Do not give the child the responsibility of managing their own medication too early buy generic levitra 20 mg on line impotence at age 70. If your child cannot manage homework and household chores purchase levitra with american express erectile dysfunction causes tiredness, it is unlikely that he or she can manage medication. Adherence to the treatment program is extremely important to safeguard your child’s well being. Complications from the disorder or side effects from medication can arise suddenly. Suicidal thoughts are not uncommon among children with bipolar disorder, even those taking medication. To monitor for these complications, parents may need to establish a tightly structured home environment by setting limits and supervising the child’s activities and behavior. Substances that can be abused should be kept away from children and frearms locked away. Because bipolar disorder tends to run in families, parents should be aware they themselves may need to evaluated and treated for bipolar disorder, especially if they experience severe changes in mood. The behavior and mood of siblings also should be considered, and an evaluation sought if their mood behaviors are outside the norm. Parents also can be their child’s advocate by reading about the disorder, joining support groups, and networking with other parents. Foster an open dialogue Children and adolescents with your child’s doctor about your concerns. Because of the nature of this can learn about bipolar illness, some of your questions may go unanswered because of the lack of disorder and play an information about bipolar disorder in children and adolescents. However, your child’s doctor should be your partner in helping you gain more informa- important role in their tion about this illness and about the best way to help your child. Positive reinforcement is often the best way to make sure children stay on their medication. If the child complains of side effects, the issue should be addressed with the prescribing doctor. It also is important that your child understands what medication he or she is taking, why it is being prescribed, and how it can be helpful. This is especially true for older children and adolescents who may have concerns about being different because they are taking medicine. You may want to compare taking medication for bipolar disorder to wearing eyeglasses. Wearing glasses helps you see better just as medication for bipolar disorder gives you better control over mood and behavior. By contrast, not taking the medication or participat- ing in psychosocial treatment can lead to a variety of negative and undesired The information contained in this guide is not intended as, and is not a substitute for, professional medical ParentsMedGuide. These include worsening or recurrence of symptoms of mania or depression, poor functioning at home, school, and with peers, suicidal thinking, substance use, and need for hospitalization. Some research even suggests that an increased number of recurring mood episodes may worsen the outcome over time. There are many good books about bipolar disorder for children that can help increase their understanding of the illness and increase compliance with medication. The role your child plays in treatment will vary according to age and maturity level. Once a child is diagnosed with bipolar disorder, the doctor should explain that the symptoms of bipolar disorder are unique for each person. Once your child understands that the symptoms of bipolar disorder are different for each person, and what his or her symptoms are, he or she will have an easier time distinguishing which behav- iors come from the symptoms of bipolar disorder and which do not. Children also can learn behavioral techniques to help manage their symptoms, such as going to bed on time, taking their medication, and reacting more positively to confict and stress. Your child’s doctor can give you advice about how active a role your child Privacy laws require should play in his or her treatment. They may pick-up on uncertainty parents or other healthcare facilities, relatives have about the treatment plan. Some children express anxiety by and other public refusing to cooperate with treatment. With patience and education, most agencies to keep your children’s unease can be calmed. Also, there are books and other resources that help parents explain bipolar disorder to their children. What should I say to family members, caretakers, school and college personnel, and others about my child’s bipolar disorder? The stigma surrounding mental disorders may make parents reluctant, or even embarrassed, to discuss their child’s mental health status. Rather than having wide variations in blood sugar, your child has wide variations in his or her mood and behavior. For most people, it helps to frst share information with the immediate family, your child’s caregivers, your child’s doctors, and those who require medical information, such as camp personnel. Sharing information with your child’s school is often necessary, especially if you plan to seek special education accommodations. Sometimes children with bipolar disorder are labeled as “diffcult” or “behavior problems” by school teachers and administrators. Yet, it is generally preferable for the school to know about your child’s diagnosis of bipolar disorder, so they can help monitor his or her behavior in school. I also joined Research has shown that a combination of medication and psychosocial 23 support groups. I’m involved in a Regardless of whether your child is on medication for bipolar disorder, psychosocial treatment can help manage the symptoms of the illness and community support lessen their impact on your child. One study showed that your child’s doctor group and another may be able to lower your child’s medication dosage if psychosocial treatment 57 on the Internet. Parents need help Forms of psychosocial treatment include psychotherapy (talk therapy) to get themselves educational intervention, self-help groups, psychodynamic therapy, cognitive through those times behavioral therapy, and family therapy. Self-help stress reduction techniques, good nutrition, regular sleep and exercise, and participation in support groups also are an important part of treatment. Many parents fnd the best way to implement psychosocial treatment is to work with a therapist who has experience in treating children and adolescents with bipolar disorder. A support group for the child or adolescent with the disorder also can be benefcial. Most psychotherapists acknowledge the importance of creating a team of mental health professionals to help diagnose, treat, and monitor children and adolescents with bipolar disorder. A team approach can help clarify the diagnosis, alleviate issues if the child is reluctance to take medication, and identify stresses that trigger behavioral issues. Many doctors recommend that parents and guardians attend parenting classes, particularly those focused on how to manage the child’s moods and behaviors.

