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With persistent and more severe hypercalcemia primary hiv infection stories purchase movfor once a day, kidney function is affected hiv infection during pregnancy cheap movfor 200mg with amex, resulting in polyuria, nocturia, and proteinuria, in addition to neurologic symptoms such as seizures, confusion, and ataxia. Calcium deposition in soft tissues can damage the heart, blood vessels, and lungs; calcium deposition in the kidneys can cause nephrolithiasis. Very large doses of vitamin D can cause decalcification of bone, resulting in osteoporosis; mobilization of bone calcium can occur despite the presence of high calcium concentrations in blood. Treatment consists of stopping vitamin D intake, reducing calcium intake, and increasing fluid intake. Pharmacokinetics As a rule, vitamin D is administered orally and then absorbed from the small intestine. Viewing Vitamin D as a Hormone Although referred to as a vitamin, vitamin D has all the characteristics of a hormone. With sufficient exposure to sunlight, the body can manufacture all the vitamin D it needs. Following its production in the skin, vitamin D travels to other locations (liver, kidney) for activation. Like other hormones, activated vitamin D then travels to various sites in the body (bone, intestine, kidney) to exert regulatory actions. Also like other hormones, vitamin D undergoes feedback regulation: As plasma levels of calcium fall, activation of vitamin D increases; when plasma levels of calcium return to normal, activation of vitamin D declines. Therapeutic Uses the primary indications for vitamin D are nutritional rickets, osteomalacia, and hypoparathyroidism. Preparations, Dosage, and Administration There are five preparations of vitamin D. Three of these-ergocalciferol, cholecalciferol, and calcitriol-are identical to forms of vitamin D that occur naturally. Two forms of vitamin D-vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol)-are used routinely as dietary supplements. Vitamin D3 [Delta-D] is given as a dietary supplement, and for prophylaxis and treatment of vitamin D deficiency. Compared with ergocalciferol (vitamin D2), cholecalciferol (vitamin D3) is more effective at raising blood levels of vitamin D. Calcitriol [Rocaltrol, Vectical, Calcijex, Silkis is indicated for treatment of hypoparathyroidism and management of hypocalcemia in patients undergoing chronic renal dialysis. Doxercalciferol [Hectorol] is indicated for prevention and treatment of secondary hyperparathyroidism in patients undergoing chronic renal dialysis. With oral administration, treatment begins with 10 mcg 3 times weekly administered at dialysis; dosage may be gradually increased to a maximum of 20 mcg 3 times a week. Like doxercalciferol, paricalcitol [Zemplar] is indicated for prevention and treatment of secondary hyperparathyroidism in patients undergoing chronic renal dialysis. With oral administration, two schedules may be used: (1) once daily and (2) 3 times a week. Treatment begins at 1 to 2 mcg/dose (with the oncedaily schedule) or 2 to 4 mcg/dose (with the 3-times-weekly schedule). Calcitonin-salmon, given by nasal spray or injection, is indicated for treatment of established postmenopausal osteoporosis-but not for prevention. The treatment program should include supplemental calcium and adequate intake of vitamin D. Calcitonin can lower plasma calcium levels in patients with hypercalcemia secondary to hyperparathyroidism, vitamin D toxicity, and cancer. Levels of calcium (and phosphorus) are reduced owing to inhibition of bone resorption and increased renal excretion of calcium. Although calcitonin is effective against hypercalcemia, it is not a preferred treatment. Adverse Effects With intranasal dosing, nasal dryness and irritation are the most common complaints.

