By O. Gorn. Iowa State University.

Caution should be taken when using opioids in long term paediatric conditions and alternative strategies to pain management should be sought order discount prilosec line chronic active gastritis definition. However discount prilosec 40 mg fast delivery gastritis vs gerd symptoms, the ability to alter the dose of one of the component agents without altering the other is lost buy prilosec 40 mg online gastritis zeluca. There is also the additional risk of patients double dosing on a medication from failure to recognize the active components of the drug (e. Simple and compound analgesics Paracetamol (acetaminophen) Paracetamol is thought to reduce pain by inhibiting prostaglandin synthesis within thecentral nervous system. It has both analgesic and antipyretic activity without anti-inflammatory activity. Opioid analgesics Opioid drugs act as agonists at opioid receptors which are found mainly in the brain and spinal cord and also peripherally. Counsel caution over driving and use of machinery Hepatic toxicity Avoid in known significant liver disease, reduce dose in mild disease Renal toxicity Avoid in known significant renal disease, reduce dose in mild disease Blood dyscrasia E. Note codeine is not known to be harmful as concentration are very small; however, individuals vary in rate of metabolism and close observation should be made for signs of infant morphine overdose Gastrointestinal Opioids induce nausea, vomiting, constipation, pancreatitis, obstruction Neuropsychiatric Opioids induce headache, confusion, dys/euphoria, hallucinations, mood change, seizures Genitourinary Sexual dysfunction, urinary retention, avoid in significant obstructive prostatic hypertrophy Age Reduce dosage in the elderly, avoid in childhood Commonly used weak opioids: codeine and dihydrocodeine • Codeine and dihydrocodeine (also available as modified release) can be used as a single agent to maximum daily adult dosage of 240 mg (usually 2 × 30 mg tablets four times a day). In the majority of countries however, it remains prescription only due to concerns over dependency and misuse. Travellers with legitimate prescriptions are advised to carry documentation of their condition from their physician. It inhibits the reuptake of both serotonin and norepinephrine (noradrenaline) at the dorsal horn. It is available in modified-release 12-hourly preparations (200 mg twice daily) and in combination with paracetamol. Its mixed effect reduces the risk of dependence and is less likely to be used as a substance of abuse. However, this is offset by a greater risk of intolerance from neuropsychiatric effects. Commonly used strong opioids These include morphine sulfate and oxycodone hydrochloride 5–10 mg, both 4– 6-hourly (can be titrated up to 400 mg per day in severe cases); the latter also has a compound of oxycodone/naloxone, which may be beneficial in those with severe constipation from opioids despite trials of different classes of laxative. Thereafter, escalation might move to morphine salts, but before any of these are utilized it is common to try patch formulations. Opioids delivered through transdermal patches These are applied to the skin and, therefore, in addition to the above-mentioned cautions, be aware of allergic reaction with localized sensitivity. BuTrans 5 micrograms/hour 7-day patch, gradually building dose, perhaps every 2 weeks depending on tolerance and response of symptoms. It is inevitable, however, that those with long- term conditions for which remission is less than optimal will require long-term therapy. The ‘rule of thumb’ of lowest possible dose for shortest possible period of time applies. The decision to prescribe should always be based on the severity and responsiveness/stability of asthma in each individual. Antidepressants Several antidepressants are used in the management of pain, usually as a single agent given at bedtime, sometimes in combination with other drugs using different mechanisms of action, and often at lower doses than typically used for controlling depression. Serotonin and norepinephrine reuptake inhibitors Tricyclics Tricyclics are predominantly serotonin and/or norepinephrine re-uptake inhibitors. The ‘typical’ agents in this group include amitriptyline, clomipramine, imipramine, and dosulepin. Given at doses up to 75 mg/day taken before bedtime, it is often titrated from a baseline of 10–25 mg in 10 mg steps gradually until a balance between maximum efficacy and tolerability is reached. Also note caution with driving or using machinery Antimuscarinic Caution in those with ocular (closed-angle glaucoma), action genitourinary (retention, prostatic hypertrophy), dry eyes/mouth, constipation Cardiovascular Risk of dysrhythmias especially ventricular (e. Side effects include nausea, headache, insomnia, dizziness, constipation, hepatic dysfunction, hyponatraemia, and orthostatic hypotension (duloxetine) and hypertension (milnacipran). Through cytochrome