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1.
Artigo em Inglês | MEDLINE | ID: mdl-34232286

RESUMO

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

2.
Curr Pharm Teach Learn ; 13(7): 862-867, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34074519

RESUMO

BACKGROUND AND PURPOSE: The novel severe acute respiratory syndrome coronavirus 2 restricted student involvement in direct patient care. Virtual learning is an effective education strategy in pharmacy curriculums. This study aimed to evaluate student perceptions of virtual learning advanced pharmacy practice experiences (APPE) utilizing an electronic 12-question survey. EDUCATIONAL ACTIVITY AND SETTING: Virtual learning was developed and implemented, and students were surveyed at the end of the APPE. The survey was comprised of one open-ended and 11 Likert scale questions. It assessed implementation and use of virtual learning in place of a standard on-site APPE. FINDINGS: Responses were attained from 19 students. Questions regarding resources provided and virtual learning enabling autonomous, independent learning had the highest percent of strong agreement. No responses indicated strong disagreement. Three questions solicited >10% response rate of somewhat disagree, 16% associated with virtual learning helping the student become a better member of the healthcare team after graduation. Open-ended responses acknowledged appreciation of the virtual APPE and presented material. One in six students commented on the ability to apply the learned information to direct patient care. Feedback was delivered on consideration for increased utility of patient care-orientated applications to facilitate simulation of real-life patient cases. SUMMARY: Students who completed the virtual APPE were satisfied overall. Virtual teaching modalities may be incorporated into APPEs, particularly when direct patient care access is limited, but should not be used to completely replace the experience gained during direct patient care.


Assuntos
Currículo , Educação à Distância/métodos , Educação em Farmácia/métodos , Aprendizagem Baseada em Problemas/métodos , Competência Profissional , Estudantes de Farmácia , Humanos
3.
JAAPA ; 34(6): 32-39, 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-34031312

RESUMO

ABSTRACT: Recent development of immunotherapy has led to remarkable advancement in cancer therapy. Drugs that inhibit the cytotoxic T-lymphocyte-associated protein (CTLA-4) and programmed death-1 (PD-1) immune checkpoint pathways have shown improved patient survival. However, by altering the immune response to fight cancer, a new class of adverse reactions has emerged, known as immune-related adverse events. These adverse events are due to overactivation of the immune system in almost any organ of the body, can occur at any point in a patient's treatment course, and may become life-threatening. This article describes how to promptly recognize and manage these toxicities.

4.
Am J Health Syst Pharm ; 78(15): 1385-1394, 2021 07 22.
Artigo em Inglês | MEDLINE | ID: mdl-33895793

RESUMO

PURPOSE: Nearly half of intensive care unit (ICU) patients will develop delirium. Antipsychotics are used routinely for the management of ICU delirium despite limited reliable data supporting this approach. The unwarranted continuation of antipsychotics initiated for ICU delirium is an emerging transitions of care concern, especially considering the adverse event profile of these agents. We sought to evaluate the magnitude of this issue across 6 centers in New Jersey and describe risk factors for continuation. METHODS: This multicenter, retrospective study examined adult ICU patients who developed ICU delirium from June 2016 to June 2018. Patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission. RESULTS: Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital. CONCLUSION: The continuation of antipsychotics for the management of delirium during transitions of care was a common practice across ICUs in New Jersey. Several risk factors for continuation of antipsychotics were identified. Efforts to reduce unnecessary continuation of antipsychotics at transitions of care are warranted.


Assuntos
Antipsicóticos , Delírio , Adulto , Antipsicóticos/efeitos adversos , Delírio/induzido quimicamente , Delírio/diagnóstico , Delírio/tratamento farmacológico , Humanos , Unidades de Terapia Intensiva , New Jersey , Estudos Retrospectivos
5.
Pharmacotherapy ; 40(12): 1180-1191, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33068459

RESUMO

Evidence-based management of analgesia and sedation in COVID-19-associated acute respiratory distress syndrome remains limited. Non-guideline recommended analgesic and sedative medication regimens and deeper sedation targets have been employed for patients with COVID-19 due to exaggerated analgesia and sedation requirements with extended durations of mechanical ventilation. This, coupled with a desire to minimize nurse entry into COVID-19 patient rooms, marked obesity, altered end-organ function, and evolving medication shortages, presents numerous short- and long-term challenges. Alternative analgesic and sedative agents and regimens may pose safety risks and require judicious bedside management for appropriate use. The purpose of this commentary is to provide considerations and solutions for designing safe and effective analgesia and sedation strategies for adult patients with considerable ventilator dyssynchrony and sedation requirements, such as COVID-19.


