What are the normal values of blood pressure, blood sugar, blood lipids and uric acid for people of different ages?👀👀👀

Blood pressure, blood sugar, blood lipids and uric acid are the four basic
indicators for evaluating the health of the human body. However, the values of these indicators are not fixed and it will change with age. Therefore, some people will mistakenly think that they are unhealthy when they find that the value of the index is different from the standard value after the physical examination.

What is the normal blood pressure value?

A person's blood pressure should neither be too high nor too low. Excessive blood pressure can damage organs or tissues such as the cardiovascular system and kidneys. It also increases the risk of stroke. Low blood pressure prevents sufficient delivery of oxygen and blood to all parts of the body. It can cause fatigue, weakness, dizziness, and even fainting. Low blood pressure also increases the risk of stroke. However, in fact, people's blood pressure is not always stable. A person's blood pressure can vary at different times of the day and in different physical conditions. The following is the reference value of normal blood pressure for people of various ages:

Age	Systolic blood pressure (Male)	Diastolic blood pressure (Male)	Systolic blood pressure (Female)	Diastolic blood pressure (Female)
16-20 y/o	115	73	110	70
21-25 y/o	115	73	110	71
26-30 y/o	115	75	112	73
31-35 y/o	117	76	114	74
36-40 y/o	120	80	116	77
41-45 y/o	124	81	122	78
46-50 y/o	128	82	128	79
51-55 y/o	134	84	134	80
56-60 y/o	137	84	139	82
61-65 y/o	148	86	145	83

The following table will indicate the blood pressure status represented by each blood pressure range:

Type	Systolic blood pressure	Diastolic blood pressure
Hypotension	Below 90	Below 60
Ideal blood pressure	About 120	About 80
Normal blood pressure	Below 130	Below 85
Normal hypertension	130-139	85-89
Borderline hypertension	140-149	90-94
Mild hypertension	140-159	90-99
Simple systolic hypertension	Over140	Below 90
Moderately hypertension	160-179	100-109
Highly hypertension	Over 180	Over110

However, many factors such as mood, exercise and temperature can affect blood pressure values. Therefore, a single blood pressure measurement cannot be used as a diagnostic result.

What is the normal blood glucose value?

Similarly, too high or too low blood sugar will also have adverse effects on the human body. Excessive blood glucose can cause disease in the patient's large blood vessels. These lesions include atherosclerosis in the basilar arteries, coronary arteries, aorta, renal arteries, and peripheral arteries. These patients tend to have severe atherosclerosis and high mortality. About 70 to 80% of diabetic patients die of diabetic macrovascular disease. In addition, hypoglycemia will also damage the patient's health. Hypoglycemia may lead to memory loss, slow reaction time, dementia, coma, and even death. Hypoglycemia may also induce arrhythmia and myocardial infarction in patients. People's blood glucose levels change as they eat, digest and absorb food. Therefore, fasting blood glucose and postprandial blood glucose are generally used as reference values. 

	Venous (whole blood)	Capillary	Venous (plasma)
Normal value - fasting	3.9 – 6.1
Normal values – 2hrs after meals	Below 7.8
Diabetics - fasting	Over 6.1	Over 6.1	Over 7.0
Diabetics - 2hrs after meals	Over 10	Over 11.1	Over 11.1
Impaired glucose tolerance - fasting	Below 6.1	Below 6.1	Below 7.0
Impaired glucose tolerance - 2hrs after meals	6.7 – 10.0	7.8 – 11.1	7.8 – 11.1
Impaired fasting glucose - fasting	5.6 – 6.1	5.6 – 6.1	6.1 – 7.0
Impaired fasting glucose - 2hrs after meals	Below 6.7	Below 7.8	Below 7.8

What is the normal blood lipid value?

Patients with hyperlipidemia will make the blood thicken. Blood becomes prone to deposits on the walls of blood vessels, gradually forming plaques. These plaques can gradually build up and grow and clog blood vessels. It slows or even blocks blood flow. However, blood lipid levels are not as low as possible. Some studies have pointed out that when the cholesterol level of the elderly over 70 years old is lower than 4.16mmol/L, their risk of acute cardiovascular and cerebrovascular events is similar to that of the elderly whose cholesterol level is higher than 6.24 mmol/L. The normal reference values of blood lipids are as follows:

Types	Normal values
Total Cholesterol	2.8 – 5.17 mmol/L
Triglycerides	0.56 – 1.7 mmol/L
High Density Lipoprotein (Male)	0.96 – 1.15 mmol/L
High Density Lipoprotein (Female)	0.90 – 1.55 mmol/L
Low Density Lipoprotein	0 – 3.1 mmol/L

What is the normal uric acid value?

Under a normal diet, hyperuricemia is clinically diagnosed when the blood uric acid value of males exceeds 420 μmol/L and that of females exceeds 360 μmol/L in two tests on different days. 

	The range of normal blood uric acid level
Male	237.9 – 420 μmol/L
Female	178.4 – 360 μmol/L

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How should patients take Ambroxol?😷😷😷

Ambroxol is a very commonly used expectorant in clinical practice. Recently, more and more people pay attention to other pharmacological effects of ambroxol. The following relevant knowledge can help us use ambroxol rationally.

1. Chemical structure of Ambroxol.

Ambroxol is the active product produced by the metabolism of bromhexine. Due to its local anesthetic properties, it is given as a lozenge to soothe sore throats. Ambroxol is broken down by light, so it needs to be stored away from light. Its granule form needs to be dissolved in room temperature water. The injection form of ambroxol will produce free base precipitation of ambroxol due to the increase of the pH value of the solution, so it should not be mixed with an alkaline solution with a pH>6.3.

