Treatment Considerations for Autistic Spectrum Disorder Patients at the Institute for Molecular Medicine by Prof. Garth L. Nicolson* The Institute for Molecular Medicine, 16371 Gothard St. H, Huntington Beach,Tel: (714) 596-6636 Fax: (714) 596-3791 E-mail: firstname.lastname@example.org
There are a number of considerations when children are undergoing therapy for AutisticSpectrum Disorder (autism, Asperger Syndrome, etc. and also other similar conditions:ADD, ADHD) including whether to use traditional as well as integrative nutraceuticalapproaches. The Institute realizes that many families cannot afford traditional treatmentprograms for ASD, and thus emphasis has been placed on non-invasive approaches,including diet, nutritional supplements and other approaches. These are discussed in thefollowing sections, including antibiotic/antiviral/antifungal therapies for chronicbacterial, viral and fungal infections and dietary supplements. The Institute forMolecular Medicine is a nonprofit institution and does not endorse commercial productsor treatment approaches. The products and procedures below are only examples of thetypes of approaches and substances that could be beneficial to patients with autism, ADDand other chronic childhood illnesses. Consult your physician for advice on treatments,dosing and schedules that can vary for each patient. *The author has no financial interest in any product discussed below.
Testing and Therapy for Heavy Metal Contamination
The Institute for Molecular Medicine has found that many chronic illness patients have heavymetal contamination that must be considered in any treatment scheme. Most clinical studies haveconcentrated on Mercury, Lead, Aluminum, Cadmium and other heavy metals. Although heavymetal removal is a long-term process, sometimes often taking over one year, it does not requireexpensive, invasive, weekly (or more often) treatments at clinics. Patients should have a heavymetal analysis of hair, stool and urine at a reputable diagnostic laboratory (Doctors’ Data,www.doctorsdata.com, 800-323-2784 Great Smokies Diagnostic Laboratories, www.gsdl.com,800-522-4762). Results should be evaluated by a physician. Parents should be aware that suchanalyses are only of excreted heavy metals; deposits deep in tissues cannot be tested using theseprocedures. Non-invasive treatments to remove heavy metals include oral dosing, trans-dermalpatches and anal suppositories containing chelating agents. The former can be found atwww.edtachelation.com and the latter is available from World Health Products (Detoxamin,www.detoxamin.com, 877-656-4553) and can be used long-term with very few or no side effects. For heavy metal removal, and it is claimed that Garlic Plus (Longevity, 800-580-7587,www.longevityplus.net) has proved useful, but there are no long-term studies to substantiate theabove claims. Diagnosis and Antibiotic Therapy for Chronic Infections
The Institute for Molecular Medicine has found that over 70% of autism patients have chronicinfections, such as Mycoplasma species, Chlamydia pneumoniae, among others. Also,approximately 30% have HHV-6 and some have other viruses, such as CMV. In the Eastern U.S. many children have Borrelia infections and co-infections (Lyme Disease). Many autism patientsalso have fungal infections. Mycoplasma, Chlamydia, Borrelia and other bacterial, viral (HHV-6,
CMV etc.) and fungal infections must be identified and treated properly. This requires analysis ofa blood sample obtained by a physician. We recommend Unevx Laboratories, 1664 N. VirginiaSt., Reno, NV 89557, Tel: 775-682-8280, Fax: 775-682-8290 For treatment of intracellular
bacterial infections, as much as 3 months (without a break), then 6-wk on 2-wk off oral antibioticcycles may be necessary (azithromycin, biaxin, low dose doxycycline, as capsules without starch