Although there is no cure for bipolar disorder order levitra 10mg otc impotence causes, medicine along with psychoso- cial treatment can play a critical role in helping manage the symptoms of this illness buy levitra men's health erectile dysfunction pills. While medication may lessen the symptoms of bipolar disorder, psychosocial treatment in the form of family and behavioral therapy is equally as important “Before I started in helping the child manage their illness. In fact, a study of adults with bipolar treatment, my disorder found that people taking medications to treat bipolar disorder personal life was are more likely to get well faster and stay well longer if they also receive intensive behavioral therapy. Since holds true for children, especially for those with signifcant emotional and I was a kid, my behavioral issues. I didn’t fore, psychosocial treatment is a key element in helping to prevent a relapse realize I had bipolar and promote healthy emotional growth and development. My par- year study found that psychosocial treatment that emphasized interpersonal coping strategies helped patients with bipolar disorder control the symptoms ents didn’t know of the disorder and function better in society. They just thought I was a In most cases, psychosocial treatment includes teaching parents techniques to bad kid. It also includes teaching parents techniques to redirect their child’s behavior toward more positive outcomes. By far, suicide is the most dangerous consequence of leaving bipolar disorder untreated. In any given year, 44 percent of all adolescents with untreated bipolar disorder have been suicidal. For more information about the risk of suicide among children and adolescents with bipolar disorder, please see page 16 of this guide. Also, children with bipolar disorder are more likely to have problems in school, at home, and with friends. Adolescents with the disorder are at risk for unplanned pregnancies, problems with authority and the law, diffculties fnding a job, and substance use. Unlike antibiotics and other medications that are taken for short periods of time to treat infections and other ailments, there is no medication that will cure bipolar disorder. However, there are medications that can help alleviate many of the symptoms of the illness. There also are psychosocial treatments that can help those with bipolar disorder better manage the condition. Asking your child’s doctor a lot of questions about the diagnosis and the proposed treatment plan is normal. Most doctors invite questions from parents and children, especially when medication is being prescribed. Just like with diabetes or epilepsy, many people with bipolar disorder will require lifelong treatment. When children or adolescents show signs of improvement, or are in remission (showing “normal” functioning similar to the level from before the illness episode), parents should discuss the risks and benefts of stopping medication with the child’s doctor. Can over-the-counter or prescription medication interfere with medication for bipolar disorder? The doctor will let you know which medicines are safe to take along with medication for bipolar disorder. You also can ask the pharmacist about drug interactions before purchasing a non-prescription medication, supplement, The information contained in this guide is not intended as, and is not a substitute for, professional medical ParentsMedGuide. For example, patients taking lithium should not take nonsteroidal anti-infammatory medica- tions (including aspirin, Motrin®, Aleve®, Voltaren®, Naprosyn®, Celebrex®, ibuprofen). Nonsteroidal anti-infammatory medications have been shown to increase lithium levels, which can lead to lithium toxicity. Please consult your doctor about which anti-infammatory medications are safe to take while on lithium. If medication is working properly, you will know because your child or adolescent’s moods and behaviors will have signifcantly improved. Finding the correct medication and dosage for children and adolescents with bipolar disorder takes time. Even once the proper medication and dosage is deter- mined, it can take many weeks or longer to see results. For some medication, it can take 2 months or longer before families will start seeing improvement in mood and behavior. If your child’s symptoms are not better after being on a full therapeutic dose of a traditional mood stabilizer for 8 weeks or more, or an atypical antipsychot- ic for 3 to 4 weeks or more, talk to your child’s doctor. The prescribing doctor may consider switching medications, adding another medication, or adjusting the dose. Mood stabilizers (which include several different types of medications) and atypical antipsychotics are the most often prescribed medications to “Since fnding the help control symptoms of bipolar disorder. These medications are usually most effective when they are used in combination and accompanied by correct medication, psychosocial