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var title_f0_58_928="Black esophagus Endosc";

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" &copy;2013 UpToDate",
" <sup>",
" &reg;",
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" Acute esophageal necrosis",
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" </div>",
" <div class=\"lgnd\">",
" Black discloration of the distal esophagus is visible on this endoscopic image
of a patient with acute esophageal necrosis.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Courtesy of Daniel Gelrud, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_58_928=[""].join("\n");
var outline_f0_58_928=null;
var title_f0_58_929="Accessory AV pathways I";
var content_f0_58_929=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" <sup>",
" &reg;",
" </sup>",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=CARD
%2F73740&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=0\" onclick=\"\">",
" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=CARD
%2F73740&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=0\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 470px\">",
" <div class=\"ttl\">",
" AV conduction with a concealed accessory pathway",
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" </div>",
" <div class=\"lgnd\">",
" Schematic representation of atrioventricular conduction. The normal pacemaker
is in the sinoatrial (SA) node at the junction of the superior vena cava and the
right atrium. The SA node activates the right and left atria (shown in green). In
the absence of an accessory pathway (AP) or, as in this case, if the AP is
concealed, ventricular activation results from the impulse traversing the AV node,
the specialized infranodal conducting system (His bundle and bundle and fascicular
branches, shown in red), thereby activating the ventricular myocardium (shown in
yellow). The ECG shows a normal PR interval and a narrow QRS complex. The inset on
the right shows the timing of SA node (SAN), right (RA) and left atrial (LA), His
bundle (H), and the beginning of normal ventricular activation (V",
" <sub>",
" N",
" </sub>",
" ). All of ventricular activation (shown in yellow) is due to normal AV nodal
and infranodal conduction.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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" <div class=\"graphic\">",
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" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" <p>",
" &nbsp;",
" </p>",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_58_930=[""].join("\n");
var outline_f0_58_930=null;
var title_f0_58_931="High blood pressure treatment in children";
var content_f0_58_931=[" <h1 id=\"patTopicTitle\">",
" Patient information: High blood pressure treatment in children (Beyond the
Basics)",
" </h1>",
" <div id=\"patTopicContributors\">",
" <div class=\"rcTop\">",
" <div>",
" </div>",
" </div>",
" <div class=\"rcContent\">",
" <table>",
" <tr>",
" <td>",
" <a class=\"contributor contributor_credentials patTopicContributorsType\"
href=\"UTD.htm?0/58/931/contributors\">",
" Author",
" </a>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/58/931/contributors\" id=\"au6305\">",
" Tej K Mattoo, MD, DCH, FRCP",
" </a>",
" </td>",
" <td>",
" <a class=\"contributor contributor_credentials patTopicContributorsType\"
href=\"UTD.htm?0/58/931/contributors\">",
" Section Editors",
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" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/58/931/contributors\" id=\"se5276\">",
" Patrick Niaudet, MD",
" </a>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/58/931/contributors\" id=\"se5611\">",
" David R Fulton, MD",
" </a>",
" </td>",
" <td>",
" <a class=\"contributor contributor_credentials patTopicContributorsType\"
href=\"UTD.htm?0/58/931/contributors\">",
" Deputy Editor",
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" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/58/931/contributors\" id=\"de7255\">",
" Melanie S Kim, MD",
" </a>",
" </td>",
" </tr>",
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" </div>",
" </div>",
" </div>",
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" <div id=\"topicText\">",
" <p class=\"headingAnchor\" id=\"H1\">",
" <span class=\"h1\">",
" HIGH BLOOD PRESSURE OVERVIEW",
" </span>",
" </p>",
" <p>",
" This topic discusses the treatment options for children and adolescents with
high blood pressure. The causes and diagnosis of high blood pressure (hypertension)
in children are discussed separately. (See",
" <a class=\"medical medical_patient\" href=\"UTD.htm?37/28/38337?
source=see_link\">",
" \"Patient information: High blood pressure in children (Beyond the
Basics)\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H2\">",
" <span class=\"h1\">",
" WHY TREAT HYPERTENSION?",
" </span>",
" </p>",
" <p>",
" There are several important reasons to treat high blood pressure in
children:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" To",
" <span class=\"nowrap\">",
" prevent/treat",
" </span>",
" complications of hypertension in childhood, such as seizures or heart
failure.",
" </li>",
" <li>",
" Hypertension that begins in childhood and adolescence may persist into
adulthood. Adult hypertension is a major risk factor contributing to early heart
attack or stroke.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H3\">",
" <span class=\"h1\">",
" HYPERTENSION TREATMNET",
" </span>",
" </p>",
" <p>",
" The first step in the treatment of hypertension is to treat any underlying
cause for hypertension.",
" </p>",
" <p>",
" If treating the underlying cause does not adequately reduce blood pressure,
or if there is no known underlying cause, treatments to reduce the blood pressure
are recommended.",
" </p>",
" <p>",
" Treatment may include lifestyle changes (diet changes, regular exercise, and
if appropriate, weight loss)",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" medications.",
" </p>",
" <p class=\"headingAnchor\" id=\"H4\">",
" <span class=\"h1\">",
" LIFESTYLE CHANGES",
" </span>",
" </p>",
" <p>",
" Lifestyle changes are recommended for children with hypertension (defined as
blood pressure &gt;95",
" <sup>",
" th",
" </sup>",
" percentile) or prehypertension (defined as blood pressure &gt;90",
" <sup>",
" th",
" </sup>",
" to the 95",
" <sup>",
" th",
" </sup>",
" percentile",
" <strong>",
" or",
" </strong>",
" if blood pressure exceeds",
" <span class=\"nowrap\">",
" 120/80",
" </span>",
" mmHg).",
" </p>",
" <p>",
" Lifestyle changes include:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Weight loss for obesity-related hypertension",
" </li>",
" <li>",
" Regular exercise",
" </li>",
" <li>",
" Dietary changes, including reducing salt intake and avoiding alcohol",
" </li>",
" <li>",
" Although cigarette smoke does not directly affect blood pressure, exposure
to exposure to cigarette smoke (including second hand exposure) is a risk factor
for cardiovascular disease and should be avoided",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor2\" id=\"H5\">",
" <span class=\"h2\">",
" Weight loss",
" </span>",
" &nbsp;&mdash;&nbsp;A child is said to be obese or overweight based upon the
body mass index, which can be calculated here for boys (",
" <a class=\"calc calc_patient\" href=\"UTD.htm?42/49/43796?
source=see_link\">",
" calculator 1",
" </a>",
" ) and here for girls (",
" <a class=\"calc calc_patient\" href=\"UTD.htm?12/19/12596?
source=see_link\">",
" calculator 2",
" </a>",
" ).",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Children who are between the 85",
" <sup>",
" th",
" </sup>",
" and 95",
" <sup>",
" th",
" </sup>",
" percentile are said to be overweight while children who are above the 95",
" <sup>",
" th",
" </sup>",
" percentile are said to be obese.",
" </li>",
" <li>",
" In children who are obese or overweight, losing weight can help to lower
blood pressure. In some cases, the child will be referred to a nutritionist, who
can work with the child and parents to formulate a healthy eating plan.",
" </li>",
" </ul>",
" </p>",
" <p>",
" Weight loss is most effective at reducing the blood pressure when it is
combined with exercise.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H6\">",
" <span class=\"h2\">",
" Exercise",
" </span>",
" &nbsp;&mdash;&nbsp;Regular exercise can help to lower blood pressure in
children and adolescents. Although exercise recommendations for an individual child
may vary, general recommendations include the following:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Twenty to thirty minutes of aerobic exercise per day most days of the week.
Aerobic exercise includes walking, swimming, and biking, but not weight lifting or
strength training.",
" </li>",
" <li>",
" Sedentary activities (watching television",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" playing video and computer games) should be limited to less than two hours
per day.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor2\" id=\"H7\">",
" <span class=\"h3\">",
" Participation in sports",
" </span>",
" &nbsp;&mdash;&nbsp;Children who have controlled high blood pressure are
generally allowed to participate in competitive sports. Children and adolescents
with high blood pressure are advised to avoid weight lifting until the blood
pressure is better controlled.",
" </p>",
" <p>",
" Exceptions to these recommendations include children with uncontrolled stage
2 hypertension, who are generally advised to avoid competitive sports.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H8\">",
" <span class=\"h2\">",
" Diet",
" </span>",
" &nbsp;&mdash;&nbsp;Reducing salt intake and eating more fresh fruits and
vegetables and low-fat dairy products can help to reduce blood pressure in children
and adolescents with hypertension. When possible, the entire family should make
these changes to encourage the child to develop healthy eating habits.",
" </p>",
" <p>",
" To reduce salt intake, some experts recommend using a no-salt added diet and
avoiding or eating fewer foods with a high salt content. A full discussion of a low
salt diet is available separately. (See",
" <a class=\"medical medical_patient\" href=\"UTD.htm?38/61/39890?
source=see_link\">",
" \"Patient information: Low sodium diet (Beyond the Basics)\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor2\" id=\"H9\">",
" <span class=\"h2\">",
" Smoking and alcohol",
" </span>",
" &nbsp;&mdash;&nbsp;Children and adolescents who have hypertension should not
smoke because it significantly increases their risk of heart disease and lung
cancer. Family members of a child with hypertension are encouraged to quit smoking
as well because exposure to second-hand smoke also increases the child's risk of
developing heart disease. (See",
" <a class=\"medical medical_patient\" href=\"UTD.htm?19/13/19670?
source=see_link\">",
" \"Patient information: Quitting smoking (Beyond the Basics)\"",
" </a>",
" .)",
" </p>",
" <p>",
" Multiple studies in adults have shown that drinking more than two alcoholic
beverages per day significantly increases the risk of developing hypertension.
Although studies in children are not available, children and adolescents should
avoid alcohol for many other health and safety reasons.",
" </p>",
" <p class=\"headingAnchor\" id=\"H10\">",
" <span class=\"h1\">",
" MEDICATIONS",
" </span>",
" </p>",
" <p>",
" In children and adolescents, one or more medications may be recommended to
reduce high blood pressure in the following circumstances:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Hypertension associated with symptoms that are related to elevated blood
pressure, such as headaches or seizures",
" </li>",
" <li>",
" Stage 2 hypertension, defined as blood pressure levels that are 5 mmHg
greater than the 99",
" <sup>",
" th",
" </sup>",
" percentile.",
" </li>",
" <li>",
" Stage 1 hypertension that persists after four to six months of
nonpharmacologic therapy.",
" </li>",
" <li>",
" There are physical signs of hypertension, such as a thickened wall of the
left ventricular chamber of the heart.",
" </li>",
" <li>",
" Stage 1 hypertension in patients with diabetes mellitus or other conditions
that increase the risk of heart disease or stroke, such as high cholesterol or
lipids, obesity or chronic kidney disease.",
" </li>",
" <li>",
" Prehypertension with more than one risk factor for heart disease (obesity,
abnormal cholesterol or lipid levels, diabetes, or chronic kidney disease).",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor2\" id=\"H11\">",
" <span class=\"h2\">",
" Classes of antihypertensive medications",
" </span>",
" &nbsp;&mdash;&nbsp;There are several classes of antihypertensive
medications",
" <strong>",
" </strong>",
" commonly used to treat children. These include thiazide diuretics,
angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers
(ARBs), calcium channel blockers, and beta blockers.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H12\">",
" <span class=\"h3\">",
" Thiazide diuretics",
" </span>",
" &nbsp;&mdash;&nbsp;It is thought that diuretics lower blood pressure
primarily by causing the kidneys to excrete more water and sodium, which reduces
fluid volume throughout the body. Thiazide diuretics are safe and effective, and
are most effective when used in combination with a low salt diet. (See",
" <a class=\"local\" href=\"#H8\">",
" 'Diet'",
" </a>",
" above.)",
" </p>",
" <p>",
" The most commonly used thiazide diuretics in children are hydrochlorothiazide
(HCTZ) and chlorothiazide. These medications are usually taken by mouth once or
twice per day. Side effects are uncommon with low doses of thiazide diuretics.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H13\">",
" <span class=\"h3\">",
" ACE inhibitors/ARBs",
" </span>",
" &nbsp;&mdash;&nbsp;ACE inhibitors block production of the hormone angiotensin
II, a compound in the blood that causes narrowing of blood vessels and increases
blood pressure. By reducing production of angiotensin II, ACE inhibitors cause
dilation (widening of the blood vessels), which lowers blood pressure. The most
common side effect of ACE inhibitors is a dry cough.",
" </p>",
" <p>",
" ARBs block the effects of angiotensin II on cells in the heart and blood
vessels. Similar to ACE inhibitors, ARBs dilate blood vessels and lower blood
pressure. Some people who take ARBs experience dizziness, drowsiness, headache,
nausea, dry mouth, abdominal pain, or other side effects.",
" </p>",
" <p>",
" The most commonly used ACE inhibitors in children include enalapril and
lisinopril. Losartan is an ARB that is approved for children. These drugs are not
recommended for sexually active girls due to the potential risk of harm to the
fetus if the girl became pregnant.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H14\">",
" <span class=\"h3\">",
" Beta blockers",
" </span>",
" &nbsp;&mdash;&nbsp;Beta blockers reduce some of the effects of the
sympathetic nervous system, such as increases in the heart rate and blood pressure.
