Pattayadoctor by Dr.Kijakarn

Category: Internal Medicine

  • PostExposure medicines(PEP) for HIV

    PostExposure medicines(PEP) for HIV PEP =Post Exposure Prophylaxis for HIV typically consists of a 28-day regimen. Common regimens include:

    Tenofovir disoproxil fumarate (TDF) 300 mg + Emtricitabine (FTC) 200 mg + Raltegravir 400 mg twice daily (preferred for most exposures). – Alternatively, TDF 300 mg + FTC 200 mg + Dolutegravir 50 mg once daily (if raltegravir is unavailable or contraindicated). – For higher-risk exposures, boosted protease inhibitors (e.g., darunavir/cobicistat) may be added. – Rationale: Guidelines (e.g., CDC, WHO) recommend these regimens due to high efficacy and tolerability. – Effectiveness:
    If initiated within 72 hours of exposure, PEP reduces HIV transmission risk by ~80%. – Adherence to the full 28-day course is critical for effectiveness. – Rationale: Early initiation and adherence prevent viral replication and integration. – Side Effects:
    Common: Nausea, fatigue, headache, diarrhea (usually mild and transient). – Less common: Elevated liver enzymes, renal impairment (with TDF), or rash (with integrase inhibitors). – Severe: Rare, but monitor for hypersensitivity reactions or lactic acidosis (with older NRTIs). – Rationale: Side effects are generally manageable; dose adjustments or regimen switches may be needed.

  • Traveler’s diarrhea

    Definition: Traveler’s diarrhea (TD) is defined as the passage of ≥3 unformed stools in 24 hours, often accompanied by abdominal cramps, nausea, vomiting, or fever, typically occurring within the first 2 weeks of travel to endemic areas. –

    Etiology:

    Bacterial (70–80%): E. coli (ETEC, EPEC, EIEC, EHEC), Campylobacter, Shigella, Salmonella, Aeromonas, Plesiomonas. – Viral (10–20%): Norovirus, rotavirus, adenovirus. – Parasitic (5–10%): Giardia, Cryptosporidium, Entamoeba histolytica. –

    Risk Factors:
    Destination (high-risk: Latin America, Africa, South Asia). – Season (warmer months). – Dietary habits (street food, raw produce, contaminated water). –

    Prevention:
    Vaccination: No widely available vaccine; consider Dukoral (cholera vaccine) for high-risk travelers. – Chemoprophylaxis: Not routinely recommended; consider for high-risk groups (e.g., immunocompromised, inflammatory bowel disease). –

    Rationale: Risk of resistance and side effects outweigh benefits for most travelers. – Behavioral: Food/water precautions (avoid ice, uncooked foods, unpeeled fruits; drink bottled/boiled water). –

    Diagnosis:
    Clinical: Based on symptoms; stool culture not routinely needed unless severe (bloody diarrhea, fever, systemic symptoms). –

    Laboratory: Stool culture, PCR, or microscopy if symptoms persist >72 hours or severe.
    Traveler’s diarrhea (TD) is defined as ≥3 unformed stools in 24 hours with at least one symptom (abdominal pain, cramps, fever, nausea, vomiting). –

    Severity classification:
    Mild: <4 stools/day, no fever, no blood. – Moderate: 4–5 stools/day, mild fever, no blood. – Severe: ≥6 stools/day, fever ≥38°C, blood, or severe dehydration. –

    Management : Oral Rehydration and Salt Intake Essential for all cases; use oral rehydration solutions (ORS) or salty broths. –

    Rationale: Prevents dehydration, maintains electrolyte balance. –

    Treatment Options Mild cases: Symptomatic management (loperamide, bismuth subsalicylate). – Loperamide (4 mg initial, then 2 mg after each loose stool, max 16 mg/day). – Bismuth subsalicylate (2 tablets 4x/day). –

    Moderate/severe cases: Antibiotics (azithromycin 500 mg single dose, or ciprofloxacin 500 mg single dose). –

    Rationale: Reduces duration and severity; azithromycin preferred due to fluoroquinolone resistance in some regions. –

    Antibiotic Prophylaxis: Not routinely recommended; reserved for high-risk travelers (e.g., immunocompromised, inflammatory bowel disease). –

    Options: Rifaximin 200 mg/day or azithromycin 500 mg/week. – Special Considerations Children: Same as adults but adjust doses (e.g., azithromycin 10 mg/kg single dose). –

    Pregnancy: Avoid fluoroquinolones; use azithromycin or loperamide. –

    Bloody diarrhea: Stool culture indicated; consider invasive pathogens (e.g., Campylobacter, Shigella). –

    Prevention Food/water precautions: Avoid tap water, unpeeled fruits, undercooked meat. –

    Vaccination: No specific vaccine; consider typhoid vaccine for high-risk areas. –

    Follow-Up Persistent diarrhea (>1 month) warrants evaluation for parasitic infections (e.g., Giardia, Cryptosporidium)

  • New cholesterol lowering medicines.

    New cholesterol lowering medicines In 2025 .