P450 enzyme system interactions, duloxetine may prolong opioid effects. There is no compelling evidence for their use in chronic pain in children and adolescents. Gabapentin • Dose: oral, titrated from 300 mg daily to maximum 3600 mg daily in divided doses, e. Other concerns include leucopenia, ataxia, Stevens–Johnson syndrome, hepatitis, and pancreatitis. Pregabalin • Dose: oral, titrated after 3–7 days from 150 mg to maximum 600 mg daily in 2–3 divided doses. Other concerns include visual disturbance, neutropenia, ataxia, arrhythmia, Stevens–Johnson syndrome, and pancreatitis. Where indicated, the rheumatologist should seek advice from a neurologist if spasm pain is considered to be the consequence of a neurological condition. It should be prescribed with caution in patients with arrhythmia and avoided or dose halved in hepatic and renal impairment. One risk is a severe burning and irritation if contact is made with mucous membranes, including the lips and conjunctiva. Disease-specific indications and dosing regimens are stated in each relevant chapter of this book. Terminology can be confusing since the introduction of ‘biologics’, which are also ‘disease-modifying’. Patients should always be informed of this, clarifying expectations and improving compliance. There is a lack overall of robust data as few randomized trials have been undertaken. A trial off treatment may be appropriate but hair growth may not recover for ≥1 hair cycle, i. If moderate to severe, treat hypertension first (see advice for ciclosporin on dose reduction). Consider the cause of weight loss and reduce the dose or stop for a trial period depending on the severity. It is a calcineurin inhibitor and has a fairly selective action on lymphocytes: blocking mitosis and inhibiting lymphokine release. A rise in creatinine >30% above baseline on two consecutive readings 7 days apart warrants stopping the drug and reassessing. If the potassium rises above the laboratory threshold the drug should be stopped and re-assessed (having ensured it is not a result of other medication changes). Rapid removal of the active metabolite can be achieved using washout with colestyramine 8 g three times a day or activated charcoal 50 g four times a day for 11 days. Blood concentrations should be checked twice, 14 days apart prior to conceiving (levels should be <0. Near-vision testing should demonstrate the capacity to read small print N8 or N6 on an acuity chart. A washout is achieved using colestyramine 8 g three times a day or activated charcoal 50 g four times a day for 11 days.

Since this event potentially resulted in the death of the patient 40 mg prilosec visa erosive gastritis definition, you are asked to participate in a root cause analysis order prilosec 10 mg mastercard gastritis prevention. Answer: B—To minimize the risk of a faulty analysis purchase cheapest prilosec and prilosec gastritis jugo de papa, a group brainstorming session is required. A fshbone diagram (Answer C) is a useful tool to document the output of the brainstorming session; however, further analysis is required to rule in or rule out each potential root cause with data. A multidisciplinary team, not one individual (Answer E), should then analyze the sequence of events leading to the error, with the goal of identifying how the event occurred through identifcation of active errors and why the event occurred through systematic identifcation and analysis of latent errors. Autopsy reveals that the patient had undiagnosed type 2 diabetes mellitus, which lead to cerebral edema, raised intracranial pressure, and death. Investigation of the event by laboratory staff reveals that the nurse’s aide performed the test incorrectly, and that there is no evidence of a defect in any of the components of the point-of-care glucose test system. There is no legal requirement to report this event, since the cause has been identifed C. There is no legal requirement to report this event, since the device was not defective in any way Concept: When deaths occur in the hospital that could be the result of human or device error, regulatory agencies must be notifed as soon as possible. A root cause investigation should take place, and once the cause is identifed, further notifcation may become necessary (e. The choices (Answers A and C) are incorrect because they specify that only one of the parties be notifed. The choices (Answers B and E) are incorrect because the event must be reported regardless of the individual cause and even if they device was not defective. In order to gather preliminary data, you decid to do a retrospective case-control study. Classically, it is a study that starts with the identifcation of people with the disease and a suitable control group without the disease. The relationship of an exposure to a disease with regard to how frequently the exposure is present or, if quantitative, the level of the exposure, in each of the groups, will be quantifed. All the other