Beta blockers lower blood pressure in part by decreasing the rate and force with
which the heart pumps blood. Commonly used beta blockers include metoprolol,
atenolol, and bisoprolol.",
" </p>",
" <p>",
" Side effects of beta blockers can include fatigue, dizziness, insomnia, a
decreased ability to exercise, a slow heart rate, rash, and cold hands or feet due
to reduced blood flow to the limbs. Beta blockers should not be used in children
with asthma or heart block.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H15\">",
" <span class=\"h3\">",
" Calcium channel blockers",
" </span>",
" &nbsp;&mdash;&nbsp;Muscle cells require calcium to contract. Calcium channel
blockers drugs reduce the amount of calcium that enters the smooth muscle in blood
vessel walls and heart muscle. Thus, by inhibiting the flow of calcium across
muscle cell membranes, calcium channel blockers cause muscle cells to relax and
blood vessels to dilate, reducing blood pressure.",
" </p>",
" <p>",
" Side effects of calcium channel blockers can include headache, dizziness,
flushing, nausea, overgrowth of the gum tissue (gingival hyperplasia), or swelling
of the lower legs or feet.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H16\">",
" <span class=\"h2\">",
" How long are medications needed?",
" </span>",
" &nbsp;&mdash;&nbsp;It is difficult to know how long a child will require
antihypertensive medication(s). The length of treatment depends upon the type of
hypertension (essential versus secondary), the success of nonpharmacologic
treatments, and the ability to reverse any underlying medical problems.",
" </p>",
" <p class=\"headingAnchor\" id=\"H17\">",
" <span class=\"h1\">",
" BLOOD PRESSURE MONITORING AND GOALS",
" </span>",
" </p>",
" <p>",
" Children and adolescents with prehypertension who are treated with
nonpharmacologic therapies usually have their blood pressure monitored every four
to six months. Those with hypertension are generally monitored more often depending
upon the severity of their hypertension.",
" </p>",
" <p>",
" The goal blood pressure for most children with hypertension is less than the
95",
" <sup>",
" th",
" </sup>",
" percentile. If the child is obese or has high cholesterol, diabetes, or has
organ damage related to hypertension, the blood pressure goal is less than the 90",
" <sup>",
" th",
" </sup>",
" percentile. Blood pressure percentiles can be calculated here for boys (",
" <a class=\"calc calc_professional\" href=\"UTD.htm?9/15/9463?
source=see_link\">",
" calculator 3",
" </a>",
" ) and here for girls (",
" <a class=\"calc calc_professional\" href=\"UTD.htm?9/33/9751?
source=see_link\">",
" calculator 4",
" </a>",
" ).",
" </p>",
" <p class=\"headingAnchor\" id=\"H18\">",
" <span class=\"h1\">",
" WHERE TO GET MORE INFORMATION",
" </span>",
" </p>",
" <p>",
" Your child's healthcare provider is the best source of information for
questions and concerns related to your child's medical problem.",
" </p>",
" <p>",
" This article will be updated as needed on our web site (",
" <a class=\"external\" href=\"file://www.uptodate.com/patients\">",
" www.uptodate.com/patients",
" </a>",
" ). Related topics for patients, as well as selected articles written for
healthcare professionals, are also available. Some of the most relevant are listed
below.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H194141464\">",
" <span class=\"h2\">",
" Patient level information",
" </span>",
" &nbsp;&mdash;&nbsp;UpToDate offers two types of patient education
materials.",
" </p>",
" <p class=\"headingAnchor2\" id=\"H194141479\">",
" <span class=\"h3\">",
" The Basics",
" </span>",
" &nbsp;&mdash;&nbsp;The Basics patient education pieces answer the four or
five key questions a patient might have about a given condition. These articles are
best for patients who want a general overview and who prefer short, easy-to-read
materials.",
" </p>",
" <p>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?29/37/30290?
source=see_link\">",
" Patient information: High blood pressure in children (The Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?33/58/34722?
source=see_link\">",
" Patient information: High blood pressure in adults (The Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?39/56/40835?
source=see_link\">",
" Patient information: Controlling your blood pressure through lifestyle (The
Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?36/31/37363?
source=see_link\">",
" Patient information: Glomerular disease (The Basics)",
" </a>",
" </p>",
" <p class=\"headingAnchor2\" id=\"H194141471\">",
" <span class=\"h3\">",
" Beyond the Basics",
" </span>",
" &nbsp;&mdash;&nbsp;Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are best for patients who
want in-depth information and are comfortable with some medical jargon.",
" </p>",
" <p>",
" <a class=\"medical medical_patient\" href=\"UTD.htm?37/28/38337?
source=see_link\">",
" Patient information: High blood pressure in children (Beyond the Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_patient\" href=\"UTD.htm?38/61/39890?
source=see_link\">",
" Patient information: Low sodium diet (Beyond the Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_patient\" href=\"UTD.htm?19/13/19670?
source=see_link\">",
" Patient information: Quitting smoking (Beyond the Basics)",
" </a>",
" <br/>",
" </p>",
" <p class=\"headingAnchor2\" id=\"H194141504\">",
" <span class=\"h2\">",
" Professional level information",
" </span>",
" &nbsp;&mdash;&nbsp;Professional level articles are designed to keep doctors
and other health professionals up-to-date on the latest medical findings. These
articles are thorough, long, and complex, and they contain multiple references to
the research on which they are based. Professional level articles are best for
people who are comfortable with a lot of medical terminology and who want to read
the same materials their doctors are reading.",
" </p>",
" <p>",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/21/25943?
source=see_link\">",
" Ambulatory blood pressure monitoring in children",
" </a>",
" <br/>",
" <a class=\"medical medical_review\" href=\"UTD.htm?16/45/17113?
source=see_link\">",
" Definition and diagnosis of hypertension in children and adolescents",
" </a>",
" <br/>",
" <a class=\"medical medical_review\" href=\"UTD.htm?41/7/42105?
source=see_link\">",
" Epidemiology, risk factors, and etiology of hypertension in children and
adolescents",
" </a>",
" <br/>",
" <a class=\"medical medical_review\" href=\"UTD.htm?2/42/2729?
source=see_link\">",
" Evaluation of hypertension in children and adolescents",
" </a>",
" <br/>",
" <a class=\"medical medical_review\" href=\"UTD.htm?26/62/27626?
source=see_link\">",
" Treatment of hypertension in children and adolescents",
" </a>",
" <br/>",
" <br/>",
" The following organizations also provide reliable health information.",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" National Library of Medicine",
" </li>",
" </ul>",
" </p>",
" <p>",
" &nbsp; &nbsp; &nbsp;(",
" <a class=\"external\"
href=\"file://www.nlm.nih.gov/medlineplus/healthtopics.html\">",
" www.nlm.nih.gov/medlineplus/healthtopics.html",
" </a>",
" )",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" The Nemours Foundation",
" </li>",
" </ul>",
" </p>",
" <p>",
" &nbsp; &nbsp; &nbsp;(",
" <a class=\"external\"
href=\"file://kidshealth.org/parent/medical/heart/hypertension.html\">",
" file://kidshealth.org/parent/medical/heart/hypertension.html",
" </a>",
" )",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" The National Kidney Foundation",
" </li>",
" </ul>",
" </p>",
" <p>",
" &nbsp; &nbsp; &nbsp;(",
" <a class=\"external\" href=\"file://www.kidney.org/atoz/atozItem.cfm?
id=164\">",
" www.kidney.org/atoz/atozItem.cfm?id=164",
" </a>",
" )",
" </p>",
" <p>",
" [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/931/abstract/1-5\">",
" 1-5",
" </a>",
" ]",
" </p>",
" </div>",
" </div>",
" <div id=\"literatureReviewDate\">",
" <span class=\"emphasis\">",
" Literature review current through:",
" </span>",
" Oct 2013.",
" <span class=\"pipeSpace\">",
" |",
" </span>",
" <span class=\"emphasis\">",
" This topic last updated:",
" </span>",
" Jun 28, 2012.",
" </div>",
" <div class=\"patTopicTool\" id=\"patTopicToolBottom\">",
" <a class=\"toolbutton findicon findInPageLink\" href=\"#\" title=\"Find in
Topic\">",
" Find",
" </a>",
" <a class=\"toolbutton printicon\" href=\"UTD.htm?0/58/931?view=print\"
title=\"Print This Topic\">",
" Print",
" </a>",
" </div>",
" <div id=\"disclaimer\">",
" The content on the UpToDate website is not intended nor recommended as a
substitute",
"for medical advice, diagnosis, or treatment. Always seek the advice of your own
physician or",
"other qualified health care professional regarding any medical questions or
conditions. The",
"use of this website is governed by the",
" <a href=\"/home/terms-use\" target=\"_blank\">",
" UpToDate Terms of Use",
" </a>",
" &copy;2013 UpToDate, Inc.",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <div id=\"patTopicRefHeader\">",
" <div id=\"patTopicRefHeaderHeader\">",
" References",
" </div>",
" <div id=\"patTopicRefHeaderTop\">",
" <a href=\"#top\">",
" <img alt=\"\" src=\"./../images/top_arrow.myextg\">",
" Top",
" </img>",
" </a>",
" </div>",
" </div>",
" <ol id=\"reference\">",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/931/abstract/1\">",
" National High Blood Pressure Education Program Working Group on High Blood
Pressure in Children and Adolescents. The fourth report on the diagnosis,
evaluation, and treatment of high blood pressure in children and adolescents.
Pediatrics 2004; 114:555.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/931/abstract/2\">",
" Williams CL, Hayman LL, Daniels SR, et al. Cardiovascular health in
childhood: A statement for health professionals from the Committee on
Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on
Cardiovascular Disease in the Young, American Heart Association. Circulation 2002;
106:143.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/931/abstract/3\">",
" McNiece KL, Poffenbarger TS, Turner JL, et al. Prevalence of hypertension
and pre-hypertension among adolescents. J Pediatr 2007; 150:640.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/931/abstract/4\">",
" Falkner B, Gidding SS, Portman R, Rosner B. Blood pressure variability and
classification of prehypertension and hypertension in adolescence. Pediatrics 2008;
122:238.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/931/abstract/5\">",
" Lande MB, Flynn JT. Treatment of hypertension in children and adolescents.
