the drug and its active metabolites may be reduced in the elderly, also increasing the plasma curve. Thus, in prescribing the normal adult dosage your patient will be exposed to unnecessary and possibly harmful side effects. For example, two tablets once daily are much more convenient than half a tablet four times daily. Complex dosage schedules decrease patient adherence to treatment, especially when more than one drug is used, and thus decrease effectiveness. If you had not adapted the schedule, the P-drug treatment would have been less effective, or unsafe. You can prevent this by carefully checking the suitability of the standard dosage schedule before writing the prescription. How to adapt a dosage schedule Figure 5: Relation between There are three ways to restore the mismatch between frequency and fluctuations curve and window: change the dose, change the in plasma concentration frequency of administration, or both. The daily dose determines the mean plasma concentration, while the frequency of administration defines the fluctuations in the plasma curve. For example, twice daily 200 mg will give the same mean plasma concentration as four times daily 100 mg, but with more fluctuations in plasma level. The minimum fluctuation would be obtained by delivering 400 mg in 24 hours by means of a continuous infusion (Figure 5). Beware of antibiotics, because some may need high peaks in plasma concentration to be effective. Doubling the dose while maintaining the same frequency not only doubles the mean plasma level, but also increases the fluctuations on both sides of the curve. In drugs with a narrow safety margin the curve may now fluctuate outside the therapeutic window. However, few patients like taking drugs 12 times a day and a compromise has to be found to maintain adherence to treatment. After changing the daily dose it takes four times the half-life of the drug to reach the new steady state. Table 7 lists those 59 Guide to Good Prescribing drugs for which it is advisable to start treatment with a slowly rising dosage schedule. Many doctors not only prescribe too much of a drug for too long, but also frequently too little of a drug for too short a period. In one study about 10% of patients on benzodiazepines received them for a year or longer. Another study showed that 16% of outpatients with cancer still suffered from pain because doctors were afraid to prescribe morphine for a long period. The duration of the treatment and the quantity of drugs prescribed should also be effective and safe for the individual patient. The patient receives unnecessary treatment, or drugs may lose some of their potency. Some reconstituted drugs, such as eye drops and antibiotic syrups, may become contaminated. The treatment is not effective, and more aggressive or expensive treatment may be needed later. Exercise: patients 21-28 For each of the following cases verify whether the duration of treatment and total quantity of the drugs are suitable (effective, safe). R/mefloquine 250 mg, 1 tablet weekly, give 7 tablets; start one week before departure and continue four weeks after return. Patient 21 (depression) A dose of 25 mg per day is probably insufficient to treat her depression. Although she can start with such a low dose for a few days or a week, mainly to get used to side effects of the drug, she may finally need 100-150 mg per day. With 30 tablets the quantity is sufficient for one month, if the dosage is not changed before that time. The risk of suicide also has to be considered: depressive patients are more liable to commit suicide in the initial stages of treatment when they become more active because of the drug, but still feel depressed.

If you join during 1 of the 3 months before you turn 65 purchase 10 mg benicar, your coverage will begin the frst day of the month you turn 65 cheap 20 mg benicar visa. If you join during the month you turn 65 or 1 of the 3 months afer you turn 65 order 10 mg benicar with visa, your coverage will begin the frst day of the month afer you ask to join a plan. If you get Medicare due to a disability, you can join a Medicare drug plan during the 7-month period that begins 3 months before your 25th month of getting disability, includes your 25th month of getting disability, and ends 3 months afer your 25th month of getting disability. If you join during 1 of the 3 months before your 25th month of disability, your coverage will begin the frst day of the 25th month of disability. If you join during your 25th month of getting disability or 1 of the 3 months afer your 25th month of getting disability, your coverage will begin the frst day of the month afer you ask to join a plan. Your coverage begins January 1 the following year, as long as the plan gets your request during Open Enrollment. Your coverage will begin the frst day of the month afer you qualify for Extra Help and ask to join a plan. Note: In certain limited circumstances, you may be able to join, drop, or switch to another Medicare drug plan at other times. For example, you may be able to switch at other times if: You permanently move out of your drug plan’s service area. If you currently have Medicare drug coverage, you may want to review your coverage each fall. If you’re happy with your coverage, cost, and customer service, and your Medicare drug plan is still ofered in your area, you don’t have to do anything to continue your coverage for another year. However, if you decide another plan will better meet your needs, you can switch to a diferent plan. You don’t need to tell your current drug plan you’re leaving or send them anything because joining a diferent Medicare drug plan, at the times listed on the previous page, disenrolls you from your current drug plan. Your new Medicare drug plan should send you a letter telling you when your coverage with your new plan begins. You may be able to enroll on the plan’s website, or by mailing or faxing a completed enrollment form to the plan. To join a Medicare drug plan, you’ll need to give your Medicare number and the date your Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) coverage started, which you’ll fnd on your Medicare card. Te late enrollment penalty is an amount that’s added to your Part D Words in premium if, at any time afer your Part D Initial Enrollment Period is red are over, there’s a period of 63 or more days in a row when you don’t have defned Part D or other creditable prescription drug coverage. Currently, the late enrollment penalty is calculated by multiplying the 1% penalty rate times the “national base benefciary premium” ($35. Te “national base benefciary premium” may go up each year, so the penalty amount may also go up each year. In addition to your premium each month, you may have to pay this penalty for as long as you have a Medicare drug plan. Martinez is currently eligible for Medicare, and her Initial Enrollment Period ended on May 31, 2014. She didn’t join by May 31, 2014, and instead joined during the Open Enrollment Period that ended December 7, 2016. Martinez was without creditable prescription drug coverage from June 2014–December 2016, her penalty in 2017 was 31% (1% for each of the 31 months) of $35. Martinez’s monthly late enrollment penalty for 2017 When you join a Medicare drug plan, the plan will tell you if you owe a penalty and what your premium will be. It may send you this information in a letter, or let you know in a newsletter or other piece of mail. Keep this information, because you may need it if you join a Medicare drug plan later. When you join a Medicare drug plan, the plan may send you a letter asking if you have creditable prescription drug coverage if the plan believes you went 63 or more days in a row without other creditable prescription drug coverage. If you don’t tell your plan about your creditable prescription drug coverage, you may have to pay the late enrollment penalty. Is my prescription drug coverage through the Marketplace considered creditable health insurance? When you join a Medicare Prescription Drug Plan that works with Original Medicare, the plan will mail you a separate card to use when you fll your prescriptions. Within 2 weeks afer your plan gets your completed application, you’ll get a letter letting you know it got your information. If you need to go to the pharmacy before your membership card arrives, you can use any of these as proof of membership: Te acknowledgement, confrmation, or welcome letter you got from the plan An enrollment confrmation number you got from the plan, and the plan name and phone number A temporary card you may be able to print from MyMedicare. If you qualify for Extra Help, see page 43 for more information about what you can use as proof of Extra Help. If you don’t have any of the items on the previous page, and your pharmacist can’t get your drug plan information any other way, you may have to pay out-of-pocket for the entire cost of your drugs. Save the receipts and contact your plan if you do pay for your drugs out-of-pocket—you may be able to get back some of the cost or have the amount credited toward your out-of-pocket costs.