fillers: details follow in sections below). If the patient does not tolerate drug capsules, analternative is to mix the contents into applesauce or other children’s food. Although suchtreatments have helped children with chronic infections, care should be exercised in the long-termuse of any drug in children. Oral antibiotics must be taken with a glass of water, crackers orbread to avoid esophageal irritation (do not let patients lie down for at least 1 hr). Direct sunlightmust be avoided during treatment. To overcome Herxheimer reactions (die-off involving chills,fever, night sweats, muscle aches, joint pain, short term memory loss and fatigue or a generalworsening of symptoms), oral Benadryl (diphenhydramine, 25 mg) can be given at least 30 minbefore antibiotics and lemon/olive drink (1 blended whole lemon, 1 cup fruit juice, 1 tbs oliveoil—strain and drink liquid) is useful for some patients. This period usually passes within a fewweeks and differs from allergic reactions that can cause rashes, itching, swelling, dizziness,trouble breathing—if these occur, seek immediate medical attention. For patients who cannot takeantibiotics, Rain Tree has 3 products (Myco+, C-F for kids, Immune Support), 800-780-5902,www.rain-tree.com. Some of these come also as liquid extracts. Diagnosis and Antiviral Therapy for Chronic Infections
Large subsets of autism patients show evidence of chronic viral infections, such as HHV-6 orCMV. For HHV-6 and CMV infections, a blood sample is required for testing (see sectionabove). Ganciclovir is an antiviral that can be used. It is usually given intravenously (5 mg/Kgbody weight i.v. over 1 hr every day) or oral in 3-wk cycles. Some patients have benefited fromthe use of Famvir. This can be used as an oral dose for 2 wks. Consult your physician for properdosing. Nutraceutical treatments can be used instead or concurrently, such as Genistein (insoy/red clover, www.iherb.com) to inhibit viral kinase, rosemary/lemon balm to reducecomplement activation, selenite (see minerals) to inhibit viral replication, barley grass and lauricacid (www.coconutoil.com) to inhibit lipid metabolism of viruses and Phyllanthus amarus/niruri(www.tropilab.com) to inhibit viral reverse transcriptase. The IMM does not recommend use ofantivirals without a thorough discussion of its benefits and possible adverse reactions with yourchild’s physician. Immune enhancement and nutraceuticals should be considered before usingantivirals (see section below). General Nutritional Considerations
Autism and chronic illness patients, in general, are immunosuppressed and susceptible toopportunistic infections, so proper nutrition is important. Fresh fluids should be consumed, suchas fruit juices or pure water. High sugar and high fat foods, such as fast foods and acid forming,allergen-prone and system stressing foods or high sugar/fat junk foods should be avoided. ManyASD patients benefit from gluten-free and/or casein-free diets. Increase intake of freshvegetables, fruits and non-wheat grains, and decrease intake of fats and simple or refined sugarsthat can suppress your child’s immune system. Cruciferous vegetables foods, such as prunes, fishand some whole grains, are useful, and various diets can be found on autism support websites. Insome patients exclusive use of 'organic' foods has been beneficial, because some children aresensitive to chemicals present in food. Diet is also important to control yeast infections. Vitamins and Minerals
Chronic illness patients and especially ASD patients are often depleted in certain vitamins(especially B complex, C, E, CoQ-10) and certain minerals. This illness can result in poorabsorption. Therefore, vitamin/mineral supplements are necessary, especially if heavy metalchelators are being used. Certain vitamins, such as vitamin B complex, cannot be easily absorbedby the gut (oral dose). Sublingual liquid (under the tongue) natural B-complex (Total B, RealLife Research, Norwalk, CA, 562-926-5522 or at www.4discountsupplements.com, or at GNC)
should be used instead of swallowed capsules. General vitamins plus extra C, E, CoQ-10, beta-
carotene, folic acid, bioflavoids and biotin are best. Some have suggested extra L-cysteine, L-tyrosine, L-glutamine, L-carnitine, malic acid and flaxseed or fish oils, but the latter lipids shouldbe replaced by NTFfactor (see below), and supplementation with excess amino acids should beoverseen by a physician. Certain minerals are depleted in essentially all chronic illness patients,