Pediatr Nephrol 2009; 24:1939.",
" </a>",
" </li>",
" </ol>",
" </div>",
" </div>",
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" <p>",
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" <ul>",
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" <a href=\"#H1\">",
" HIGH BLOOD PRESSURE OVERVIEW",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#H2\">",
" WHY TREAT HYPERTENSION?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#H3\">",
" HYPERTENSION TREATMNET",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#H4\">",
" LIFESTYLE CHANGES",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#H10\">",
" MEDICATIONS",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#H17\">",
" BLOOD PRESSURE MONITORING AND GOALS",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#H18\">",
" WHERE TO GET MORE INFORMATION",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#references\">",
" REFERENCES",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" CALCULATORS",
" </h1>",
" <div id=\"relatedCalculators\">",
" <ul>",
" <li class=\"plainItem\">",
" <a class=\"calc calc_patient\" href=\"UTD.htm?42/49/43796?
source=related_link\" title=\"calculator 1\">",
" Calculator: Body mass index for boys (Patient information)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"calc calc_patient\" href=\"UTD.htm?12/19/12596?
source=related_link\" title=\"calculator 2\">",
" Calculator: Body mass index for girls (Patient information)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"calc calc_professional\" href=\"UTD.htm?9/15/9463?
source=related_link\" title=\"calculator 3\">",
" Calculator: Blood pressure percentiles for boys (2 to 17 years)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"calc calc_professional\" href=\"UTD.htm?9/33/9751?
source=related_link\" title=\"calculator 4\">",
" Calculator: Blood pressure percentiles for girls (2 to 17 years)",
" </a>",
" </li>",
" </ul>",
" </div>",
" </div>",
" </div>",
" </div>",
" </div>",
" </div>",
" </div>"].join("\n");
var title_f0_58_932="Porokeratosis on finger";
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" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
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" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
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" <div class=\"figure\" style=\"width: 524px\">",
" <div class=\"ttl\">",
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MkYucep5NFZ3/LSigs/9k=);\">",
" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Reproduced with permission from: www.visualdx.com. Copyright Logical Images,
Inc.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_58_932=[""].join("\n");
var outline_f0_58_932=null;
var title_f0_58_933="Dabigatran: Patient drug information";
var content_f0_58_933=[" <noscript>",
" <div id=\"javascriptDisabled\">",
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JavaScript is required in order for our site to behave correctly. Please enable
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" <img alt=\"UpToDate\" src=\"./../images/UTD2_masthead.myextg\">",
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" <!-- TC:TOPIC_PAGE -->",
" <div id=\"topicContent\">",
" <div id=\"disclaimer\">",
" The content on the UpToDate website is not intended nor recommended as a
substitute",
"for medical advice, diagnosis, or treatment. Always seek the advice of your own
physician or",
"other qualified health care professional regarding any medical questions or
conditions. The",
"use of this website is governed by the",
" <a href=\"/home/terms-use\" target=\"_blank\">",
" UpToDate Terms of Use",
" </a>",
" &copy;2013 UpToDate, Inc.",
" </div>",
" <div id=\"drugTitle\">",
" Dabigatran: Patient drug information",
" </div>",
" <div id=\"lexiTitleImg\">",
" <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
width=\"71\"/>",
" </div>",
" <div class=\"clear\">",
" </div>",
" <div id=\"drugCopy\">",
" Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
" </div>",
" <div id=\"topicText\">",
" <p>",
" (For additional information",
" <a class=\"drug drug_general\" href=\"UTD.htm?8/39/8825?source=see_link\">",
" see \"Dabigatran: Drug information\"",
" </a>",
" )",
" </p>",
" <div class=\"list ubnlist drugH1Div drugBrandNames\" id=\"F10968125\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Brand Names: U.S.",
" </span>",
" <ul>",
" <li>",
" Pradaxa&reg;",
" </li>",
" </ul>",
" </div>",
" <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F6209555\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Brand Names: Canada",
" </span>",
" <ul>",
" <li>",
" Pradaxa&reg;",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt war-os drugH1Div\" id=\"F10018849\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Warning",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2700602",
" </span>",
" </span>",
" <span class=\"content\">",
" Sometimes drugs are not safe when you take them with certain other drugs.
Taking them together can cause bad side effects. This is one of those drugs. Be
sure to talk to your doctor about all the drugs you take.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2700454",
" </span>",
" </span>",
" <span class=\"content\">",
" This drug comes with an extra patient fact sheet called a Medication Guide.
Read it with care. Read it again each time this drug is refilled.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yya-os drugH1Div\" id=\"F10018851\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What is this drug used for?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2691655",
" </span>",
" </span>",
" <span class=\"content\">",
" It is used to thin the blood so that clots will not form.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt coi-os drugH1Div\" id=\"F10018850\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What do I need to tell my doctor before I take this drug?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2701882",
" </span>",
" </span>",
" <span class=\"content\">",
" If you have an allergy to dabigatran etexilate or any other part of this
drug.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2705171",
" </span>",
" </span>",
" <span class=\"content\">",
" If you are allergic to any drugs, foods, or other substances. Tell your
doctor about the allergy and what signs you had, like rash; hives; itching;
shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or
any other signs.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2703718",
" </span>",
" </span>",
" <span class=\"content\">",
" If you have bleeding problems.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s4084842",
" </span>",
" </span>",
" <span class=\"content\">",
" If you have had a heart valve replaced.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yye-os drugH1Div\" id=\"F10018855\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What are some things I need to know or do while I take this drug?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697780",
" </span>",
" </span>",
" <span class=\"content\">",
" Wear disease medical alert ID (identification).",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2696820",
" </span>",
" </span>",
" <span class=\"content\">",
" Do not run out of this drug.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697282",
" </span>",
" </span>",
" <span class=\"content\">",
" If you have kidney disease, talk with your doctor.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697346",
" </span>",
" </span>",
" <span class=\"content\">",
" If you have ulcer disease, talk with your doctor.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2696717",
" </span>",
" </span>",
" <span class=\"content\">",
" Check all drugs you are taking with your doctor. This drug may not mix well
with some other drugs.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699677",
" </span>",
" </span>",
" <span class=\"content\">",
" Keep a list of all your drugs (prescription, natural products, vitamins,
OTC) with you. Give this list to your doctor.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697633",
" </span>",
" </span>",
" <span class=\"content\">",
" Tell dentists, surgeons, and other doctors that you use this drug.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s4128402",
" </span>",
" </span>",
" <span class=\"content\">",
" If you drink grapefruit juice or eat grapefruit often, talk with your
doctor.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697641",
" </span>",
" </span>",
" <span class=\"content\">",
" Tell your doctor if you are pregnant or plan on getting pregnant. You will
need to talk about the benefits and risks of using this drug while you are
pregnant.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697636",
" </span>",
" </span>",
" <span class=\"content\">",
" Tell your doctor if you are breast-feeding. You will need to talk about any
risks to your baby.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyf-os drugH1Div\" id=\"F10018856\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What are some side effects of this drug?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697891",
" </span>",
" </span>",
" <span class=\"content\">",
" Belly pain.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697879",
" </span>",
" </span>",
" <span class=\"content\">",
" Anemia.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2697901",
" </span>",
" </span>",
" <span class=\"content\">",
" Bleeding problems.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyh-os drugH1Div\" id=\"F10018858\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What are some side effects that I need to call my doctor about right away?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698721",
" </span>",
" </span>",
" <span class=\"content\">",
" If you think there has been an overdose, call 1-800-222-1222 (the American
Association of Poison Control Centers), your local poison control center
(file://www.aapcc.org), or emergency room (ER) right away.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699066",
" </span>",
" </span>",
" <span class=\"content\">",
" Signs of an allergic reaction, like rash; hives; itching; red, swollen,
blistered, or peeling skin with or without fever; wheezing; tightness in the chest
or throat; trouble breathing or talking; unusual hoarseness; or swelling of the
mouth, face, lips, tongue, or throat.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699023",
" </span>",
" </span>",
" <span class=\"content\">",
" Very bad dizziness or passing out.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698653",
" </span>",
" </span>",
" <span class=\"content\">",
" A fall or crash when you hit your head. Talk with your doctor even if you
feel fine.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699058",
" </span>",
" </span>",
" <span class=\"content\">",
" Change in thinking clearly and with logic.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699031",
" </span>",
" </span>",
" <span class=\"content\">",
" Very bad headache.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699051",
" </span>",
" </span>",
" <span class=\"content\">",
" Very bad swelling.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699105",
" </span>",
" </span>",
" <span class=\"content\">",
" Any bruising or bleeding.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698607",
" </span>",
" </span>",
" <span class=\"content\">",
" Black, tarry, or bloody stools.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698633",
" </span>",
" </span>",
" <span class=\"content\">",
" Coughing up blood.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698603",
" </span>",
" </span>",
" <span class=\"content\">",
" Any rash.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698977",
" </span>",
" </span>",
" <span class=\"content\">",
" Side effect or health problem is not better or you are feeling worse.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyc-os drugH1Div\" id=\"F10018853\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" How is this drug best taken?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
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var title_f0_58_934="Long-term complications of pelvic inflammatory disease";
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" Long-term complications of pelvic inflammatory disease",
" </div>",
" <div id=\"topicContributors\">",
" <div>",
" <a id=\"authors\">",
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" Authors",
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0/58/934/contributors\">",
" Jeffrey F Peipert, MD, PhD",
" </a>",
" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/58/934/contributors\">",
" Tessa Madden, MD, MPH",
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href=\"UTD.htm?0/58/934/contributors\">",
" Section Editor",
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" <br/>",
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0/58/934/contributors\">",
" Robert L Barbieri, MD",
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href=\"UTD.htm?0/58/934/contributors\">",
" Deputy Editor",
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0/58/934/contributors\">",
" Vanessa A Barss, MD",
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" Jul 16, 2012.",
" </div>",
" <div id=\"topicText\">",
" <p class=\"headingAnchor\" id=\"H1\">",
" <span class=\"h1\">",
" INTRODUCTION",
" </span>",
" &nbsp;&mdash;&nbsp;Pelvic inflammatory disease (PID) refers to infection of
the female upper genital tract leading to one or more of the following:
endometritis, salpingitis, oophoritis, pelvic peritonitis, and perihepatitis [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/1\">",
" 1",
" </a>",
" ]. Prompt diagnosis and treatment are important to reduce the risk of both
short- and long-term complications. However, even with timely treatment and
clinical improvement in symptoms, long-term sequelae frequently occur; this is
thought to be secondary to the scarring and adhesion formation that accompany
healing of infection-damaged tissues. These sequelae &mdash; chronic pelvic pain,
infertility, and ectopic pregnancy &mdash; account for much of the morbidity,
suffering, and cost of PID [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/2\">",
" 2",
" </a>",
" ]. One group estimated that a cohort of 100,000 females acquiring PID between
20 and 24 years of age would go on to have 18,600 cases of chronic pelvic pain;
16,800 cases of infertility; and 8550 ectopic pregnancies [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/3\">",
" 3",
" </a>",
" ].",
" </p>",
" <p>",
" Long-term complications of PID will be reviewed here; other issues related to
this disorder are discussed separately:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/45/11992?
source=see_link\">",
" \"Pathogenesis of and risk factors for pelvic inflammatory disease\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/0/1032?
source=see_link\">",
" \"Clinical features and diagnosis of pelvic inflammatory disease\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/63/35832?
source=see_link\">",
" \"Treatment of pelvic inflammatory disease\"",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H21129257\">",
" <span class=\"h1\">",
" RECURRENT PID",
" </span>",
" &nbsp;&mdash;&nbsp;Women with a history of PID are at increased risk of
recurrence. As an example, a study of primarily low income African American women
with mild-moderate PID found that 15 percent reported a recurrence within 35 months
and 21 percent reported a recurrence within 84 months. In the adjusted analysis,
adolescents were 50 percent more likely than adult women to experience a recurrence
[",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/4\">",
" 4",
" </a>",
" ]. Other populations may have lower or higher recurrence risks.",
" </p>",
" <p class=\"headingAnchor\" id=\"H3\">",
" <span class=\"h1\">",
" HYDROSALPINX",
" </span>",
" &nbsp;&mdash;&nbsp;After PID resolves, the damaged fallopian tube can become
blocked, fill with sterile fluid, and become enlarged. Damage to the fallopian tube
from previous surgery or adhesions can also result in hydrosalpinx.",
" </p>",
" <p>",
" Hydrosalpinx may be associated with pain or may be asymptomatic except for
tubal factor infertility.",
" </p>",
" <p class=\"headingAnchor\" id=\"H4\">",
" <span class=\"h1\">",
" CHRONIC PELVIC PAIN",
" </span>",
" &nbsp;&mdash;&nbsp;Chronic pelvic pain is defined as menstrual or non-
menstrual pain of at least six months' duration that occurs below the umbilicus and
is severe enough to cause functional disability. As many as one-third of women with
PID develop chronic pelvic pain [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/5,6\">",
" 5,6",
" </a>",
" ]. While the precise etiology is unknown, the pain may result from scarring
and adhesions that develop from inflammation related to the infectious process.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?40/26/41384?
