Corticosteroids , In the Treatment of Skin Disorders
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Transcript of Corticosteroids , In the Treatment of Skin Disorders
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Whos Afraid of
Cortisone?
Corticosteroids
in the Treatment of Skin Disorders
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Foreword
Corticosteroids play an important role in
the treatment of many skin disorders and have
been used very successfullysometimes in
combination with other medicinesto treatboth the acute stages of a disease as well as
chronic illnesses.
Despite corticosteroids high success rate, the
very word cortisone often evokes fear and
mistrust in patients. There are a number of
reasons for this fear that include: concernabout corticosteroids side-effects, doubt that
such a strong medicine is really necessary,
and anxiety about all the misinformation
currently associated with corticosteroids.
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The informed patient wants clear, comprehensive
information about all aspects of
corticosteroids, which is exactly what this
patient advisory brochure is offering. It
explains the differences between the
external and the internal use of corticosteroids,
the varying potencies available,
what kind of symptoms require which
specific treatment, and last but not least,
how serious side-effects can be avoided.
The better informed a patient is, the less he
or she will suffer from confusion and fear.
This brochure significantly contributes
towards a better understanding and wider
acceptance of the treatment of skin disorders
with corticosteroids, by clarifying
their effects and demonstrating the importanceof this kind of medication.
Foreword
Prof. Dr. med.
Roland Niedner
Director, Skin ClinicPotsdam
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Contents
I.The Basics of
Corticosteroids
1. Whos Afraid of
Cortisone?
2. A Look at the History
of Corticosteroids3. How Do Corticosteroids
Work?
II. Corticosteroid
Therapy
1. When Are Corticosteroids
Used?
2. Why Are Corticosteroids
Used?
3. Treatment from the
Outside
4. Cream or Ointment
the Role of Galenics
III. When Doctors Prescribe
Corticosteroids
1. The Doctors Diagnosis andRecommended Treatment
2. The Patients Co-operation
3. An Overview:
the Most Common Uses
of Corticosteroids
IV. MisunderstandingsAbout Cortisone
1. The Ten Most Common Error
2. The Package Insert
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The Basics of
Corticosteroids
1. Whos Afraid of Cortisone?
2. A Look at the History ofCorticosteroids
3. How Do Corticosteroids Work?
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1. Whos Afraid of Cortisone?
First of all, cortisone as such is not amedication, it is a natural hormone that is
produced in the adrenal gland. To be more
precise this hormone is called hydrocortisone
or cortisol. In terms of medication, the
active ingredients are called corticosteroids
and are a subcategory of steroids, along with
all artificial hormones of a specific molecular
structure. Therefore, in the following text, we
will be speaking of cortisone as the naturalhormone and a corticosteroid as its artificial
twin.
The adrenocortical hormone cortisone performs
vital functions for the human body, without
which life would not be possible. During times
of stress, the body increases production of the
natural cortisone which helps it to cope in
situations like car accidents, or excessive
mental strain, or even inflammation or fever.At the same time, it regulates the metabolic
processes and protects against allergies.
Produced by artificial cloning,this
Multitalented medication has been around for
Decades as a drug. Corticosteroids are used to
treat rheumatism; asthma; skin and kidney
disease;arterial, blood, intestinal, and liver
disorders;nervous disorders and shock; and
Organ transplant patients. Why, then, doso many people mistrust this drug?
Cortisone for my child? Never!" Even today,doctors still hear this kind of reaction when
they recommend treatment withCorticosteroids for atopic eczema
(neurodermatitis),
for example, or other eczema. Many people
refuse to be treated with corticosteroids, and
even when they accept it, they have strong
reservations.
On the one hand, many have had good
Experiences with corticosteroids, while on
the other, misunderstanding and prejudicestill remain. Clearly, these extremely effective
medicines seem to need some explanation.
As they play an important part in
dermatology. the study of skin diseaseand
can be used in a variety of ways to soothe
and heal,there are many good reasons forclearing up these misunderstandings.
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2. A Look at the History of Corticosteroids
Before it became possible to produce this
substance artificially (to synthesize it), doctors
used natural extracts from the adrenal gland.
Then, during the 1950s, these new medicines
were used internally (systemically) for treating
rheumatism, and this new wonder drug
quickly went on to assert itself in dermatologyas a treatment for psoriasis and eczema. The
discovery of this substance, which is also very
effective when applied to the skin externally
(topically), is now recognized as a milestone in
dermatology, perhaps as significant as the
discovery of penicillin. And it was their
Cosmetically gratifying properties as much
as their dramatic medical effectiveness
that ensured the quick triumph of corticosteroids.Until their development, skin disorders could
only be treated with products that burn, stink, or
stain and they were often less effective.
