Injection solumedrol
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methylprednisolone Solu-Medrol injection indications dosage mechanism
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Injection Solu-Medrol (Methylprednisolone Sodium Succinate)
Drug Class & Identity
Methylprednisolone is a synthetic glucocorticoid (corticosteroid). Solu-Medrol is the sodium succinate salt, formulated specifically for IV or IM injection. It is distinct from:
- Depo-Medrol (acetate suspension) - for IM, intra-articular, intralesional, and soft-tissue injection only. Must NOT be given IV.
- Medrol / Medrol Dosepack - oral tablets (2, 4, 8, 16, 32 mg)
Available strengths (Solu-Medrol): 40 mg, 125 mg, 500 mg, 1000 mg vials (sterile powder for reconstitution).
Note: Multi-dose vials contain benzyl alcohol - avoid in premature infants.
Mechanism of Action
Methylprednisolone exerts a pluripotent anti-inflammatory effect via inhibition of inflammatory mediator gene transcription. It binds intracellular glucocorticoid receptors, which translocate to the nucleus and modulate gene expression, suppressing synthesis of pro-inflammatory cytokines (IL-1, IL-6, TNF), prostaglandins, and leukotrienes. It also stabilizes cell membranes and, at high doses, inhibits free radical-induced lipid peroxidation (proposed neuroprotective mechanism in spinal cord injury).
Relative anti-inflammatory potency: methylprednisolone = 5 (vs. hydrocortisone = 1, prednisone = 4, dexamethasone = 25).
Indications
When oral therapy is not feasible, IV/IM Solu-Medrol is indicated for:
| Category | Examples |
|---|---|
| Allergic states | Severe asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity, serum sickness, transfusion reactions, anaphylaxis |
| Inflammatory conditions | Rheumatoid arthritis flares, SLE, vasculitis, IBD |
| Pulmonary | Asthma exacerbations, COPD exacerbation, severe eosinophilic pneumonia, diffuse alveolar hemorrhage |
| Neurological | Multiple sclerosis acute relapse, acute spinal cord injury (controversial) |
| Oncology | Chemotherapy-induced nausea/vomiting (premedication), immunotherapy-related adverse events |
| ENT | Sudden sensorineural hearing loss (intratympanic route) |
| Gout | Acute gout when oral agents are contraindicated |
| Transplant/Immunosuppression | Graft rejection prevention/treatment |
Dosing
Dosage must be individualized based on disease severity and patient response.
Adults
| Indication | Dose |
|---|---|
| General anti-inflammatory | 10-40 mg IV/IM; repeat Q4-6 hr as needed |
| Severe/life-threatening conditions | 30 mg/kg IV over ≥30 min; may repeat Q4-6 hr x 48 hr |
| MS acute relapse (pulse therapy) | 1000 mg/day IV x 3-5 days |
| Asthma exacerbation | 40-80 mg/24 hr ÷ Q12-24 hr |
| Chemotherapy anti-emetic (severely emetogenic) | 250 mg IV over ≥5 min, 1 hr before + at initiation of chemo |
| Acute spinal cord injury (controversial) | 30 mg/kg IV over 15 min; 45 min pause; then 5.4 mg/kg/hr x 47 hr |
Pediatrics (Harriet Lane)
| Indication | Dose |
|---|---|
| Anti-inflammatory/immunosuppressive | 0.5-1.7 mg/kg/24 hr ÷ Q6-12 hr IV/IM/PO |
| Asthma exacerbation ≤12 yr | 1-2 mg/kg/24 hr ÷ Q12 hr (max 60 mg/24 hr) IV/IM |
| Asthma exacerbation >12 yr | 40-80 mg/24 hr ÷ Q12-24 hr |
| Single IM dose (vomiting/adherence) - child >4 yr | 240 mg IM x 1 (acetate product) |
| Acute spinal cord injury | Same as adult (weight-based) |
Administration
- Preferred route for emergencies: IV injection or infusion
- Doses ≤250 mg - give IV over at least 5 minutes
- Doses >250 mg - give IV over at least 30 minutes
- Rapid IV bolus (>500 mg in <10 min) is dangerous - risk of arrhythmia, circulatory collapse, cardiac arrest - requires ECG monitoring
- May be diluted in 5% dextrose in water, normal saline, or D5 in NS for infusion
- Dose excreted nearly completely within 12 hours; if constant levels needed, repeat Q4-6 hr
- IM route: also rapidly absorbed, similar kinetics to IV
Contraindications
- Systemic fungal infections
- Intrathecal administration (succinate salt)
- Hypersensitivity to methylprednisolone
- Live or attenuated vaccines (relative - increased risk of infection)
- Idiopathic thrombocytopenic purpura (IM route contraindicated)
- Herpes simplex keratitis
- Arrested tuberculosis (unless used as adjunct with anti-TB therapy)
- Premature neonates (benzyl alcohol in multi-dose vials)
Adverse Effects
Adverse effects are dose- and duration-dependent, generally significant with >10 mg/day prednisone equivalent (>8 mg/day methylprednisolone) for prolonged periods.