source=see_link&amp;anchor=H6#H6\">",
" \"Causes of chronic pelvic pain in women\", section on 'Pelvic inflammatory
disease'",
" </a>",
" .)",
" </p>",
" <p>",
" A study of risk factors for chronic pelvic pain in women with symptoms and
signs of PID found recurrent PID was the strongest predictor for the development of
this type of pain (OR 2.84, 95% CI 1.07-7.54) [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/7\">",
" 7",
" </a>",
" ]. Other risk factors included non-black race, married status, smoking, and
poor mental health score.",
" </p>",
" <p class=\"headingAnchor\" id=\"H6\">",
" <span class=\"h1\">",
" INFERTILITY",
" </span>",
" &nbsp;&mdash;&nbsp;Both symptomatic and asymptomatic PID can cause permanent
injury to the fallopian tube, especially the endosalpinx. Changes to the fallopian
tube, including loss of ciliary action, fibrosis, and occlusion, lead to tubal
infertility [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/8\">",
" 8",
" </a>",
" ]. There may be additional mechanisms of infertility, as well.",
" </p>",
" <p>",
" Subclinical PID, defined as histologic endometritis with no symptoms of acute
PID, appears to decrease subsequent fertility, even in patients who are treated for
chlamydia, gonorrhea, and bacterial vaginosis [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/9\">",
" 9",
" </a>",
" ]. Treatment of cervicitis without endometritis does not appear to have this
effect.",
" </p>",
" <p>",
" The prevalence of infertility after acute PID depends upon multiple factors
(discussed below), but appears to be increased several-fold. This was illustrated
by a prospective cohort study of 2501 Swedish women with suspected PID who
underwent diagnostic laparoscopy and were followed for as long as 25 years [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/10\">",
" 10",
" </a>",
" ]. Among women desiring pregnancy, 16 percent of those with laparoscopically-
confirmed PID (group 1) and 2.7 percent of those with normal laparoscopic findings
(group 2) failed to conceive. Tubal factor accounted for 67.6 percent of
infertility diagnoses, but was not a cause of infertility in any woman in group
2.",
" </p>",
" <p class=\"headingAnchor\" id=\"H7\">",
" <span class=\"h2\">",
" Risk factors",
" </span>",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" <strong>",
" Chlamydial infection",
" </strong>",
" &mdash; Among the microorganisms that cause PID, Chlamydia trachomatis
appears to carry the greatest risk of infertility. Approximately one in four women
with tubal factor infertility seeking care in an infertility clinic has serum
antibodies to C. trachomatis [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/11\">",
" 11",
" </a>",
" ] and serum titers of C. trachomatis antibodies correlate inversely with
pregnancy rates [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/11,12\">",
" 11,12",
" </a>",
" ]. In one study, the pregnancy rates in women with the highest and lowest
titers were 59 and 73 percent, respectively, seven years post-infection [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/13\">",
" 13",
" </a>",
" ]. In another study, women with antibody titers to chlamydia in the highest
tertile had significantly lower pregnancy rates than women in the lowest quartile
after adjusting for confounding factors (hazard ratio 0.47, 95% CI 0.28-0.79) [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/12\">",
" 12",
" </a>",
" ].",
" <br/>",
" <br/>",
" These data suggest that infertility after PID may result, at least in part,
from the host&rsquo;s immune response to chlamydial infection. A high titer may be
associated with a greater inflammatory response.",
" </li>",
" <li>",
" <strong>",
" Delay in seeking care for PID",
" </strong>",
" &mdash; In one study, women with PID who delayed seeking treatment for three
or more days were threefold more likely to be diagnosed with infertility than women
who sought care in a timely manner [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/14\">",
" 14",
" </a>",
" ]. In women with chlamydial infection, 17.8 percent of those who delayed
seeking care had impaired fertility, whereas none of those who sought care promptly
suffered sequelae.",
" </li>",
" <li>",
" <strong>",
" Increasing number of PID episodes",
" </strong>",
" &mdash; A classic review found that pregnancy rates after one, two, or three
or more episodes of PID were 89, 77, and 46 percent, respectively [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/15\">",
" 15",
" </a>",
" ].",
" </li>",
" <li>",
" <strong>",
" Severity of infection",
" </strong>",
" &mdash; The cumulative proportions of women achieving a livebirth after
mild, moderate, and severe PID were 90, 82, and 57 percent, respectively [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/16\">",
" 16",
" </a>",
" ].",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H8\">",
" <span class=\"h1\">",
" ECTOPIC PREGNANCY",
" </span>",
" &nbsp;&mdash;&nbsp;Tubal damage caused by PID increases the risk of tubal
pregnancy, as well as infertility. The increased expression of certain proteins
involved in implantation may play a role in the pathophysiology [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/17\">",
" 17",
" </a>",
" ]. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?21/15/21752?
source=see_link\">",
" \"Incidence, risk factors, and pathology of ectopic pregnancy\"",
" </a>",
" .)",
" </p>",
" <p>",
" In the prospective Swedish cohort study discussed above [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/10\">",
" 10",
" </a>",
" ], the incidence of ectopic pregnancy in the first pregnancy after
laparoscopically-confirmed PID was 7.8 percent versus 1.3 percent in women without
PID at laparoscopy. The risk of ectopic pregnancy increased with the number of
episodes and severity of PID:",
" </p>",
" <p>",
" <ul class=\"hyphen-block\">",
" <li>",
" After one, two, and three episodes of PID, the ratio of ectopic pregnancy to
intrauterine pregnancy was 1:15, 1:6, and 1:3, respectively.",
" </li>",
" <li>",
" In women with a single episode of mild, moderate, or severe PID, the ratio
of ectopic pregnancy to intrauterine pregnancy was 1:35, 1:25, and 1:5,
respectively.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H12435232\">",
" <span class=\"h1\">",
" OVARIAN CANCER",
" </span>",
" &nbsp;&mdash;&nbsp;A population-based, case-controlled study from Taiwan
reported that a history of PID was associated with an almost two-fold increase in
the risk of ovarian cancer (HR 1.92, 95% CI 1.27-2.92), with the highest risk in
women with multiple episodes of PID (HR 2.46, 95% CI 1.48-4.09 for women who had at
least five episodes of PID) [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/18\">",
" 18",
" </a>",
" ]. Additional studies have reported similar associations [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/19,20\">",
" 19,20",
" </a>",
" ]. It is not known whether PID is an independent risk factor for ovarian
cancer, as PID increases the risk of low parity, nulliparity, nulligravidity, and
infertility, which are also risk factors for ovarian cancer.",
" </p>",
" <p class=\"headingAnchor\" id=\"H9\">",
" <span class=\"h1\">",
" PREDICTION AND PREVENTION OF LONG-TERM SEQUELAE",
" </span>",
" &nbsp;&mdash;&nbsp;Signs and symptoms associated with acute PID are poor
predictors of the eventual development of chronic sequelae [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/21\">",
" 21",
" </a>",
" ]. Furthermore, clinical",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" microbiologic cure of acute disease does not preclude development of the long-
term complications described above. Therefore, clinicians should not assume that
women with a complete recovery from PID have avoided the increased risk of long-
term complications.",
" </p>",
" <p>",
" As discussed above, recurrent PID is associated with an almost two-fold
increase in infertility and more than four-fold increase in chronic pelvic pain;
therefore, prevention of recurrent disease is important [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/7,15,22\">",
" 7,15,22",
" </a>",
" ]. Options to reduce the risk of recurrence include:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" <strong>",
" Condoms",
" </strong>",
" - Women whose partners consistently use condoms are less likely to develop
recurrent PID or infertility [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/23\">",
" 23",
" </a>",
" ]. In addition, condom use protects against acquisition of sexually
transmitted infections, and in the PEACH trial, women with PID who subsequently
acquired a lower genital tract infection were 2.3 times more likely to develop
chronic pelvic pain than those who did not (adjusted OR 2.3, 95% CI 1.2-3.2) [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/22\">",
" 22",
" </a>",
" ].",
" </li>",
" <li>",
" <strong>",
" Progestins",
" </strong>",
" - Progestin-based contraceptives may decrease the risk of PID because
progestin thickens cervical mucus, thereby possibly providing an enhanced barrier
against ascending infection.",
" </li>",
" <li>",
" <strong>",
" Oral contraceptive pills",
" </strong>",
" - The protective role of oral contraceptives in the acquisition of PID is
controversial; some studies found the use of oral contraceptives conferred a
protective effect against the development of chlamydial PID [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/24,25\">",
" 24,25",
" </a>",
" ], while others did not [",
" <a class=\"abstract\" href=\"UTD.htm?0/58/934/abstract/26\">",
" 26",
" </a>",
" ].",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H10\">",
" <span class=\"h1\">",
" TREATMENT",
" </span>",
" &nbsp;&mdash;&nbsp;Treatment of recurrent PID, chronic pelvic pain,
infertility, and ectopic pregnancy can be found separately:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/63/35832?
source=see_link\">",
" \"Treatment of pelvic inflammatory disease\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?28/18/28969?
source=see_link\">",
" \"Treatment of chronic pelvic pain in women\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?14/5/14425?
source=see_link\">",
" \"Overview of treatment of female infertility\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?26/49/27417?
source=see_link\">",
" \"Methotrexate treatment of tubal and interstitial ectopic pregnancy\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?5/53/5976?
source=see_link\">",
" \"Surgical treatment of ectopic pregnancy and prognosis for subsequent
fertility\"",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"PATIENT_INFORMATION\">",
" <span class=\"h1\">",
" INFORMATION FOR PATIENTS",
" </span>",
" &nbsp;&mdash;&nbsp;UpToDate offers two types of patient education materials,
&ldquo;The Basics&rdquo; and &ldquo;Beyond the Basics.&rdquo; The Basics patient
education pieces are written in plain language, at the 5",
" <sup>",
" th",
" </sup>",
" to 6",
" <sup>",
" th",
" </sup>",
" grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10",
" <sup>",
" th",
" </sup>",
" to 12",
" <sup>",
" th",
" </sup>",
" grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.",
" </p>",
" <p>",
" Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
&ldquo;patient info&rdquo; and the keyword(s) of interest.)",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Basics topic (see",
" <a class=\"medical medical_basics\" href=\"UTD.htm?26/14/26850?
source=see_link\">",
" \"Patient information: Pelvic inflammatory disease (The Basics)\"",
" </a>",
" )",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H11\">",
" <span class=\"h1\">",
" SUMMARY AND RECOMMENDATIONS",
" </span>",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" The major complications of pelvic inflammatory disease (PID) are tuboovarian
abscess, chronic pelvic pain, infertility, and ectopic pregnancy. Treatment of PID
may not prevent long-term sequelae because of the scarring and adhesion formation
that accompany healing of infection-damaged tissues. (See",
" <a class=\"local\" href=\"#H1\">",
" 'Introduction'",
" </a>",
" above.)",
" </li>",
" <li>",
" The risk of complications increases with the number of episodes and severity
of PID. (See",
" <a class=\"local\" href=\"#H4\">",
" 'Chronic pelvic pain'",
" </a>",
" above and",
" <a class=\"local\" href=\"#H6\">",
" 'Infertility'",
" </a>",
" above and",
" <a class=\"local\" href=\"#H8\">",
" 'Ectopic pregnancy'",
" </a>",
" above.)",
" </li>",
" <li>",
" Risk factors for infertility after PID include the number of infections, the
severity of infection, presence of chlamydial infection, and delay in initiating
treatment. (See",
" <a class=\"local\" href=\"#H6\">",
" 'Infertility'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
" <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
target=\"_blank\">",
" Subscription and License Agreement",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
" </h1>",
" <ol id=\"reference\">",
" <li>",
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" Centers for Disease Control and Prevention. Sexually transmitted diseases
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" </li>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/2\">",
" Soper DE. Pelvic inflammatory disease. Obstet Gynecol 2010; 116:419.",
" </a>",
" </li>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/3\">",
" Yeh JM, Hook EW 3rd, Goldie SJ. A refined estimate of the average lifetime
cost of pelvic inflammatory disease. Sex Transm Dis 2003; 30:369.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/4\">",
" Trent M, Haggerty CL, Jennings JM, et al. Adverse adolescent reproductive
health outcomes after pelvic inflammatory disease. Arch Pediatr Adolesc Med 2011;
165:49.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/5\">",
" Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and
outpatient treatment strategies for women with pelvic inflammatory disease: results
from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH)
Randomized Trial. Am J Obstet Gynecol 2002; 186:929.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/6\">",
" Westr&ouml;m L. Effect of acute pelvic inflammatory disease on fertility. Am
J Obstet Gynecol 1975; 121:707.",
" </a>",
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" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/7\">",
" Haggerty CL, Peipert JF, Weitzen S, et al. Predictors of chronic pelvic pain
in an urban population of women with symptoms and signs of pelvic inflammatory
disease. Sex Transm Dis 2005; 32:293.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/8\">",
" Cates W Jr, Joesoef MR, Goldman MB. Atypical pelvic inflammatory disease:
can we identify clinical predictors? Am J Obstet Gynecol 1993; 169:341.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/9\">",
" Wiesenfeld HC, Hillier SL, Meyn LA, et al. Subclinical pelvic inflammatory
disease and infertility. Obstet Gynecol 2012; 120:37.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/10\">",
" Westr&ouml;m L, Joesoef R, Reynolds G, et al. Pelvic inflammatory disease
and fertility. A cohort study of 1,844 women with laparoscopically verified disease
and 657 control women with normal laparoscopic results. Sex Transm Dis 1992;
19:185.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/11\">",
" Svenstrup HF, Fedder J, Kristoffersen SE, et al. Mycoplasma genitalium,
Chlamydia trachomatis, and tubal factor infertility--a prospective study. Fertil
Steril 2008; 90:513.",
" </a>",
" </li>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/12\">",
" Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treatment
strategies of some women with pelvic inflammatory disease: a randomized trial.