The goal is to counteract the potassium-wasting effects of the more powerful diuretic hiv infection when undetectable discount movfor online visa. Because of the risk of hyperkalemia capside viral anti vca-igg buy generic movfor 200 mg, caution must be employed when combining spironolactone with potassium supplements, salt substitutes (which contain potassium chloride), or another potassium-sparing diuretic. Preparations, Dosage, and Administration Spironolactone [Aldactone] is dispensed in tablets (25, 50, and 100 mg) for oral dosing. Spironolactone is also marketed in a fixed-dose combination with hydrochlorothiazide under the trade name Aldactazide. Triamterene Mechanism of Action Like spironolactone, triamterene [Dyrenium] disrupts sodiumpotassium exchange in the distal nephron. The net effect of inhibition is a decrease in sodium reabsorption and a reduction in potassium secretion. Because it inhibits ion transport directly, triamterene acts much more quickly than spironolactone. Is pharmacologically inert (ie, it has no direct effects on the biochemistry or physiology of cells). Therapeutic Uses Triamterene can be used alone or in combination with other diuretics to treat hypertension and edema. When combined with other diuretics (eg, furosemide, hydrochlorothiazide), triamterene augments diuresis and helps counteract the potassiumwasting effects of the more powerful diuretic. Hyperkalemia is most likely when triamterene is used alone, but can also occur when the drug is combined with thiazides or loop diuretics. Caution should be employed when triamterene is used in conjunction with another potassium-sparing diuretic or with potassium supplements or salt substitutes. Relatively common side effects include nausea, vomiting, leg cramps, and dizziness. Preparations, Dosage, and Administration Triamterene [Dyrenium] is available in 50- and 100-mg capsules for oral use. Triamterene is also marketed in fixed-dose combinations with hydrochlorothiazide under the trade names Dyazide and Maxzide. As a result, most of the filtered drug remains in the nephron, creating an osmotic force that inhibits passive reabsorption of water. The degree of diuresis produced is directly related to the concentration of mannitol in the filtrate: the more mannitol present, the greater the diuresis. Mannitol has no significant effect on the excretion of potassium and other electrolytes. Under certain conditions (eg, dehydration, severe hypotension, hypovolemic shock), blood flow to the kidney is decreased, causing a great reduction in filtrate volume. When the volume of filtrate is this low, transport mechanisms of the nephron are able to reabsorb virtually all of the sodium and chloride present, causing complete reabsorption of water as well. Because filtered mannitol is not reabsorbed-even when filtrate volume is small-filtered mannitol will remain in the nephron, drawing water with it. Thiazides and loop diuretics are not as effective for this application because, under conditions of low filtrate production, there is such an excess of reabsorptive capacity (relative to the amount of filtrate) that these drugs are unable to produce sufficient blockade of reabsorption to promote diuresis. There is no risk of increasing cerebral edema because mannitol cannot exit the capillary beds of the brain. The hyperosmotic plasma creates an osmotic force that draws ocular fluid into the blood. Both drugs inhibit potassium loss by direct blockade of sodiumpotassium exchange in the distal nephron. Although it can be employed alone as a diuretic, amiloride is used primarily to counteract potassium loss caused by more powerful diuretics (thiazides, loop diuretics). Accordingly, concurrent use of other potassium-sparing diuretics or potassium supplements must be monitored closely. Mannitol can leave the vascular system at all capillary beds except those of the brain.

Other long-acting products-sustained-release hiv infection no fever buy movfor 200 mg on line, controlled-release hiv infection rate mexico effective movfor 200 mg, or timed-release (eg, Slo-Niacin)- should be avoided, owing to increased risk of liver damage. Exercise caution in patients with gout, and even in patients who have hyperuricemia but no symptoms of gout. Administration Instruct patients to mix cholestyramine powder and colestipol granules with water, fruit juice, soup, or pulpy fruit (eg, applesauce, crushed pineapple) to reduce the risk of esophageal irritation and impaction. Inform patients that the sequestrants are not water soluble, so the mixtures will be cloudy suspensions, not clear solutions. Ongoing Evaluation and Interventions Evaluating Therapeutic Effects Blood lipid levels should be monitored monthly early in treatment and at longer (3- to 6-month) intervals thereafter. Advise patients that flushing can the importance of diet in controlling lipid levels and arrange for dietary counseling. In addition to following the guide- Ongoing Evaluation and Interventions Evaluating Therapeutic Effects Cholesterol levels should be monitored monthly early in treatment and at longer intervals thereafter. Inform patients that be reduced by taking 325 mg of aspirin 30 minutes before each dose, or by using an extended-release product (eg, Niaspan). Niacin may injure the liver, causing constipation can be minimized by increasing dietary fiber and fluids. Administration Instruct patients to administer gemfibrozil 30 minutes before the morning and evening meals. Cholestyramine and colestipol-but not colesevelam-can bind with other drugs and prevent their absorption. Advise patients to administer other medications 1 hour before these sequestrants or 4 hours after. Cholestyramine and colestipol- Ongoing Evaluation and Interventions Evaluating Therapeutic Effects Obtain periodic tests of blood lipids. Identifying High-Risk Patients Gemfibrozil is contraindicated for patients with liver disease, severe renal dysfunction, and gallbladder disease. Warn patients to report any signs