| System | Effect |
|---|---|
| Endocrine/Metabolic | Hyperglycemia, iatrogenic Cushing syndrome, weight gain, adrenal suppression (>3 weeks use), adrenal crisis on abrupt withdrawal |
| Musculoskeletal | Osteoporosis, proximal myopathy, avascular necrosis (femoral head, humeral head, tibial plateau) |
| Cardiovascular | Hypertension, dyslipidemia, arrhythmia (with rapid IV bolus) |
| GI | GI bleeding/peptic ulcer, especially with concurrent NSAIDs |
| Ophthalmologic | Cataracts, glaucoma |
| Immunologic | Increased susceptibility to infection; may mask signs of infection; PJP prophylaxis if prednisone ≥20 mg for >1 month |
| Psychiatric | Insomnia, euphoria, nervousness, depression, psychosis |
| Dermatologic | Acne, purpura, cutaneous atrophy |
| Pediatric specific | Hypertrophic cardiomyopathy in premature infants; pseudotumor cerebri; growth suppression |
Drug Interactions
| Drug | Interaction |
|---|---|
| Barbiturates, phenytoin, rifampin | Enhance methylprednisolone clearance (reduced effect) |
| Erythromycin, itraconazole, ketoconazole | Increase methylprednisolone levels |
| Cyclosporine, tacrolimus | Methylprednisolone increases their levels |
| CYP3A4 substrates (simvastatin, sirolimus) | Methylprednisolone decreases their levels |
| Live vaccines | Contraindicated - risk of disseminated infection |
| NSAIDs | Additive GI ulceration risk |
| Warfarin | Variable effect on anticoagulation - monitor INR |
| Macimorelin | Interferes with GH stimulation test - allow washout |
Special Populations
- Pregnancy: Use with caution; may cross placenta
- Renal impairment: Use with caution; dialyzable - dose adjustment may be needed
- Hepatic impairment: Use with caution
- Systemic sclerosis: Use with caution (risk of scleroderma renal crisis)
Osteoporosis Prevention (with chronic use)
From the first day of steroid therapy:
- Calcium 1-1.5 g/day PO
- Vitamin D 1000 units/day PO
- Bisphosphonate (most commonly used for prophylaxis)
- Weight-bearing exercise; avoid alcohol and tobacco
Key Clinical Notes
- For acute spinal cord injury: high-dose methylprednisolone is controversial - should NOT be given routinely per Tintinalli's Emergency Medicine. The NASCIS protocol is still used at some centers but evidence is disputed.
- Prednisone (PO) and methylprednisolone (IV) are generally the preferred glucocorticoids in clinical practice due to cost and half-life considerations (Washington Manual).
- Pulse therapy (1 g/day IV) is used in MS relapses, lupus nephritis, and severe vasculitis.
- Intratympanic methylprednisolone (62.5 mg/mL) is used for sudden sensorineural hearing loss, achieving much higher inner-ear concentrations than systemic dosing.
- On stopping after prolonged use, taper gradually to prevent acute adrenal insufficiency.
Sources: Harriet Lane Handbook 23rd ed., Washington Manual of Medical Therapeutics, Lippincott Illustrated Reviews Pharmacology, FDA Prescribing Information (Solu-Medrol, updated 2024), Tintinalli's Emergency Medicine, Goodman & Gilman's Pharmacological Basis of Therapeutics.