Obstet Gynecol 2005; 106:573.",
" </a>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/13\">",
" Ness RB, Soper DE, Richter HE, et al. Chlamydia antibodies, chlamydia heat
shock protein, and adverse sequelae after pelvic inflammatory disease: the PID
Evaluation and Clinical Health (PEACH) Study. Sex Transm Dis 2008; 35:129.",
" </a>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/14\">",
" Hillis SD, Joesoef R, Marchbanks PA, et al. Delayed care of pelvic
inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol
1993; 168:1503.",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/15\">",
" Westr&ouml;m L. Incidence, prevalence, and trends of acute pelvic
inflammatory disease and its consequences in industrialized countries. Am J Obstet
Gynecol 1980; 138:880.",
" </a>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/16\">",
" Lepine LA, Hillis SD, Marchbanks PA, et al. Severity of pelvic inflammatory
disease as a predictor of the probability of live birth. Am J Obstet Gynecol 1998;
178:977.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/17\">",
" Quintar AA, Mukdsi JH, del Valle Bonaterra M, et al. Increased expression of
uteroglobin associated with tubal inflammation and ectopic pregnancy. Fertil Steril
2008; 89:1613.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/18\">",
" Lin HW, Tu YY, Lin SY, et al. Risk of ovarian cancer in women with pelvic
inflammatory disease: a population-based study. Lancet Oncol 2011; 12:900.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/19\">",
" Seidman JD, Sherman ME, Bell KA, et al. Salpingitis, salpingoliths, and
serous tumors of the ovaries: is there a connection? Int J Gynecol Pathol 2002;
21:101.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/20\">",
" Risch HA, Howe GR. Pelvic inflammatory disease and the risk of epithelial
ovarian cancer. Cancer Epidemiol Biomarkers Prev 1995; 4:447.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/21\">",
" Trautmann GM, Kip KE, Richter HE, et al. Do short-term markers of treatment
efficacy predict long-term sequelae of pelvic inflammatory disease? Am J Obstet
Gynecol 2008; 198:30.e1.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/22\">",
" Trent M, Bass D, Ness RB, Haggerty C. Recurrent PID, subsequent STI, and
reproductive health outcomes: findings from the PID evaluation and clinical health
(PEACH) study. Sex Transm Dis 2011; 38:879.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/23\">",
" Ness RB, Randall H, Richter HE, et al. Condom use and the risk of recurrent
pelvic inflammatory disease, chronic pelvic pain, or infertility following an
episode of pelvic inflammatory disease. Am J Public Health 2004; 94:1327.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/24\">",
" W&oslash;lner-Hanssen P, Eschenbach DA, Paavonen J, et al. Decreased risk of
symptomatic chlamydial pelvic inflammatory disease associated with oral
contraceptive use. JAMA 1990; 263:54.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/25\">",
" Spinillo A, Gorini G, Piazzi G, et al. The impact of oral contraception on
chlamydial infection among patients with pelvic inflammatory disease. Contraception
1996; 54:163.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/58/934/abstract/26\">",
" Ness RB, Soper DE, Holley RL, et al. Hormonal and barrier contraception and
risk of upper genital tract disease in the PID Evaluation and Clinical Health
(PEACH) study. Am J Obstet Gynecol 2001; 185:121.",
" </a>",
" </li>",
" </ol>",
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" <div id=\"topicVersionRevision\">",
" Topic 5469 Version 13.0",
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" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <div id=\"outline\">",
" <ul>",
" <li>",
" <a class=\"sr_button\" href=\"#H11\" id=\"summRecButton\">",
" <span>",
" SUMMARY &amp; RECOMMENDATIONS",
" </span>",
" </a>",
" </li>",
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" INTRODUCTION",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H21129257\">",
" RECURRENT PID",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H3\">",
" HYDROSALPINX",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H4\">",
" CHRONIC PELVIC PAIN",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H6\">",
" INFERTILITY",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H7\">",
" Risk factors",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H8\">",
" ECTOPIC PREGNANCY",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H12435232\">",
" OVARIAN CANCER",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H9\">",
" PREDICTION AND PREVENTION OF LONG-TERM SEQUELAE",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H10\">",
" TREATMENT",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#PATIENT_INFORMATION\">",
" INFORMATION FOR PATIENTS",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H11\">",
" SUMMARY AND RECOMMENDATIONS",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#references\">",
" REFERENCES",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" RELATED TOPICS",
" </h1>",
" <div id=\"relatedTopics\">",
" <ul>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?40/26/41384?
source=related_link\">",
" Causes of chronic pelvic pain in women",
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" </li>",
" <li class=\"plainItem\">",
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/2Q==);\">",
" </div>",
" <div class=\"lgnd\">",
" A) Low-power photomicrograph of a retroperitoneal, high-grade malignant
peripheral nerve sheath tumor (MPNST). Note the dense cellularity of the neoplasm
completely surrounding normal nerve fascicles (arrows). H&amp;E, x40. B) The tumor
cells are spindle-shaped, and mitoses are easily found on high-power (arrows).
H&amp;E, x400. C) MPNST's can also have an epithelioid appearance, as seen in
another retroperitoneal example. H&amp;E, x200.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Courtesy of John E Donahue, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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var outline_f0_58_935=null;
var title_f0_58_936="Lichen planus hyperkeratosis";
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" <sup>",
" &reg;",
" </sup>",
" </div>",
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" <a class=\"etacLink\" href=\"#\">",
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title=\"Email graphic(s)\"/>",
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" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
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" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 470px\">",
" <div class=\"ttl\">",
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6nibVIYneKMtDclflZf4l47eq9CKKKLIZWvLxXs2WyikhDKEMrptkkHGCo6BcfTsABUWo2txFDbz6cbIG3n
QzT3LlVigB3SlsD5nUZK5wMnkgCiik1ZAnc0VW2hVZt/mWtzGrjYAw5wRhlOCMd/1pV00mxTy2ieRCSFdfk
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TG5BGVPbgkZHYmiipkrPQCp9pN40O6C24/eK8jBzx0ZR2Pv2p0ZSckSljEhCjjYhPrkdfw4ooqrIRowyAgA
LtXHByCDWPdeHrUamup2mbe6QSfIjssEhfG5pIgQrtwfmIzzRRWezGVJoNJtddkgYXd3easrTRQSF3hiWFE
RghxtiHKnHG4k9a07dYLaRYLe3iimYBnVPmIPUD3PuelFFUuwBFaRzzamDYmyM7K0lzGVV5yFA3Ejk4UBcn
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GXPoaKKqegIzhaXGmWF3Hps1vPq04ZoWu8oruBgbyoJPv361qWYmSFFufLMxGXMYIUt3wDk4ooqGBlzWNg/
iGS8uLaT7StmbZ5HkPktCzZ2lM7ScjqRnBIzg1Y09p1UrbwxtaGRfJYSY/dbRk7do24OQAM5ABzzRRVPa4H
LXdiLPxVo1/qFze32qWoeFpLf8AcRSJKxA3xgkNsUjrxnngmtmwsr0Xd1MHSaB7jzYTcsWwuDnywPuc/n+N
FFN6K4kYN3caVqet3CXOiaiH0RHkhuZIJI48yqUkWFwdrttJGPpiqfg2DTDDb+VqFtexS20c1nJcxf6ZHbP
8iI0j/OQT8nIyOQSaKKpgi6usto1va33iOzh0zUbyRbY2kc3mhFGWco4A3ARqGPAwAfStQeJ7b7Rdi5a9si
k8kaJdQN86o2zemzIKEqSCcE+nSiiiKu0TKVkf/9k=);\">",
" </div>",
" <div class=\"lgnd\">",
" Prominent granular layer, irregular acanthosis, saw-toothed pattern of rete
ridges, band-like infiltrate in apposition to basal layer.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Reproduced with permission from Ridley, CM, Neill, SM (Eds), The Vulva, 2nd
ed, Blackwell Science, Oxford 1999. Copyright &copy; 1999 Blackwell Science.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_58_936=[""].join("\n");
var outline_f0_58_936=null;
var title_f0_58_937="Lisinopril: Drug information";
var content_f0_58_937=[" <noscript>",
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JavaScript is required in order for our site to behave correctly. Please enable
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" <div id=\"printHeader\">",
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" <img alt=\"UpToDate\" src=\"./../images/UTD2_masthead.myextg\">",
" <img align=\"right\" alt=\"Wolters Kluwer Health\" height=\"40\"
src=\"./../images/logoWKH.myextg\" width=\"175\">",
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" <div id=\"printHeaderLinks\">",
" <a class=\"TOPIC\" href=\"#\" id=\"printHeaderPrint\" rel=\"3\" title=\"Click
here to print\">",
" Print",
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" Back",
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" </div>",
" </div>",
" <!-- TC:TOPIC_PAGE -->",
" <div id=\"topicContent\">",
" <div id=\"drugTitle\">",
" Lisinopril: Drug information",
" </div>",
" <div id=\"lexiTitleImg\">",
" <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
width=\"71\"/>",
" </div>",
" <div class=\"clear\">",
" </div>",
" <div id=\"drugCopy\">",
" Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
" </div>",
" <div id=\"topicText\">",
" (For additional information",
" <a class=\"drug drug_patient\" href=\"UTD.htm?9/32/9734?source=see_link\">",
" see \"Lisinopril: Patient drug information\"",
" </a>",
" and",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?15/38/15976?
source=see_link\">",
" see \"Lisinopril: Pediatric drug information\"",
" </a>",
" )",
" <br/>",
" For abbreviations and symbols that may be used in Lexicomp (",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?23/39/24183\">",
" show table",
" </a>",
" )",
" <div class=\"block black-box-warn drugH1Div\" id=\"F5709016\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" ALERT: U.S. Boxed Warning",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" The FDA-approved labeling includes a boxed warning. See Warnings/Precautions
section for a concise summary of this information. For verbatim wording of the
boxed warning, consult the product labeling or",
" <a href=\"file://www.fda.gov\" target=\"_blank\">",
" www.fda.gov",
" </a>",
" .",
" </p>",
" </div>",
" <div class=\"list ubnlist drugH1Div drugBrandNames\" id=\"F189191\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Brand Names: U.S.",
" </span>",
" <ul>",
" <li>",
" Prinivil&reg;;",
" </li>",
" <li>",
" Zestril&reg;",
" </li>",
" </ul>",
" </div>",
" <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F189192\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Brand Names: Canada",
" </span>",
" <ul>",
" <li>",
" Apo-Lisinopril&reg;;",
" </li>",
" <li>",
" CO Lisinopril;",
" </li>",
" <li>",
" Dom-Lisinopril;",
" </li>",
" <li>",
" JAMP-Lisinopril;",
" </li>",
" <li>",
" Mint-Lisinopril;",
" </li>",
" <li>",
" Mylan-Lisinopril;",
" </li>",
" <li>",
" PMS-Lisinopril;",
" </li>",
" <li>",
" Prinivil&reg;;",
" </li>",
" <li>",
" PRO-Lisinopril;",
" </li>",
" <li>",
" RAN&trade;-Lisinopril;",
" </li>",
" <li>",
" ratio-Lisinopril;",
" </li>",
" <li>",
" ratio-Lisinopril P;",
" </li>",
" <li>",
" ratio-Lisinopril Z;",
" </li>",
" <li>",
" Riva-Lisinopril;",
" </li>",
" <li>",
" Sandoz-Lisinopril;",
" </li>",
" <li>",
" Teva-Lisinopril (Type P);",
" </li>",
" <li>",
" Teva-Lisinopril (Type Z);",
" </li>",
" <li>",
" Zestril&reg;",
" </li>",
" </ul>",
" </div>",
" <div class=\"ex_sect_xr thclist drugH1Div drugBrandNames\" id=\"F189238\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pharmacologic Category",
" </span>",
" <ul>",
" <li>",
" Angiotensin-Converting Enzyme (ACE) Inhibitor",
" </li>",
" </ul>",
" </div>",
" <div class=\"block doa drugH1Div\" id=\"F189196\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Adult",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Heart failure:",
" </b>",
" Oral: Initial: 2.5-5 mg once daily; then increase by no more than 10 mg
increments at intervals no less than 2 weeks to a maximum daily dose of 40 mg.