of muscle injury, such as tenderness, weakness, or unusual muscle pain. Gemfibrozil enhances the effects of warfarin, thereby increasing the risk of bleeding. Obtain more frequent measurements of prothrombin time and assess the patient for signs of bleeding. Reduction of warfarin dosage may be required, and reassessment and readjustment of the warfarin dosage may be needed if the fibrate is stopped. The principal determinants of cardiac oxygen demand are heart rate, myocardial contractility, and, most importantly, intramyocardial wall tension. Under resting conditions, the heart extracts nearly all of the oxygen delivered to it by the coronary vessels. Therefore, the only way to accommodate an increase in oxygen demand is to increase blood flow. When oxygen demand increases, coronary arterioles dilate; the resultant decrease in vascular resistance allows blood flow to increase. It is important to note that myocardial perfusion takes place only during diastole (ie, when the heart relaxes). Perfusion does not take place during systole because the vessels that supply the myocardium are squeezed shut when the myocardium contracts. Anginal pain is precipitated when the oxygen supply to the heart is insufficient to meet oxygen demand. Most often, angina occurs secondary to atherosclerosis of the coronary arteries, so angina should be seen as a symptom of a disease and not as a disease in its own right. In the United States, more than 10 million people have chronic stable angina; about 500,000 new cases develop annually. In this chapter, we focus on antianginal drugs (ie, drugs that prevent myocardial ischemia and anginal pain). There are three main families of antianginal agents: organic nitrates (eg, nitroglycerin), beta blockers (eg, metoprolol), and calcium channel blockers (eg, verapamil). In addition, a fourth agent- ranolazine-can be combined with these drugs to supplement their effects. Beta blockers and calcium channel blockers are discussed at length in previous chapters, and so consideration here is limited to their use in angina.

To help avoid drug-disease mismatches early hiv symptoms sinus infection buy movfor cheap, the medical history should identify all comorbid conditions hiv infection rates white females purchase 200 mg movfor with visa. With this information, the prescriber can choose drugs that are least likely to make the comorbid condition worse. High initial doses and rapid dosage escalation can increase the incidence and severity of adverse effects. Lastly, antihypertensive drugs can cause a number of adverse effects, ranging from sedation to hypotension to impaired sexual function. It is difficult to convince people who are feeling good to take drugs that may make them feel worse. Some people may decide that exposing themselves to the negative effects of therapy today is paying too high a price to avoid the adverse consequences of hypertension at some indefinite time in the future. Promoting Adherence the major cause of treatment failure in patients with chronic hypertension is lack of adherence to the prescribed regimen. In this section we consider the causes of nonadherence and discuss some solutions. Why Adherence Is Often Hard to Achieve Much of the difficulty in promoting adherence stems from the nature of hypertension itself. Hypertension is a chronic, slowly progressing disease that, through much of its course, is devoid of overt symptoms. Because symptoms are absent, it can be difficult to convince patients that they are ill and need treatment. In addition, since there are no symptoms to relieve, drugs cannot produce an obvious therapeutic response. In the absence of such a response, it can be difficult for patients to believe that their medication is doing anything useful. Because hypertension progresses very slowly, the disease tends to encourage procrastination. For most people, the adverse effects of hypertension will not become manifest for many years. Realizing this, patients may reason (incorrectly) that they can postpone therapy without significantly increasing risk. Antihypertensive regimens can be complex and Ways to Promote Adherence Patient Education. Patients should be taught about the consequences of hypertension and the benefits of treatment. Because hypertension does not cause discomfort, it may not be clear to patients that their condition is indeed serious. Patients must be helped to understand that, left untreated, hypertension can cause heart disease, kidney disease, and stroke. In addition, patients should appreciate that, with proper therapy, the risks of these long-term complications can be minimized, resulting in a longer and healthier life. Lastly, patients must understand that drugs do not cure hypertension-they only control symptoms. This increases patient involvement and provides positive feedback that can help promote adherence. If we expect patients to comply with long-term treatment, we must keep adverse effects to a minimum. As discussed above, adverse effects can be minimized by (1) encouraging patients to report side effects, (2) discontinuing objectionable drugs and substituting more acceptable ones, (3) avoiding drugs that can exacerbate comorbid conditions, and (4) using doses that are low initially and then gradually increased. The patient who feels like a collaborative partner in the treatment program is more likely to comply than is the patient who feels that treatment is being imposed. Collaboration allows the patient to help set treatment goals, create the treatment program, and evaluate progress. In addition, a collaborative relationship facilitates communication about side effects. Antihypertensive regimens may consist of several drugs taken multiple times a day. Therefore, to promote adherence, the dosing schedule should be as simple as possible. Once an effective regimen has been established, dosing just once or twice daily should be tried. Adherence can be promoted by giving positive reinforcement when therapeutic goals are achieved.