such as zinc, magnesium, calcium, chromium and selenium, but most vitamin supplements madefor children have appropriate amounts of these minerals. Vitamins and minerals should not betaken at the same time of day as antibiotics, antivirals (2 hr difference) or heavy metal chelatingagents (4 hr difference), because they can affect absorption or act against therapy. The suggesteddoses of vitamins can vary dramatically among patients depending on age and weight; consultwith your physician or nutritionist for appropriate dosage. Some patients may require analysis ofvitamins, minerals and amino acids so that appropriate doses can be recommended. Lipid Replacement Therapy for Chronic Infections and Restoring Mitochondrial Function
Lipid Replacement Therapy can be useful in providing membrane lipids in unoxidized form torepair nerve membranes and mitochondrial membranes that are damaged by heavy metals,chemicals and infections. For autism/ADD patients we recommend the oral supplement HealthyAging containing NTFactor (Nutritional Therapeutics, Inc. www.NTFactor.com, 800-982-9158). This product comes as tablets that should be ground up between two spoons into a course powderthat can be added to several spoonfuls of applesauce. The NTFactor is not bitter, but it is slightlysour, and some children actually like the taste. The dose should be 1/2-1 tablet for children up to2 years-old, 2 tablets for 2-3 years old and 3-4 tablets for 4-5 years-old and 4-5 tablets 5 years-oldand older. Research has demonstrated no adverse responses with NTFactor even many timesthese doses. Since this formulation is a completely natural membrane lipid mixture, there are noknown toxicities and no known toxic dose limits. Oxidative Therapy for Chronic Infections and Chemical Exposures
Oxidative therapy can be useful in suppressing a variety of anaerobic infections and removingcertain chemicals. For example, several weeks of Hyperbaric Oxygen (1.5-2 ATM, 60 min)treatments, or peroxide baths using 2 cups of Epsom salt in a hot bath or Jacuzzi have been used. After 5 min in an Epson salt bath, add 2-4 bottles (16 oz.) of 3% hydrogen peroxide. Thehydrogen peroxide is added after the pores open in the hot water. Repeat twice per week; novitamins 8 hr before the bath or hyperbaric oxygen. Hydrogen peroxide can also be directlyapplied to skin after a hot shower/tub. Leave hydrogen peroxide on for 5 min, and then wash off. For oral irrigation to treat oral infections, mix 1 part 3% hydrogen peroxide with 2 parts waterand use like a mouth wash 3X per day. Most chronic illness patients have periodontal problems,and oral infections and bone cavitation infections are common. These should not be ignored,because these infections can become systemic and spread to other sites. Replacement of Natural Gut Flora and Suppressing Bowel Disorders
Patients undergoing treatment with antibiotics and other substances risk destruction of normal gutflora. Antibiotic use that depletes normal gut bacteria and can result in over-growth of lessdesirable bacteria. To supplement bacteria in the gastrointestinal system yogurt and especiallylive cultures of Lactobacillusacidophilus in capsules or powder are strongly recommended. Mixtures of Lactobacillusacidophillus, L.bifidus, B. bifidum, L. bulgaricus and FOS(fructoologosaccharides) to promote growth of these probiotics in the gut (example, DDS-1,DDS-Plusor, Multi-Flora, UAS Labs, 800-422-3371, www.uaslabs.com); Theralac, 800-926-2961, www.theralac.com, L. acidophillus mixtures (>3 billion live organisms) should be taken 3Xper day or 2 hr after antibiotics. For irritable bowel, the nutraceutical Calm Colon (Samra, 310-202-9999) has proven to be very effective in clinical trials. For heavy metal removal, Garlic Plus(Longevity, 800-580-7587, www.longevityplus.net) has proved useful. For help with bowelbacteria and bladder infections, many recommend D-mannose (Biotech Co., 800-345-1199). Thisnatural sugar inhibits binding of bacteria to biological membranes. In addition, to improvedigestion and especially absorption enzyme mixtures have proved useful. The best known ofthese is Wobenzym (The Health Stores, 800-578-5939, www.healthstores.com or Zooscape, 800-
Natural Immunomodulators and Remedies