2. The expectorant effect of ambroxol.

The main components of sputum secreted by humans are a small amount of acidic glycoprotein and a large amount of water. When inflammation occurs in the respiratory tract, there will also be a small amount of residual DNA from damaged inflammatory cells in the sputum. There are disulfide bonds (-S-S-) in the acid glycoprotein molecular structure, so the sputum has a certain viscosity. It is also the main component in white sputum. Ambroxol can reduce the production of acidic mucopolysaccharides in the trachea, bronchial glands and goblet cells to reduce the viscosity of sputum. In addition, it can also promote the movement of cilia on the trachea and increase the expectoration of sputum. Ambroxol is suitable for patients with white and sticky sputum that is not easy to cough up.

3. Common dosage forms and dosages of ambroxol.

Ambroxol is generally administered 2 to 3 times a day. Its half-life is about 10 hours. If ambroxol is in the form of injection, its dosage is about half that of oral administration. Inhaled dosage forms will have smaller doses. 

1. Ambroxol Hydrochloride Tablets: Adults take orally three times a day, 30 to 60 mg each time, after meals.
2. Ambroxol hydrochloride oral solution: 1 to 2 years old, twice a day, 15mg each time. From 2 to 6 years old, three times a day, 15mg each time. 6 to 12 years old, two to three times a day, 30mg each time. Over 12 years old and adults, twice a day, 60mg each time.
3. Ambroxol Hydrochloride Injection: Children under 2 years old twice a day, 7.5mg each time. From 2 to 6 years old, three times a day, 7.5mg each time. 6 to 12 years old, two to three times a day, 15mg each time. Over 12 years old and adults, two to three times a day, 15 to 30mg each time.
4. Ambroxol hydrochloride solution for inhalation: children from 6 months to 2 years old inhale once or twice a day, 7.5mg each time. From 2 to 12 years old, inhale once or twice a day, 15mg each time. Over 12 years old and adults inhale once or twice a day, 15 to 22.5mg each time.

4. What is Neonatal Respiratory Distress Syndrome?

The site of gas exchange in the lungs is the alveoli. Oxygen in the alveoli will diffuse into the blood through the liquid membrane on the inner surface of the alveoli, the epithelial cells of the alveoli, the interstitium between the epithelium of the alveoli and the endothelium of the pulmonary capillaries, the endothelial cells of the capillaries, and then enter the blood. Alveolar epithelial cells are classified into type I and type II. Type II alveolar epithelial cells are inlaid between type I alveolar epithelial cells. It can synthesize and secrete alveolar surfactant. The main component of this surface active substance is phospholipid protein. It reduces the surface tension of the alveoli, preventing the alveoli from collapsing or overinflating. Neonatal respiratory distress syndrome refers to symptoms such as progressive dyspnea and respiratory failure in newborns. Its main cause is a series of symptoms caused by alveolar atrophy due to the lack of alveolar surfactant. Because ambroxol can increase the synthesis and secretion of alveolar surfactant, it has been approved for the treatment of respiratory distress syndrome in premature infants and neonatal infants. The dosage is 30mg/kg as the total daily dosage, divided into 4 doses. It should be administered with a syringe pump and administered intravenously over at least 5 minutes. In addition, when amoxicillin, cefuroxime, erythromycin, doxycycline and other antibiotics are taken together with ambroxol, the concentration of antibiotics in lung tissue can be increased.

5. Off-label use of ambroxol.

Taking large doses of ambroxol has the effects of anti-inflammation, anti-oxidation and scavenging free radicals in the body. It also increases alveolar surfactant. This has a protective and therapeutic effect on lung damage. It is used off-label to prevent postoperative atelectasis in patients with chronic obstructive airway disease. It is used continuously for six days from the third day before the patient's lung surgery to the second day after the operation, with a daily dose of 1000mg. Ambroxol can cause adverse reactions such as nausea, stomach discomfort, and loss of appetite, so it is recommended to take ambroxol oral preparations after meals. Ambroxol may also cause severe skin reactions such as toxic epidermal necrolysis. If patient develops symptoms of progressive rash, discontinue use ambroxol and seek medical attention immediately.

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What are the common problems of gout?🔍🔍🔍

Gout is a very common metabolic disease clinically. Here are some practical facts and frequently asked questions about gout.

1. What is the difference between hyperuricemia and gout?

Hyperuricemia refers to the blood uric acid levels of both men and women are higher than 420 μmol/L twice on different days. In patients with hyperuricemia, urate crystallizes and deposits in the body. It can cause patients to develop gouty arthritis, uric acid nephropathy, and kidney stones called gout. Some researchers now refer to gouty arthritis as gout. In addition, some patients with hyperuricemia have no obvious symptoms such as arthritis for life, which is called asymptomatic hyperuricemia. Subclinical gout can be diagnosed in patients with asymptomatic hyperuricemia if sodium urate crystal deposition and/or gouty bone erosions are found on examination.

2. Are Gout and Hyperuricemia Inherited to Offspring?

The probability of blood uric acid level being inherited is approximately 27 to 41% and the probability of gout being inherited is about 30%. About 20% of gout patients have a family history of it. Environmental factors such as alcohol consumption, overeating and weather are closely related to the occurrence of gout. Environmental factors such as alcohol consumption, overeating and weather are closely related to the occurrence of gout. Acute gouty arthritis has the characteristics of rapid onset. Within hours, patients experience redness, swelling, heat, pain, and dysfunction in affected joints. Midnight or early morning is the more common time of onset. In addition, due to the poor blood supply, low skin temperature, low interstitial fluid pH and high pressure of the foot, the first metatarsophalangeal joint is the first joint of most gout.

