Aust Prescr
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Digoxin toxicity can emerge during long-term therapy as well as after an overdose. It can occur even when the serum digoxin concentration is within the therapeutic range. Toxicity causes anorexia, nausea, vomiting and neurological symptoms. ⋯ Digoxin-specific antibody fragments are safe and effective in severe toxicity. Monitoring should continue after treatment because of the small risk of rebound toxicity. Restarting therapy should take into account the indication for digoxin and any reasons why the concentration became toxic.
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The pharmacokinetics of a drug may be altered in patients with renal impairment who require dialysis. Some drugs are contraindicated. The drug's clearance and therapeutic index determine if a dose adjustment is needed. ⋯ Consult a reference source or the patient's nephrologist before prescribing. Start at a low dose and increase gradually. If possible give once-daily drugs after dialysis.
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If there are no features of serious disease, suspected gastro-oesophageal reflux disease can be initially managed with a trial of a proton pump inhibitor for 4-8 weeks. This should be taken 30-60 minutes before food for optimal effect. Once symptoms are controlled, attempt to withdraw acid suppression therapy. ⋯ Weight loss has the strongest evidence for efficacy. Further investigation and a specialist referral are required if there is no response to proton pump inhibitor therapy. Atypical symptoms or signs of serious disease also need investigation.
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An anal fissure is a common, mostly benign, condition that can be acute or chronic. The diagnosis is usually made on history and physical examination, but further investigations are sometimes necessary. Primary fissures are usually benign and located in the posterior or anterior position. ⋯ If these treatments are ineffective the patient will need a surgical referral. Secondary anal fissures require further investigation. Multidisciplinary management is preferable and is essential in the case of malignancy.