A number of natural remedies, such as ginseng root, herbal teas, lemon/olive drink, olive leafextract with antioxidants are sometimes useful, especially during or after antibiotic therapy. More important examples are immune modulators, such as bioactive whey protein (ImuPlus, 800-310-8311, www.imuplus.com; Immunocal, 800-337-2411, www.immunocal.com), ImmunoPro(Needs, 800-634-1380, www.needs.com or www.immunesupport.com). Alternatively, TransferFactor (4-Life, 800-852-7700, www.transferfactor-4-life.com) or Chisolm Biologicals, 800-664-1333, www.chisolmbio.com, Immuni-T (Longevity, 800-580-7587, www.longevityplus.net),MGN3 (Lane Labs, 800-526-3005, www.lanelabs.com), or Mushroom Immune Defense and BestDefense (ProHealth, www.immunesupport.com, 800-366-6056) can be used. Some additionalremedies are: olive leaf extract (several sources), NSC-100 (Nutritional Supply, 888-246-7224;www.smartbomb.com, 800-495-3115), Tahitian Noni (800-445-8596, www.tahitiannoni.com),Laktoferrin (Nutricology, www.nutricology.com, 888-563-1506, www.iherb.com), Echinacea-C(NF Formulas, www.bio-life-essentials.com, 800-547-4891). These products have been used toboost immune systems. Although they appear to help many patients, their clinical effectivenessin autism, ADD and other chronic illnesses has not been carefully evaluated. They appear to beuseful during therapy to boost the immune system or after antibiotic/antiviral therapy in amaintenance program to prevent relapse and opportunistic secondary infections. For the mostpart dosing has not been carefully established in children, so you may have to contact themanufacturer for advice. Yeast/Fungal or Bacterial Overgrowth
Yeast overgrowth can occur, especially during antibiotic therapy. Nizoral, Diflucan, Mycelex, oranti-yeast creams can be used for skin fungal infections. Metronidazole [Flagyl, Prostat] has beenused to prevent fungal or parasite overgrowth or other antifungals [Nystatin, Amphotericin B,Fluconazole, Diflucan or Pau d’ arco, 1-2 capsules/2X/day] have been administered for fungalinfections that can occur while on antibiotics. Your physician will know the proper dose. Somepatients have as their principal problem systemic fungal infections that can be seen using darkfield microscopy of blood smears. For superficial fungal infections, such as fungal nail, a topicalmixture of Laminsil in 17% DMSO 2X/day is effective. As mentioned above, L.acidophillusmixtures should be used to restore gut flora. Nutraceutical approaches to controlling yeastinfections include: Pau d’ arco, grapefruit extract, olive leaf, caprylic acid, garlic extract andoregano oil. The exact dose and schedule are quite different among children, and parents shouldtry initially low doses and increase slowly. Contact the manufacturer for advice. Avoid Antidepressants, Narcotics, etc.
Antibiotic uptake and immune responses may be inhibited by some drugs, and antidepressants(sertaline [Zoloft], fluoxetine [Prozac], amitriptyline [Elavil], maprotiline [Ludiomil],desipramine [Norpramin], clomipramine [Anafranil], nortriptyline [Pamelor], bupropion[Wellbutrin]), muscle relaxants (cyclobenzaprine [Flexeril]), opiate agonists, anticonvulsives orcertain analgesics (oxycodone [Percodan], carbamazepine [Tegretol], acetaminophen/hydrocodone [Vicodin]), narcotics (codeine w/Penergan, propoxyphene [Darvon], morphine),antacids, antidiarrheas among others should not be taken, if possible, or gradually decreasedduring therapy. Some drugs (certain antibiotics, antidepressants, analgesics, narcotics, etc.) mayinhibit immune responses and interfere with therapy. These should be decreased and graduallyeliminated. The above statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.Antibiotics/Antivirals Recommended by the Institute for Molecular Medicine when Indicated for Treatment of Chronic Bacterial/Viral Infections in Autistic Spectrum Disorder Patients The Institute for Molecular Medicine, 15162 Triton Lane, Huntington Beach, CaliforniaTel: (714) 903-2900 Fax: (714) 379-2082 e-mail: email@example.com Website:
_______________________________________________________________Doxycycli ne (aka Vibramycin, Doxychel, Doxy-D, Doryx) (Children 8 Years and Older)
Doxycycline is a broad-spectrum tetracycline with good lipid solubility and ability to penetratethe blood-brain-barrier. This antibiotic acts by inhibiting microorganism protein synthesis; it isreadily absorbed by the (normal) gut, and peak blood concentrations are maintained between 2-18hrs (half-life, 18-22 hrs) after an oral dose of drug. Food, calcium, magnesium, antacids andsome drugs reduce absorption, and alcohol, phenytoin [Dilantin] or barbiturates reduce bloodhalf-life or suppress the immune system.