choices (Answers A, B, C, and E) are incorrect based on the formula. It is used as measure of association for both randomized controlled trials and cohort studies. However, in epidemiological studies, the risk is the main variable of interested (and not the odds). Sometimes it has to rely on recall information Concept: For a classical case-control study, you should select cases based on a precise defnition or diagnosis of the disease. Incident cases are newly diagnosed cases, which can take an extended amount of time to collect, if you are studying a rare disease. Prevalent cases are patients who have already been diagnosed with the disease and are thus already available to study. Selecting controls is the most diffcult and the most important part of the case-control design. Controls are selected from the same population that gives rise to the actual cases. The purpose of having a control group is to provide the exposure distribution of the source population. The methods used to select the control will affect the validity and the generalizability of the study. Relatively inexpensive and can be conducted quickly based on available existing records 3. Allows study of multiple disease etiologies Disadvantages include the following: 1. Rate of disease in exposed and non-exposed group cannot be determined (Answer A) 33. However, it should be conducted if there is a genuine clinical equipoise exists, and its result will change clinical practice. Furthermore, having a concurrent control and experiment group avoids differences in quality of data collection, disease defnition, and standard of treatment. It uses intention-to-treat analysis to prevent statistical bias because intention-to-treat is an exact, nonparametric test that allows a valid inference about the P-value, without any assumption regarding the distribution. For example, it may not be possible to design a trial that is blinded to the treatment group if it is a procedure (i. However, only the primary outcomes should be used to change clinical practice because all the allowable type I error has been used to treat the primary hypothesis for the primary outcome. Subjects must be free of the disease of interest at the beginning of the study and also must be at risk for developing the disease C. Classically, it is a study in which the investigator selects a group of exposed individuals and a group of nonexposed individuals and then follows them into future and monitors them for development of the disease under study. Both follow participants longitudinally and monitor rates of one or more than one outcome. Both select groups to achieve comparability, although the relative proportion of subjects in compared groups do not refect that of the general population. For instance, experimental study investigators allocate the exposure themselves, and cohort study subjects choose their exposures. Experimental studies use randomization to achieve comparability while cohort studies must carefully select groups and measure potential confounders to achieve comparability. Answer: B—The fundamental assumption underlying the design of all cohort study is that the subjects in a cohort study are disease-free at the beginning of the study and they also must be at risk for developing the disease. This is important because it ensures the postulated cause is assessed before the occurrence of the disease. A cohort-design study also allows us to study multiple outcomes at the same time, as well as estimate the incidence of the disease in a population. In order to have high internal validity, there must be a mechanism to ensure high follow-up rate. Therefore, it is essential to choose the populations that are well- defned, so it is possible to gain access to data through centralized sources and minimize loss to follow-up. Since both groups in the cohort study do not have the disease at the beginning, and if the disease is rare, it would take a long time to acquire enough cases; thus, the cohort study is not the best design to study rare diseases (Answer D). Case control design may be a better design for rare diseases or disease with long period of latency. How long records must be kept for a suspected transfusion reaction evaluation/investigation? How long records must be kept for annual review of policies, processes, and procedures? A focus on quality is critical in order to meet the needs of customers and ensure the safety, purity, and potency of the blood products transfused to patients. Regulatory agencies and accrediting organizations provide over- sight for these processes by scheduling inspections and setting up profciency testing. This chapter re- views quality and regulatory concepts in blood banking and introduces some principles related to disaster management. Process improvement Concept: A quality management system encompasses all processes required for an organization to deliver the desired service and consistently meet the needs and expectations of the customers.