Assuntos
Analgésicos/uso terapêutico , COVID-19/complicações , COVID-19/tratamento farmacológico , Medicina Baseada em Evidências/métodos , Hipnóticos e Sedativos/uso terapêutico , Respiração Artificial/métodos , Humanos , SARS-CoV-2
6.
Curr Pharm Teach Learn ; 12(11): 1320-1328, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32867930

RESUMO

INTRODUCTION: Simulation-based teaching is an effective instructional strategy gaining momentum in pharmacy education but remains variable across programs. This is the first known report depicting the development of a multifaceted, integrated simulation program during concurrent initiation of a new skills-based pharmacy curriculum. METHODS: A significant infrastructure expansion created simulation areas whose availability corresponded with the initiation of a new skills-based curriculum. Integration of simulation occurred with existing personnel resources using area pilots. Pilots developed operational and educational design standards spanning the pre-simulation, simulation, and debriefing phases. The value of high-fidelity simulation pilots detailed here was assessed through both student survey and successful transference of tools to other courses. RESULTS: The pilots developed core operational and educational design standards, super-user faculty groups, and created an operational director position, essential for simulation promulgation throughout the curriculum. In the high-fidelity patient simulation pilot, operational elements included mannequin and equipment procedures, best practices for faculty and confederate engagement, and formulary development. Educational design standards addressed objective development, session flow, team roles, and debriefing. A grading rubric template aligned goals and assessed outcomes. All elements were structured into a planning worksheet. Student survey reflected the perceived value of this pilot. CONCLUSIONS: Operational support, integration coordination, and perceived value are all essential elements for successful curricular integration of simulation in a pharmacy curriculum. The pilots created the operational and educational structure establishing standards and defining required resources to sustain success. These pilots allowed for rapid curricular proliferation of simulation across the first and third professional years.

8.
J Pharm Pract ; 32(5): 529-533, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29685062

RESUMO

BACKGROUND: The practice guidelines for the management of pain, agitation, and delirium (PAD) from the Society of Critical Care Medicine shifted from primarily focusing on the treatment of anxiety in 2002 to the treatment of pain in 2013. OBJECTIVE: This prospective, observational, multicenter study aimed to assess the degree of practice adherence to the PAD guidelines for ventilated patients in New Jersey intensive care units (ICUs). METHODS: Pharmacist investigators at 8 centers designated 4 days at least 10 days apart to evaluate all patients on mechanical ventilation. The primary outcomes included adherence to 4 guideline recommendations: treatment of pain before sedation, use of nonnarcotic analgesic medications, use of nonbenzodiazepine sedative medications, and use of goal-directed sedation. RESULTS: Of 138 patients evaluated, 50% had a primary medical diagnosis (as opposed to surgical, cardiac, or neurological diagnosis), and the median Sequential Organ Failure Assessment (SOFA) score was 7. Pain was treated prior to administration of sedatives in 55.4% of subjects, with fentanyl being the primary analgesic used. In addition, 19% received no analgesia, and 11.5% received nonopioid analgesia. Sedative agents were administered to 87 subjects (48 nonbenzodiazepine and 39 benzodiazepine). Of those receiving benzodiazepines, 22 received intermittent bolus regimens and 16 received continuous infusions, of which 5 were for another indication besides sedation. Validated scales measuring the degree of sedation were completed at least once in 56 (81.6%) patients receiving sedatives. CONCLUSIONS: Current sedation practices suggest that integration of evidence-based PAD guidelines across New Jersey adult ICUs is inconsistent despite pharmacist involvement.