As with many other medicines, it took time for
the medical industry to learn about the correct
use of the new drug. Certainly in the euphoria
of its initial discovery, too much was expected
of it, and its administration was not always
properlyregulated.
Although the first of these synthetically
produced hormones were very effective
against inflammations, they also had several
unwelcome side effects. One of the worst was
that when taken as a pill or when injected, they
often caused a softening of the bones
(osteoporosis)and water retention in connective
tissues. This swelling effect was sensationallyreported in the newspapers and on television;
with images of moon-faced people
plastered everywhere, cortisone became a
household word. On top of that, the extended
external use of creams or ointments would
often cause a thinning of the skin (atrophy).
Since then a great deal has changed, but the
results of research in this field have not always
been brought to the attention of the generalpublic. Scientists all over the world have
improved and modified the molecular structure
of corticosteroids and have created new variants
which means that since the 90s, the socalled
fourth generation corticosteroids have
been available for external application.
Today, corticosteroids are divided into four
strengths; therefore the appropriate strength
of medication can be found for almost allstagesfrom mild to severeof illnesses thatcan be treated with steroids.
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3. How Do Corticosteroids Work?
Regardless of their potency, stage of
development (first, second, third, or fourth
generation), and form of application (internal
or external), corticosteroids essentially functionin one of four different ways.
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Anti-Inflammatory Effect
Corticosteroids work especially well against
inflammation so that the typical symptoms of
redness, swelling, heat and pain, quicklydisappear. Above all, itching, a common
symptom of skin disorders, is quickly relieved
under the influence of corticosteroids. This is
important because if itching isnt relieved, a
vicious cycle of inflammation-itching-scratching-
inflammation will begin . The anti-inflammatory effect ofcorticosteroids is especially significant for rheumatism,
asthma and atopic eczema.
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Anti-Allergic Effect
An allergy is an oversensitive reaction by the
body to diverse substances. Certain foods,
pollen, metals, and latex can all trigger anallergy and hay fever, hives, (contact) eczema or
asthma will result.
These illnesses usually accompany an inflammation
of the affected organ (skin or mucous
membrane), and therefore corticosteroids can
be used very effectively.
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Immunomodulatory Effect
When the body has an especially strong reaction
to internal or external substances, the
symptoms are similar to those of an allergy.These defensive reactions are often positive
and necessary, but in some cases they are
unnecessarily strong or prolonged. Here,
corticosteroids work as modulators, minimizing
the effects of the reaction. A well known
example is that of patients who have an organtransplanted from a donor, and in this case, the
internal application (pill or injection) of corticosteroids
will help prevent the body from rejecting
the new organ.
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Anti-Proliferative Effect
Proliferation means cell division, and when
cell division is speeded up it is called hyperproliferation.
The hyper proliferation of skin cells(epidermal cells) is, for example, a particularly
violent symptom of psoriasis, and corticosteroids
can be used very effectively against
this increased cell division (which is often also
connected with an inflammation).
This broad range of effects is why corticosteroidsare used to treat such a variety of
symptoms and diseases.
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Corticosteroid Therapy:
1. When Are Corticosteroids Used?
2. Why Are Corticosteroids Used?
3. Treatment from the Outside4. Cream, Ointment or Fatty Ointmentthe Role of
Galenics
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1. When Are Corticosteroids Used?
Corticosteroids have a broad usage spectrum,
and therefore can be applied to a variety
of areas. Looking beyond their ability to
Alleviate skin disorders quickly and effectively,
Corticosteroids are also used against:
Rheumatic inflammations
Bronchial asthma
Kidney disease
Vascular and blood disorders
Intestinal and liver disorders
Nerve inflammation
Allergic shock
Post-organ transplant
Those who suffer from a sluggish adrenal
gland need to take a regular, constant dose of
corticosteroids because the production of
natural cortisones is disrupted. This disorder,
called Addisons disease, afflicted, for
example, the American ex-President John F.
Kennedy.
Skin disordersespecially all mild and moderate
disorderscan usually be treated by the
external application of corticosteroids in the
form of creams and ointments, etc. This has
several advantages. For example, the skin is
one of the few organs that can be treated
directly and easily, and so the medication, or
active ingredient, can be applied directly to the
affected area. Another advantage is that direct
application prevents the entire organism from
being affected, thereby avoiding possible
Side effects. If used correctly, it is almost
Impossible for systemic effects like increased
water retention or osteoporosis to occur as a
result of the topical application of corticosteroid
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Topical (external) All forms of eczema, even
atopic dermatitis
All forms of psoriasis Physical skin damage from
exposure
Sunburn
Other skin disorders
caused by disturbances
in the immune system
Areas for Applying
Corticosteroidsto Alleviate Skin Disorders
Areas for Applying
Corticosteroidsto Alleviate Skin Disorders
Systemic (internal) Serious forms of eczema
Serious allergies; e.g., hives
Serious psoriasis withextensive effects on skin
or joints
Other serious skin and
immune system disorders
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2.Why Are Corticosteroids Used?