treatment. He is (Seroquel ), and aripiprazole (Abilify ) for use in children aged 10 and older with bipolar disorder. These medications have been approved to treat not having morbid mania and mixed mania. Olanzapine (Zyprexa®) has been approved to sleep at night and for adolescents aged 13 and older. Aripiprazole and lithium also are approved as treatments to prevent the recurrence of bipolar symptoms. The evidence that these medica- bipolar disorder tions are safe and effective in children and adolescents is more limited than in adults. Prescribing medications for a use or for an age-group other than what they were approved for is called “off label” use. While primary care doctors or pediatricians may prescribe these medications, it is recommended that children and adolescents diagnosed with bipolar disorder see a child and adolescent psychiatrist for a consultation before proceeding with medication. Some of the more common medications used to treat the symptoms of bipolar disorder in children and adolescents include: Traditional Mood Stabilizers Traditional mood stabilizers include lithium and antiseizure medications. Lithium is most often effective in controlling mania and preventing the recurrence of both The information contained in this guide is not intended as, and is not a substitute for, professional medical ParentsMedGuide. This medication is not effective in treating serious oppositional behaviors or irritability unless bipolar disorder is the underlying cause. Some side effects children and adolescents may experience from taking lithium include nausea, diarrhea, abdominal distress, sedation, diffculty concentrat- ing, trembling hands, increased thirst and urination, weight gain, and acne. Staying on lithium can be particularly problematic for adolescents who fnd the possibility of weight gain and acne poor incentives for continued treatment. For children taking lithium, it is important to drink plenty of fuid, especially when it is hot or when exercising a lot, to avoid high concentrations of lithium caused by dehydration. Side effects and toxicity can occur at therapeutic levels or at those only slightly higher than desired.

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The chemical composition of carbidopa/levodopa prevents the drug from dissolving completely in water or other liquid 10mg levitra with visa erectile dysfunction sample pills, but a liquid can be prepared for use in certain unusual situations (see Appendix C) order levitra 20mg free shipping drugs for erectile dysfunction ppt. This provides a smooth absorption of the medicine and can cut down on motor fluctuations and dyskinesia. One of the major drawbacks to the pump approach is the need for a percutaneous gastrojejunostomy (a small feeding tube). These types of tubes can be the starting locations for infections and other complications. Below you will find information every patient interested in the pump should be familiar with. For more information on Duopa, including information on support services, visit www. The cassettes are a little smaller than a cellular phone, and usually last about 14-16 hours. Understanding which patients are appropriate for each technique will be important. This is currently not clearly delineated and will require a detailed discussion with the neurologist or expert clinician. The term dyskinesia describes involuntary, erratic, writhing movements of the face, arms, legs and/or trunk. These usually occur one to two hours after a dose of levodopa has been absorbed into the bloodstream and is having its peak clinical effect. They can be severe enough to interfere with a person’s normal functioning and to cause discomfort if they can’t be controlled. This makes it difficult to achieve the satisfactory benefit characteristic of the smooth “on” response that is typical of the levodopa response early in the course of the illness. Patients should be reassured that the likelihood of developing dyskinesia remains low early in the disease, and – if it occurs – is usually quite mild. As movement disorder specialists, general neurologists and primary care doctors have learned, patients often require doses of Sinemet® that exceed 800 mg/day and can easily tolerate the higher doses used to minimize symptoms. Different dopamine agonists have been created that bind to different dopamine receptors with varying strengths. Dopamine agonists have longer half-lives (longer duration of action) than levodopa and for that reason can be helpful in reducing the intensity of the “wearing-off” reaction or to generally enhance the effect of levodopa. However, certain side effects, such as excessive daytime sleepiness, visual hallucinations, confusion and swelling of the legs, occur more commonly with the use of dopamine agonists than with levodopa. This may be partly due to a higher likelihood of other illnesses (also known as comorbidities) and the greater risk of undesirable interactions