3. What is the relationship between high blood pressure and hyperuricemia/gout?

It is generally believed that for every 60 μmol/L increase in blood uric acid in a patient, his relative risk of hypertension will increase by 1.4 times. Blood vessels and kidneys can be damaged by high blood pressure. It will reduce uric acid excretion and increase blood uric acid level. Angiotensin converting enzyme inhibitors (eg, captopril), angiotensin-receptor blockers (eg, irbesartan, except losartan.), β-blockers (eg, metoprolol), and thiazide diuretics (eg, hydrochlorothiazide and indapamide) significantly increase the risk of gout attacks. Patients with hypertension complicated with hyperuricemia or gout should preferably choose antihypertensive drugs that do not affect blood uric acid levels, such as amlodipine and losartan. Atorvastatin is the first choice for patients with hyperuricemia or gout combined with hypercholesterolemia, which can promote the excretion of uric acid by the kidneys. Fenofibrate is the first choice for patients with hyperuricemia or gout with hypertriglyceridemia, which can inhibit uric acid reabsorption.

4. Are people with hyperuricemia or gout more likely to develop diabetes?

For every 60 μmol/L increase in the blood uric acid level of a patient, the risk of new-onset diabetes increased by 17%. Uric acid-lowering treatment can reduce the incidence of diabetes in people with hyperuricemia. Their incidence of cardiovascular and renal complications will also be reduced. In addition, insulin can lead to elevated blood uric acid levels in patients. Therefore, hypoglycemic drugs such as α-glucosidase inhibitors, metformin, SGLT-2 inhibitors and thiazolidinediones will increase insulin levels in patients. Patients with gout who use hypoglycemic drugs should try to avoid using the above drugs.

5. Do patients with asymptomatic hyperuricemia need uric acid-lowering therapy?

Non-drug treatments such as diet adjustment and weight control will be the first choice for patients with asymptomatic hyperuricemia. Treatment guidelines in China and Japan suggest that patients with asymptomatic hyperuricemia should be treated with uric acid-lowering drugs when the blood uric acid level is ≥540 μmol/L. Treatment guidelines in Europe and the United States recommend that patients with asymptomatic hyperuricemia need to start uric acid-lowering drug therapy only when they have chronic kidney disease and cardiovascular risk factors. Among the urate-lowering drugs, allopurinol can cause fatal allergic reactions in patients, benzbromarone can seriously damage the liver function of patients and febuxostat can increase the risk of cardiovascular events in patients.

6. What value should the blood uric acid target value be reduced to in patients with gout?

Studies have pointed out that when the patient's blood uric acid is controlled at <360 μmol/L for a long time, it can dissolve the urate crystals in the patient's body, and reduce the number and volume of crystals. It also prevents the formation of new urate crystals in the body. It is recommended to control the blood uric acid level of all gout patients to <360 μmol/L, and the blood uric acid level of severe gout patients to be controlled to <300 μmol/L. However, it is not recommended to control the patient's blood uric acid level at <180 μmol/L for a long time.

7. Which uric acid-lowering drugs can be used in patients with gout?

Allopurinol, benzbromarone, and febuxostat are the first-line drugs for uric acid-lowering therapy in patients with gout. Allopurinol and febuxostat inhibit uric acid synthesis in patients. Benzbromarone stimulates the excretion of uric acid. Allopurinol and benzbromarone are the first-line uric acid-lowering drugs for patients with asymptomatic hyperuricemia. If the patient's blood uric acid still does not reach the target value after using a sufficient amount and a full course of monotherapy, two uric acid-lowering drugs with different mechanisms of action can be considered in combination.

8. What uric acid-lowering drugs should be used in patients with gout and chronic kidney disease?

For gout patients with chronic kidney disease, uric acid-lowering therapy can inhibit the progression of their chronic kidney disease. Uric acid synthesis inhibitors such as allopurinol and febuxostat will be given priority to gout patients with chronic kidney disease stage 3 or above (glomerular filtration rate <60ml/min).Since the fatality rate of hypersensitivity reaction to allopurinol is as high as 30% and is obviously related to the HLA-B*5801 gene, patients should be tested for their HLA-B*5801 gene before using it. Therefore, febuxostat is especially suitable for gout patients with chronic renal insufficiency.

9. Do patients with gout who taking benzbromarone need to also take sodium bicarbonate?

Although oral administration of sodium bicarbonate has a certain effect on reducing uric acid in patients with gout, the effect on reducing uric acid is limited. In addition, long-term use of sodium bicarbonate can cause water and sodium retention in patients, which can cause and aggravate high blood pressure and induce heart failure. Therefore, patients only need to take sodium bicarbonate if the pH of the morning urine is <6.0.

10. What is the correct way to use colchicine?

Compared with taking large doses of colchicum, the effect of small doses of gout is similar and the side effects will be significantly reduced. When the patient has an acute gout attack, the first dose of colchicine is 1 mg, and then an additional 0.5 mg is given every hour. Until 12 hours later, take 0.5mg once or twice a day. When patients start uric acid-lowering drug therapy, fluctuating blood uric acid levels can easily induce acute gout attacks. Therefore, patients can take colchicine for at least 3 to 6 months to prevent acute gout attacks. The dosage is 0.5 to 1 mg per day.

11. Why are obese people more prone to gout attacks?

Gout is a metabolic disease and many patients with gout will be accompanied by obesity. The daily caloric intake of obese patients will be greater than the daily consumption. Purine synthesis in the body will increase with the increase in calorie intake, and the production of uric acid will also increase. In addition, obesity, especially abdominal obesity, can cause insulin resistance in patients. Insulin resistance can increase blood uric acid levels in the body. Therefore, many gout treatment guidelines recommend that patients with gout control their weight. 