Although therapeutic doses of acetaminophen may be safe for alcohol drinkers antiviral products movfor 200mg amex, high doses certainly are not antiviral used to treat flu purchase generic movfor from india. There is evidence that acetaminophen may increase the risk of bleeding in patients taking warfarin (an oral anticoagulant). The best guess is that acetaminophen may inhibit warfarin metabolism, which would cause warfarin levels to rise. Accordingly, for patients taking more than 1 gm of acetaminophen daily for several days, responses to warfarin should be monitored closely. Acetaminophen and other analgesic-antipyretics can blunt the immune response to childhood vaccines. Accordingly, routine use of these drugs to prevent vaccinationassociated pain and/or fever should be discouraged. Undernourished people are at risk because they have low stores of glutathione, the cofactor needed to convert the toxic metabolite of acetaminophen to a nontoxic form. To help reduce overdosage, McNeil Consumer Healthcare, maker of the Tylenol brand of acetaminophen, changed the dosing recommendations on Tylenol labels. On the new labels, issued in 2011, the maximum daily dose of ExtraStrength Tylenol (500 mg/tablet) is stated as 3000 mg (6 tablets), and the maximum daily dose of Regular Strength Tylenol (325 mg/tablet) is stated as 3250 mg (10 tablets). In fact, patients who just take a prescription combination product by itself can easily exceed 4000 mg of acetaminophen a day. You should note that the new limit applies only to prescription combination products. Numerous acetaminophen-containing products are on the market, including a wide assortment of fixed-dose combinations. Many products are available over the counter, and many others require a prescription. All these products are mentioned here because they create a significant risk of overdose-either from taking two or more products that both contain acetaminophen, or from taking too much of a singleingredient product (owing to failure to carefully read the label). The recommended oral dosage for adults and children over 12 years is 325 to 650 mg every 4 to 6 hours, up to a maximum of Therapeutic Uses Acetaminophen is indicated for relief of pain and fever. In addition, acetaminophen may be a safe alternative to aspirin for patients who have experienced aspirin hypersensitivity reactions. Because of its weak antiinflammatory actions, acetaminophen is not useful for treating arthritis or rheumatic fever. Acute Toxicity: Liver Damage Overdose with acetaminophen can cause severe liver injury and death. In the United States, acetaminophen overdose-intentional or unintentional-is the leading cause of acute liver failure, accounting for about 50% of all cases. Risk of liver injury is increased by fasting, chronic alcohol use, and taking more than 4000 mg of acetaminophen a day. Early symptoms of poisoning (nausea, vomiting, diarrhea, sweating, abdominal discomfort) belie the severity of intoxication. It is not until 48 to 72 hours after drug ingestion that overt indications of hepatic injury appear. Liver damage can be minimized by giving acetylcysteine [Mucomyst, Acetadote], a specific antidote to acetaminophen. Acetylcysteine reduces injury by substituting for depleted glutathione in the reaction that converts the toxic metabolite of acetaminophen to its nontoxic form. When given within 8 to 10 hours of acetaminophen overdose, acetylcysteine is 100% effective at preventing severe liver injury. And even when administered as much as 24 hours after poisoning, it can still provide significant protection. For oral therapy, acetylcysteine is supplied in solution (100 and 200 mg/mL), and should be diluted to 50 mg/mL with water, fruit juice, or a cola beverage. Conventional treatment consists of a loading dose (140 mg/kg) followed by 17 more doses (70 mg/kg) given every 4 hours for 72 hours. The first dose-150 mg/kg (in 200 mL of 5% dextrose)-is infused over 15 minutes to 1 hour. And the third dose-100 mg/kg (in 1000 mL of 5% dextrose)-is infused over 16 hours. Fortunately, these reactions tend to be mild and self-limiting, and can be minimized by infusing the initial dose slowly (over a 1-hour interval).