Malaria medication
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malaria treatment WHO guidelines 2025 antimalarial drugs first line
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Malaria Medications - Complete Reference
Overview of Plasmodium Species
There are 5 species causing human malaria - each responds differently to drugs:
- P. falciparum - most dangerous, highest chloroquine resistance, no hypnozoites
- P. vivax - forms dormant liver stage (hypnozoites), relapse risk; increasingly chloroquine-resistant in some regions
- P. ovale - forms hypnozoites, relapse risk; remains chloroquine-sensitive
- P. malariae - no hypnozoites; chloroquine-sensitive
- P. knowlesi - zoonotic; short 24 hr cycle, can rapidly become severe; artemisinin preferred
Drug Classification by Class
| Drug | Class | Primary Use |
|---|---|---|
| Chloroquine | 4-Aminoquinoline | Treatment/prophylaxis (sensitive strains) |
| Amodiaquine | 4-Aminoquinoline | ACT partner drug (active vs some CQ-resistant Pf) |
| Piperaquine | Bisquinoline | ACT partner drug (DHA-PPQ) |
| Quinine | Quinoline methanol | Oral/IV treatment of P. falciparum |
| Mefloquine | Quinoline methanol | Prophylaxis and treatment of CQ-resistant Pf |
| Primaquine | 8-Aminoquinoline | Radical cure of P. vivax/P. ovale; gametocytocidal |
| Tafenoquine | 8-Aminoquinoline | Single-dose radical cure of P. vivax/P. ovale |
| Artemisinins (artesunate, artemether, DHA) | Sesquiterpene lactone endoperoxides | Cornerstone of all ACT; IV artesunate for severe disease |
| Lumefantrine | Amyl alcohol | ACT partner (with artemether - Coartem) |
| Pyronaridine | Mannich base acridine | ACT partner (with artesunate - Pyramax) |
| Atovaquone-proguanil (Malarone) | Quinone + folate antagonist | Treatment and prophylaxis of Pf |
| Sulfadoxine-pyrimethamine (Fansidar) | Folate antagonist combination | ACT partner; IPT in pregnancy/children |
| Doxycycline | Tetracycline | With quinine for treatment; prophylaxis |
Section 1: Treatment of Uncomplicated P. falciparum (Chloroquine-Resistant)
First-Line: Artemisinin-Based Combination Therapies (ACTs)
Artemisinin monotherapy is strongly discouraged - combination is mandatory to prevent resistance selection.
| ACT Regimen | Brand | Notes |
|---|---|---|
| Artemether 20mg + Lumefantrine 120mg | Coartem, Riamet | Most widely used worldwide; FDA approved; 4 tabs twice daily x 3 days |
| Artesunate + Amodiaquine (ASAQ) | - | First-line in many African countries |
| Artesunate + Mefloquine | - | Standard in parts of Southeast Asia and South America |
| Dihydroartemisinin + Piperaquine (DHA-PPQ) | - | Excellent efficacy; resistance emerging in SE Asia |
| Artesunate + Pyronaridine | Pyramax | Newer, highly efficacious regimen |
| Artesunate + Sulfadoxine-Pyrimethamine | - | India first-line (except NE states); not recommended where SP resistance is high |
Second-Line / Alternative Oral Therapy
- Quinine sulfate 650 mg TID x 3-7 days plus doxycycline 100 mg BID x 7 days (or clindamycin 600 mg BID x 7 days)
- Atovaquone-proguanil (Malarone) 4 tabs daily x 3 days
- Mefloquine 750 mg then 500 mg 6-8 hours later (or 1250 mg single dose, less tolerated)
Section 2: Treatment of Uncomplicated P. vivax / P. ovale
- Chloroquine-sensitive areas (most): Chloroquine 25 mg/kg divided over 3 days + primaquine for radical cure
- Chloroquine-resistant P. vivax: ACT (any WHO-recommended ACT) + primaquine
Radical Cure (to eliminate hypnozoites and prevent relapse)
- Primaquine: 30 mg base (0.5 mg/kg) daily x 14 days
- Tafenoquine: 300 mg single dose (new, more convenient)
- Mandatory G6PD testing before either drug - both cause hemolysis in G6PD deficiency
- Primaquine is contraindicated in pregnancy (G6PD status of fetus unknown); tafenoquine is also contraindicated
- For India (Park's): Chloroquine 25 mg/kg over 3 days + primaquine 0.25 mg/kg/day x 14 days
Section 3: Treatment of P. malariae
- Chloroquine alone (no radical cure needed - no hypnozoites; but long erythrocytic cycle so prefer longer half-life drugs)
Section 4: Treatment of Severe / Complicated Malaria
Severe malaria is a medical emergency. Features include: coma, repeated convulsions, renal failure (creatinine >3 mg/dL), jaundice (bilirubin >3 mg/dL), severe anemia (Hb <5 g/dL), pulmonary edema/ARDS, hypoglycemia, circulatory collapse, hyperparasitemia (>5% parasitized RBCs), DIC, hemoglobinuria.