    Bempedoic acid (Nexletol)

    Mechanism: Inhibits ATP citrate lyase, reducing cholesterol synthesis. – Dose: 180 mg once daily. – Use: Heterozygous familial hypercholesterolemia (HeFH) or established atherosclerotic cardiovascular disease (ASCVD) with statin intolerance. – Side effects: Hyperuricemia, gout, elevated liver enzymes.

    What it is: An oral medication that is part of the class of drugs called ACLY inhibitors.
    How it works: Inhibits the ACLY enzyme in the liver, which reduces the production of cholesterol. It also has other metabolic and anti-inflammatory effects.
    Primary use: To lower LDL cholesterol in adults with heterozygous familial hypercholesterolemia, or other high-risk patients who require additional LDL reduction.
    Administration: Oral tablet.
    Key considerations: Can increase uric acid levels, potentially leading to gout. It also increases the blood concentration of some statins, so caution and dose adjustments are needed when co-administered with certain statins.

    Inclisiran (Leqvio)
    Mechanism: Small interfering RNA (siRNA) that reduces PCSK9 production, increasing LDL receptor activity. – Dose: 300 mg subcutaneously every 6 months. – Use: HeFH or ASCVD with elevated LDL-C despite maximally tolerated statin therapy. – Side effects: Injection-site reactions, flu-like symptoms.

    Evolocumab (Repatha)
    Mechanism: Monoclonal antibody that inhibits PCSK9, increasing LDL receptor activity. – Dose: 140 mg every 2 weeks or 420 mg monthly. – Use: HeFH or ASCVD with elevated LDL-C despite statin therapy. – Side effects: Injection-site reactions, flu-like symptoms, diabetes.

    Alirocumab (Praluent)
    Mechanism: Monoclonal antibody that inhibits PCSK9, increasing LDL receptor activity. – Dose: 75–300 mg every 2 weeks. – Side effects: Injection-site reactions, flu-like symptoms, myalgia.

    Ezetimibe (Zetia)
    Mechanism: Inhibits cholesterol absorption in the small intestine. – Dose: 10 mg once daily. – Use: Primary hyperlipidemia, HeFH, or ASCVD with elevated LDL-C. – Side effects: Diarrhea, abdominal pain, headache. –

    Bococizumab

    Bococizumab is a monoclonal antibody (mAb) that targets proprotein convertase subtilisin/kexin type 9 (PCSK9), a protein involved in low-density lipoprotein (LDL) receptor degradation. – Mechanism: Binds to PCSK9, preventing it from binding to LDL receptors, thereby increasing LDL receptor availability on the liver surface and enhancing LDL clearance from the bloodstream. – Indication: Used for the treatment of heterozygous familial hypercholesterolemia (HeFH) and clinical atherosclerotic cardiovascular disease (ASCVD) to reduce LDL cholesterol (LDL-C) levels. – Administration: Subcutaneous injection, typically administered every 2 weeks or monthly, depending on the dosing regimen. – Efficacy: Demonstrated significant reductions in LDL-C levels (up to 50–70% from baseline) in clinical trials, but its use has been limited due to concerns about immunogenicity and injection-site reactions. – Rationale: PCSK9 inhibitors like bococizumab are crucial for managing patients with refractory hypercholesterolemia or high ASCVD risk who do not achieve adequate LDL-C reduction with statins and ezetimibe.
    What it is: A humanized monoclonal antibody that targets the PCSK9 protein.
    How it works: By binding to and inhibiting PCSK9, it prevents the degradation of LDL receptors on liver cells, leading to more LDL being cleared from the blood.
    Primary use: In clinical trials to lower LDL cholesterol and reduce the risk of major cardiovascular events in high-risk patients.
    Administration: Subcutaneous injection, typically every two to four weeks.
    Key considerations: Although it has shown efficacy, long-term responsiveness may be affected by the development of anti-drug antibodies

  • Basilar Migraine

    Basilar Migraine (BM): Definition: A rare subtype of migraine with aura, characterized by symptoms originating from the brainstem and/or both hemispheres of the brain.

    – Diagnosis:
    Criteria (IHS): At least two attacks with fully reversible symptoms (e.g., dysarthria, vertigo, tinnitus, diplopia, ataxia, decreased level of consciousness) lasting 5–60 minutes, followed by headache. –

    Exclusion: Other causes (e.g., stroke, epilepsy) must be ruled out via imaging (MRI, MRA) and EEG. – Prevalence: Estimated at 1–2% of migraine patients, more common in adolescents and young adults. –

    Treatment:
    Acute: Triptans (e.g., sumatriptan), antiemetics (e.g., metoclopramide), or NSAIDs (e.g., ibuprofen). – Prophylaxis: Beta-blockers (e.g., propranolol), tricyclic antidepressants (e.g., amitriptyline), or topiramate. –

    Complications:
    Rare: Migraine stroke (if aura lasts >60 minutes), persistent neurological deficits, or status migrainosus (prolonged attack). – Rationale: BM’s brainstem involvement increases stroke risk; prompt treatment reduces complications. Note: Always consult a neurologist for confirmation and tailored management.