Assuntos
Analgésicos/normas , Fidelidade a Diretrizes/normas , Hipnóticos e Sedativos/normas , Unidades de Terapia Intensiva/normas , Manejo da Dor/normas , Guias de Prática Clínica como Assunto/normas , Idoso , Idoso de 80 Anos ou mais , Analgésicos/administração & dosagem , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Masculino , Pessoa de Meia-Idade , New Jersey/epidemiologia , Dor/tratamento farmacológico , Dor/epidemiologia , Manejo da Dor/métodos , Estudos Prospectivos
9.
Open Forum Infect Dis ; 5(11): ofy280, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30488041

RESUMO

Background: Multidrug-resistant Pseudomonas aeruginosa infections remain common in hospitals worldwide. We investigated the outcomes associated with the use of ceftolozane-tazobactam for the treatment of these infections. Methods: Data were collected retrospectively from 20 hospitals across the United States about adults who received ceftolozane-tazobactam for the treatment of multidrug-resistant P aeruginosa infections of any source for at least 24 hours. The primary outcome was a composite of 30-day and inpatient mortality, and secondary outcomes were clinical success and microbiological cure. Multivariable regression analysis was conducted to determine factors associated with outcomes. Results: Two-hundred five patients were included in the study. Severe illness and high degrees of comorbidity were common, with median Acute Physiology and Chronic Health Evaluation (APACHE) II scores of 19 (interquartile range [IQR], 11-24) and median Charlson Comorbidity Indexes of 4 (IQR, 3-6). Delayed initiation of ceftolozane-tazobactam was common with therapy started a median of 9 days after culture collection. Fifty-nine percent of patients had pneumonia. On susceptibility testing, 125 of 139 (89.9%) isolates were susceptible to ceftolozane-tazobactam. Mortality occurred in 39 patients (19%); clinical success and microbiological cure were 151 (73.7%) and 145 (70.7%), respectively. On multivariable regression analysis, starting ceftolozane-tazobactam within 4 days of culture collection was associated with survival (adjusted odds ratio [OR], 5.55; 95% confidence interval [CI], 2.14-14.40), clinical success (adjusted OR, 2.93; 95% CI, 1.40-6.10), and microbiological cure (adjusted OR, 2.59; 95% CI, 1.24-5.38). Conclusions: Ceftolozane-tazobactam appeared to be effective in the treatment of multidrug-resistant P aeruginosa infections, particularly when initiated early after the onset of infection.

10.
Infect Drug Resist ; 11: 1975-1981, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30464539

RESUMO

Purpose: To evaluate the use of aztreonam as an active empiric therapy against subsequent culture of Pseudomonas aeruginosa (P. aeruginosa). Methods: This was a retrospective cohort study conducted among patients who received either aztreonam or an antipseudomonal beta-lactam (BL) as an empiric therapy with subsequent culture with P. aeruginosa. All patients with at least one positive culture for P. aeruginosa between January 2014 and August 2016 were included in this analysis. The primary composite outcome was empiric therapy failure, defined as inappropriate empiric therapy, alteration of empiric antibiotic following culture results, or 30-day in-hospital mortality. Secondary outcomes included appropriate empiric therapy, alteration of empiric therapy, 30-day-in-hospital mortality, and post-culture hospital length of stay. Results: The primary outcome of empiric therapy failure was significantly higher in the aztreonam group than in the BL group (77.8% vs 41.9%; P=0.004). The aztreonam group had a lower rate of appropriate empiric therapy compared with the BL group (44.4% vs 66.1%; P=0.074) and higher alteration of empiric therapy once susceptibilities were known than when compared with the BL group (61.1%vs 28.2%; P=0.005). Although numerically higher, 30-day-in-hospital mortality and median hospital length of stay were not significantly different between the two groups. Conclusion: Empiric therapy failure occurred more often when initially using aztreonam vs a BL in a patient who subsequently had a P. aeruginosa infection. Only a third of patients within the aztreonam group had a documented BL allergy, demonstrating an inclination for clinicians to utilize this drug as an empiric therapy when there were more appropriate therapies available.

11.
P T ; 42(12): 767-772, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29234216

RESUMO

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) continue to represent the most common nosocomial-associated infections, resulting in significant attributable mortality, increased length of hospital stay, and financial burden.1 The updated Infectious Diseases Society of America (IDSA) guidelines provide guidance on the diagnosis and management of nonimmunocompromised hosts with HAP and VAP.

12.
P T ; 41(11): 703-712, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27904303

RESUMO

Rapid-acting bronchodilators, systemic corticosteroids, and antibiotics are among the keys to managing exacerbations of chronic obstructive pulmonary disease. Preventing exacerbations should also be a component of therapy for the disease.