Parenteral Treatment (start immediately, do not delay)
| Drug | Regimen |
|---|---|
| IV Artesunate (preferred, 1st line) | 2.4 mg/kg IV every 12 hr on Day 1; then once daily for 2 more days |
| IV Quinine dihydrochloride (alternative) | 20 mg/kg loading over 4 hr; then 10 mg/kg every 8 hr (requires cardiac monitoring) |
| IM Artemether | 3.2 mg/kg IM loading; then 1.6 mg/kg/day |
- IV artesunate is superior to quinine for severe malaria and is FDA-approved in the USA
- Give parenteral therapy for minimum 24 hours; then switch to complete oral ACT course when tolerated
- IM artesunate or intrarectal artesunate are options when IV access is limited
Section 5: Malaria in Pregnancy
| Trimester | P. falciparum | P. vivax |
|---|---|---|
| 1st trimester | Quinine + clindamycin (ACTs not routinely recommended due to limited safety data) | Chloroquine |
| 2nd & 3rd trimester | ACT (artemether-lumefantrine preferred; artesunate for severe disease) | Chloroquine |
| Radical cure | Primaquine is contraindicated in all trimesters (fetal G6PD unknown) | Give post-partum |
| After severe malaria | Secondary prophylaxis with mefloquine until delivery (for Pf) | - |
Section 6: Chemoprophylaxis
| Drug | Schedule | Areas / Notes |
|---|---|---|
| Atovaquone-proguanil (Malarone) | 1 tab daily, start 1-2 days before travel, continue 7 days after | All malarious areas; preferred for short trips; not for children <5 kg |
| Doxycycline | 100 mg daily, start 1-2 days before, continue 4 weeks after | All areas including SE Asia; CI in pregnancy, children <8 yr |
| Mefloquine | 250 mg weekly, start 2-3 weeks before, continue 4 weeks after | Most areas except SE Asia with mefloquine resistance; CI with seizures, psychiatric/cardiac history |
| Chloroquine | 500 mg weekly | Only in areas with no chloroquine resistance (Central America, Caribbean, some Middle East) |
| Primaquine | 30 mg daily (terminal or presumptive anti-relapse therapy) | Alternative prophylaxis; also used for radical cure of P. vivax/P. ovale after return |
Section 7: Drug Mechanisms of Action
| Drug | Mechanism |
|---|---|
| Artemisinins | Iron-catalyzed cleavage of endoperoxide bridge → free radical generation → oxidative damage to parasite; active vs blood trophozoites; kills young gametocytes |
| Chloroquine / Aminoquinolines | Accumulate in parasite food vacuole; inhibit heme polymerization → toxic heme accumulates; active vs blood schizonts |
| Quinine | Similar to chloroquine; also inhibits heme polymerization; kills gametocytes of P. vivax/P. ovale (not Pf) |
| Primaquine / Tafenoquine | Oxidative mechanism; active vs liver hypnozoites (P. vivax, P. ovale), gametocytes of all species, and pre-erythrocytic stages |
| Atovaquone-Proguanil | Atovaquone inhibits mitochondrial electron transport (cytochrome bc1 complex); proguanil inhibits dihydrofolate reductase; synergistic causal prophylaxis |
| Sulfadoxine-Pyrimethamine | Inhibit dihydropteroate synthase + dihydrofolate reductase (folate pathway); blood schizonticides |
| Doxycycline | Inhibits protein synthesis; slow-acting blood schizonticide; always used with faster-acting drug |
