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Acute
Mountain Sickness & Periodic Breathing
Acute
Mountain Sickness & Period Breathing The 125 mg dose twice a day may be less than enough for larger patients and a third dose can be taken mid-day or during the night if headache or other symptoms appear. Taking it for three to four days may be a sufficient. It also is very effective for periodic breathing. It can be restarted any time if symptoms recur. It is a category C drug and not recommended in pregnancy or breast feeding due to lack of safety studies.
Recent literature suggests that it is safer to use acetazolamide in patients
with a known allergy to sulfa antibiotics than once thought. This
article concluded that a persons predisposition to allergic reactions,
rather than cross-reactivity with sulfonamide-based drugs was the most
important issue. Dexamethasone (Decadron®) is a potent steroid that can be used for AMS. The dose is 4 mg every six hours. It is usually used to treat AMS symptoms or the more serious conditions of high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). It can be used to prevent AMS symptoms when acetazolamide (Diamox®) is not tolerated. Short term use is considered safe, but this medicine can cause significant blood sugar elevation in diabetics. Ondansetron (Zofran®) though not a new drug, has recently been promoted in the field of AMS. It does not prevent AMS like acetazolamide, but is particularly useful for treating the nausea and vomiting that may accompany AMS. This drug is well tolerated and avoids the drowsiness and extra-pyramidal (neurologic) side effects that may occur with other anti-emetics (anti-nausea drugs).
Malaria-Emergency Self Treatment
The following medications are no longer recommended by the CDC for emergency self treatment of malaria:
On April 8, 2009, the U.S. Food and Drug Administration
approved Coartem tablets (artemether and lumefantrine) for the treatment of
acute, uncomplicated malaria infections in adults and children weighing at
least five kilograms (approximately 11 pounds). Coartem is expected to be
available within 4-6 weeks from the approval date.
A number of counterfeit versions of this drug
have been reported in
Africa & Asia. On June 21, 2007, the Food and Drug Administration (FDA)
approved investigational new drug (IND) protocol # 76,725, entitled
Intravenous Artesunate for Treatment of Severe Malaria in the United States.
This IND makes a new class of antimalarial medication-artemisinins-available
in the United States for the first time.
Malaria-Prevention (Prophylaxis) Malarone® is available in many countries, and is the combination of drug atovaquone/proquanil. The adult dose is 250 mg. Brand named Malanil® in South Africa and Promal® in Austria. However, do not count on it being available in some developing countries. Take one tab daily starting the day before entering a malarious area and continue daily until seven days after leaving that area. It is tolerated well and highly effective. Rarely, patients will experience mouth sores or diarrhea, both of which resolve when medication is stopped. It is very useful on short trips with short exposures to malaria. It is expensive to use on extended trips. Malarone® is pregnancy Category C. The safety of atovaquone and proguanil hydrochloride when administered concurrently (as Malarone®) for use in human pregnancy has not been established and the potential risk is unknown. Animal studies have not shown evidence of teratogenicity of the combination. This drug can cause those on coumadin to experience higher Pro-Times or INR levels. It should not be used in patients with kidney failure. Adult tablets are not scored. Pediatric Tablets, containing 62.5 mg atovaquone and 25 mg proguanil which is 1/4 the strength of the adult tablet. Pediatric dosages are weight based so that a child is given one, two or three pediatric tablets as one dose daily. Children over 40 kg. (88 lbs.) may take one adult dose daily. Tablets may be crushed and taken with food. Chloroquine 500 mg (300 mg base) is brand named Aralen® in the US. There are many brand names world wide. Take one tab weekly starting one to two weeks before entering a malarious area and weekly while there. Experts recommend that people over 75 kg (165 lbs) take one 500 mg tab every 5-6 days rather than weekly. Continue it for four weeks after leaving that area. It is not recommended in people with seizure disorders (epilepsy) or psoriasis. It should not be used with other similarly derived drugs like amodiaquine, mefloquine, primaquine, quinidine, quinine, and tafenoquine. It has been used widely since the 1940's and generally well tolerated. There is a very low rate of side effects (1-5%) including abdominal pain, anxiety, depression, headache, muscle cramps, itching, rash, sleep disturbance, tingling, tiredness, visual difficulties or vivid dreams. It is only suitable for limited parts of the world due to highly resistant malarial organisms. Low to moderately expensive. It can be used in children of all ages with or without proguanil and is dosed by weight. It is safe in all three trimesters of pregnancy. Doxycycline 100 mg usually sold as a generic. Take one capsule daily starting the day before entering a malarious area and daily for 30 days after leaving that area. It is usually tolerated well and is highly effective. It can cause severe "heart burn" if capsule sticks in the esophagus. Upset stomach, indigestion, easily sun burning and vaginal yeast infections may occur. If using doxycycline when traveling, women should carry an OTC anti-yeast cream, such as Gyne-Lotrimin 3® or it's generic clotrimazole. An oral anti-yeast medication, such as fluconazole requires a prescription but could be used instead for self treatment. Like most antibiotics, doxycycline may reduce the effectiveness of BCP's. It is the least expensive of antimalarials. Do not use doxycycline in children under the age of eight years, in pregnancy or breast feeding. It is recommended to wait one week after doxycycline use before becoming pregnant. However, unplanned pregnancy while on preventative doses of mefloquine (Larium®) or doxycycline is not considered to be an indication for termination of pregnancy. Lariam® is available in most countries, the generic name is mefloquine. The usual adult dose is 250 mg. It is brand named Mefliam® in South Africa, Mequin® in Thailand and Mephaquin® in many other countries. Take one tab weekly starting two weeks before entering a malarious area, continue weekly while there and for four weeks after