13.
P T ; 41(10): 619-622, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27757000

RESUMO

Mepolizumab (Nucala) for severe eosinophilic asthma.

14.
Drugs Aging ; 33(8): 557-74, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27417446

RESUMO

Constipation is a common and often debilitating condition in the elderly, which may be caused by underlying disease conditions, structural abnormalities in the bowel, and a variety of medications such as anticholinergics, antidepressants, and opiates. In this review, we focus on opioid-induced constipation (OIC), which is often underrecognized and undertreated in the elderly. When opioid therapy is initiated, healthcare providers are encouraged to evaluate risk factors for the development of constipation as part of a thorough patient history. To this end, the patient assessment should include the use of validated instruments, such as the Bristol Stool Scale and Bowel Function Index, to confirm the diagnosis and provide a basis for evaluating treatment outcomes. Healthcare providers should use a stepwise approach to the treatment of OIC in the elderly. Conventional laxatives are a first-line option and considered well tolerated with short-term use as needed; however, evidence is lacking to support their effectiveness in OIC. Moreover, because of the risk of adverse events and other considerations, such as chewing difficulties and swallowing disorders, conventional oral laxatives may be inappropriate for the treatment of OIC in the elderly. Thus, the availability of new pharmacologic agents such as the peripherally acting µ-opioid receptor antagonists methylnaltrexone and naloxegol, which target the underlying causes of OIC, and the secretagogue lubiprostone may provide more effective treatment options for elderly patients with OIC.


Assuntos
Analgésicos Opioides/efeitos adversos , Constipação Intestinal/induzido quimicamente , Dor/tratamento farmacológico , Idoso , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Constipação Intestinal/tratamento farmacológico , Pessoal de Saúde , Humanos , Laxantes/administração & dosagem , Laxantes/uso terapêutico , Naltrexona/administração & dosagem , Naltrexona/análogos & derivados , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/uso terapêutico , Compostos de Amônio Quaternário/administração & dosagem , Compostos de Amônio Quaternário/uso terapêutico , Receptores Opioides mu/metabolismo , Resultado do Tratamento
15.
Pharmacotherapy ; 36(7): 797-822, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-27196747

RESUMO

Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with γ-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.


Assuntos
Estado Terminal , Etanol/efeitos adversos , Síndrome de Abstinência a Substâncias/tratamento farmacológico , Baclofeno/uso terapêutico , Benzodiazepinas/uso terapêutico , Dexmedetomidina/uso terapêutico , Humanos , Tempo de Internação , Fenobarbital/uso terapêutico
16.
Ann Pharmacother ; 50(7): 569-77, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-27126547

RESUMO

OBJECTIVE: To review the management of hepatic encephalopathy (HE), including lifestyle modifying strategies and pharmacological interventions. DATA SOURCES: A literature search of PubMed through March 2016 was conducted utilizing the keywords hepatic encephalopathy, ammonia, and cirrhosis All published articles evaluating treatments for HE were considered. STUDY SELECTION AND DATA EXTRACTION: Available English-language data from reviews, abstracts, presentations, and clinical trials of the treatment of HE in humans were reviewed; relevant clinical data were selected and included. DATA SYNTHESIS: HE is a prevalent complication of portal hypertension and cirrhosis that results in altered mental status and neuropsychiatric impairment. Although the pathogenesis has not been elucidated, numerous treatment options exist. This review will explore the role of dietary interventions and supplements, including use of zinc, acetyl-l-carnitine, and probiotics, in the management of HE. Additionally, the use of various ammonia-lowering agents will be evaluated. The nonabsorbable disaccharides represent first-line therapies for the management and prophylaxis of HE; rifaximin use has been demonstrated to be effective for both treatment and prophylaxis of HE symptoms, with use relegated to those patients who fail to respond to or tolerate the nonabsorbable disaccharides. In light of toxicities associated with the use of neomycin and metronidazole, recent guidelines recommend both as alternatives for the treatment of HE, with the use of vancomycin discouraged. CONCLUSION: Although numerous treatment options are available, management of HE remains a clinical challenge. Additional research is needed to explore the pathogenesis and better understand the role of pharmacotherapy in managing this condition.