| Mefloquine | Unknown exact mechanism; blood schizonticide; no activity on liver stages or gametocytes |
Section 8: Key Toxicities
| Drug | Major Adverse Effects |
|---|---|
| Chloroquine | Pruritus (dark skin), retinopathy (cumulative dose >100 g), cardiac arrhythmias (acute overdose), QT prolongation |
| Artemisinins | Generally well tolerated; delayed hemolysis post-IV artesunate; neurotoxicity at very high doses (experimental) |
| Quinine | Cinchonism (tinnitus, headache, nausea, visual disturbance); hypoglycemia (stimulates insulin); QT prolongation; cardiac arrhythmias (requires ECG monitoring IV) |
| Mefloquine | Neuropsychiatric effects (anxiety, depression, psychosis, seizures - FDA black box warning 2013); GI upset; cardiac conduction changes |
| Primaquine | Hemolytic anemia in G6PD deficiency - test G6PD before use; methemoglobinemia; GI intolerance |
| Tafenoquine | Same as primaquine (hemolysis in G6PD deficiency); single-dose convenience |
| Doxycycline | Photosensitivity, GI upset, esophagitis; CI in pregnancy and children <8 yr |
| Atovaquone-proguanil | GI side effects; expensive |
| Amodiaquine | Agranulocytosis, hepatitis with chronic use - not recommended for prophylaxis |
Section 9: Special Notes on Resistance
- P. falciparum chloroquine resistance is widespread in sub-Saharan Africa, South/Southeast Asia, Oceania - ACTs are mandatory in these areas
- Artemisinin partial resistance (delayed parasite clearance) emerged in Southeast Asia and has now been detected in East Africa - a major concern since no replacement drug is yet available
- Multiple first-line therapy (MFT) strategy: WHO now recommends deploying 2+ different ACTs simultaneously in a region to reduce drug pressure and slow resistance spread
- Artemisinin monotherapy is banned in India and officially discouraged globally
- SP resistance is high in most areas; SP remains useful for intermittent preventive treatment (IPT) in pregnancy (IPTp) and children at lower dosing intervals
- Tafenoquine is being introduced as an alternative to primaquine for anti-relapse therapy (single dose vs 14-day course)
Sources: Goldman-Cecil Medicine, International Edition; Katzung's Basic & Clinical Pharmacology 16th ed.; Harrison's Principles of Internal Medicine 22nd ed. (2025); Park's Textbook of Preventive & Social Medicine; Harriet Lane Handbook 23rd ed.; WHO Guidelines for Malaria August 2025; FDA prescribing information.
Inj monocef according to weight
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Excellent - comprehensive data gathered. Here is the full weight-based dosing reference:
Injection Monocef (Ceftriaxone) - Weight-Based Dosing
Monocef is a brand name for ceftriaxone sodium - a 3rd generation cephalosporin antibiotic. Available as 250 mg, 500 mg, 1 g, and 2 g vials for IV/IM injection.
PEDIATRIC DOSING (Weight-Based)
Neonate (< 1 month)
Important: Ceftriaxone should generally be avoided in neonates (especially <44 weeks corrected gestational age) due to risk of bilirubin displacement and ceftriaxone-calcium salt precipitation in lungs and kidneys. Use cefotaxime instead where possible.