12. Why are patients prone to gout attacks after drinking alcohol?

Some studies have pointed out that liquor and beer can increase the risk of gout attacks in patients, but there is little evidence that red wine increases the risk of gout attacks. Some studies have pointed out that hard alcohol and beer can increase the risk of gout attacks in patients, but there is little evidence that red wine increases the risk of gout attacks. Metabolism of alcohol increases consumption of ATP. Serum lactic acid will increase due to alcohol, thereby reducing uric acid excretion. The purines in alcohol lead to increased uric acid production. These are the reasons why alcohol consumption can increase blood uric acid levels.

13. What vegetables and fruits should patients with gout eat?

Patients with gout should not eat foods with too much sugar. Therefore, fruits with too much sugar such as apples, oranges and grapefruit should not be eaten too much. Plant foods with high purine content such as mushrooms, seaweed and kelp should not be eaten too much. Patients with gout can eat watermelon, coconut, grapes, strawberries, plums and peaches in moderation. Lemons, cherries and olives have certain benefits for patients with gout. It is recommended to eat low-purine foods such as most melons, tubers, root and leafy vegetables.

14. What kind of meat should patients with gout eat?

White meat such as chicken and duck has lower purine content than red meat such as beef and pork. The purine content of animal offal is generally higher than that of meat. Patients with gout should not consume more than 100g of meat per day. Cured or smoked meats are high in purines and sodium, which interfere with the metabolism of uric acid. Patients with gout are not suitable for eating these foods.

15. How much and how should patients with gout drinking water?

Patients with gout but without contraindications such as kidney disease or heart failure are recommended to drink 2 to 3L of water per day. Patients should try to maintain a daily urine output of about 2 L and a urine pH of 6.3 to 6.8. In addition, lemon water can help lower uric acid. It can add 1 to 2 fresh lemon slices to 2 to 3L of water.

16. How can patients with gout exercise?

Vigorous exercise can increase sweating in patients with gout. It reduces blood volume, renal blood flow, and uric acid excretion. It can even induce gout attacks. Low-intensity aerobic exercise such as jogging can reduce gout attacks in patients. Low-intensity aerobic exercise such as jogging can reduce gout attacks in patients. It is recommended that patients perform low-intensity aerobic exercise 4 to 5 times a week, 0.5 to 1 hour each time. In addition, since low temperature can easily induce acute gout attacks in patients, patients should avoid taking cold baths after exercise.

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What are the precautions for using hypnotics?😴😴😴

In today's society, many people suffer from insomnia. Insomnia is the most common sleep disorder clinically. About 10 to 15% of adults meet the criteria for a diagnosis of insomnia. Generally recommended for the treatment of insomnia psychotherapy and drug therapy. For patients with insomnia, medication is generally used on the basis of psychotherapy. Hypnotic drugs are given according to the patient's condition to relieve insomnia symptoms, improve sleep quality and improve the patient's quality of life.

What medications can be used to treat insomnia?

The principles of drug therapy should be individualized, on demand, intermittent and sufficient. The drug treatment guidelines for insomnia are generally recommended as follows: non-benzodiazepine drugs are the first choice. Short and medium-acting benzodiazepines or melatonin receptor agonists are the second choice. Antidepressants with sedative effects are optional only when necessary, but they are especially indicated for insomniacs with depression and/or anxiety. Treatment guidelines do not recommend the use of antipsychotics and antiepileptics as first-line drugs, and they are only applicable to certain special situations and special populations. 

Non-benzodiazepines: These drugs selectively activate the α subunit of the γ-aminobutyric acid receptor A (GABA_A). Their hypnotic effects are similar to those of benzodiazepines. Due to the short half-life of these drugs, their next-day residual effects are greatly reduced. They generally do not cause daytime drowsiness in patients and have a lower risk of dependence than benzodiazepines. Therefore, non-benzodiazepines can be safe and effective in the treatment of insomnia, and their long-term use has no significant adverse drug effects. Sudden discontinuation of the drug may cause transient insomnia rebound in patients. Because non-benzodiazepines are less muscle relaxant, they cause a lower risk of falls than benzodiazepines. Therefore, non-benzodiazepines are especially suitable for elderly patients with insomnia. CYP3A4 metabolizes non-benzodiazepines such as eszopiclone, zopiclone and zaleplon. Therefore, CYP3A4 inhibitors such as clarithromycin will inhibit their metabolism. It can increase blood levels of non-benzodiazepine drugs and increase the occurrence of adverse reactions. Inducers of CYP3A4, such as rifampin, lower their blood levels and reduce their efficacy. Co-administration of alcohol or other central depressants with non-benzodiazepines increases the central depressant effect. 

1. Eszopiclone: This is indicated for the treatment of trouble falling asleep or maintaining sleep. It has a peak time of 1 to 1.5 hours and a half-life of 6 hours. Adults take 1 to 3 mg orally before going to bed. Its common adverse reaction is abnormal taste. Eszopiclone was better tolerated than zopiclone.
2. Zaleplon: It is indicated for the treatment of difficulty falling asleep. It has a peak time of ≤1 hour and a half-life of 0.7 to 1.4 hours. Adults take 5 to 20 mg orally before going to bed. Its common adverse reactions are dizziness and ataxia.
3. Zopiclone: It is indicated for the treatment of trouble falling asleep or maintaining sleep. It has a peak time of 1.5 to 2 hours and a half-life of 5 hours. Adults take 3.75 to 7.5 mg orally at bedtime. Its common adverse reaction is bitter taste in mouth. 
4. Zolpidem: This is indicated for the treatment of trouble falling asleep or maintaining sleep. It has a peak time of 0.5 to 3 hours and a half-life of 0.7 to 3.5 hours. Adults take 1.75 to 10 mg orally or 6.25 to 12.5 mg sustained-release tablets before going to bed. Its common adverse effects are headache, dizziness and forgetfulness.

