Clinical Course and Clinical Manifestation ...... 6 Book 7 Diagnosis ...... 7 Managing of Hepatitis B ...... 7 Preface ...... i Prevention ...... 7 Hepatitis B Vaccine ...... 7 Editorial Board ...... ii Postexposure ...... 8 Chronic Hepatitis B ...... 9 Book 7 Panel ...... iii Interferon ...... 9 Lamivudine ...... 9 Disclosure of Potential Conflicts of Interest ...... ix Adefovir Dipivoxil ...... 10 Recommendations for Treating Continuing Education and Program Evaluation HBeAg-positive CHB ...... 11 Instructions ...... x Recommendations for Treating HBeAg-negative CHB ...... 11 Roles of ACCP and BPS ...... xiii Investigational Drugs for CHB ...... 12 Entecavir ...... 12 Clevudine ...... 12 Gastroenterology I Emtricitabine ...... 13 Telbivudine ...... 13 VIRAL HEPATITIS Pegylated Interferons ...... 13 Learning Objectives ...... 1 Hepatitis C ...... 13 Introduction ...... 1 Virology and Pathogenesis ...... 14 History ...... 1 Epidemiology and Risk Factors ...... 14 Definitions of Acute and Chronic Hepatitis ...... 1 Natural History ...... 14 Hepatitis A ...... 1 Clinical Course and Clinical Manifestation ...... 14 Virology and Pathogenesis ...... 1 Diagnosis and Serological Testing ...... 15 Epidemiology and Risk Factors ...... 2 Managing Hepatitis C ...... 15 Clinical Course and Clinical Manifestations ...... 2 Prevention ...... 15 Diagnosis and Serological Testing ...... 3 Treating Hepatitis C ...... 16 Managing of Hepatitis A ...... 3 HIV/HCV Coinfection ...... 18 Preexposure Prophylaxis ...... 4 Treating Recurrent HCV after Liver Postexposure Prophylaxis ...... 4 Transplantation ...... 18 Hepatitis A Vaccine ...... 4 Treating Nonresponders ...... 19 Treatment ...... 5 Treatment Duration for Hepatitis C ...... 20 Hepatitis B ...... 5 Side Effects Associated with HCV Therapy Virology and Serology ...... 5 and Management ...... 20 Epidemiology ...... 6 Flu-like Symptoms ...... 20 Risk Factors ...... 6 Psychological Symptoms ...... 20 Natural History ...... 6 Hematological Adverse Effects ...... 20

Pharmacotherapy Self-Assessment Program, 5th Edition xv Table of Contents Anemia ...... 20 Measurements of Intestinal Transit and Motility . . . .38 Neutropenia ...... 21 Gastric Emptying ...... 38 Thrombocytopenia ...... 21 Scintigraphy ...... 38 Other Adverse Effects ...... 22 Acetaminophen Absorption Model ...... 39 Contraindications and Warnings ...... 22 Carbon Radioisotopes ...... 39 Role of the Pharmacist in Treating Chronic Manometry ...... 39 Hepatitis C ...... 22 Small Intestinal Transit ...... 39 Investigational Drugs for Chronic Hepatitis C . . . . .22 Overview ...... 39 Viramidine ...... 22 Intolerance to Enteral Feeding ...... 39 Merimepodib ...... 22 Causes ...... 39 Thymosin Alpha 1 ...... 23 Prokinetic Drugs ...... 40 Therapeutic Vaccine ...... 23 Selection ...... 40 Hepatitis D ...... 23 Non-pharmacological Strategies ...... 40 Virology and Pathogenesis ...... 23 Feeding Tube Placement ...... 40 Epidemiology ...... 23 Ileus ...... 41 Diagnosis, Clinical Course, and Clinical Causes ...... 41 Manifestation ...... 23 Complications ...... 41 Managing Hepatitis D ...... 24 Management ...... 41 Prevention ...... 24 Acute Intestinal Pseudo-obstruction ...... 41 Treating Hepatitis D ...... 24 Management ...... 42 Hepatitis E ...... 24 Mechanical Bowel Obstruction ...... 42 Virology and Pathogenesis ...... 24 Causes ...... 42 Epidemiology ...... 24 Complications ...... 