between Parkinson’s drugs and drugs taken for other purposes. One possible adverse effect of dopamine agonists is the occurrence of drug-induced compulsive behaviors, such as uncontrolled eating, shopping, gambling and sexual urges. The underlying physiology is likely related to over- -)(11#$ 0 stimulation of dopamine receptors in the part of the brain responsible for instant gratification. Dopamine Agonist Started Stopped 2% 2% The Parkinson’s Outcomes Project is the largest clinical study of Parkinson’s in the world. This chart shows the percentage of people using and not using dopamine Used 38% agonists at each of the more than 19,000 visits tracked Not Used in the study as of May 2015. Frequency surveys have shown that these abnormal behaviors are more common with dopamine agonists but can also be seen with carbidopa/levodopa. Those at greatest risk include patients with a family history of gambling and those who are younger, unmarried, and/or cigarette smokers. Additional study will likely provide more insight into the true risk associated with the addition of these dopaminergic medications, as the newer questionnaire may be more likely to pick up such behaviors. Remember also that the people suffering from impulse control issues may not have insight into the behavioral problems, and this lack of insight underscores the importance of involving caregivers in any proactive monitoring plan. Neither of these dopamine agonists is ergot- derived, nor have they been associated with abnormalities of the heart valves. The side effects are similar, with the addition of usually mild local skin irritation under the patch in up to 40% of patients. Fewer than 5% of those studied in the clinical trials discontinued its use due to skin irritation. The initial formulation of the patch was removed from the market worldwide in 2008 because of technical problems with the delivery system. The original patches had a tendency to show a crystallized substance on their surface after they were stored in pharmacies and in patient medicine cabinets for weeks. Neupro® was redesigned and returned in 2012 with dosing available in 1, 2, 3, 4, 6 and 8 mg daily. Its short half-life (average 40 minutes) and chemical structure make it difficult, if not impossible, to take by mouth. In the person affected by severe “off” reactions, during which disabling bradykinesia and rigidity interfere with function, a self-injected dose of Apokyn® can reverse the “off” period within minutes and bridge the gap of one to two hours until the next dose of levodopa takes effect. An anti-nausea medication (usually trimethobenzamide or Tigan®) is required prior to injection in the early phase of treatment but can be discontinued after the first week or two. Selegiline was shown to delay the need for levodopa by nine months, suggesting neuroprotection, but this benefit may simply have been from the antiparkinson symptom effect of selegiline. Selegiline is available in two formulations: standard oral (Eldepryl®, l-deprenyl) and orally- disintegrating (Zelapar®). Standard oral selegiline is converted to an amphetamine like by-product which may contribute to side effects of jitteriness and confusion. Conversely, Zelapar® is dissolved in the mouth and absorbed directly into the bloodstream (no byproduct) without these side effects. Because of Zelapar®’s absorption in the mouth, it may be preferred for convenience or out of necessity for the person who has difficulty swallowing. Clinical trials of Azilect® as monotherapy or adjunctive therapy showed mild but definite efficacy, and there was also an unproven hint of slowing disease progression. A worldwide, multi-institutional clinical trial of rasagiline’s potential for neuroprotection was published in 2008 and follow-up data from the original studies has also been examined closely. A study was published in 2011 that fortunately found no cases of dangerous blood pressure shifts in 18 Parkinson’s Disease: Medications over 2000 patients taking rasagiline in combination with many of the anti-depressant medications on the market today. Additional side effects include confusion, hallucinations, discoloration of urine (reddish-brown or rust-colored) and diarrhea. Entacapone is prescribed with each dose of levodopa, whereas tolcapone is taken three times a day, no matter how many doses of levodopa are prescribed. Tolcapone was removed from the American market in the early 2000s because of a few instances of liver toxicity in people who used it. Tolcapone is currently available with the condition that blood tests of liver function be conducted every two to four weeks for the first six months after beginning treatment, then periodically thereafter. It works by providing relief for the motor symptoms as well as reducing “off” time. By combining the two drugs into one tablet, the manufacturer has made pill-taking a little more convenient compared with carbidopa/ levodopa + entacapone taken separately.