The goal is to relieve airway obstruction and hypoxemia antiviral mushrooms discount movfor, and normalize lung function as quickly as possible garlic antiviral order 200mg movfor with amex. Following resolution of the crisis and hospital discharge, an oral glucocorticoid is taken for 5 to 10 days. It is important to note that diagnosis is not based on spirometry alone; rather, the patient must have respiratory symptoms as well. Drugs for Exercise-Induced Bronchospasm Exercise increases airway obstruction in practically all people with chronic asthma. Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or intensive care unit admission) indicate poorer disease control. For treatment purposes, patients who had two or more exacerbations requiring oral glucocorticoids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma. The four classes of increasing severity are (1) mild, (2) moderate, (3) severe, and (4) very severe. Theophylline is reserved for use only when other bronchodilators are not available. Long-term inhaled glucocorticoids are recommended when symptoms are severe or when longacting bronchodilators are inadequate for management of exacerbations. Adverse effects include diarrhea, reduced appetite, weight loss, nausea, headache, back pain, insomnia, and depression. Roflumilast should be used in combination with tiotropium, a long-acting inhaled beta2 agonist, or an inhaled glucocorticoid. Other agents that may be used to control and shorten exacerbations include antibiotics for patients who have signs and symptoms of infection and supplemental oxygen to maintain an oxygen saturation of 88% to 92%. Most drugs for asthma are administered by inhalation, a route that increases therapeutic effects (by delivering drugs directly to their site of action), reduces systemic effects (by minimizing drug levels in blood), and facilitates rapid relief of acute attacks. Glucocorticoids are the most effective antiinflammatory drugs for asthma management. As an added bonus, glucocorticoids appear to promote synthesis of bronchial beta2 receptors, and increase their responsiveness to beta2 agonists. Inhaled and systemic glucocorticoids are used for longterm prophylaxis of asthma-not for aborting an ongoing attack. Their principal side effects are oropharyngeal candidiasis and dysphonia, which can be minimized by employing a spacer device during administration and by rinsing the mouth and gargling after use. Inhaled glucocorticoids can slow the growth rate of children, but they do not reduce adult height. To minimize loss, dosage should be as low as possible, and patients should perform regular weight-bearing exercise and should ensure adequate intake of calcium and vitamin D. Prolonged therapy with oral glucocorticoids can cause serious adverse effects, including adrenal suppression, osteoporosis, hyperglycemia, peptic ulcer disease, and growth suppression. Cromolyn reduces inflammation primarily by preventing release of mediators from mast cells. For prophylaxis of exercise-induced bronchospasm, cromolyn is taken 15 minutes before anticipated exertion. Beta2 agonists promote bronchodilation by activating beta2 receptors in bronchial smooth muscle. Three inhaled beta2 agonists-arformoterol, formoterol, and salmeterol-have a long duration of action and are indicated for long-term control. Excessive dosing with oral beta2 agonists can cause tachycardia and angina by activating beta1 receptors on the heart. Theophylline, a member of the methylxanthine family, relieves asthma by causing bronchodilation. Theophylline has a narrow therapeutic range and can cause serious adverse effects; it has been largely replaced by safer and more effective medications. There are four classes of chronic asthma: intermittent, mild persistent, moderate persistent, and severe persistent.

In contrast hiv infection rate greece movfor 200 mg line, among patients with hemophilia B hiv infection rate syria purchase 200 mg movfor with mastercard, only 20% to 45% have severe disease. Although severe hemophilia can be devastating, most patients can live normal and productive lives, thanks to the availability of safe factor concentrates for replacement therapy. However, serious bleeding can be induced by significant trauma, tooth extractions, and surgery. Joint bleeding may occur, but the frequency is much lower than with severe hemophilia. In the past, factor replacement was performed only to terminate a bleeding episode. Today, however, there is increasing emphasis on primary prophylaxis, especially for young children. By minimizing bleeding episodes, prophylaxis can minimize long-term damage to joints. Other treatments are also available, as discussed below under Managing Patients Who Develop Inhibitors. To minimize the risk of hepatitis (see below), all patients with newly diagnosed hemophilia should be vaccinated for hepatitis A and hepatitis B, as should all other patients with hemophilia who are not seropositive for hepatitis A or B. Family members who administer clotting factors at home should also be immunized, provided they test negative for hepatitis. First, aspirin causes irreversible inhibition of platelet aggregation, and can thus increase bleeding risk. Immunization Children with hemophilia should undergo the normal immunization schedule (see Chapter 68). Symptoms of a mild reaction include hives, rash, urticaria, stuffy nose, and fever. Symptoms of this potentially fatal reaction include wheezing, tightness in the throat, shortness of breath, and swelling in the face. Theoretically, the third-generation products-Advate and Xyntha-which are never exposed to any proteins of animal or human origin, are safer than the first- or second-generation products. With all three generations, the risk of human viral contamination is essentially zero. The iliopsoas is a compound muscle consisting of the iliacus and psoas major muscles, located in the groin region. Data from World Federation of HemoPhilia: Guidelines for the Management of Hemophilia. On-demand therapy is indicated for patients who are bleeding or about to undergo surgery. Continuous infusion may also be done, but only by a clinician with special training. For example, when treating a joint bleed, the dosing target is 40% of the normal activity level. The goal is to prevent bleeding, and thereby prevent life-threatening hemorrhage and long-term injury to joints. Options include an external catheter (eg, Hickman catheter) or an implanted venous port (eg, Port-A-Cath). Both types of device are intended for longterm use, and can remain in place for several years. It should be noted, however, that although these devices make prophylaxis much easier, they do carry risks, especially infection and thrombosis. Desmopressin can be used to stop episodes of trauma-induced bleeding, and can be given preoperatively to maintain hemostasis during surgery. The basic pharmacology of desmopressin, along with its use in hypothalamic diabetes insipidus, is discussed in Chapter 59. For patients who weigh 50 kg or more, the dosage is 150 mcg/nostril, for a total of 300 mcg.