leaving that area. It is highly effective. Stomach upset, ingestion, difficulty sleeping and vivid dreams may occur. More rarely agitation, anxiety, confusion or hallucinations may occur, in which case, the drug must be stopped immediately and a substitute antimalarial drug used. Lariam® should not be used in patients with with active depression, a recent history of depression, generalized anxiety disorder, psychosis, schizophrenia or other major psychiatric disorders, or with a history of convulsions. The benefits of Lariam® therapy should be weighed against the possibility of adverse cardiac effects in elderly patients, especially those with heart block. Moderately expensive. Lariam may be used in infants weighting 5 kg (11 lbs) or more. The pediatric dose is approximately 5 mg/kg body weight once weekly decreasing in proportion to body weight for children weighing 45 kg or less. Children weighing over 45 kg (100 lbs.) take the adult dosage once per week. Lariam® may be taken from the 4th month of pregnancy on, though not generally not recommended during pregnancy. It is recommended to wait three months after Lariam use before becoming pregnant. However, unplanned pregnancy while on malaria preventative doses of Larium® or doxycycline is not considered to be an indication for termination of pregnancy. Primaquine 15 mg base is usually sold as a generic but brand named Primakinder® in Brazil and Primacin® in Australia. Take two tabs daily for persons over 60 kg and one tab daily for persons weighting less than 60 kg starting the day before entering a malarious area. Continue daily for two to seven days after leaving that area. Your physician should check your blood for G-6-PD (glucose-6-phosphate dehydrogenase) deficiency before starting this drug. Do not use in pregnancy, G-6-PD deficiency, rheumatoid arthritis, lupus erythematosus, quinacrine (Atabrine®) therapy or in pregnancy. This antimalarial was widely used during the Korean War but was supplanted by chloroquine soon after as the major drug for preventing malaria. It is now making a come back because of its usefulness in short or long term exposure to malaria and effectiveness in areas of chloroquine resistance. It is well tolerated. Upset stomach or gastrointestinal symptoms occasionally occur, in which case it should be taken with food. Moderately expensive. Primaquine has the advantage of preventing late onset disease from Plasmodium vivax and Plasmodium oval malaria. At this time, it is not commonly prescribed in the USA for prophylaxis (prevention), but is recommended so in Canada. Canadian recommendations for the prevention and treatment of malaria among international travelers. CCDR2004;30S1:1-62. Fatal malaria has occurred in persons who have switched prophylactic (preventative) antimalarials in favor of less effective drugs. Antimalarials sold in other parts of the world may have less than the desired effectiveness or safety and are not recommended by the CDC. Examples of antimalarials to avoid include:
No antimalarial drug is 100% effective. Unexplained fever or flu like symptoms anytime within a year of being in a malarious area should be evaluated for malaria.
Travelers'
Diarrhea Xifaxan® is the brand name of rifaximin. It is taken as 200 mg three times a day for three days at the onset of symptoms. Well tolerated and highly effective against E. coli which is the most common cause of travelers diarrhea. Some travel clinics prescribe a 200 mg tab twice a day as a preventative for TD on short trips. It many not be effective in cases of bloody diarrhea. Zithromax® is the brand name of azithromycin. Most often prescribed as a Z-PAK® containing six 250 mg tabs or a TRI-PAK® containing three 500 mg tabs. Take 500 mg daily for three days at onset of symptoms. It may cause nausea and cramps, in which case taking 250 mg twice a day (or breaking the 500 mg tab in half) will be equally effective. This drug is thought to be highly effective world wide and is the preferred drug for travel in Thailand and India due to resistance to ciprofloxacin. Some experts consider it to be the antibiotic of choice for traveler's diarrhea in children. Imodium A-D® is the brand name of Loperamide. It is sometimes added to the above regimens as 2 mg or 4 mg four times a day. This has been shown to be more effective than ciprofloxacin alone. Do not use loperamide for extended periods of time or if there is bloody diarrhea, increasing abdominal pain or increasing abdominal distention.
Vivotif®
Typhoid Vaccine-oral capsules
Adapted from "Travel &
Routine Immunizations" by Shoreland, Pgs 206-210, 18th ed, Published 2009.
Motion
Sickness Dimenhydrinate 50 mg is sold as a generic or the brand name Dramamine® over the counter. Take one every four hours as needed. Very sedating. Diphenhydramine 50 mg sold as a generic or the brand name Benadryl® over the counter. It is usually sold as an antihistamine for allergies but can be used for motion sickness if needed. Take one every four hours. Very sedating. The above drugs for motion sickness are all antihistamines and very helpful in combating motion sickness. As a rule, they are sedating so caution should be used operating vehicles. They are more effective when taken an hour before you need them.Scopace® is one brand name of oral scopolamine hydrobromide. It is sold as 0.4 mg tablets by prescription. The typical dose is 1-2 tablets taken an hour before travel. For prompt absorption and action, the dose should be taken on an empty stomach. Each dose comforts for up to 8 hours.Transderm scopolamine patch is brand named Transderm Scop® and sold by prescription. Apply one patch 8 hours before needed. Do not touch eyes after placing patch as this medication can temporarily dilate pupils. Wash hands after application. One patch is good for 72 hours. Do not cut patch in half.The above two scopolamine drugs are usually tolerated well, but can have side effects like any drug. Persons with severe motion sickness often find these very helpful.Since drowsiness, disorientation, and confusion may occur with the use of scopolamine, patients are warned of the possibility and cautioned against engaging in activities that require mental alertness, such as driving a motor vehicle or operating dangerous machinery. Scopolamine is contraindicated in the presence of narrow-angle glaucoma, prostatic hypertrophy, and pyloric obstruction. It should not be administered to patients with impaired renal or hepatic function or to those who have an idiosyncrasy to anticholinergic drugs.
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