Benzodiazepines: These drugs bind nonselectively to GABA_A receptors. They have anxiolytic, sedative, muscle relaxant and anticonvulsant properties. Therefore, this class of drugs has a better effect on patients with anxiety insomnia. Benzodiazepines commonly used in clinical practice include estazolam, flurazepam, quazepam, temazepam and triazolam. Among them, triazolam and temazepam are relatively recommended for the treatment of insomnia. Other commonly used benzodiazepines are alprazolam, diazepam, and lorazepam. These drugs are dependent. Therefore, after long-term use, patients may experience withdrawal symptoms after stopping the drug. Most benzodiazepines are contraindicated in pregnant or lactating women, patients with impaired liver and kidney function, patients with obstructive sleep apnea syndrome, and patients with severe ventilatory impairment. In addition to lorazepam and temazepam, CYP3A4 has a certain ability to metabolize benzodiazepines. Therefore, both CYP3A4 inducers and inhibitors affect their plasma concentrations. CNS depressants and alcohol also enhance the CNS depressant properties of benzodiazepines.

1. Estazolam: It is indicated for the treatment of difficulty falling asleep or maintaining sleep. The adult dosage is 1 to 2 mg orally at bedtime. It has a peak time of 3 hours and a half-life of 10 to 24 hours. Its common adverse effects include dry mouth, hangover and weakness.
2. Flurazepam: It is indicated for the treatment of trouble falling asleep or sleep maintenance. The adult dosage is 15 to 30 mg orally at bedtime. It has a peak time of 1.5 to 4.5 hours and a half-life of 48 to 120 hours. Its common adverse effects include ataxia, dizziness and hangover.
3. Quazepam: It is indicated for the treatment of difficulties falling asleep or maintaining sleep. The adult dose is 7.5 to 15 mg orally at bedtime. It has a peak time of 2 to 3 hours and a half-life of 48 to 120 hours. Its common adverse effects include dizziness, drowsiness, dry mouth, headache and unsteadiness on standing.
4. Temazepam: It is indicated for the treatment of difficulty falling asleep or maintaining sleep. The dosage for adults is 7.5 to 30 mg orally at bedtime. It has a peak time of 1.2 to 1.6 hours and a half-life of 3.5 to 18.4 hours. Its common adverse effects include ataxia and dizziness.
5. Triazolam: It is indicated for the treatment of difficulty falling asleep. The dosage for adults is 0.125 to 0.25 mg orally at bedtime. It has a peak time of 0.2 to 0.5 hours and a half-life of 1.5 to 5.5 hours. Its common adverse effects include amnesia, euphoria, upset stomach and skin tingling.

Melatonin receptor agonists: The sleep-wake cycle is regulated by melatonin. Melatonin can effectively improve symptoms caused by jet lag, delayed sleep phase syndrome, and circadian rhythm sleep disorders. Melatonin receptor agonists can be used as an alternative treatment for patients who cannot tolerate benzodiazepines or who have developed drug dependence. Melatonin and ramelteon tablets are commonly used melatonin receptor agonists.

1. Melatonin: It is indicated for patients who have difficulty falling asleep or maintaining sleep. Adults take 2 mg orally before going to bed. It has a peak time of 0.75 to 3 hours and a half-life of 6 hours. Its common side effects are dizziness, drowsiness and fatigue.
2. Ramelteon: It is indicated for patients who have trouble falling asleep. Adults take 8 mg orally before going to bed. It has a peak time of 0.75 to 1 hour and a half-life of 1 to 2.6 hours. Its common adverse reactions are dizziness, drowsiness and fatigue. It is especially effective and safe for insomniacs with sleep-disordered breathing. CYP1A2 is the main metabolic enzyme of ramelteon. CYP2C and CYP3A4 also metabolize a small amount of it. Therefore, CYP1A2 inhibitors such as ciprofloxacin will increase its plasma concentration and should not be used in combination.

Antidepressants: Serotonin and norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and other antidepressants are also used to treat insomnia.

Serotonin and norepinephrine reuptake inhibitors (SNRIs): Venlafaxine and duloxetine can be used to treat depression and anxiety to improve insomnia.

Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine, fluvoxamine, paroxetine, sertraline, etc. are commonly used clinical SSRIs. They improve insomnia symptoms in patients by treating depression and anxiety disorders. Among them, fluvoxamine has a sedative effect and is a better choice for insomnia patients.

1. Fluvoxamine: It prevents the degradation of melatonin and increases the concentration of endogenous melatonin. It is the only sedating drug among the SSRIs. The combination of doxepin and it will increase the blood concentration of the two drugs, so the dose should be reduced when used in combination. Its starting dose is 50mg or 100mg taken daily at bedtime. The commonly used effective dose is 100 mg per day.

Tricyclic antidepressants: Amitriptyline and doxepin are commonly used tricyclic antidepressants. However, because of its anticholinergic effects, amitriptyline can cause adverse reactions such as dry mouth and increased heart rate in patients, so it will not be used as the drug of choice for the treatment of insomnia.

1. Amitriptyline: It can treat anxiety and depression patients with insomnia. It has a peak time of 2 to 5 hours and a half-life of 10 to 100 hours. Adults take 10 to 25 mg orally before going to bed. Its common adverse reactions are anticholinergic effects, cardiac damage, excessive sedation, and orthostatic hypotension.
2. Doxepin: Doxepin in small doses (3 to 6 mg orally at bedtime) has a specific antihistamine mechanism. It improves insomnia symptoms in adults and elderly patients with chronic insomnia. It also can treat sleep maintenance disorders. It was clinically well tolerated and had no withdrawal effects. It has become one of the recommended drugs for the treatment of insomnia in recent years. It has a peak time of 1.5 to 4 hours and a half-life of 10 to 50 hours. Its common adverse reactions are drowsiness and headache.

Other antidepressants: Small doses of mirtazapine and trazodone can calm the patient and relieve insomnia symptoms. They are used to treat both insomnia and rebound insomnia after hypnotic drug withdrawal.