Many skin disorders heal by themselves ifthe cause of the disorder is removed. However,
there are still many reasons to treat the
symptoms. First of all, symptoms like redness
and swelling are often very annoying and
sometimes even painful. It is completely
understandable that patients who suffer, for
example, from obvious disfigurements to their
face or hands will want to be free of these
symptoms as quickly as possible. Another
reason is that skin disorders are often accompanied
by itching. Excruciating itching is one
of the most unpleasant symptoms of skin
disorders, and it can disturb sleep and theability to concentrate, which in turn causes
mental strain. Moreover, many patients often
unconsciouslyalmost as a natural reflexwill
try to scratch away the itching, only adding
to the problem as the infection cannot heal and
new inflammation may occur, causing more
itching a vicious cycle that must be brokenas soon as possible!
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2.Why Are Corticosteroids Used?
(Continued.)
On the other hand, there are skin disorders
for which there are still no known cures, like
psoriasis, which is the result of a genetic
defect. Is treatment of psoriasis with cortisone,
then, a sham? Not at all! Here again, effective
therapy is required. The illness progresses in
phases during which there are times that the
patient is virtually free from symptoms, and
other times when the symptoms are very
strong. In this case, treatment is carefully
tailored to the patient and his or her lifestyle,so that the symptoms of each phase of the
disorder are kept well under control, thereby
significantly improving the quality of life. The
short-term use of corticosteroids can also
shorten the length of the acute phases.
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3.Treatment from the Outside
Skin disorders are normally treated from
the outside, with medication being applied,
in the form of creams or ointments, to the
skin. Actually, the effect is the same whether
the drugs are administered topically or
systemically. However, if a medication mustfirst pass through the stomach, intestines,
and/or bloodstream before arriving at its
destination, its long journey will take it
through the entire organism, increasing the
chance of unwanted medical side-effects
(see also Chapter I.2). By taking medicinethrough the skin (resorption), the chance of
side-effects is highly unlikely. Modern
corticosteroids
have dual protection mechanisms
that almost completely preclude an
unwanted impact on the organism.
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3.Treatment from the Outside
An ExampleThe corticosteroid Methylprednisolonaceponate
(MPA) can be applied to the skin as one
of five different preparations (from very greasy
to completely oil-free). As long as the active ingredient
is in the tube, however, it is not a
highly active medication. It is first activated to
its full potency by the inflammatory enzymesfound in the afflicted skin. This is what is called
a pro-drug. It also means that it cannot harm
healthy skin, even if it is spread outside the
afflicted area.
After this bio-activation, MPA will reach its full
potency and relieve the inflammation with
biochemical processes in both the cellular
core and the cellular membrane. Having doneits job, the active ingredientas with all other
medicinesis transported away in the bloodstream,
leaving the body by way of the
kidneys. However, the moment MPA enters the
body it bonds with glucuronic acid (a detoxifying
agent), which robs MPA of its specific corticosteroid
potency, thus preventing it fromcausing side-effects due to systemic activity.
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4.Cream or Ointmentthe Role
of Galenics
Skin disorders like atopic eczema (neurodermatitis)
or psoriasis run in phases; periods free of symptoms alternate with
periods when the disorder becomes acute, and clearly
visible, tangible signs appear on the skin. In the problem-free phases,
called remission, it is enough to care for the skin as you usually
would, according to the individual skin type. However, this care must
be consistent, and would include, for example, moisturizing the
skin carefully after every bath or shower. Patients can considerably
extend the periods without symptoms in this way!
Should the disorder recur (relapse), the medication
would usually need to be started again.
While using the right potency will make a difference (e.g., a stronger
or weaker corticosteroid), the different types of compounds that
transport the medicine are also important. In dermatology, these
compounds are called galenics and come in the form of creams,
ointments, milks, solutions, etc. The main differencebetween them is in the amount of water they contain.
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4.Cream or Ointmentthe Role of Galenics
(Continued..)
All of these different compounds can be
applied to very specific areas. This is important
because whether or not a fatty, low-fat, or
completely fat-free formula is required willdepend on the location of the afflicted patch of skin,
and the stage of the illness.