42 Diagnosis, Clinical Course, and Clinical Management ...... 42 Manifestation ...... 25 Constipation ...... 42 Managing Hepatitis E ...... 25 Causes ...... 42 Conclusion ...... 25 Prevention ...... 43 Annotated Bibliography ...... 25 Management ...... 43 Self-Assessment Questions ...... 27 Laxative Agents ...... 43 Diarrhea ...... 43 GASTROINTESTINAL COMPLICATIONS Secretory Diarrhea ...... 43 IN THE INTENSIVE CARE UNIT Clostridium difficile Colitis ...... 43 Learning Objectives ...... 33 Causes ...... 43 Introduction ...... 33 Laboratory Evaluation ...... 44 Pathophysiology ...... 33 Treatment ...... 44 Gastrointestinal Motility ...... 33 Antibiotic-associated Causes of Diarrhea ...... 44 Gastrointestinal Secretion ...... 34 Probiotic Organisms ...... 44 Gastrointestinal Mucosal Perfusion ...... 34 Exudative, Osmotic, and Altered-transit Diarrhea . .44 Clinical Considerations for Drug Administration . . . . .34 Management ...... 44 Diagnostic Considerations ...... 35 Postoperative Nausea and Vomiting ...... 45 Radiocontrast Media ...... 35 Incidence and Risk Factors ...... 45 Oral Radiocontrast Agents ...... 35 Complications ...... 45 Intravenous Radiocontrast Agents ...... 35 Pathophysiology ...... 45 Radiocontrast Media ...... 35 Drug Prophylaxis ...... 45 Drugs to Avoid ...... 36 Rescue Treatment ...... 46 Selecting a Radiocontrast Agent ...... 36 Pharmacist Involvement ...... 46 Imaging Studies ...... 36 Stress-related Mucosal Disease ...... 46 Endoscopy ...... 37 Introduction ...... 46 Laparoscopy and Surgical Interventions ...... 37 Definition of Clinically Significant Bleeding ...... 46 Clinical Monitoring ...... 37 Pathophysiology ...... 47 Gastric pH ...... 37 Risk Factors for GI Bleeding in ICU Patients ...... 47 Gastric Tonometry ...... 37 Impact of Enteral Nutrition ...... 47 Alterations in GI Motility ...... 38 Pharmacological Approach ...... 48 Gastrointestinal Hypomotility ...... 38 Sucralfate ...... 48 Causes ...... 38 Histamine-2 Receptor Antagonists ...... 48 Pharmacist Involvement ...... 38 Proton-pump Inhibitors ...... 48

Table of Contents xvi Pharmacotherapy Self-Assessment Program, 5th Edition Tolerance ...... 49 Etiology ...... 70 Nosocomial Pneumonia ...... 49 Genetic Influences ...... 70 Comparison of Stress Ulcer Prophylaxis Drugs . . . . .50 Environment Influences ...... 70 Treatment Recommendations ...... 50 Immunologic Influences ...... 70 Economic Considerations ...... 51 Clinical Characteristics and Complications ...... 71 Upper GI Bleeding ...... 51 Ulcerative Colitis ...... 71 Variceal Upper GI Bleeding ...... 51 Clinical Manifestations of UC ...... 71 Pathophysiology ...... 51 Complications of UC ...... 71 Primary Prophylaxis ...... 51 Crohn’s Disease ...... 72 Acute Management ...... 51 Clinical Manifestations of CD ...... 72 Octreotide ...... 52 Complications of CD ...... 72 Antibiotic Drugs ...... 52 Diagnostic Approach and Tools ...... 73 Prevention of Variceal Rebleeding ...... 52 Patient-based Questionnaires ...... 74 Pharmacological Options ...... 52 Disease Progression ...... 74 Nonvariceal Upper GI Bleeding ...... 53 Ulcerative Colitis ...... 74 Introduction ...... 53 Crohn’s Disease ...... 75 Risk Factors for GI Rebleeding and Mortality . . . . .53 Therapeutic Goals and Outcomes ...... 75 Acute Management ...... 53 Quality Patient Care ...... 75 Preventing Peptic Ulcer Rebleeding ...... 53 Pharmacotherapy ...... 75 Potential Therapies for GI Rebleeding Prevention . .53 Treatment of UC ...... 