Usual maintenance: 5-40 mg/day as a single dose. Target dose: 20-40 mg once daily
(ACC/AHA 2009 Heart Failure Guidelines)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" <b>",
" Note:",
" </b>",
" If patient has hyponatremia (serum sodium &lt;130 mEq/L) or renal impairment
(Cl",
" <sub>",
" cr",
" </sub>",
" &lt;30 mL/minute or creatinine &gt;3 mg/dL), then initial dose should be 2.5
mg/day",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Hypertension:",
" </b>",
" Oral: Usual dosage range (JNC 7): 10-40 mg/day",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" <i>",
" Not maintained on diuretic:",
" </i>",
" Initial: 10 mg/day",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" <i>",
" Maintained on diuretic:",
" </i>",
" Initial: 5 mg/day",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" <b>",
" Note:",
" </b>",
" Antihypertensive effect may diminish toward the end of the dosing interval
especially with doses of 10 mg/day. An increased dose may aid in extending the
duration of antihypertensive effect. Doses up to 80 mg/day have been used, but do
not appear to give greater effect.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Patients taking diuretics should have them discontinued 2-3 days prior to
initiating lisinopril if possible. Restart diuretic after blood pressure is stable
if needed. If diuretic cannot be discontinued prior to therapy, begin with 5 mg
with close supervision until stable blood pressure. In patients with hyponatremia
(&lt;130 mEq/L), start dose at 2.5 mg/day.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Acute myocardial infarction (within 24 hours in hemodynamically stable
patients):",
" </b>",
" Oral: 5 mg immediately, then 5 mg at 24 hours, 10 mg at 48 hours, and 10 mg
every day thereafter for 6 weeks. Patients should continue to receive standard
treatments such as thrombolytics, aspirin, and beta-blockers.",
" </p>",
" </div>",
" <div class=\"block dop drugH1Div\" id=\"F189217\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Pediatric",
" </span>",
" <p>",
" (For additional information",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?15/38/15976?
source=see_link\">",
" see \"Lisinopril: Pediatric drug information\"",
" </a>",
" )",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Hypertension:",
" </b>",
" Children &ge;6 years: Oral: Initial: 0.07 mg/kg once daily (up to 5 mg);
increase dose at 1- to 2-week intervals; doses &gt;0.61 mg/kg or &gt;40 mg have not
been evaluated.",
" </p>",
" </div>",
" <div class=\"block doe drugH1Div\" id=\"F189197\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Geriatric",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Refer to adult dosing. In the management of hypertension, consider lower
initial doses (eg, 2.5-5 mg/day) and titrate to response (Aronow, 2011).",
" </p>",
" </div>",
" <div class=\"block dor drugH1Div\" id=\"F189198\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Renal Impairment",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" Heart failure: Adults: Cl",
" <sub>",
" cr",
" </sub>",
" &lt;30 mL/minute or creatinine &gt;3 mg/dL: Initial: 2.5 mg/day",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" Hypertension:",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" Adults: Initial doses should be modified and upward titration should be
cautious, based on response (maximum: 40 mg/day)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:6em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" Cl",
" <sub>",
" cr",
" </sub>",
" &gt;30 mL/minute: Initial: 10 mg/day",
" </p>",
" <p style=\"text-indent:-2em;margin-left:6em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" Cl",
" <sub>",
" cr",
" </sub>",
" 10-30 mL/minute: Initial: 5 mg/day",
" </p>",
" <p style=\"text-indent:-2em;margin-left:6em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" Hemodialysis: Initial: 2.5 mg/day; dialyzable (50%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;margin-right:0em;margin-
top:0em;text-align:justify;\">",
" Children: Use in not recommended in pediatric patients with GFR &lt;30
mL/minute/1.73 m",
" <sup>",
" 2",
" </sup>",
" </p>",
" </div>",
" <div class=\"block doh drugH1Div\" id=\"F16265640\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Hepatic Impairment",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" No dosage adjustment provided in manufacturer&rsquo;s labeling.",
" </p>",
" </div>",
" <div class=\"block foc drugH1Div\" id=\"F189166\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosage Forms: U.S.",
" </span>",
" <p style=\"text-indent:0em;text-align:justify;display:inline\">",
" Excipient information presented when available (limited, particularly for
generics); consult specific product labeling.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Tablet, oral: 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40 mg",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Prinivil&reg;: 5 mg, 10 mg, 20 mg [scored]",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Zestril&reg;: 2.5 mg",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Zestril&reg;: 5 mg [scored]",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Zestril&reg;: 10 mg, 20 mg, 30 mg, 40 mg",
" </p>",
" </div>",
" <div class=\"block geq drugH1Div\" id=\"F189151\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Generic Equivalent Available: U.S.",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Yes",
" </p>",
" </div>",
" <div class=\"block adm drugH1Div\" id=\"F189170\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Administration",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Watch for hypotensive effects within 1-3 hours of first dose or new higher
dose.",
" </p>",
" </div>",
" <div class=\"block use drugH1Div\" id=\"F189169\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Use",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Treatment of hypertension, either alone or in combination with other
antihypertensive agents; adjunctive therapy in treatment of heart failure
(afterload reduction); treatment of acute myocardial infarction within 24 hours in
hemodynamically-stable patients to improve survival; treatment of left ventricular
dysfunction after myocardial infarction",
" </p>",
" </div>",
" <div class=\"block mst drugH1Div\" id=\"F189246\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Medication Safety Issues",
" </span>",
" <div class=\"collapsible\">",
" <span class=\"collapsible-title\">",
" Sound-alike/look-alike issues:",
" </span>",
" <div class=\"collapsible-wrap\">",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Lisinopril may be confused with fosinopril, Lioresal&reg;, Lipitor&reg;,
RisperDAL&reg;",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Prinivil&reg; may be confused with Plendil&reg;, Pravachol&reg;,
Prevacid&reg;, PriLOSEC&reg;, Proventil&reg;",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Zestril&reg; may be confused with Desyrel, Restoril&trade;, Vistaril&reg;,
Zegerid&reg;, Zerit&reg;, Zetia&reg;, Zostrix&reg;, ZyPREXA&reg;",
" </p>",
" </div>",
" </div>",
" <div class=\"collapsible\">",
" <span class=\"collapsible-title\">",
" International issues:",
" </span>",
" <div class=\"collapsible-wrap\">",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Acepril [Malaysia] may be confused with Accupril which is a brand name for
quinapril [U.S.]",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Acepril: Brand name for lisinopril [Malaysia], but also the brand name for
captopril [Great Britain]; enalapril [Hungary, Switzerland]",
" </p>",
" </div>",
" </div>",
" </div>",
" <div class=\"block ars drugH1Div\" id=\"F189236\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Adverse Reactions Significant",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" <b>",
" Note:",
" </b>",
" Frequency ranges include data from hypertension and heart failure trials.
Higher rates of adverse reactions have generally been noted in patients with heart
failure. However, the frequency of adverse effects associated with placebo is also
increased in this population.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;margin-top:2em;text-
align:justify;\">",
" 1% to 10%:",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Cardiovascular: Orthostatic effects (1%), hypotension (1% to 4%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Central nervous system: Headache (4% to 6%), dizziness (5% to 12%), fatigue
(3%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Dermatologic: Rash (1% to 2%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Endocrine &amp; metabolic: Hyperkalemia (2% to 5%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Gastrointestinal: Diarrhea (3% to 4%), nausea (2%), vomiting (1%), abdominal
pain (2%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Genitourinary: Impotence (1%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Hematologic: Decreased hemoglobin (small)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Neuromuscular &amp; skeletal: Chest pain (3%), weakness (1%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Renal: BUN increased (2%); deterioration in renal function (in patients with
bilateral renal artery stenosis or hypovolemia); serum creatinine increased (often
transient)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Respiratory: Cough (4% to 9%), upper respiratory infection (1% to 2%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" &lt;1% (Limited to important or life-threatening): Acute renal failure,
alopecia, anaphylactoid reactions, angioedema, anuria, arrhythmia, arthralgia,
arthritis, asthma, ataxia, atrial fibrillation, atrial tachycardia, azotemia, bone
marrow suppression, bradycardia, cardiac arrest, cutaneous pseudolymphoma, diabetes
mellitus, eosinophilia, eosinophilic pneumonitis, erythrocyte sedimentation rate
increased, gout, hemolytic anemia, hemoptysis, hepatic necrosis, hepatitis, herpes
zoster, hypersomnia, hyponatremia, interstitial nephritis, intestinal angioedema,
leukopenia, lung neoplasms (malignant), memory impairment, MI, mood changes,
neutropenia, oliguria, orthostatic hypotension, pancreatitis, pemphigus, peripheral
neuropathy, photosensitivity, pleural effusion, pneumonia, positive ANA, psoriasis,
pulmonary embolism, pulmonary infarction, SIADH, skin infections, Stevens-Johnson
syndrome, stroke, syncope, systemic lupus erythematosus, thrombocytopenia, TIA,
toxic epidermal necrolysis, urinary tract infection, vasculitis, ventricular
tachycardia, viral infection, vision loss, visual hallucinations (Doane, 2013)",
" </p>",
" </div>",
" <div class=\"block coi drugH1Div\" id=\"F189174\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Contraindications",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Hypersensitivity to lisinopril or any component of the formulation;
angioedema related to previous treatment with an ACE inhibitor; patients with
idiopathic or hereditary angioedema; concomitant use with aliskiren in patients
with diabetes mellitus",
" </p>",
" </div>",
" <div class=\"block war drugH1Div\" id=\"F189155\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Warnings/Precautions",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Concerns related to adverse effects:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Angioedema: At any time during treatment (especially following first
dose), angioedema may occur rarely with ACE inhibitors; it may involve the head and
neck (potentially compromising airway) or the intestine (presenting with abdominal
pain). African-Americans may be at an increased risk. Prolonged frequent monitoring
may be required especially if tongue, glottis, or larynx are involved as they are
associated with airway obstruction. Patients with a history of airway surgery may
have a higher risk of airway obstruction. Aggressive early and appropriate
management is critical. Use in patients with idiopathic or hereditary angioedema or
previous angioedema associated with ACE inhibitor therapy is contraindicated.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Cholestatic jaundice: A rare toxicity associated with ACE inhibitors
includes cholestatic jaundice, which may progress to fulminant hepatic necrosis;
discontinue if marked elevation of hepatic transaminases or jaundice occurs.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Cough: An ACE inhibitor cough is a dry, hacking, nonproductive one
that usually occurs within the first few months of treatment and should generally
resolve within 1-4 weeks after discontinuation of the ACE inhibitor. Other causes
of cough should be considered (eg, pulmonary congestion in patients with heart
failure) and excluded prior to discontinuation.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Hyperkalemia: May occur with ACE inhibitors; risk factors include
renal dysfunction, diabetes mellitus, concomitant use of potassium-sparing
diuretics, potassium supplements and/or potassium containing salts. Use
cautiously, if at all, with these agents and monitor potassium closely.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Hypersensitivity reactions: Anaphylactic/anaphylactoid reactions can
occur with ACE inhibitors. Severe anaphylactoid reactions may be seen during
hemodialysis (eg, CVVHD) with high-flux dialysis membranes (eg, AN69), and rarely,
during low density lipoprotein apheresis with dextran sulfate cellulose. Rare cases
of anaphylactoid reactions have been reported in patients undergoing sensitization
treatment with hymenoptera (bee, wasp) venom while receiving ACE inhibitors.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Hypotension/syncope: Symptomatic hypotension with or without syncope
can occur with ACE inhibitors (usually with the first several doses); effects are
most often observed in volume-depleted patients; correct volume depletion prior to
initiation; close monitoring of patient is required especially with initial dosing
and dosing increases; blood pressure must be lowered at a rate appropriate for the
patient's clinical condition. Although dose reduction may be necessary, hypotension
is not a reason for discontinuation of future ACE inhibitor use especially in
patients with heart failure where a reduction in systolic blood pressure is a
desirable observation.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Neutropenia/agranulocytosis: Another ACE Inhibitor, captopril, has
been associated with rare cases of agranulocytosis, neutropenia, or leukopenia with
myeloid hypoplasia. Patients with renal impairment are at high risk of developing
neutropenia. Patients with both renal impairment and collagen vascular disease (eg,
systemic lupus erythematosus) are at an even higher risk of developing neutropenia.