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Creams contain more water than fat. They are
therefore very pleasant to use (they dont leave
a film on the skin) and do not form a barrier
against perspiration. This means they can also
be used during acute inflammations, when theskin needs to be able to release moisture and
heat.
Creams
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Ointments have both water and relatively high
levels of fatty components. They are also
called
universal creams because they can be used
in many ways, and are particularly appropriatewhen the skin neither weeps, nor is chronically
altered.
Ointments
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Fatty ointments consist essentially of oils and
contain no water. They coat the skin with a film
through which neither water nor air can penetrate.
These compounds are used for very dry
chronic conditions. They ensure that the
medicine is very concentrated, that the skin is
prevented from drying-out further, and that oil
is replenished.
Fatty ointments
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When Doctors Prescribe
Corticosteroids
1.The Doctors Diagnosis and
Recommended Treatment
2.The Patients Co-operation
3.An Overview: the Most CommonUses of Corticosteroids
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1.The Doctors Diagnosis
and Recommended TreatmentLike many medications, corticosteroids
are prescription drugs, and with good
reason.
Thanks to their medical training and
experience, doctors are able to assess the
patients symptoms according to followingcriteria.
What is the disorder?
At which stage is it?
With which medications can
it be treated?
Is the application of corticosteroidsindicated?
Which concentration of the drug
is appropriate?
Which galenic should be used?
How often should the drug be
taken and for how long
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The success or failure of a treatment is not
the sole responsibility of the doctor. Quite theopposite. Particularly with skin disorders,
which are generally treated by the patient
over a long period of time, the patients trust
and co-operation are often deciding factors in
the success or failure of a treatment. Here are
a few of the most important considerations.
Length of Therapy
It is possible that the primary results of treatment
will been seen very quickly. However, thetreatment should not be discontinued without
the doctors consent because the inflammation
must be stopped completely.
Weaning
To prevent symptoms from recurringsometimes
recurring symptoms are even more
severe if the treatment stops suddenly
(rebound effect)patients should be tapered
off the medication gradually. In other words,over a period of a few days, the medication is
applied less often and in smaller doses, or with
a lower concentration.
Localization
Do not use a medicine that your doctor
prescribed for the backs of the knees on other
places like the face or groin. Active ingredients
and galenics are always specific to an area of
skin, and using them elsewhere can cause
unwanted side-effects.
2.The Patients Co-operation
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3.An Overview:
the Most Common Uses of CorticosteroidsAtopic Eczema (Neurodermatitis)
Atopic eczema or dermatitis, also known as
neurodermatitis, appears when the immune
system responds to various environmental
substances, and often, more aggressively, as
a symptom of mental strains such as stress.
This can result in eczema of varying degrees
afflicting the entire body, including the headand scalp. As a rule, though, only the backs of
the knees and insides of the elbows are
affected. Atopic eczema is a chronically recurring
disorder, i.e., acute stages alternate with
intervals of less inflammation or a complete
lack of symptoms. Even without acute eczema,
though, the skin is dry and irritable, so consistent
basic skincare is necessary.
Children are especially affected, sufferingparticularly from itching that doesnt let them
sleep at night or concentrate at school.1
Atopic eczema often fades as they get older,
although the skin usually remains dry and
sensitive. Patients with atopic eczema also
tend to react to allergens that cause hay fever,
which can later become asthma. This is
calledsomewhat harshlyan allergy career,
but can often be avoided with consistent care.
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Contact Eczema
Allergies to environmental reagents have
become much more common in recent years.
They are triggered by direct contact with a
specific substance, but generally disappear
once the cause is removed. Even so, a fast,effective therapy can be importantespecially for
painful inflammations and visible parts of the body. A
typical example is the chrome nickel-allergy which is
triggered by fashion jewellery. Body piercing, so
popular today, causes this kind of allergy more than
anything else (most of the complications from piercing
come less from allergens and more fromunprofessional and unhygienic work).
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Misunderstandings About Cortisone
1.The Ten Most Common Errors
2.The Package Insert
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1. The Ten Most Common Errors
A poll showed that there are still many
misunderstandings about corticosteroids,
mainly concerning their side-effects. These
concerns can cause misgivings leading to a
treatment not being followed, or being stopped
too soon, and can influence the patients
cooperation.The following are a few clarifications
of the most common misconceptions.
Cortisone is purely chemical.Cortisone is an anti-inflammatory hormone
that every human produces in the adrenal
gland. The artificial clones of cortisone, the
corticosteroids, have an indispensable placein the treatment of skin disorders. Corticosteroids
count among the best and most
important anti-inflammatory substances in
modern medicine.