| Indication | Dose |
|---|---|
| Gonococcal ophthalmia / prophylaxis | 25-50 mg/kg IM/IV x 1; max 250 mg |
Infant (>1 month) and Child
| Indication | Dose | Frequency | Max Dose |
|---|---|---|---|
| Mild/moderate infections | 50-75 mg/kg/day | Q12-24 hr IV/IM | 2 g/24 hr |
| Severe infections | 75-100 mg/kg/day | Q12-24 hr IV/IM | 2 g/dose; 4 g/24 hr |
| Meningitis | 100 mg/kg/day | Q12 hr IV/IM | 2 g/dose; 4 g/24 hr |
| Penicillin-resistant pneumococcus (outside CNS) | 80-100 mg/kg/day | Q12-24 hr | 2 g/dose; 4 g/24 hr |
| Acute otitis media | 50 mg/kg IM/IV x 1 | Single dose (or x3 for persistent) | 1 g/dose |
| Lyme disease | 50-75 mg/kg/dose | Once daily IV | 2 g/dose |
| Endocarditis prophylaxis | 50 mg/kg IV/IM | 30-60 min before procedure | 1 g |
| Gonococcal exposure / STI prophylaxis | 50 mg/kg IM x 1 | Single dose | 1 g |
Quick Weight-Based Dose Calculator (Mild/Moderate: 50 mg/kg/day)
| Weight | 50 mg/kg | 75 mg/kg | 100 mg/kg (Meningitis) |
|---|---|---|---|
| 5 kg | 250 mg | 375 mg | 500 mg |
| 8 kg | 400 mg | 600 mg | 800 mg |
| 10 kg | 500 mg | 750 mg | 1000 mg |
| 12 kg | 600 mg | 900 mg | 1200 mg |
| 15 kg | 750 mg | 1000 mg (cap) | 1500 mg |
| 18 kg | 900 mg | 1000 mg (cap) | 1800 mg |
| 20 kg | 1000 mg | 1000 mg (cap) | 2000 mg (cap) |
| 25 kg | 1000 mg (cap) | 1000 mg (cap) | 2000 mg (cap) |
| ≥30 kg | → Use adult dose |
Cap = maximum dose applies; do not exceed 2 g/day for non-meningitis, 4 g/day for meningitis
ADULT DOSING
| Indication | Dose | Frequency | Max Daily Dose |
|---|---|---|---|
| General infections (mild-moderate) | 1 g | Once daily IV/IM | 4 g/day |
| Serious infections | 1-2 g | Q12-24 hr IV/IM | 4 g/day |
| Meningitis / CNS infections | 2 g | Q12 hr IV | 4 g/day |
| Community-acquired pneumonia (hospitalized) | 1-2 g | Once daily | 4 g/day |
| Typhoid / enteric fever | 1-2 g | Once daily x 10-14 days | - |
| Uncomplicated gonorrhea (<150 kg) | 500 mg IM | Single dose | - |
| Uncomplicated gonorrhea (≥150 kg) | 1 g IM | Single dose | - |
| PID (severe) | 1 g IV | Once daily + doxy + metro | - |
| Surgical prophylaxis | 1 g IV | 30-60 min before surgery | - |
| Endocarditis prophylaxis | 1 g IV/IM | 30-60 min before procedure | - |
| MSSA infections | 2-4 g | Divided doses | 4 g/day |
Administration
| Route | Details |
|---|---|
| IV slow infusion | Dilute in NS or D5W; infuse over 30 minutes (preferred) |
| IV direct | Can give doses ≤500 mg slowly over 5 min; larger doses need infusion |
| IM | Reconstitute with 1% lidocaine (reduces pain) to 250-350 mg/mL concentration; 250 mg/mL preferred (fewer injection site reactions) |
Special Situations
| Scenario | Recommendation |
|---|---|
| Neonates | Avoid; use cefotaxime. If must use: never mix with IV calcium products (fatal pulmonary/renal precipitates reported) |
| Hyperbilirubinemia | Contraindicated - displaces bilirubin from albumin |
| Renal impairment | Dose reduction for CrCl <10 mL/min; max 2 g/day if combined hepatic + renal failure |
| Hepatic impairment | No adjustment unless combined with severe renal impairment |
| Pregnancy | Generally safe (Category B) |
| Obese/overweight children | Dose based on actual measured body weight |
Key Contraindications & Cautions
- Never mix with IV calcium-containing solutions (Ringer's lactate, TPN) - causes precipitation; fatal in neonates, risky in all ages
- Hypersensitivity to cephalosporins or penicillins (cross-reactivity ~1-2%)
- Caution in gallbladder/biliary disease (35-45% biliary excretion; can cause biliary sludge/pseudolithiasis)
- May cause false-positive Coombs test, false-positive urine glucose (Clinitest/Benedict's), and interfere with creatinine assays (Jaffe method)
Common Side Effects
- Injection site pain/phlebitis (IV), local pain (IM)
- Diarrhea (may cause C. difficile - use with caution in prolonged courses)
- Transient rise in liver enzymes
- Rash
- Reversible biliary sludge / cholelithiasis
- Rarely: reversible encephalopathy, seizures (especially in renal failure at high doses)
Sources: Harriet Lane Handbook 23rd ed. (Johns Hopkins); FDA Prescribing Information (Ceftriaxone); Perth Children's Hospital ChAMP Monograph; Pfizer Prescribing Information.
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