For bacterial infections in children aged 8 or older, the recommended oral dose (based on weight)is given for a period of 6 months: 100 lbs. or less, 1-2 mg/LB per day divided into two doses;weight over 100 lbs use adult dose of 200 mg/day (100 mg in morning and 100 mg at night). After 6 months, 6 week cycles are suggested (2-weeks in-between). Use in children under 8 yearsis not recommended due to tooth discoloration, but lower doses of doxycycline have proven to bevery effective in children with chronic bacterial infections. Doxycycline can exacerbate chronicsigns and symptoms (Herxheimer reactions or adverse responses, such as transient fever, skin, gutdiscomfort, etc.) but these are usually reduced within a few weeks (see first section). Patientsusually start feeling better with alleviation of major signs and symptoms within 12 weeks, but insome patients’ major symptoms are not alleviated until after 12 weeks. Some patients react to thestarch filler in the capsules and must use Doryx, a granular form of doxycycline. Virtually allpatients relapse (with the same major signs/symptoms) if they stop therapy too soon.
Doxycycline is primarily bacteriostatic and effective against the following organisms: gram-negative bacteria (N. gonorrhoeae, Haemophilus influenzae, Shigella species, Yersinia pestis,Brucella species, Vibrio cholera); gram-positive bacteria (Streptococcus pneumoniae,Streptococcus pyogenes); mycoplasmas (Mycoplasma pneumoniae, Mycoplasma fermentans [inc. incognitis strain], Mycoplasma penetrans); others (Bacillus anthracis [anthrax], Clostridiumspecies, Chlamydia species, Actinomyces species, Entamoeba species, Treponemapallidum[syphilis], Plasmodium falciparum [malaria] and Borrelia [Lyme] species). Precautions: Avoid direct sunlight and drink fluids liberally, especially with oral capsules. Doxycycline therapy may result in overgrowth of fungi or yeast and nonsensitive microorganisms(see Considerations, first page). Patients on anticoagulants may require lower anticoagulantdoses. Patients with impaired kidney function and patients taking diuretics should not takedoxycycline. Other drugs can affect uptake or immune systems (see above). Adverse Reactions: In a small percentage of patients doxycycline causes gastrointestinalirritation, anorexia, vomiting, nausea, diarrhea, rashes, mouth dryness, hoarseness and in rarecases hypersensitivity reactions, hemolytic anemia, skin hyper-sensitivity and reduced whiteblood cell counts. In general, doxycycline is considered a very safe drug, in that there are fewadverse reactions reported in the literature. Azithromycin (aka Zithromax) (No Age Limit in Children)
Azithromycin is a azalide (macrolide) antibiotic with good absorption and a serum half-life of~68 hrs. This class of drug acts by binding to the 50S ribosomal subunit of susceptible organismswhere it interferes with protein synthesis. Food decreases absorption rate, but absorption isunaffected by antacids containing magnesium, aluminum or other salts; other drugs may affectabsorption (see above).
For children the recommended dose is 10 mg/Kilogram body weight/day (oral capsules taken atonce) for each 6-wk cycle of therapy. Azithromycin should not be taken with meals (1 hr beforeor 1 hr after). Initially, azithromycin may exacerbate some symptoms but these are usually gonewithin a few weeks. Patients usually start feeling better with alleviation of most majorsigns/symptoms within several weeks, but in some patients major symptoms are not alleviatedwithin months. Azithromycin has been used for patients aged less than 8 years, in whichdoxycycline cannot be tolerated, or in patients that no longer respond to doxycycline. Herxheimer reactions usually pass within a few days to weeks. Virtually all patients relapse(show the same major signs/symptoms) after terminating therapy in less than 12 wks. Additionalcycles of antibiotic result in milder relapses after drug is discontinued. Azithromycin has beenshown to be safe for pediatric use (at 10 mg/KG/day).