Assuntos
Antibacterianos/uso terapêutico , Dissacarídeos/uso terapêutico , Encefalopatia Hepática/dietoterapia , Encefalopatia Hepática/tratamento farmacológico , Probióticos/uso terapêutico , Rifamicinas/uso terapêutico , Antibacterianos/administração & dosagem , Antibacterianos/efeitos adversos , Dissacarídeos/administração & dosagem , Dissacarídeos/efeitos adversos , Encefalopatia Hepática/epidemiologia , Encefalopatia Hepática/etiologia , Humanos , Cirrose Hepática/etiologia , Cirrose Hepática/prevenção & controle , Metronidazol/administração & dosagem , Metronidazol/efeitos adversos , Metronidazol/uso terapêutico , Neomicina/administração & dosagem , Neomicina/efeitos adversos , Neomicina/uso terapêutico , Guias de Prática Clínica como Assunto , Rifamicinas/administração & dosagem , Rifamicinas/efeitos adversos , Rifaximina , Índice de Gravidade de Doença
17.
P T ; 41(1): 43-50, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26765867

RESUMO

Use of sodium polystyrene sulfonate (SPS) dominates the long-term treatment of hyperkalemia, but two new agents, sodium zirconium cyclosilicate and the recently FDA-approved patiromer, may offer potential advantages compared with SPS.

19.
Pharmacotherapy ; 35(6): 631-48, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26032691

RESUMO

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is a substantial source of disability in the United States. Moderate-to-severe acute exacerbations of COPD (AECOPD) can progress to respiratory failure, necessitating ventilator assistance in patients in the intensive care unit (ICU). Patients in the ICU with AECOPD requiring ventilator support have higher morbidity and mortality rates as well as costs compared with hospitalized patients not in the ICU. The mainstay of management for patients with AECOPD in the ICU includes ventilator support (noninvasive or invasive), rapid-acting inhaled bronchodilators, systemic corticosteroids, and antibiotics. However, evidence supporting these interventions for the treatment of AECOPD in critically ill patients admitted to the ICU is scant. Corticosteroids have gained widespread acceptance in the management of patients with AECOPD necessitating ventilator assistance, despite their lack of evaluation in clinical trials as well as controversies surrounding optimal dosage regimens and duration of treatment. Recent studies evaluating the safety and efficacy of corticosteroids have found that higher doses are associated with increased adverse effects, which therefore support lower dosing strategies, particularly for patients admitted to the ICU for COPD exacerbations. This review highlights recent findings from the current body of evidence on nonpharmacologic and pharmacologic treatment and prevention of AECOPD in critically ill patients. In addition, the administration of bronchodilators using novel delivery devices in the ventilated patient and the conflicting evidence surrounding antibiotic use in AECOPD in the critically ill is explored. Further clinical trials, however, are warranted to clarify the optimal pharmacotherapy management for AECOPD, particularly in critically ill patients admitted to the ICU.


Assuntos
Estado Terminal , Doença Pulmonar Obstrutiva Crônica , Corticosteroides/uso terapêutico , Antibacterianos/uso terapêutico , Broncodilatadores/uso terapêutico , Ensaios Clínicos como Assunto , Cuidados Críticos , Progressão da Doença , Humanos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/prevenção & controle , Respiração Artificial , Fatores de Risco
20.
JAAPA ; 28(6)2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25989429

RESUMO

Chronic stable angina is a significant problem in older adults. The goal of therapy is to provide symptomatic relief, improve patient quality of life, and prevent subsequent angina or myocardial infarction that could lead to sudden death. The efficacy and safety of drugs such as beta-blockers and calcium channel blockers for managing chronic stable angina in older adults has not been rigorously investigated. Drug selection should be based on physiologic alterations, patient comorbidities, adverse reaction profile, and cost.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Angina Estável/tratamento farmacológico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Fármacos Cardiovasculares/uso terapêutico , Bloqueadores dos Canais de Sódio/uso terapêutico , Vasodilatadores/uso terapêutico , Benzazepinas/uso terapêutico , Humanos , Dinitrato de Isossorbida/análogos & derivados , Dinitrato de Isossorbida/uso terapêutico , Ivabradina , Nicorandil/uso terapêutico , Nitroglicerina/uso terapêutico , Ranolazina/uso terapêutico
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