1. Mirtazapine: It can relieve symptoms of sleep disorders in depressed patients and treat anxiety and depression with insomnia. It has a peak time of 0.25 to 2 hours and a half-life of 20 to 40 hours. Adults take 3.75 to 15 mg orally at bedtime. Its common adverse effects are anticholinergic effects, appetite and weight gain, and excessive sedation.
2. Trazodone: Although its antidepressant effect is weak, it has strong hypnotic power. It can be used in patients with anxiety and depression with insomnia, sleep disturbance or severe sleep apnea syndrome. It may also be used to treat rebound insomnia after the hypnotic drug is discontinued. It has a peak time of 1 to 2 hours and a half-life of 3 to 14 hours. Adults take 25 to 150 mg orally at bedtime. Its common adverse reactions are dizziness, orthostatic hypotension, and priapism.

Orexin receptor antagonist: Orexin has a refreshing effect, also known as hypocretin.

1. Suvoresan: It is an orexin receptor antagonist. It has been approved in some countries for adults with trouble falling asleep or sleep maintenance disorders. It has a different target than other sleeping pills. Studies have shown that it has good clinical efficacy and tolerability. It has a peak time of 0.5 to 6 hours and a half-life of 9 to 13 hours. Adults take 5 to 20 mg orally before going to bed. Its common adverse reaction is residual sedation.

Non-benzodiazepines such as zolpidem and eszopiclone are generally the first choice for clinical treatment of insomnia. If the first-line drug is ineffective, melatonin receptor agonists, short- to medium-acting benzodiazepines, or orexin receptor antagonists can be replaced. Antidepressants may be added to patients with insomnia who are anxious or depressed.

When should patients use hypnotics?

1. Hypnotics may be taken 5-10 minutes before bedtime when the patient anticipates difficulty falling asleep.
2. If the patient fails to fall asleep 30 minutes after going to bed, hypnotics can be taken immediately.
3. Hypnotics can be taken immediately if the patient cannot fall asleep again after waking up at night and is more than 5 hours away from the expected time of waking up. It recommends using hypnotics with a short half-life.
4. Patients with chronic insomnia were treated intermittently with non-benzodiazepines. It will generally take the hypnotics on selected nights per week rather than on consecutive nights.

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Seven drugs should not be used in combination with omeprazole.🈲🈲🈲

Omeprazole is a proton pump inhibitor. It is also the most commonly used gastric acid suppressant drug. It is a fat-soluble weakly basic drug. After oral administration by patients, it will be specifically distributed in the secretory tubules of the parietal cells of the gastric mucosa. A high acid environment will convert it into the active ingredient of sulfenamide. It inhibits the activity of hydrogen-potassium ATPase on the gastric parietal cells to block the secretion of gastric acid and increase the pH of gastric juice. Therefore, its inhibitory effect on gastric acid secretion caused by various reasons is long-lasting and potent. Omeprazole is suitable for stomach diseases such as gastric ulcer and duodenal ulcer.

What diseases can omeprazole be used to treat?

1. Gastroesophageal reflux: These patients experience symptoms such as acid reflux and heartburn. Omeprazole can inhibit the secretion of gastric acid to control the symptoms and promote the recovery of esophagitis.
2. Peptic ulcer: abnormal secretion of gastric acid and pepsin can be treated with omeprazole. It can effectively suppress stomach acid and promote the healing of peptic ulcer. At the same time, it can also relieve various related symptoms and reduce complications.
3. Upper gastrointestinal bleeding: Omeprazole can increase the pH of the stomach and reduce the redissolution of blood clots in the stomach. Therefore, upper gastrointestinal bleeding in patients caused by various diseases can be treated with omeprazole.

Which drugs should not be used in combination with omeprazole?

Acidic drugs: Omeprazole is a weakly basic drug. It decomposes rapidly in an acidic environment. Therefore, omeprazole is often made into enteric-coated tablets or capsules. When acidic drugs and omeprazole are used in combination, a neutralization reaction may occur and affect the efficacy of the drug. Acidic drugs such as ambroxol hydrochloride, ornidazole and vitamin B6 should not be used in combination with omeprazole.

Clopidogrel: It is an anti-platelet aggregation drug. Most proton pump inhibitors reduce the production of the active metabolite of clopidogrel, thereby reducing the efficacy of clopidogrel. Among the proton pump inhibitors, omeprazole has a significant effect on clopidogrel. If clopidogrel needs to be used in combination with a proton pump inhibitor, a proton pump inhibitor with less effect such as rabeprazole or pantoprazole should be used.

Digoxin: It is a commonly used cardiac glycoside drug in clinical practice. Its hydrolysis needs to be carried out in an acidic environment. Therefore, omeprazole inhibits gastric acid secretion, which will increase the pH value in the stomach and reduce the hydrolysis of digoxin. The combination of the two will reduce or eliminate the activity of digoxin.

Iron supplements: Growing children or pregnant women sometimes need to take iron supplements to supplement the iron in the body in order to avoid iron deficiency anemia. However, the stomach needs an acidic environment to absorb iron properly. Because omeprazole inhibits gastric acid secretion, the body cannot absorb iron normally.

Nifedipine: It is a commonly used antihypertensive drug in clinical practice. Omeprazole inhibits the enzymes that metabolize nifedipine, thereby increasing the body's absorption of nifedipine. There is an increased risk of hypotension and the risk of adverse effects.

Ketoconazole: It is an antifungal medicine. The release of its drug effect needs to rely on the secretion of gastric acid. The secretion of gastric acid is inhibited by omeprazole to increase the pH value of the stomach. The release of ketoconazole is thus reduced and the bioavailability is reduced, which in turn weakens the antifungal effect.