Azithromycin is effective against the following organisms: gram-negative bacteria (Bordetellapertussis,Shigella species, Haemophilus influenzae, Chlamydia species, Yersinia pestis, Brucellaspecies, Vibrio cholera); gram-positive bacteria (Streptococci group C, F, G); mycoplasmas(Mycoplasma species); others (Clostridium species, Treponemapallidum [syphilis], and Borreliaspecies). Precautions: Azithromycin is principally absorbed by the liver, and caution should be exercisedwith patients with impaired liver function. Antacids containing magnesium, aluminum or othersalts should not be taken at the same time of day with azithromycin. Adverse Reactions: Adverse antibiotic responses were mild to moderate in clinical trials andincluded diarrhea (5%), nausea (3%), abdominal pain (3%). In rare cases (<1%) azithromycinmay cause cardiovascular problems (palpitations, tachycardia, chest pain) and central nervoussystem (dizziness, headache, vertigo), allergic (rash, photosensitivity, angioderma), fatigue andother reactions (<1%). In pediatric patients >80% of the adverse responses were gastrointestinal. In children, doses above the suggested 10 mg/kg/day have been shown to produce hearing loss insome patients. Clarithromycin (aka Biaxin)
Clarithromycin is a broad spectrum macrolide antibiotic with good absorption and serum half-life. This drug acts by binding to the 50S ribosomal subunit of susceptible organisms andinterfering with protein synthesis. The drug is mostly bacterostatic but high concentrations can bebactericidal. Food decreases absorption rate, but absorption is unaffected by antacids containingmagnesium, aluminum or other salts. Some drugs may interfere with absorption or depressimmune systems (see above).
For children the recommended dose is 15 mg/KG body weight/day (oral capsules, taken inmorning) for 6 months of therapy, then 6-wk cycles. Clarithromycin should not be taken withmeals (1 hr before or 1 hr after). Initially, clarithromycin may exacerbate some symptoms due toHerxheimer reactions and bacterial death but these are usually gone within weeks. Patientsusually start feeling better with alleviation of most major signs and symptoms within 1-2 weeks,but in some patients major symptoms are not alleviated until after 12 weeks or so. Clarithromycin has been used for patients that do not respond or cannot tolerate doxycycline. Herxheimer reactions usually pass within days to wks. Virtually all patients relapse (show thesame major signs/symptoms) when therapy is stopped within 12 weeks. Additional cycles ofantibiotic result in milder relapses after drug is discontinued.
Clarithromycin is effective against the following organisms: gram-negative bacteria (Neisseriagonorrhoeae, N. menigitidis, Moraxella catarrhalis, Campylobacter jejuni, Eikenella corrodens,Haemophilus ducreyi,Bordetella pertussis,Shigella species, Salmonella species, Haemophilusinfluenzae, Chlamydia species, Yersinia pestis, Brucella species, Vibrio cholera, Aeromonosspecies, E. coli, gram-positive bacteria (Streptococcus pyogenes, S. pneumeniae, anerobic
Streptococci, Enterococcus faccalis, Staphlococcus aureus, S. epidermidis, Bacillus anthracis,Corynebacterium diptheriae, C. minutissimum, Listeria monocytogenes, Actinomyces israelii);mycoplasmas (Mycoplasma species, M. pneumoniae, Ureaplasma urealyticum); others(Clostridium species, Treponemapallidum [syphilis], Legionella pneumophilia, L. micdadei,Mycobacterium avium, M. chelonae, M. chelonae absessus, M. fortuitim, Rickettsia species andBorrelia species). Yeasts, fungi and viruses are resistant. Precautions: Clarithromycin is principally absorbed by the liver, and caution should be exercisedwith patients with impaired liver function. Antacids containing magnesium, aluminum or othersalts should not be taken at the same of day as azithromycin. Macrolides like clarithromycinshould not be used with cyclosporin [Sandimmune]. Adverse Reactions: Adverse antibiotic responses were mild to moderate in clinical trials andincluded diarrhea, nausea, and abdominal pain. In rare cases (<1%) biaxin may causecardiovascular problems (palpitations, tachycardia, chest pain) and central nervous system(dizziness, headache, vertigo), allergic (rash, photosensitivity, angioderma) and fatigue. Ganciclovir (aka Cytovene)
Ganciclovir is a synthetic antiviral made from a guanine derivative that is active againstcytomegalovirus (CMV) and related herpes simplex viruses, such as HHV-6 viruses. Ganciclovirinhibits replication of herpes viruses by inhibiting viral DNA replication by its incorporation intoviral DNA and by inhibition of viral DNA elongation.
