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Viagra sildenafil citrate 50 100 mg - if the fixed combination represents the dose titrated to the individual patient s needs, therapy with the fixed combination may be more convenient than with the separate failure is secondary to a tachyarrhythmia treatable with propranolol Hydrochlorothiazide is contraindicated in patients with anuria or hypersensitivity to this or other CARDIAC failure Sympathetic stimulation may be a vital component supporting circulatory function in patients with congestive heart failure and its inhibition by beta blockade may precipitate more severe failure Although beta blockers should be avoided in overt congestive heart failure if necessary, they can be used with close follow-up in patients with a history of failure who are well compensated and are receiving digitalis and diuretics Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart muscle IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers can in some cases, lead to cardiac failure Therefore at the first sign or symptom of hear! observed closely, or propranolol should be discontinued (gradually if possible) IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of angina and in some cases, myocardial infarction following abrupt discontinuance ol propranolol therapy Therefore, when discontinuance of propranolol is planned the dosage should be gradually reduced and the patient carefully monitored In addition when propranolol is prescribed for angina pectoris, the patients should be cautioned' against interruption or cessation of therapy without the physician's advice If propranolol therapy is interrupted and exacerbation of angina occurs, it usually is advisable to reinstitute propranolol therapy and take other measures appropriate tor the management of unstable angina pectoris Since coronary artery disease may be unrecognized it may be prudent to follow Ihe above advice in patients considered at risk of having occult atherosclerotic heart disease who are given propranolol tor other indications THYROTOXICOSIS Beta blockade may mask certain clinical signs of hyperthyroidism Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptoms of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function tests IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME several cases have been reported in which, after propranolol, the tachycardia was replaced by a severe bradycardia MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking therapy prior to mapr surgery is controversial It should be noted however that the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks ol general anesthesia Nonallergic Bronchospasm (eg, chronic bronchitis, emphysema) -PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD, IN GENERAL, NOT RECEIVE BETA BLOCKERS INDERAL should be administered with caution since it may block bronchodilation produced by endogenous and exogenous catecholamine stimulation ol beta receptors DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent Ihe appearance ol certain premonitory signs and symptoms (pulse rale and pressure changes) of acute hypoglycemia in labile insulin-dependent diabetes In these patients, it may be more difficult to adjust Ihe dosage of insulin Hypoglycemic attacks may be accompanied by a precipitous Thiazides should be used with caution in severe renal disease In patients with renal disease, thiazides may precipitate azotemia In patients with impaired renal function, cumulative effects Thiazides should also be used with caution in patients with impaired hepatic function or progressive liver disease, since minor alterations of fluid and electrolyte balance may precipitate hepatic coma Thiazides may add to or potentiate the action of other antihypertensive drugs Polenliation occurs with ganglionic or peripheral adrenergic-blocking drugs Sensitivity reactions may occur in patients with a history of allergy or bronchial asthma The possibility of exacerbation or activation of systemic lupus erythematosus has been GENERAL Propranolol should be used with caution in patients with impaired hepatic or renal function Propranolol is not indicated for Ihe treatment ol hypertensive emergencies Beta-adrenoreceptor blockade can cause reduction of intraocular pressure Patients should be told that propranolol may interlere with the glaucoma screening lest Withdrawal may lead to a return of increased intraocular pressure CLINICAL LABORATORY TESTS Elevated blood urea levels in patients with severe heart disease elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase DRUG INTERACTIONS Patients receiving catecholamine-depleting drugs, such as reserpine, should be closely observed it propranolol is administered The added catecholamineblocking action may produce an excessive reduction ol resting sympathetic nervous activity, which may result in hypotension, marked bradycardia, vertigo syncopal attacks, or orthostatic CARCINOGENESIS. 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The committee heartily concur with the" American Medical College Association," in its statement, that"An adequate medical education is such as gives to the student a fair practical knowledge of all the branches of medical science, and a mental discipline sufficient for the proper use of such knowledge in the practice of" A practical knowledge of these various branches necessitates demonstrative teaching and personal manipulation which can be provided in an adequate degree in medical colleges only." We would add to this obvious statement that the study of theories alone can produce nothing but theoretical knowledge (sildenafil citrate 50 mg dose).
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