Le sildénafil présent dans Kamagra exerce une inhibition réversible de la PDE5, modulant la cascade GMPc et favorisant une vasodilatation localisée. L’absorption digestive varie selon la forme utilisée, comprimés classiques ou gels oraux. La distribution tissulaire est large et la liaison protéique élevée, avoisinant 96 %. La métabolisation hépatique génère un métabolite actif contribuant à l’effet pharmacologique global. La demi-vie reste courte, avec disparition plasmatique en quelques heures. Les interactions significatives concernent surtout les nitrés organiques et inhibiteurs puissants du CYP3A4. Dans les publications techniques, kamagra en ligne est souvent cité dans le cadre d’analyses comparatives portant sur les différences de formulations et de cinétique d’absorption.

Microsoft powerpoint - adrenal insufficientcy and differential [compatibility mode]

Adrenal Glands
• Located bilaterally at the
superior pole of each kidney
• Known as
as a gland within
within a gland
Insufficiency
• The Cortex secretes hormones
• The Medulla secretes
epinephrine
Dr. Michael E. O’Brien
• Only the Cortex will be discussed
Dr. Frank S. Drongowski
Hormones
Glucocorticoids
• Glucocorticoids like Cortisol
Glucocorticoids like
• They Regulate the carbohydrate, fat,
• Mineralcorticoids like
and protein Metabolism
Aldosterone
• They inhibit
Inflammation
IInflammation
• Sex hormones like
• They maintain Homeostasis during
Homeostasis
Dehydroepiandosterone
• Only the Glucocorticoids will be
• Synthetics of Glucocoricoids are
Synthetics
used to treat many Inflammatory
discussed
Diseases
Pathophysiology
• Primary Disease which is uncommon
• Patient takes
e synthetic steroids
is called Addison’s Disease which
is called Addison’s
any number of inflammatory
progressive destruction of the gland
diseases
the gland
the gland
• Since the body has the normal doses
Since the body
destroyed before there are
destroyed
symptoms
of steroids the adrenal gland
steroids the adrenal gland
• Secondary Disease which is the most
which is the
not produce
any and stagnates
common and of most concern is
• When the body
needs more for stress
caused by the Administration of
the gland cannot produce more
Exogenous Synthetic Corticosteroids
Adrenal Insufficiency and Differential Local Anesthesia for Dental Hygienists – Session III
Michael E. O’Brien, DDS and Frank S. Drongowski, DDS Glucocorticoids
Equivalents
• Hydrocortisone (Cortisone) is an
example of Short acting
• 25 mg of Cortisone
• 20mg of Hydrocortisone
• Prednisone (Deltasone) is an
example of Intermediate acting
• 5 mg of Prednisone
• 0.75 mg of Dexamethasone
• Dexamethasone (Decadron) is an
example of Long acting
Rule of Twos
Consultation
• Very conservative Rule
• The patient’s physician will
• Patient taking Cortisone 20 mg
Patient taking Cortisone 20
determine the dose necessary for
or more or it’s
it’ Equivalent
it is necessary
s necessar .
• For Two weeks or longer
• He or she will use the current
• Within a Two year period
daily dose, length of time, and
• Then consult their physician
level of stress associated with the
level
procedure to determine this.
Examples
• Routine procedure with little
• You do not
w nt to treat this
stress may require current dose
emergency
or doubling of dose.
• You will probably never see a
primary (
(Addison’s)
• Whereas more major procedures
• Be very careful
with patients taking
may require quadrupling the
steroids and always consult their
dose or more and may need to be
physician
multiple days depending on post
multiple days depending on post--
• Injected joints
Injected
or Topicals are not a
op period.
Adrenal Insufficiency and Differential Local Anesthesia for Dental Hygienists – Session III
Michael E. O’Brien, DDS and Frank S. Drongowski, DDS Signs and Symptoms
Management
• If patient is conscious but
• Weakness and Fatigue
showing signs and you know
• Anorexia and
Anorexia
Weight Loss
• Hyperpigmentation of the Sk
Hyperpigmentation
from history that it may be
Mucous Membranes (only in
adrenal i
nsufficientc
Addison’s)
• Place patient in comfortable
• Nausea and Vomiting
position and give them
• Dehydration and Fever
hydrocortisone 100 mg IM.
hydrocortisone 100
• Hypotension and Hypoglycemia
• This may avert the emergency.
Management
• P - Supine with Legs Elevated
• A - Head Tilt and Chin Lift
Head Tilt and Chin Lift
• B - (LLF) Give Oxygen
(LLF) Give Oxygen
• C – (Signs of) it
(Signs of) it -- will be very
will be very
Management
• D - Definitive
Definitive Treatment - Call
Unconsciousness
911 because patient will not
911
regain c
onsciousness
consciousness, monitor
Differential
Differential
vital signs and can give
Hydrocortisone 100 mg I.M. if
Hydrocortisone 100
Diagnosis
available. However patient needs
hospitalization and massive doses
of steroids I.V. and sugar.
Adrenal Insufficiency and Differential Local Anesthesia for Dental Hygienists – Session III
Michael E. O’Brien, DDS and Frank S. Drongowski, DDS Stress Related
• Child - Hypoglycemia, Epilepsy
Hypoglycemia, Epilepsy
• Teen - 40
40 - Psychogenic Reactions
• Vasodepressor Syncope
(Vasodepressor S
Syncope),
• Hypogl
Hypoglycemia (Diabetes), Epilepsy
• Over 40
• Epilepsy
- Postural Hypotension,
Postural Hypotension,
Cardiovascular Problems (Heart
• Cardiovascular Problems
Attack, Stroke,
e Arrythmia)
(Heart Attack and Stroke)
Duration of
Pallor, Feeling Hot,
Unconsciousness
Perspiration, and Nausea
Perspiration, and
• Postural Hypotension
• Vasodepressor Syncope
• Vasodepressor Syncope
• Seizure
H poglycemia
• Hypoglycemia
• Myocardial Infarction (cold)
• Adrenal Insufficientcy
• Adrenal Insufficientcy
• If not short and ammonia does
• (Hypotension
(Hypotension -- Hypoxia)
Hypoxia)
not work then Call 911
One Mo Time
Unconsciousness
• P - Supine with Feet Elevated
Supine with
• A - Head
Head Tilt
Questions?
• B - (LLF)
(LLF) -- Give Oxygen
• C - (Signs of ) Check
(Signs of )
• D - Continue Ox
Continue Oxygen, Try Spirits
Try Spirits
Ammonia,
and if Still Un
if Still U conscious
Adrenal Insufficiency and Differential Local Anesthesia for Dental Hygienists – Session III
Michael E. O’Brien, DDS and Frank S. Drongowski, DDS

Source: https://www.lsucde.org/Webcontent/06_Adrenal_insufficiency_and_differential.pdf