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Characteristics of patients with cytomegalovirus retinitis in the era of highly active antiretroviral therapy discount levitra online mastercard erectile dysfunction young age causes. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 2 order levitra 10mg fast delivery impotence blood pressure. Oral ganciclovir for patients with cytomegalovirus retinitis treated with a ganciclovir implant. Mortality risk for patients with cytomegalovirus retinitis and acquired immune deficiency syndrome. The ganciclovir implant plus oral ganciclovir versus parenteral cidofovir for the treatment of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome: The Ganciclovir Cidofovir Cytomegalovirus Retinitis Trial. Treatment of cytomegalovirus retinitis with a sustained-release ganciclovir implant. A controlled trial of valganciclovir as induction therapy for cytomegalovirus retinitis. Risk of vision loss in patients with cytomegalovirus retinitis and the acquired immunodeficiency syndrome. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: five-year outcomes. Incidence of immune recovery vitritis in cytomegalovirus retinitis patients following institution of successful highly active antiretroviral therapy. Immune-recovery uveitis in patients with cytomegalovirus retinitis taking highly active antiretroviral therapy. Long-term posterior and anterior segment complications of immune recovery uveitis associated with cytomegalovirus retinitis. Long-term Outcomes of Cytomegalovirus Retinitis in the Era of Modern Antiretroviral Therapy: Results from a United States Cohort. Intravitreal triamcinolone acetonide for the treatment of immune recovery uveitis macular edema. Incidence of foscarnet resistance and cidofovir resistance in patients treated for cytomegalovirus retinitis. Mutations conferring ganciclovir resistance in a cohort of patients with acquired immunodeficiency syndrome and cytomegalovirus retinitis. Prediction of cytomegalovirus load and resistance patterns after antiviral chemotherapy. Mutations conferring foscarnet resistance in a cohort of patients with acquired immunodeficiency syndrome and cytomegalovirus retinitis. Change over time in incidence of ganciclovir resistance in patients with cytomegalovirus retinitis. Phenotyping of cytomegalovirus drug resistance mutations by using recombinant viruses incorporating a reporter gene. Cytomegalovirus resistance to ganciclovir and clinical outcomes of patients with cytomegalovirus retinitis. Evaluation of the United States public health service guidelines for discontinuation of anticytomegalovirus therapy after immune recovery in patients with cytomegalovirus retinitis. Long-lasting remission of cytomegalovirus retinitis without maintenance therapy in human immunodeficiency virus-infected patients. Discontinuing anticytomegalovirus therapy in patients with immune reconstitution after combination antiretroviral therapy. Absence of teratogenicity of oral ganciclovir used during early pregnancy in a liver transplant recipient. Human cytomegalovirus reinfection is associated with intrauterine transmission in a highly cytomegalovirus-immune maternal population. The potential role of infectious agents as cofactors in human immunodeficiency virus infection. Congenital and perinatal cytomegalovirus infection in infants born to mothers infected with human immunodeficiency virus. Epidemiologic characteristics of cytomegalovirus infection in mothers and their infants. Maternal human immunodeficiency virus infection and congenital transmission of cytomegalovirus. Obstetric factors and mother-to-child transmission of human immunodeficiency virus type 1: the French perinatal cohorts. Regression of fetal cerebral abnormalities by primary cytomegalovirus infection following hyperimmunoglobulin therapy. However, regardless of the clinical severity of infection, shedding on mucosal surfaces occurs frequently and can result in transmission. Classic manifestations include a sensory prodrome in the affected area, rapidly followed by the evolution of lesions from papule to vesicle, ulcer, and crust stages on the lip. Lesions recur 1 to 12 times per year and can be triggered by sunlight or physiologic stress. Typical genital mucosal or skin lesions evolve through stages of papule, vesicle, ulcer, and crust. Ulcerative lesions are usually the only stage observed on mucosal surfaces, but vesicles are commonly seen on genital skin (e. Mucosal disease is occasionally accompanied by dysuria or vaginal or urethral discharge. Inguinal lymphadenopathy is common with genital herpes, particularly in primary infection. Type-specific serologic assays are commercially available and can be used for diagnosis in asymptomatic individuals or those with atypical lesions. Guidelines for counseling are provided in the 2015 Centers for Disease Control and Prevention sexually-transmitted disease treatment guidelines. No laboratory monitoring is needed in patients receiving episodic or suppressive therapy unless they have advanced renal impairment. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. Genital herpes simplex virus infections: clinical manifestations, course, and complications. Correlation between response to acyclovir and foscarnet therapy and in vitro susceptibility result for isolates of herpes simplex virus from human immunodeficiency virus-infected patients. Knowledge of partners’ genital herpes protects against herpes simplex virus type 2 acquisition. Multicenter collaborative trial of intravenous acyclovir for treatment of mucocutaneous herpes simplex virus infection in the immunocompromised host. Increased risk of genital ulcer disease in women during the first month after initiating antiretroviral therapy. Reactivation of herpes simplex virus type 2 after initiation of antiretroviral therapy. A controlled trial comparing foscarnet with vidarabine for acyclovir-resistant mucocutaneous herpes simplex in the acquired immunodeficiency syndrome. Valacyclovir for the suppression of recurrent genital herpes in human immunodeficiency virus-infected subjects.

The unsustainability of cancer medication pricing has increasingly become a global issue creating access challenges in low-and middle-income but also high-income countries discount levitra 20mg amex erectile dysfunction under 25. This research report was written to share research results cheap levitra 10 mg online erectile dysfunction doctors in alexandria va, to contribute to public debate and to invite feedback on development and humanitarian policy and practice. Access to Cancer Treatment: A study of medicine pricing issues with recommendations for improving access to cancer medication. I thank Joseph Kaiwood for his assistance in the background research on access policies of pharmaceutical companies. I thank Krisantha Weerasurya and Peter Beyer from the World Health Organization for providing information and introductions to useful contacts. I am thankful to many others who have responded to my queries throughout this project. I would especially like to mention Leena Menghaney and Aastha Gupta for information about medicine pricing and policy in India. I am immensely grateful to the external reviewers, Niranjan Kondori from Management Sciences for Health, Rohit Malpani from Médecins sans Frontières and Marg Ewen from Health Action International, whose thoughtful comments, suggestions and corrections were essential to produce the final result. Ellen ‘t Hoen Paris, 2 May 2014 2 Access to Cancer Treatment: A study of medicine pricing issues with recommendations for improving access to cancer medication. Lung, female breast, colorectal, and stomach cancers were the most commonly diagnosed cancers: more than 40 percent of all cancers. Infection-related cancers in 3 Sub-Saharan Africa account for 33 percent and in China for 27 percent. While death rates from cancer in wealthy countries are slightly declining because of early diagnosis and the availability of treatment, this is not the case in low- and middle-income countries. The rates are rising in low- and middle-income countries, partly because of the aging of the population. That will increase to 19 million by 2025, 22 million by 2030 and 24 million by 2035. More than 60 percent of the world’s cancer cases occur in Africa, Asia, and 4 Central and South America. Some of the common cancer types such as breast cancer, cervical cancer, oral cancer, and colorectal cancer respond well to treatment when detected early. Some cancer types, such as leukaemia and lymphoma in children and testicular seminoma, can be cured provided the appropriate treatment is given, even when disseminated. In low- and middle-income countries, however, treatment for cancer is not widely available. According to the Global Task Force on Expanded Access to Cancer Care and Control, only 5 percent of global resources for cancer are spent in the developing world, yet these countries account for almost 80 5 6 percent of disability-adjusted years of life lost to cancer globally. This situation is exacerbated by the lack of financing for healthcare