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These techniques are used infrequently the dearth of available scientific evidence regarding inter- because of the certainty of producing neurologic deficit purchase prilosec mastercard gastritis symptoms after eating. None- theless purchase 10 mg prilosec with amex gastritis and gastroparesis diet, the potential for partial neurolysis and significantly worsened pain is very real buy prilosec with a mastercard gastritis kronik adalah. Like the sympathetic blocks, Positioning there has been no rigorous testing of the safety and efficacy of this treatment approach and we can rely only on small, The patient lies prone, with the head turned to one side uncontrolled observational trials for hints at usefulness. The C-arm is centered over the hemithorax The use of intercostal nerve blocks using local anesthetic on the side to be treated with 15 to 20 degrees of cau- with or without corticosteroid for treatment of chronic dal angulation. The intercostal nerves course in a groove chest wall pain unrelated to cancer, for example, intercos- beneath the rib, and the caudal angulation ensures the tal neuralgia following thoracotomy, is of limited value and needle will traverse cephalad beneath the rib margin is unlikely to produce any long-term benefit. The C-arm is centered over the hemithorax to be treated with 15 to 20 degrees of caudal angulation to ensure the needle passes in a caudal-to-cephalad direction beneath the inferior margin of the rib. Chapter 14 Intercostal Nerve Block and Neurolysis 201 Block Technique subcutaneous tissues. The rib lies just 1 to 2 cm beneath the skin in their course from the paravertebral region to the anterior the patient of average build, so care must be taken not chest wall. To obtain complete anesthesia along the trunk to advance the needle too far before confirming its tra- within the distribution of a given intercostal nerve, the jectory using fluoroscopy. The direction of the needle is nerve must be blocked before the posterior cutaneous then adjusted to direct the tip toward the inferior margin branch arises (posterior to the posterior axillary line, see of the rib and advanced to contact the rib margin. Access to the intercostal nerves is blocked by use of small-gauge needles is advocated by some experts, the overlying scapula above the level of T6 over the poste- but because they bend easily, detecting contact with bone rior chest wall; thus, the block must be carried out medial is more difficult. Once the needle is in contact with the to the medial scapular border at these levels. Although inferior margin of the rib, the slight cephalad angle of intercostal blocks can be performed with the patient in the needle is maintained, and the needle is walked off nearly any position, the simplest way to perform multi- the inferior margin of the rib and advanced 2 to 3 mm ple intercostal blocks is with the patient fully prone. A small volume of radiographic shoulder can be easily abducted, placing the forearm over contrast is then injected to ensure that the needle is in the head to swing the scapula laterally and gain access to good position and there is no intravascular injection. The flat portion of each rib is easily pal- the needle is too superficial, the contrast will layer within pated several centimeters from midline, and the inferior a muscle layer and appear striated (Fig. The levels to be blocked needle is adjacent to the intercostal nerve, the contrast should be chosen based on the pattern of pain and the typically extends along the inferior margin of the rib, out- location of any chest wall metastases. For tempo- large metastatic lesions, block of the intercostal nerves rary or diagnostic intercostal nerve block, 2 to 4 mL of one level above and below the affected rib may be neces- local anesthetic is placed at each level (0. With injection of local anesthetic, the con- The block is then carried out sequentially at each trast is diluted and spreads along the course of the inter- level. The same procedure is carried identified on fluoroscopy, and a skin wheal of local anes- out for adjacent levels. The small distance between the thetic is placed to provide anesthesia of the skin and rib’s inferior margin and the pleura must be emphasized; A Figure 14-5. Three-dimensional reconstruction com- puted tomography of the thorax as viewed in the anterior-posterior projection. Anterior-posterior radiograph of the chest during intercostal nerve block demonstrating intramuscular injection. A needle is in position just inferior to the inferior mar- gin of the third rib, ∼5cm from midline. One milliliter of radiographic contrast has been injected (iohexol 180 mg per mL) and spans the space between the third and the fourth ribs with a striated pattern extending in an inferior and lateral direction indicat- ing superficial placement within the external intercostal muscle. Clavicle Transverse process of T1 1st rib Medial border of scapula 2nd rib 3rd rib Spinous 4th rib processes Contrast Needle in external tip intercostal m. A: Anterior-posterior radiograph of the chest during the second intercostal neurolysis. A needle is in position just inferior to the inferior margin of the second rib, ∼5 cm from mid- line. Three milliliters of radiographic contrast containing phenol have been injected (10% phenol in iohexol 180 mg per mL). The neurolytic solution has spread along the course of the intercostal nerve, extending medially to the paravertebral space and several centime- ters lateral from the point of injection. Chapter 14 Intercostal Nerve Block and Neurolysis 203 Clavicle Transverse process of T1 1st rib Medial border of scapula 2nd rib 3rd rib Spinous 4th rib processes 5th rib Contrast Contrast along course in external of intercostal nn. Anterior-posterior radiograph of the chest during the fifth intercostal neurolysis. A: A nee- dle is in