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Cortisone makes you swell.These days, there is a low risk of side-effects
like weight gain or water retention from theexternal use of ointments and creams containing
corticosteroids. Modern corticosteroid
preparations work selectively; i.e., they are
activated on the area of the body that is
inflamed by the bodys own enzymes, and they
decompose after having taken effect. In
this way, healthy skin and the rest of the
organism is almost unaffected by todayssteroid therapies.
Cortisone thins the skin.Every doctor knows where the individual
problem areas of the skin are located. He
has access to a multitude of potent and
cosmetically pleasing compounds (ointments,
solutions, creams, milks) that can be adjustedprecisely so that they are absolutely appropriate
for the location and degree of the illness.
This prevents unwanted side-effects like
thinning skin. After the acute inflammation has
been relieved, treatment is gradually moved to
corticosteroid-free products (weaning). Side
effects
can result, however, if the patientattempts to diagnose and treat him or herself.
The Ten Most Common Errors
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Cortisone destroys bones.A weakening of the bones (osteoporosis) is
virtually impossible with external use of
corticosteroid preparations. Why? Modern
corticosteroids work selectively at the place of
inflammation and decompose immediately
after they take effect without unnecessarilytaxing the organism. Only the long-term,
internal use of high dosage corticosteroids can
lead to osteoporosis. The attending doctor will
carefully assess the risks of treatment in these
cases.
Cortisone damages internal organs.Again, external corticosteroid therapy is harmless
to internal organs. Modern corticosteroids
work selectively at the place of inflammation
and decompose immediately thereafter. The
healthy skin and organs remain unaffected.
The internal use of high dosage corticosteroids
(injections, pills) over a longer period of time,
though, could tax the system.
The Ten Most Common Errors
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The Ten Most Common Errors
Cortisone only helps short-term.No. Corticosteroids not only alleviate the acute
symptoms of a skin disease, they represent an
indispensable part of the entire healing process.
However, corticosteroid therapy should not be
stopped abruptly once the acute stage has
been relieved. Instead the patient should be
weaned off. This minimizes the risk of relapse.Also, even in cases of genetic skin disorders
that are not completely curable, corticosteroids
can alleviate the excruciating symptoms and
contribute to extending symptom-free phases.
Pill or ointment? Its all the same.
Yes and no. In principle, there is no differencein the working mechanism of corticosteroids
whether they are administered to the infected
cells as pills or as ointments. However, the risk
of side-effects is considerably less when they
are applied to the skin, rather than via the
bloodstream, because the rest of the organism
will remain unaffected.
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Cortisone is not intended for children.Wrong. The treatment of children with corticosteroid therapy is, as a rule,
less taxing than the illness itself. The selective, short-term use of
corticosteroids breaks the vicious cycle of inflammation, itching,
scratching and reinflammation and after just a few days the gradual shift
to corticosteroid-free products can begin. Today, even potent
corticosteroids are much better designed for use on children.
Cortisone is very harsh medicine.Corticosteroids are available in different concentrations. There are four
basic groups of corticosteroid potency: mild, moderately potent, potent,
and very potent. Doctors can choose the correct concentration to suit the
diagnosis, severity of the illness, and the patients individual preferences.
Treatment is specifically designed by the doctor to be as strong as
necessary, as gentle as possible.
Cortisone is prescribed too often.Medication is only ever administered when it is necessary. Doctors
carefully weigh its use against the possible risks. They only use
medicines as long as is necessary and as briefly as possible.
Corticosteroids are mainly prescribed for acute and especially severe
skin disorders.
The Ten Most Common Errors
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2.The Package Insert
Its always the same with almost every
prescription drug: you come home from the
pharmacy, unpack your medicine, glance at
the package insert, and are immediately put
off taking the drug because of the number of
side-effects listed. Some people dont read the
information at all; others study the package
insert very carefully and closely watch themselves
for signs of side-effects. What is the
truth about package inserts and the side effects
they describe?
Most local laws stipulate that before a medication
may be sold in the pharmacy it mustundergo several years of stringent testing.
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During testing, the following is documentedTherapeutic effects
(=potency, when healing begins, and
the duration of the healing process)
Side effects
(=unwanted medicinal effects)
Interactions
(=what happens when the drug is takensimultaneously with other medications)
This research shows
Indication
(=for which illnesses the medication
can be used)
Contraindication
(=when the medication may not
be used)
Dosage instructions
(=method, amount, and duration of
application)
Precautions
(=what to do in the case of anoverdose, etc.)
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Kashif Raees
SPO Derma South-2
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