and low health insurance and social security coverage. In low-income countries, the lack of resources requires prioritization of life-saving treatments with high public health impact over cancer care. In certain cases, the high cost of treatment and in particular the high cost of cancer medication throws up additional barriers. India is a particular focus of the report because it is an important lower middle-income country with large unmet needs in cancer care and it has considerable production capacity and potential to produce low-cost medications. Some states in India have announced programmes to provide free medicines to its 4 Access to Cancer Treatment: A study of medicine pricing issues with recommendations for improving access to cancer medication. These are two different issues and industry needs to be wise and thoughtful or else the bargain will be destroyed or never consummated in the developing countries. Particularly in a situation where the product has no competitors, buyers are at the mercy of a single provider, often the patent holder of the product. The high prices of new medicines and in particular those to treat potentially fatal diseases, also receive much attention in high- income countries. Prices of new cancer medication, for example, rise at a higher rate than public and private spending on healthcare, creating challenges even for health systems and individuals in high-income countries. The high price of cancer drugs in particular is increasingly the subject of harsh criticism by consumers and the medical 11,12,13 profession globally. Many patients there pay a considerable part of the cost of treatment out of pocket. High drug prices were responsible for 50 million Americans skipping medication in 14 2012. Nearly half of American adults were reported in 2012 to be either without coverage part of the time or permanently underinsured. Spending on ‘part B drugs’, a category dominated by anticancer drugs, rose 16 from $3bn in 1997 to $11bn in 2004. Even for those individuals that benefit from healthcare coverage, such as Medicare, the cost of certain cancer drugs can be hugely problematic because of co-payment by the patient. The monthly out of pocket cost for the typical Medicare patient is $2,200 in co- payment, which is more than the monthly income of half of the Medicare patients. In other words prescribing this drug would mean leaving half of the patients and often their families without money to live on. In an op-ed in the New York Times, three oncologists took a public stand not to prescribe the 17 drug and to opt for a less costly and equally effective treatment instead. Following the publicity of this announcement, Sanofi swiftly lowered the price of Zaltrap by 50 percent. This reduction brought the price closer to the price level of its competitor product Avastin at $5,000 a month, which is still a hefty price. The authors point out that the development cost has long been earned back by the company and that the number of patients using imatinib continues to rise, which should lead to a reduction in price. They called for immediate action when they wrote: ‘As physicians, we follow the Hippocratic Oath of “Primum non nocere”, first (or above all) do no harm. Advocating for lower drug prices is a necessity to save the lives of patients who cannot afford them. The initiative had collected sufficient signatures for the proposal to pass with an 80 percent majority at 21,22 local elections on 5 November 2013. In Western Europe the public has largely been protected from the high cost of pharmaceutical care because the financing of healthcare does not fall on individuals. However, the economic crisis and subsequent austerity measures have put the spotlight on the fact that prices of new medicines have also 23 become unsustainable in Europe. In 2011 Roche stopped the supply of cancer drugs and other medicines to Greek state hospitals because of unpaid bills. The more affluent European countries also struggle with the high cost of medicines. In 2012 the Dutch College for Health Insurance initially recommended excluding three medicines for the treatment of the rare diseases, Pompe and Fabry diseases, because they had become too expensive. Pompe disease is an inherited disorder caused by the build up of a complex sugar called glycogen in the body’s cells which impairs certain 26 organs and tissues, especially muscles, from functioning normally. Fabry disease is caused by the lack of, or faulty, enzyme needed to metabolize lipids.

By V. Kent. Southwestern Adventist University.