The recommended dosage of Ganciclovir [i.v.] is an initial induction dose of 5 mg/Kg i.v. at aconstant rate over 1 hr twice on the first day and then once /day for 3 weeks. For oral useGanciclovir is usually taken three times per day with food for a 3 wk course. The drug reaches amaximum blood dose within 3 hrs after oral administration with food with a half-life of 4.6 hrs. Ganciclovir has been used mainly for treatment of CMV retinitis, CMV in organ transplant cases,and CMV in AIDS cases. Its use in chronic CMV and HHV-6 infections has not been fullyinvestigated. Precautions: Ganciclovir should not be used in children with renal impairment or in patients withan absolute neutrophil count of <25,000 cells/microliter. Some patients should have serumcreatinine or creatinine clearance values monitored to allow for possible dose adjustments in renalimpaired patients. Ganciclovir can be used in children at the dose levels mentioned above. Inaddition, Ganciclovir should not be taken with drugs that have the potential to cause neutropeniaand anemia. For example, and Ganciclovir and zidovudine both have the potential to decreasewhite blood cells and cause anemia. Ganciclovir can change serum clearance rates of somedrugs, and Ganciclovir used with drugs that inhibit rapidly growing cell populations may showadded toxicity. Therefore, dapsone, pentamidine, flucytosine, vincristine, vinblastine,adriamycin, amphotericin B, among other drugs should not be used with Ganciclovir. Adverse Reactions: Adverse drug responses were seen in patients that are hypersensitive toGanciclovir or Acyclovir. The most common side effects were reductions in white blood cells (6-29%), anemia (9-19%), impairment in fertility, chills (7%), sweating (11%), abdominal pain(15%), vomiting (13%), diarrhea (40%), paresthesias (8%) and retinal detachment (8-11%) aswell as less frequently chest pain, headache, malaise, constipation, cough, anxiety, confusion,depression, dizziness, dry mouth, insomnia, tremor and edema. The values were obtained forpatients with CMV retinitis, organ transplants and AIDS, and they may not reflect the actualincidence rates in chronic illness patients. Final Comments/Suggestions
Recovery will be gradual not rapid, and almost all patients with bacterial and/or infections willexperience initial Herxheimer reactions that can be quite severe and can last for weeks. You willhave to be patient and not abandon therapy prematurely, because few patients who have been sickfor years recover in less than one-half to one year of therapy. Antibiotics or antivirals should notbe taken at the same time of day as vitamins, minerals, supplements, etc. Vitamins and mineralsshould be taken 2 hrs before or after antibiotics or antivirals to prevent interference with druguptake. Stop antibiotics or antivirals if adverse reactions occur. You will notice cycles of relapsewhen patients are severely physically or mentally stressed, and you should not be alarmed if somesigns and symptoms occasionally return or worsen. This is not unusual. Eventually your childrenwill be off antibiotics or antivirals, but you will need to continue various supplements to maintainyour child’s immune system and general nutritional status. Note: This material has not been evaluated by the FDA. It is general information, should not be construed as medicaladvice, and is not meant as medical advice or to prevent, diagnose, treat or cure any illness, condition or disease. It isvery important that you make no change in your healthcare plan or health support regimen without researching anddiscussing it in collaboration with your professional healthcare team.
LIMERICK COUNTY COUNCIL P L A N N I N G A P P L I C A T I O N S PLANNING APPLICATIONS GRANTED FROM 27/07/2009 TO 31/07/2009 in deciding a planning application the planning authority, in accordance with section 34(3) of the Act, has had regard to submissions or observations recieved in accordance with these Regulations; that it is the responsibility of any person wishing to use the
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