Ongoing Evaluation and Interventions Evaluating Therapeutic Effects Assess for improvements in hematologic and neurologic status hiv infection timeline symptoms cheap movfor 200mg otc. Neurologic damage may take months to improve; in some cases hiv infection symptoms after one year generic 200 mg movfor free shipping, full recovery may never occur. For patients receiving long-term therapy, vitamin B12 levels should be measured every 3 to 6 months, and blood counts should be performed. Minimizing Adverse Effects Hypokalemia may develop during the first days of therapy. Monitor serum potassium levels and observe the patient for signs of potassium insufficiency. To rule out vitamin B12 deficiency, vitamin B12 determinations and a Schilling test may be ordered. Identifying High-Risk Patients Folic acid is contraindicated for patients with pernicious anemia (except during the acute phase of treatment). Inappropriate use of folic acid by these patients can mask signs of vitamin B12 deficiency, allowing further neurologic deterioration. To reduce the risk of neural tube defects, women who might become pregnant should consume 400 to 800 mcg of supplemental folate daily-in addition to the folate they get from food. Once symptoms of hypokalemia (eg, muscle weakness, irregular heartbeat) and instruct them to report these immediately. Minimizing Adverse Interactions Folic acid can correct hematologic effects of vitamin B12 deficiency, but not the neurologic effects. By improving the hematologic picture, folic acid can mask ongoing B12 deficiency, resulting in undertreatment and progression of neurologic injury. Accordingly, when folic acid and cyanocobalamin are used concurrently, special care must be taken to ensure that the cyanocobalamin dosage is adequate. Baseline laboratory data include serum folate levels, erythrocyte and reticulocyte counts, and hemoglobin and *Patient education information is highlighted as blue text. Implementation: Measures to Enhance Therapeutic Effects Improving Nutrition If the diet is deficient in folic acid, advise the patient to increase consumption of folate-rich foods (eg, green vegetables, liver). If alcoholism underlies dietary deficiency, offer counseling for alcoholism as well as dietary advice. Ongoing Evaluation and Interventions Evaluating Therapeutic Effects Monitor hematologic status. Within 2 weeks, megaloblasts should disappear, reticulocyte counts should increase, and the hematocrit should begin to rise. Unfortunately, although these drugs can be beneficial, postmarketing surveillance has shown clear evidence of harm. The process is regulated in part by hematopoietic growth factors-naturally occurring hormones that stimulate the proliferation and differentiation of hematopoietic stem cells, and enhance function in the mature forms of those cells. In a laboratory setting, hematopoietic growth factors can cause stem cells to form colonies of mature blood cells. Because of this action, some hematopoietic growth factors are also known as colonystimulating factors. The names used for the hematopoietic growth factors are a potential source of confusion. Each product has a biologic name, a generic name, and one or more proprietary (trade) names. The protein portion of epoetin alfa is identical to that of human erythropoietin, a naturally occurring hormone. In addition, the drug can be used to elevate erythrocyte counts in anemic patients before elective surgery. The hormone is produced by peritubular cells in the proximal tubules of the kidney. In response to anemia or hypoxia, circulating levels of erythropoietin rise dramatically, triggering an increase in erythrocyte synthesis. However, because production of erythrocytes requires iron, folic acid, and vitamin B12, the response to erythropoietin is minimal if any of these is deficient. Erythropoietin has significant physiologic effects outside the hematopoietic system.