Periodically monitor CBC with differential in these patients.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Renal function deterioration: May be associated with deterioration of
renal function and/or increases in serum creatinine, particularly in patients with
low renal blood flow (eg, renal artery stenosis, heart failure) whose glomerular
filtration rate (GFR) is dependent on efferent arteriolar vasoconstriction by
angiotensin II; deterioration may result in oliguria, acute renal failure, and
progressive azotemia. Small increases in serum creatinine may occur following
initiation; consider discontinuation only in patients with progressive and/or
significant deterioration in renal function.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Disease-related concerns:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Aortic stenosis: Use with caution in patients with severe aortic
stenosis; may reduce coronary perfusion resulting in ischemia.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Cardiovascular disease: Initiation of therapy in patients with
ischemic heart disease or cerebrovascular disease warrants close observation due to
the potential consequences posed by falling blood pressure (eg, MI, stroke). Fluid
replacement, if needed, may restore blood pressure; therapy may then be resumed.
Discontinue therapy in patients whose hypotension recurs.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Collagen vascular disease: Use with caution in patients with collagen
vascular disease especially with concomitant renal impairment; may be at increased
risk for hematologic toxicity.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Hypertrophic cardiomyopathy (HCM) with outflow tract obstruction: Use
with caution in patients with HCM and outflow tract obstruction since reduction in
afterload may worsen symptoms associated with this condition.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Renal artery stenosis: Use with caution in patients with unstented
unilateral/bilateral renal artery stenosis. When unstented bilateral renal artery
stenosis is present, use is generally avoided due to the elevated risk of
deterioration in renal function unless possible benefits outweigh risks.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Renal impairment: Use with caution in pre-existing renal
insufficiency; dosage adjustment may be needed. Avoid rapid dosage escalation which
may lead to further renal impairment.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" <b>",
" <i>",
" Concurrent drug therapy issues:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;\">",
" &bull; Angiotensin receptor blockers (ARBs) and renin inhibitors: Concomitant
use of an ARB or renin inhibitor (eg, aliskiren) is associated with an increased
risk of hypotension, hyperkalemia, and renal dysfunction. Concomitant use with
aliskiren should be avoided in patients with GFR &lt;60 mL/minute and is
contraindicated in patients with diabetes mellitus (regardless of GFR).",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Special populations:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Pediatrics: Safety and efficacy have not been established in children
&lt;6 years of age or with a Cl",
" <sub>",
" cr",
" </sub>",
" &le;30 mL/minute.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Pregnancy:",
" <b>",
" [U.S. Boxed Warning]: Drugs that act on the renin-angiotensin system can
cause injury and death to the developing fetus. Discontinue as soon as possible
once pregnancy is detected.",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Other warnings/precautions:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Surgery: Use with caution before, during, or immediately after major
surgery. Cardiopulmonary bypass, intraoperative blood loss or vasodilating
anesthesia increases endogenous renin release. Use of ACE inhibitors
perioperatively will blunt angiotensin II formation and may result in
hypotension.",
" </p>",
" </div>",
" <div class=\"block cyt drugH1Div\" id=\"F13299611\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Metabolism/Transport Effects",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" None known.",
" </p>",
" </div>",
" <div class=\"block dri drugH1Div\" id=\"F189160\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Drug Interactions",
" </span>",
" <br/>",
" <br/>",
" <div class=\"lexi\" id=\"lexiInteractAddInfo\">",
" (For additional information:",
" <a class=\"dip\" href=\"./drug-interaction\" target=\"_blank\">",
" Launch Lexi-Interact&trade; Drug Interactions Program",
" </a>",
" )",
" </div>",
" <div class=\"lexi\" id=\"lexiInteractImgB\">",
" <img border=\"0\" height=\"17\"
src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\" width=\"71\"/>",
" </div>",
" <div class=\"clear\">",
" </div>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Alfuzosin: May enhance the hypotensive effect of Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Aliskiren: May enhance the hyperkalemic effect of ACE Inhibitors. Aliskiren
may enhance the hypotensive effect of ACE Inhibitors. Aliskiren may enhance the
nephrotoxic effect of ACE Inhibitors. Management: Avoid aliskiren use with ACEIs or
ARBs in patients with diabetes or estimated glomerular filtration rate below 60
mL/min. In other patients receiving these combinations, monitor serum potassium,
serum creatinine, and blood pressure periodically.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Allopurinol: ACE Inhibitors may enhance the potential for allergic or
hypersensitivity reactions to Allopurinol.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Amifostine: Antihypertensives may enhance the hypotensive effect of
Amifostine. Management: When amifostine is used at chemotherapy doses,
antihypertensive medications should be withheld for 24 hours prior to amifostine
administration. If antihypertensive therapy can not be withheld, amifostine should
not be administered.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Angiotensin II Receptor Blockers: May enhance the adverse/toxic effect of ACE
Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Antacids: May decrease the serum concentration of ACE Inhibitors. Management:
Separate fosinopril administration from antacids by at least 2 hours. US and
Canadian recommendations for use of other ACE- inhibitors with antacids may vary.
Consult appropriate labeling. Monitor for decreased therapeutic effects of ACE-
inhibitors.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Antihypertensives: May enhance the hypotensive effect of other
Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Aprotinin: May diminish the antihypertensive effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" AzaTHIOprine: ACE Inhibitors may enhance the myelosuppressive effect of
AzaTHIOprine.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Canagliflozin: May enhance the hyperkalemic effect of ACE Inhibitors.
Canagliflozin may enhance the hypotensive effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" CycloSPORINE (Systemic): ACE Inhibitors may enhance the nephrotoxic effect of
CycloSPORINE (Systemic).",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Diazoxide: May enhance the hypotensive effect of Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" DPP-IV Inhibitors: May enhance the adverse/toxic effect of ACE Inhibitors.
Specifically, the risk of angioedema may be increased.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Eplerenone: May enhance the hyperkalemic effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Everolimus: May enhance the adverse/toxic effect of ACE Inhibitors.
Specifically, the risk of angioedema may be increased.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Ferric Gluconate: ACE Inhibitors may enhance the adverse/toxic effect of
Ferric Gluconate.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Gold Sodium Thiomalate: ACE Inhibitors may enhance the adverse/toxic effect
of Gold Sodium Thiomalate. An increased risk of nitritoid reactions has been
appreciated.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Herbs (Hypertensive Properties): May diminish the antihypertensive effect of
Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Herbs (Hypotensive Properties): May enhance the hypotensive effect of
Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Hypotensive Agents: May enhance the adverse/toxic effect of other Hypotensive
Agents.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Icatibant: May diminish the antihypertensive effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Iron Dextran Complex: ACE Inhibitors may enhance the adverse/toxic effect of
Iron Dextran Complex. Specifically, patients receiving an ACE inhibitor may be at
an increased risk for anaphylactic-type reactions. Management: Follow iron dextran
recommendations closely regarding both having resuscitation equipment and trained
personnel on-hand prior to iron dextran administration and the use of a test dose
prior to the first therapeutic dose.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Lanthanum: May decrease the serum concentration of ACE Inhibitors.
Management: Administer angiotensin-converting enzyme inhibitors at least two hours
before or after lanthanum.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Lithium: ACE Inhibitors may increase the serum concentration of Lithium.
Management: Lithium dosage reductions will likely be needed following the addition
of an ACE inhibitor. Monitor patient response to lithium closely following
addition or discontinuation of concurrent ACE inhibitor treatment.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Loop Diuretics: May enhance the hypotensive effect of ACE Inhibitors.
Specifically, postural hypotension which can accompany ACE Inhibitor initiation.
Loop Diuretics may enhance the nephrotoxic effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" MAO Inhibitors: May enhance the orthostatic hypotensive effect of Orthostatic
Hypotension Producing Agents.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Methylphenidate: May diminish the antihypertensive effect of
Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Nonsteroidal Anti-Inflammatory Agents: ACE Inhibitors may enhance the
adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the
combination may result in a significant decrease in renal function. Nonsteroidal
Anti-Inflammatory Agents may diminish the antihypertensive effect of ACE
Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Pentoxifylline: May enhance the hypotensive effect of Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Phosphodiesterase 5 Inhibitors: May enhance the antihypertensive effect of
Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Potassium Salts: May enhance the hyperkalemic effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Potassium-Sparing Diuretics: May enhance the hyperkalemic effect of ACE
Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Prostacyclin Analogues: May enhance the hypotensive effect of
Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" RiTUXimab: Antihypertensives may enhance the hypotensive effect of
RiTUXimab.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Salicylates: May diminish the antihypertensive effect of ACE Inhibitors. They
may also diminish other beneficial pharmacodynamic effects desired for the
treatment of CHF. The effects are likely dose-related. 100 mg doses aspirin
appear to cause no problems, whereas 300 mg doses appear to significantly affect
ACE Inhibitor efficacy.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Sirolimus: May enhance the adverse/toxic effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Sodium Phosphates: ACE Inhibitors may enhance the nephrotoxic effect of
Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be
enhanced. Management: Consider avoiding this combination by temporarily suspending
treatment with ACEIs, or seeking alternatives to oral sodium phosphate bowel
preparation. If the combination cannot be avoided, maintain adequate hydration and
monitor renal function closely.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Temsirolimus: May enhance the adverse/toxic effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Thiazide Diuretics: May enhance the hypotensive effect of ACE Inhibitors.
Specifically, postural hypotension which can accompany ACE Inhibitor initiation.
Thiazide Diuretics may enhance the nephrotoxic effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" TiZANidine: May enhance the hypotensive effect of Lisinopril.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Tolvaptan: May enhance the hyperkalemic effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Trimethoprim: May enhance the hyperkalemic effect of ACE Inhibitors.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Yohimbine: May diminish the antihypertensive effect of Antihypertensives.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" </div>",
" <div class=\"block foi drugH1Div\" id=\"F189186\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Ethanol/Nutrition/Herb Interactions",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Food: Potassium supplements and/or potassium-containing salts may cause or
worsen hyperkalemia. Management: Consult prescriber before consuming a potassium-
rich diet, potassium supplements, or salt substitutes.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Herb/Nutraceutical: Some herbal medications may worsen hypertension (eg,
licorice); others may increase the antihypertensive effect of lisinopril (eg,
shepherd's purse). Management: Avoid bayberry, blue cohosh, cayenne, ephedra,
ginger, ginseng (American), kola, licorice, and yohimbe. Avoid black cohosh,
California poppy, coleus, golden seal, hawthorn, mistletoe, periwinkle, quinine,
and shepherd's purse.",
" </p>",
" </div>",
" <div class=\"block prf drugH1Div\" id=\"F189162\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pregnancy Risk Factor",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" D (",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?16/42/17068\">",
" show table",
" </a>",
" )",
" </p>",
" </div>",
" <div class=\"block pri drugH1Div\" id=\"F189177\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pregnancy Implications",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" <b>",
" [U.S. Boxed Warning]: Drugs that act on the renin-angiotensin system can
cause injury and death to the developing fetus. Discontinue as soon as possible
once pregnancy is detected.",
" </b>",
" Lisinopril crosses the placenta; teratogenic effects may occur following
maternal use during pregnancy. Drugs that act on the renin-angiotensin system are
associated with oligohydramnios. Oligohydramnios, due to decreased fetal renal
function, may lead to fetal lung hypoplasia and skeletal malformations. Their use
in pregnancy is also associated with anuria, hypotension, renal failure, skull
hypoplasia, and death in the fetus/neonate. Chronic maternal hypertension itself is
also associated with adverse events in the fetus/infant. ACE inhibitors are not
recommended during pregnancy to treat maternal hypertension or heart failure. Use
of an ACE inhibitor should also be avoided in any woman of reproductive age. Women
who are planning a pregnancy should be considered for other medication options if
an ACE inhibitor is currently prescribed or the ACE inhibitor should be
discontinued as soon as possible once pregnancy is detected. The exposed fetus
should be monitored for fetal growth, amniotic fluid volume, and organ formation.