Probiotics such as Bifidobacterium and Lactobacillus: They can regulate intestinal flora and improve symptoms such as constipation and diarrhea. These probiotics require an acidic environment to remain active. Therefore, they should not be used in combination with antacids.

Precautions for Omeprazole.

When omeprazole is used for peptic ulcer, 1 to 2 times a day, 20 mg each time, the patient swallows once in the morning or once in the morning and evening. The course of gastric ulcer treatment is generally 4 to 8 weeks. The course of treatment for duodenal ulcer is generally 2 to 4 weeks. When omeprazole is used for gastrinoma, the patient should take 60 mg once a day. The total daily dose is adjusted to 20 to 120 mg according to the patient's condition. If the total daily dose exceeds 80 mg, patients should take it in two divided doses. In order to prevent omeprazole from dissolving in the acidic stomach, it is generally made into enteric-coated tablets or capsules. Enteric-coated preparations are generally recommended to be taken on an empty stomach or before meals. It will ensure that the pH value of the stomach will not be affected by food, which will cause the drug to dissolve and release in the stomach in advance, resulting in ineffectiveness.

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How to treat postherpetic neuralgia?🔨🔨🔨

Herpes zoster is an infectious disease caused by a virus. The varicella-zoster virus can remain latent in the human body for a long time. They can be reactivated to cause infectious skin disease. Postherpetic neuralgia is one of the complications of shingles. Pain that persists for 1 month or more after clinical healing of the shingles rash is considered postherpetic neuralgia. Its prevalence ranges from approximately 9% to 34%. Patients with postherpetic neuralgia suffer from severe pain for a long time, which can easily lead to depression and their quality of life will be seriously reduced.

What are the clinical manifestations of postherpetic neuralgia?

1. Clinical manifestations of pain:

The clinical presentation of postherpetic neuralgia is complex and varied. It can be continuous or discontinuous. It has the following characteristics:

• Pain location: common in trigeminal nerve (mainly ophthalmic branch), neck or unilateral chest. About 50% of the patients occurred in the chest. Occurrence in the head and face, neck and waist accounted for 10% to 20% respectively. Occurs in the sacrum about 2% to 8%. Other parts are less than 1%. The painful area of postherpetic neuralgia is usually larger than the area of herpes zoster. Bilateral herpes is rarely seen in patients.
• The feeling of pain: Different patients experience different pain sensations. It can be like burning, knife cutting, needle sticking, shocking or tearing. Patients may experience one type of pain or possibly multiple pains at the same time.

2. Features of Pain:

• Spontaneous pain: Pain occurs in the rash distribution area and the surrounding area without any stimulation.
• Hyperalgesia: The patient's response to a noxious stimulus is prolonged or intensified.
• Allodynia: Nonnoxious stimuli cause pain in the patient. Such as small changes in temperature, clothing rubbing against the body, etc. will cause pain to the patient.
• Paresthesia: The patient will have some paresthesias such as numbness, itching and tightness in the painful area. Patients may also experience objective sensory abnormalities such as hypoesthesia, abnormal temperature and vibration sensations. 

3. Course of disease:

Postherpetic neuralgia persists for more than a year in 30% to 50% of patients. In some patients, the course of the disease can even reach ten years or more.

4. Other clinical manifestations:

Patients with postherpetic neuralgia are often accompanied by decreased mood, sleep and quality of life. Anxiety, depression, inability to concentrate, etc. are manifestations of moderate to severe disturbance of their emotions. Studies have pointed out that about 60% of patients have had or often have suicidal thoughts. More than 40% of patients have moderate to severe disturbance of daily life and sleep disturbance. Various systemic symptoms such as chronic fatigue, anorexia, weight loss and lack of activity may also appear in patients. 

Drug therapy for postherpetic neuralgia.

Gabapentin: It is a first generation calcium channel modulator. Its pharmacokinetic profile is non-linear and its bioavailability decreases with increasing dose. Its initial oral dose is 300 mg daily and patients need about several weeks to slowly titrate to the effective dose. Its effective dose is generally 900 to 1800 mg daily. The dose of gabapentin should be reduced in patients with renal insufficiency. In order to avoid adverse reactions of dizziness and drowsiness in patients, the dose should be started, slowly increased or gradually decreased at night.

Pregabalin: It is a second-generation calcium channel modulator. It can relieve postherpetic neuralgia. It can also improve sleep and mood disorders. Its pharmacokinetic profile is linear and has a rapid onset of action. Its oral initial dose is 150 mg daily. Its dose can be increased to 300 mg daily within a week and its maximum dose is 600 mg daily.

Amitriptyline: It is a tricyclic antidepressant. It inhibits the reuptake of serotonin and norepinephrine by the presynaptic membrane. It also blocks alpha adrenoceptors and sodium channels. The descending pathway of pain conduction will be regulated by the above mechanism to play an analgesic effect. However, its onset is slow. Its first dose should be taken at bedtime. Take two to three times a day, 12.5 to 25mg each time. The dose can be gradually increased according to the patient's response to amitriptyline. It recommends a maximum daily dose of 150mg, but in some patients up to 300mg is available. Amitriptyline should be avoided in patients with ischemic heart disease or at risk of sudden cardiac death. Patients with high risk of glaucoma, urinary retention and suicide should also use amitriptyline with caution.

5% lidocaine patch: It inhibits voltage-gated sodium channels and reduces ectopic impulses of primary afferent nerves after injury. This reduces pain perception in people with postherpetic neuralgia. Its onset of efficacy is ≤4 hours. Patients can apply 1 to 3 patches to the painful area. Each patch can be used for up to 12 hours.