position just inferior to the inferior margin of the fourth rib, ∼5cm from midline. Three milliliters of radiographic contrast containing phenol have been injected (10% phe- nol in iohexol 180 mg per mL). The neurolytic solution has spread along the course of the intercostal nerve, extending several centimeters medial and lateral from the point of injection. Thus, close attention must be paid to the total local Neurolysis of the intercostal nerves is carried out in the anesthetic dose delivered and to adequate monitoring, same manner described for intercostal nerve blocks using intravenous access, and ready availability of resuscitation local anesthetic. The use of 10% Centers with extensive experience using intercostal nerve phenol in radiographic contrast (e. Injection of 2 to 4 mL of neurolytic clinically insignificant, but radiographically demonstrable solution is usually sufficient to produce spread along a pneumothorax is somewhat higher (0. When intercostal neurol- mode (M-mode) ultrasound provides a sensitive and simple ysis is carried out close to the proximal portion of the rib, technique for detecting even the smallest pneumothoraces the contrast will often extend to the paravertebral space and (see Fig. Treatment of most pneumothoraces extend through the intervertebral foramen to the lateral epi- should be conservative, with observation and administra- dural space. Needle extension of the contrast into the epidural space is unlikely aspiration or chest tube drainage is rarely necessary and to cause adverse effects and may well improve the results of should be reserved only for patients with symptomatic neurolysis. Worsening of pain can arise during intercostal neuroly- sis and is likely the result of incomplete neurolysis of the Complications treated intercostal nerve. Such patients typically report Because of the close proximity of vascular structures to worsened pain in the distribution of the treated intercostal the intercostal nerves, there is a significant risk of direct nerve and may develop signs and symptoms of neuropathic 204 Atlas of Image-Guided Intervention in Pain Medicine pain, including burning or lancinating pain and allodynia in root for intercostal neurolysis: a case report. Phenol neurolysis for at least one case report of spinal cord injury following inter- severe chronic nonmalignant pain: is the old also obsolete? Intrathecal infusion of opioid, opioid and adjuvant analgesic combinations, or ziconotide may be used in selected patients with persistent, cancer-related pain unresponsive to more conservative treatments. Shared decision making regarding intrathecal infusion should include a specific discussion of potential complications. Neuraxial opioid trials should be performed before considering permanent implantation of intrathecal drug delivery systems. Intrathecal infusion of opioid, opioid and adjuvant analgesic combinations, or ziconotide may be used in selected patients with persistent, noncancer pain unresponsive to more conservative treatments. Shared decision making regarding intrathecal infusion should include a specific discussion of potential complications. Neuraxial opioid trials should be performed before considering permanent implantation of intrathecal drug delivery systems. The use of intrathecal morphine has been compared on Chronic Pain Management published a 2010 Prac- with maximum medical therapy in the treatment of patients tice Guideline, offering the following recommendations: with advanced cancer and shown to provide comparable pain “Ziconotide infusion may be used in the treatment of a relief with significantly fewer opioid-related adverse effects, select subset of patients with refractory chronic pain. Intrathecal ziconotide has “Intrathecal opioid injection or infusion may be used for been compared with placebo in the treatment of patients patients with neuropathic pain.

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Nutrient–Drug Interactions 109 growth order generic prilosec canada gastritis symptoms yahoo answers, pregnancy generic prilosec 40 mg free shipping chronic gastritis histology, and lactation) increase the susceptibility to drug-induced nutrient defciencies discount prilosec 20 mg gastritis home treatment. Failure to identify and address the impact of a drug–nutrient interaction can result in serious consequences. For example, the absorption of an orally admin- istered antibiotic can be reduced, leading to treatment failure. Conversely, patients could develop drug toxicity if a nutrient inhibits enzymes in the gut that detoxify the medication. When developing a therapeutic plan, it is important that the prac- titioner considers the interactions that can occur between nutritional status, disease state, and drug action, and even patient age. By defnition, pharmacodynamics is the study of the biochemical and clinical effects of drugs and the mechanisms of their action, including the correlation of actions and effects of drugs with their chemical structure, as well as the effects on the actions of another drug or nutrient. In con- trast, the quantitative description of drug disposition is termed pharmacokinetics. This refers to the exposure of drugs in the body over a period of time, including the processes of absorption, distribution in tissues, metabolism, and elimination. This chapter will review how nutrition affects drug therapy with a particular emphasis on anti-infective agents. Before reaching the systemic circula- tion and the sites of action, both nutrients and drugs delivered through the gastro- intestinal tract must go through an absorption phase. Once absorbed, the compounds go from the gastrointestinal lumen into the hepatic portal vein and subsequently to the systemic circulation through a series of complex processes, including the disso- lution of the solid dosage form, the passage of the chyme along the gastrointestinal tract (i. As a result, intraluminal pH in different areas of the gastrointestinal tract can affect medication stability, dissolution rate of solid dosage forms, and even the extent of drug absorption in some cases. Taken together, both gastric emptying and intestinal transit time have a signifcant impact on the rate and magnitude of the oral absorption of the drugs and certain nutrients. Presystemic effect occurs 110 Nutrition–Infection Interactions and Impacts on Human Health primarily in the intestine and the liver; the stomach has only a minor role. Many active transport proteins and drug-metabolizing enzymes are present in the intestinal epithelial tissues. Induction or inhibition of the enzyme in the gut by nutrients can affect the oral bioavailability of drugs. There is no well-documented dietary factor known to promote the maturation of these enzymes during the prenatal period and infancy. There are four basic classifcations of drug–food interactions that are based on their nature and mechanism. Type I ex vivo bioinactivations—These are interactions that occur between the drug and the nutrient, usually in the delivery device, through biochemi- cal or physical reactions. Examples include complexation, hydrolysis, neutralization, oxidation, and precipitation. These interactions are most commonly seen with drugs and nutrients administered intravenously or through feeding tubes. This can result in changes in tissue distribution, transport, or penetration to a specifc organ or tissue. In most instances, food will stimulate both gastric and intestinal secre- tions, thus improving drug dissolution and aiding in its absorption. In the case of high-fat meals, the intestinal uptake of highly lipophilic drugs is improved owing to the release of bile salts triggered by the dietary fat. Furthermore, dietary fat can stimulate the release of cholecystokinin, which decreases gastric motility, thus increasing the contact time between the drug and the intestine and can potentially increase drug absorption. For example, the antibiotics erythromycin ethylsuccinate and cefuroxime should both be taken with food to maximize their absorption. Conversely, the composition of some foods may hinder drug absorption through binding. In some instances, the dosage form of the antibiotic will determine if such meal timing is necessary. For example, the azalide antibiotic azithromycin, when the capsule form is administered in the fed state, exhibits a nega- tive food effect in which there is lower azithromycin bioavailability in comparison to the tablet form. Given that most drugs are absorbed in the small intestine, transport pro- teins present in the enterocytes play an essential role in facilitating the absorption of 114 Nutrition–Infection Interactions and Impacts on Human Health many drugs. This is believed to be an intrinsic protective mechanism by the host to minimize xenobiotic exposure. Hepatic transporters are membrane proteins that facilitate nutrient and drug transport into the cell through uptake transporters or pump out toxic entities through canalicular transporters. For example, isothiocyanates, a class of chemo- therapeutic agents derived from cruciferous vegetables (i. In patients unable to swallow, enteral feeding is the preferred method of providing nutrition support and also allows easy access for administering medications. However, enteral feeding for- mulas have been implicated in numerous drug–nutrient interactions. Medications may adhere to the sides of the feeding tube, and thus not be delivered to the patient, or may obstruct the tube in the case of an oral solid not properly pulverized and diluted before administration. In some instances, medica- tions are best absorbed in the “fasted” state, requiring that feedings be held so as to optimize absorption. Owing to the narrow bore of the devices and direct administration of medication into the small intestine, liquid dosage forms of medications (e. However, when administering oral dosage forms, several factors should be considered, including the osmolality of the drug, its viscosity, and particle size. Dumping can result when a hypertonic medication is not diluted before administra- tion into the small bowel. The osmolality of stomach secretions is approximately 300 mOsm/kg, and many liquid medications exceed this value signifcantly, result- ing in an osmotic-induced diarrhea if given in its undiluted state. When an undi- luted hypertonic medication is administered, gastric-emptying rates are altered, resulting in a fux of water and electrolytes into the small bowel, overwhelming its absorptive capacity. Proper dilution of the medication can prevent this fux as well as improve drug and nutrient absorption. Furthermore, if the feeding tube does ter- minate in the jejunum, the pH must also be considered to assure optimal dissolution of certain dosage forms occurs. Both undernutrition and obesity can alter drug pharmacokinetics and pharmacologic responses substantially by causing functional and structural altera- tions in organs that directly affect drug disposition. Interindividual and intraindividual variations in the pharmacokinetic responses to a medication can further complicate interpreting the real impact of altered nutritional status on drug disposition. The integrity of the intestinal mucosa is dependent on a continuous intake of adequate nutrition, as the turnover of enterocytes in the small intestine takes 2–3 days, and in the colonocytes of the large intestine 3–5 days. Therapeutic drug levels may be altered as a result of malnutrition-associated tissue receptor alterations. This suggests that close therapeutic drug monitoring and dose adjust- ments are imperative in malnourished patients. It is possible that the high morbidity or mortality, a characteristic of malnutrition, may be enhanced by adverse drug reactions.

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