Infants exposed to an ACE inhibitor",
" <i>",
" in utero",
" </i>",
" should be monitored for hyperkalemia, hypotension, and oliguria.",
" </p>",
" </div>",
" <div class=\"block lac drugH1Div\" id=\"F189202\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Lactation",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Excretion in breast milk unknown/not recommended",
" </p>",
" </div>",
" <div class=\"block brc drugH1Div\" id=\"F6198846\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Breast-Feeding Considerations",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" It is not known if lisinopril is excreted in breast milk. Breast-feeding is
not recommended by the manufacturer.",
" </p>",
" </div>",
" <div class=\"block dic drugH1Div\" id=\"F3339783\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dietary Considerations",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Use potassium-containing salt substitutes cautiously in patients with
diabetes, patients with renal dysfunction, or those maintained on potassium
supplements or potassium-sparing diuretics.",
" </p>",
" </div>",
" <div class=\"block fee drugH1Div\" id=\"F189176\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pricing: U.S. (Medi-Span&reg;)",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Tablets",
" </b>",
" (Lisinopril Oral)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 2.5 mg (100): $64.25",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 5 mg (100): $96.23",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 10 mg (100): $99.40",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 20 mg (100): $106.40",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 30 mg (100): $150.70",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 40 mg (100): $154.87",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Tablets",
" </b>",
" (Prinivil Oral)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 5 mg (90): $118.54",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 10 mg (90): $122.40",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 20 mg (90): $131.02",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Tablets",
" </b>",
" (Zestril Oral)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 2.5 mg (100): $102.46",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 5 mg (100): $153.61",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 10 mg (100): $158.60",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 20 mg (100): $169.81",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 30 mg (100): $240.42",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 40 mg (100): $248.33",
" </p>",
" </div>",
" <div class=\"block mop drugH1Div\" id=\"F189164\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Monitoring Parameters",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" BUN, serum creatinine, renal function, WBC, and potassium; if patient has
collagen vascular disease and/or renal impairment, periodically monitor CBC with
differential",
" </p>",
" </div>",
" <div class=\"list fbnlist drugH1Div drugBrandNames\" id=\"F189179\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" International Brand Names",
" </span>",
" <ul>",
" <li>",
" Acemin (AT);",
" </li>",
" <li>",
" Acepril (MY);",
" </li>",
" <li>",
" Acerbon (DE);",
" </li>",
" <li>",
" Acerdil (CN, PE);",
" </li>",
" <li>",
" Aklis (UY);",
" </li>",
" <li>",
" Alapril (IT);",
" </li>",
" <li>",
" Alfaken (MX);",
" </li>",
" <li>",
" Cipril (HK, IN);",
" </li>",
" <li>",
" Coric (DE);",
" </li>",
" <li>",
" Dapril (BF, BJ, CI, ET, GH, GM, GN, KE, LR, MA, ML, MR, MU, MW, MY, NE, NG,
RU, SC, SD, SG, SL, SN, TN, TZ, UG, ZM, ZW);",
" </li>",
" <li>",
" Diroton (EE);",
" </li>",
" <li>",
" Dosteril (MX);",
" </li>",
" <li>",
" Doxapril (AR);",
" </li>",
" <li>",
" ES (IN);",
" </li>",
" <li>",
" Eucor (EC);",
" </li>",
" <li>",
" Fersivag (MX);",
" </li>",
" <li>",
" Fibsol (AU);",
" </li>",
" <li>",
" Genopril (TW);",
" </li>",
" <li>",
" Inhitril (ID);",
" </li>",
" <li>",
" Inopril (AE, BH, CY, EG, IQ, IR, JO, KW, LB, LY, OM, QA, SA, SY, YE);",
" </li>",
" <li>",
" Irumed (HR);",
" </li>",
" <li>",
" Linopril (AE, BH, CY, EG, IQ, IR, JO, KW, LB, LY, OM, QA, SA, SY, YE);",
" </li>",
" <li>",
" Linvas (IN);",
" </li>",
" <li>",
" Liprace (AU);",
" </li>",
" <li>",
" Lipril (IN);",
" </li>",
" <li>",
" Lisdene (MY, SG);",
" </li>",
" <li>",
" Lisibeta (DE);",
" </li>",
" <li>",
" Lisigamma (DE);",
" </li>",
" <li>",
" Lisihexal (DE);",
" </li>",
" <li>",
" Lisinobell (AU);",
" </li>",
" <li>",
" Lisipril (CO, DO);",
" </li>",
" <li>",
" Lisir (TH);",
" </li>",
" <li>",
" Lisodur (AU);",
" </li>",
" <li>",
" Lisopress (BB, BM, BS, BZ, GY, HU, JM, NZ, SR, TT);",
" </li>",
" <li>",
" Lisoril (IN, SG);",
" </li>",
" <li>",
" Lispril (TH);",
" </li>",
" <li>",
" Listril (IN);",
" </li>",
" <li>",
" Longes (JP);",
" </li>",
" <li>",
" Noperten (ID);",
" </li>",
" <li>",
" Novatec (BE, LU, NL);",
" </li>",
" <li>",
" Odace (ID);",
" </li>",
" <li>",
" Pesatril (MX);",
" </li>",
" <li>",
" Presiten (DO);",
" </li>",
" <li>",
" Prinil (CH);",
" </li>",
" <li>",
" Prinivil (AT, AU, BB, BG, BM, BR, BS, BZ, CZ, FR, GR, GY, HU, IT, JM, MX,
PL, SR, TT, VE);",
" </li>",
" <li>",
" Safepril (TW);",
" </li>",
" <li>",
" Sinopren (ZA);",
" </li>",
" <li>",
" Sinopril (AE, BH, CY, EG, IQ, IR, JO, KW, LB, LY, OM, QA, SA, SY, YE);",
" </li>",
" <li>",
" Tensiphar (ID);",
" </li>",
" <li>",
" Tensopril (AR, IL);",
" </li>",
" <li>",
" Tensyn (CO);",
" </li>",
" <li>",
" Vivatec (DK, FI, NO);",
" </li>",
" <li>",
" Zestril (AE, AU, BB, BE, BF, BH, BJ, BM, BR, BS, BZ, CH, CI, CL, CN, CR, CY,
DK, DO, EG, ES, ET, FR, GB, GH, GM, GN, GR, GT, GY, HK, HN, ID, IE, IQ, IR, JM, JO,
KE, KP, KW, LB, LR, LU, LY, MA, ML, MR, MU, MW, MX, MY, NE, NG, NI, NL, OM, PA, PE,
PH, PK, PT, PY, QA, SA, SC, SD, SE, SL, SN, SR, SV, SY, TH, TN, TR, TT, TW, TZ, UG,
YE, ZM, ZW)",
" </li>",
" </ul>",
" </div>",
" <div class=\"block pha drugH1Div\" id=\"F189154\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Mechanism of Action",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Competitive inhibitor of angiotensin-converting enzyme (ACE); prevents
conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; results in
lower levels of angiotensin II which causes an increase in plasma renin activity
and a reduction in aldosterone secretion; a CNS mechanism may also be involved in
hypotensive effect as angiotensin II increases adrenergic outflow from CNS;
vasoactive kallikreins may be decreased in conversion to active hormones by ACE
inhibitors, thus reducing blood pressure",
" </p>",
" </div>",
" <div class=\"block phk drugH1Div\" id=\"F189173\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pharmacodynamics/Kinetics",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Onset of action: 1 hour",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Peak effect: Hypotensive: Oral: ~6 hours",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Duration: 24 hours",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Absorption: Well absorbed; unaffected by food",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Protein binding: 25%",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Metabolism: Not metabolized",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Bioavailability: Decreased with NYHA Class II-IV heart failure",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Half-life elimination: 11-12 hours",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Time to peak: ~7 hours",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Excretion: Primarily urine (as unchanged drug)",
" </p>",
" </div>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
" <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
target=\"_blank\">",
" Subscription and License Agreement",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
" </h1>",
" <ol id=\"reference\">",
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" </div>",
" <div class=\"lgnd\">",
" Histologic sections of skin show epidermal acanthosis with spongiosis and
microvesicle and pustule formation. The dermis shows a perivascular and
interstitial infiltrate, extending to mid-reticular dermal levels.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Copyright &copy; Greg Hosler, MD, PhD, Dermatlas; file://www.dermatlas.org.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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var outline_f0_58_938=null;
var title_f0_58_939="Effective strong ion difference";
var content_f0_58_939=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" <sup>",
" &reg;",
" </sup>",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=NEPH
%2F59352&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=6\" onclick=\"\">",
" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=NEPH
%2F59352&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=6\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\">",
" <div class=\"ttl\">",
" Effective strong ion difference formula",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Effective SID (SIDeff)",
" </td>",
" </tr>",
" <tr>",
" <td>",
" <span style=\"font-family: verdana,sans-serif; font-size: 10pt;\">",
" SIDeff = (12.2 &times; Pco",
" <sub>",
" 2",
" </sub>",
" /10",
" <sup>",
" -pH",
" </sup>",
" ) + 10 &times; [Albumin &times; (0.123 &times; pH &ndash; 0.631)] + [PO",
" <sub>",
" 4",
" </sub>",
" &nbsp;&times; (0.309 &times; pH &ndash; 0.469)]",
" </span>",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_58_939=[""].join("\n");
var outline_f0_58_939=null;
var title_f0_58_940="Treatment recommend ovar GCT";
var content_f0_58_940=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" <sup>",
" &reg;",
" </sup>",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=ONC
%2F55704&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=6\" onclick=\"\">",
" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=ONC
%2F55704&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=6\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\">",
" <div class=\"ttl\">",
" Summary of recommendations for treatment of ovarian germ cell tumors",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td class=\"subtitle1\">",
" Tumor type",
" </td>",
" <td class=\"subtitle1\">",
" Recommended treatment",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\" colspan=\"2\" rowspan=\"1\">",
" Dysgerminoma",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Stage I",
" </td>",
" <td>",
" Surgery",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Stage IB or IC",
" </td>",
" <td>",
" Surgery plus three cycles of BEP or CE",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Stage II to III",
" </td>",
" <td>",
" Surgery plus four cycles of BEP or CE",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Stage IV",
" </td>",
" <td>",
" Surgery plus four cycles of BEP",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\" colspan=\"2\" rowspan=\"1\">",
" Immature teratoma",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Stage I unruptured, grade 1",
" </td>",
" <td>",
" Surgery",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Stage I ruptured or grade 2 or 3",
" </td>",
" <td>",
" Surgery plus three cycles of BEP",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\" colspan=\"2\" rowspan=\"1\">",
" All other histologies",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Stage I",
" </td>",
" <td>",
" Surgery plus three cycles of BEP*",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Stage II to III, completely resected",
" </td>",
" <td>",
" Surgery plus four cycles of BEP",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Gross residual or stage IV",
" </td>",
" <td>",
" Surgery plus six cycles of BEP",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" BEP: bleomycin, etoposide, cisplatin; CE: carboplatin etoposide.",
" <br>",
" * Whether carboplatin can be substituted for cisplatin unclear; most prefer
cisplatin.",
" </br>",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
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var title_f0_58_941="Hormonal response to Na load";
var content_f0_58_941=[" <div id=\"graphicsToolbar\">",
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" &copy;2013 UpToDate",
" <sup>",
" &reg;",
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" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 470px\">",
" <div class=\"ttl\">",
" Hormonal response to increasing sodium intake",
" </div>",
" <div class=\"cntnt\" style=\"width: 394px; height: 233px; background-image:
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" <div class=\"lgnd\">",
" Increasing plasma levels of atrial natriuretic peptide (ANP) and falling
plasma renin activity in normal subjects given a progressively increasing sodium
intake from 10 to 350 meq/day after a 5-day equilibration period. These hormonal
responses promote urinary excretion of the excess sodium.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Data from Sagnella GA, Markandu ND, Buckley MG, et al. Am J Physiol 1989;
256:R1171.",
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var title_f0_58_942="Effect of globin charge on hemoglobin assembly";
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" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 516px\">",
" <div class=\"ttl\">",
" Effect of charge of the mutant &beta;-globin chain on in vitro assembly of the
abnormal hemoglobin",
" </div>",
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" </div>",
" <div class=\"lgnd\">",
" In these in vitro experiments, equal amounts of normal and mutant beta chains
were incubated with limiting quantities of normal alpha chains. The fraction of
total hemoglobin represented by the abnormal hemoglobin is plotted here versus the
net charge of the mutant beta chain. Separate experiments for 72 stable beta globin
variants are each represented by a single open circle. The normal beta chain, which
has a net charge of -2.5 at pH 7.2, is shown as the red circle at the 50 percent
point. Under the same conditions, the normal alpha chain has a net charge of
+2.4.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Data from Bunn, HF. Blood 1987; 69:1.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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var outline_f0_58_942=null;
var title_f0_58_943="Behcet disease uveitis";
var content_f0_58_943=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" <sup>",
" &reg;",
" </sup>",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=RHEUM
%2F64705&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\">",
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title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=RHEUM
%2F64705&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 470px\">",
" <div class=\"ttl\">",
" Uveitis in Beh&ccedil;et's disease",
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" </div>",
" <div class=\"lgnd\">",
" Widespread intraretinal hemorrhage from a patient with Beh&ccedil;et's
disease. The hemorrhage is secondary to retinal vasculitis.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Courtesy of James T Rosenbaum, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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