Tramadol: It acts on μ-opioid receptors, serotonin receptors, and norepinephrine receptors to achieve analgesic effects. It can relieve burning pain, pin prick pain and allodynia caused by postherpetic neuralgia. However, it has no obvious analgesic effect on lightning-like and knife-like pain. Its initial dose is 25 to 50 mg once or twice daily. The maximum daily dose is 400mg. Nausea, vomiting, dizziness, constipation and other adverse reactions are dose-related.

Opioid analgesics such as morphine, oxycodone, and fentanyl are effective in the treatment of postherpetic neuralgia, but their addiction and tolerance limit them to second-line treatment. In addition, neurotrophic drugs can help relieve nerve pain and neuroinflammation. Commonly used drugs are methylcobalamin, vitamin B1 and vitamin B12. They can be given orally or injected intramuscularly.

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How should cough medicine be chosen?😷😷😷

Cough is one of the body's important defense mechanisms against pathogens. It clears respiratory secretions and substances that are harmful to the respiratory tract. However, severe and frequent cough can seriously affect the patient's life and work. According to the course of the disease, cough can be divided into chronic cough (>8 weeks), subacute cough (3 to 8 weeks) and acute cough (<3 weeks). According to the volume of sputum, it can also be divided into dry cough and wet cough (sputum volume > 10 ml per day). There are different treatment options for different types of coughs. Therefore, the following will introduce the different types of cough medicines.

1. The patient had frequent and severe cough, less or no sputum volume, no itchy throat, nasal congestion, runny nose, belching, acid reflux and other symptoms.

For this type of patients, it is recommended to use only single-ingredient antitussives. Antitussives can be divided into peripheral antitussives and central antitussives. Commonly used in clinical are dextromethorphan, pentoxyverine and phenproperine.

1. Dextromethorphan is a commonly used antitussive drug in clinical practice. Its effects are similar to codeine, but without the hypnotic and analgesic effects. Therapeutic doses generally have no inhibitory effect on the respiratory center and are not addictive. Adults are orally administered three times a day, 15 to 30 mg each time.
2. Pentoxyverine also has antispasmodic and anticonvulsant properties. It should be used with caution in patients with cardiac insufficiency and glaucoma. Adults are orally administered three times a day, 25 mg each time.
3. Phenproperine is a non-narcotic antitussive that inhibits peripheral afferent nerves. It also has some central cough-relieving effects. Adults are orally administered three times a day, 20 to 40 mg each time.

Phenproperine is the first choice for patients with severe cough, followed by dextromethorphan. Phenproperine or pentoxyverine is recommended for patients with an irritating dry cough. Phenproperine is indicated for patients with a cough that occurs mainly during the day. Dextromethorphan is used for patients who cough mainly at night. Studies have pointed out that the same dose of codeine and dextromethorphan have similar effects in reducing the frequency of chronic cough, but the antitussive effect of codeine is not as strong as dextromethorphan. In addition, dextromethorphan had no significant effect on treating nocturnal cough in children.

2. Patients with cough and phlegm or phlegm that is difficult to cough up.

The use of antitussives alone is not suitable for this type of patients, especially strong antitussives such as codeine. They reduce the secretion of the bronchial glands. It makes mucus thick and difficult to cough up. Not only can it worsen the infection, it can even increase the risk of choking. Therefore, mucolytics or expectorants (eg, acetylcysteine, ambroxol, ammonium chloride, bromhexine) should be the mainstay of treatment for this type of patient. Expectorant therapy enhances the clearing effect of cough on airway secretions. They increase phlegm discharge and enhance the antitussive effect. 

Ambroxol and bromhexine are mucolytics. Bromhexine is metabolized into ambroxol in the human body. It reduces the viscosity of secretions and promotes ciliary movement in the airways. In addition, it can increase the concentration of antibacterial drugs in the respiratory tract. 

• Ambroxol: Adults take 30-60 mg orally three times a day. 
• Bromhexine: Adults take 8-16 mg orally three times a day.

Acetylcysteine can reduce the viscosity of the patient's sputum. Adults take 600 mg orally once or twice a day, or 200 mg (granules) three times a day.

3. Patients with dry cough or low sputum production and nasal symptoms such as runny nose and/or nasal congestion and sneezing.

This cough is usually caused by a cold or rhinitis. Antihistamines or decongestants can significantly relieve cough symptoms in these patients. However, caution should be exercised when prescribing these medications for children. Central or peripheral antitussives can be used in patients with severe cough. First-generation antihistamines (chlorpheniramine), decongestants (ephedrine, pseudoephedrine), and antitussives (codeine, dextromethorphan, pholcodine) are used to treat the common cold with cough. Medications containing codeine are contraindicated for children under 18 years of age. Drugs containing ephedrine and pseudoephedrine should be used with caution in patients with hypertension and heart disease.

4. Patients cough with shortness of breath or wheezing but no nasal symptoms.

It is recommended to treat this type of patient with drugs that suppress bronchospasm and relieve cough during asthma attacks, such as aminophylline and methoxyphenamine. When patients use aminophylline, lincosamides (clindamycin, lincomycin), macrolides (clarithromycin, erythromycin, roxithromycin), quinolones (ciprofloxacin, norfloxacin, ofloxacin), tetracyclines (doxycycline, minocycline). They inhibit the excretion of aminophylline and cause aminophylline poisoning. Azithromycin and moxifloxacin can be used in combination with aminophylline because they have no obvious interaction.

5. Patients with cough accompanied by one or more symptoms of typical acid reflux, such as acid reflux, belching, burning sensation behind the breastbone, and epigastric fullness.

This cough is due to gastroesophageal reflux. Patients are generally treated for the cause and do not require antitussive therapy.

6. Cough caused by cough variant asthma, eosinophilic bronchitis, allergic cough, pharyngitis, drug-induced cough, and psychogenic cough.

Antitussive therapy is generally not required for these patients. Treatment should be directed at the cause of the patient's cough.

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