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serum ck elevation before symptoms clinical features myalgias type of discomfort pain; cramp sensation; muscle tenderness pain present at rest; increased with exercise may occur with normal ck progress to myoglobinuria unless drug stopped weakness myoglobinuria recovery days to months after stopping drug laboratory serum ck myopathy high; 1 of patients taking statins myalgias may be normal pathology scattered necrotic muscle fibers fibric acid derivatives fibrates specific drugs clofibrate; bezafibrate; ciprofibrate; clofibrate; gemfibrozil primary metabolism renal epidemiology frequency 6 cases per 10,000 patients relative risk of myopathy in fibrate users vs controls 42x 6 increased risk renal failure nephrotic syndrome drugs, concurrent probenecid; furosemide; statins onset after 2 to 3 months of treatment associated cardiomyopathy biochemistry reduced fatty acid branched chain amino acid oxidation reduced carnitine palmitoyl transferase activity hmg-coa reductase inhibitors statins 9 drugs all statins associated with myopathic disorders lovastatin; simvastatin; pravastatin; fluvastatin; atorvastatin; cervistatin relative risks increased incidence of myopathy when compared to controls 6 8x statin relations higher doses used statins with longer half life relative toxicity atorvastatin pravastatin simvastatin lovastatin fluvastatin correlates with drug half-life statins are given with drugs that inhibit metabolism in liver gemfibrozil, niacin, cyclosporine; azoles; diltiazem; erythromycin; colchicine organ failure hepatobiliary dysfunction; renal failure cytochrome p450 polymorphisms with reduced activity except pravastatin rosuvastatin slco1b1 encodes organic anion-transporting polypeptide, oatp1b1 regulates hepatic uptake of statins odds ratio for simvastatin myopathy with non-coding cc snp polymorphism 16.

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adding furosemide 10 to 20 mg will usually enhance the mobilization of water from the brain by mannitol.

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diuretics eg, furosemide, hydrochlorothiazide because excessive decreases in blood pressure may occur, which may cause dizziness, especially upon standing, or fainting dextran sulfate because it may increase the risk of allergic reaction eg, rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue and lightheadedness upon standing nonsteroidal anti-inflammatory drugs nsaids eg, aspirin, indomethacin because they may decrease vasotec s effectiveness and the risk of kidney damage may be increased oral diabetes medicine eg, glyburide because side effects, including a low blood sugar level eg, dizziness, headache, hunger, shakiness or weakness, sweating , may be increased by vasotec lithium or thiopurines eg, azathioprine because the risk of serious side effects may be increased by vasotec certain gold-containing medicines eg, sodium aurothiomalate because flushing, nausea, vomiting, and low blood pressure may occur potassium-sparing diuretics eg, amiloride or potassium supplements may cause high blood potassium levels eg, abnormal skin sensations of the arms and legs, confusion, heaviness of the limbs, listlessness, slow or irregular heartbeat, stopping of the heart when used with vasotec.

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