78 Octreotide ...... 53 Proctitis ...... 78 Histamine-2 Receptor Antagonists ...... 54 Left-sided Colitis ...... 78 Proton-pump Inhibitors ...... 54 Pancolitis ...... 79 Comparison of Antisecretory Drugs for Recurrent Fulminant Colitis ...... 79 Bleeding Prevention ...... 54 Surgical Intervention ...... 79 Economic Considerations ...... 55 Refractory UC ...... 79 Development of Treatment Guidelines ...... 56 Alternative Therapies for UC ...... 79 Severe Intra-abdominal Infections ...... 56 Nicotine ...... 79 Pathophysiology ...... 56 Infliximab ...... 80 Classification ...... 56 Treatment of CD ...... 80 Primary Peritonitis ...... 56 Crohn’s Ileitis ...... 80 Secondary Peritonitis ...... 56 Peritonitis ...... 81 Tertiary Peritonitis ...... 57 Ileocolitis ...... 81 Gastrointestinal Microflora and Microbiology ...... 57 Refractory Disease ...... 81 Treatment ...... 57 Fistulae ...... 82 Non-pharmacological ...... 57 Postoperative Recurrence ...... 82 Pharmacological ...... 58 Adjunctive Therapies for IBD ...... 82 Acute Management ...... 58 Antidiarrheal Drugs ...... 83 Vasopressors ...... 58 Psychotropic Drugs ...... 83 Antimicrobial Drug Therapy ...... 58 Fish Oil ...... 83 Irrigation Solutions ...... 58 Probiotics ...... 83 Controversies ...... 59 Nutritional Considerations ...... 83 Therapy Duration ...... 59 Issues in Special Patient Populations ...... 84 Utility of Intra-abdominal Cultures ...... 59 Reproductive Health ...... 84 Summary ...... 59 Pediatric and Adolescent Patients ...... 84 Annotated Bibliography ...... 59 Investigational and Alternative Therapies for IBD . .84 Self-Assessment Questions ...... 61 Budesonide ...... 85 Anti-integrin Antibodies ...... 85 Gastroenterology II Thalidomide ...... 85 Additional Anti-TNF Antibody Therapies ...... 85 INFLAMMATORY BOWEL DISEASE Growth Hormone ...... 85 Learning Objectives ...... 69 Antimycobacterial Therapy ...... 85 Introduction ...... 69 Monitoring ...... 86 Pathophysiology of IBD ...... 69 System Support for Drug Use Process ...... 86 Definitions ...... 69 Documentation ...... 86 Epidemiology ...... 70 Patient Education ...... 87

Pharmacotherapy Self-Assessment Program, 5th Edition xvii Table of Contents Patient Support ...... 87 Helicobacter pylori as a Risk Factor ...... 120 Economics ...... 87 Treating and Preventing NSAID-induced Quality Improvement ...... 88 Gastropathy ...... 121 Conclusion ...... 88 General Management Strategies ...... 121 Annotated Bibliography ...... 88 Pharmacological Options ...... 122 Self-Assessment Questions ...... 91 Antacids and Sucralfate ...... 122 Misoprostol ...... 122 SHORT BOWEL SYNDROME Antisecretory Drugs ...... 123 Learning Objectives ...... 95 Drugs Targeting COX-2 ...... 124 Introduction ...... 95 Comparing COX-2 Inhibitors and PPIs ...... 126 Pathophysiology ...... 95 Recommendations for Pharmacological Duodenum ...... 96 Management ...... 126 Jejunum ...... 96 Patients With No Risk Factors ...... 126 Ileum ...... 96 Patients With Two or More Risk Factors ...... 126 Ileocecal Valve ...... 97 Patients Receiving Aspirin ...... 127 Colon ...... 97 Comparative Non-gastrointestinal Toxicity Diagnosis and Management ...... 98 of NSAIDs and COX-2 Inhibitors ...... 127 Therapeutic Goals and Outcomes ...... 98 Renal and Hemodynamic Effects ...... 127 Acute Phase ...... 98 Cardiovascular Effects ...... 128 Nutrition ...... 98 Pharmacoeconomic Aspects of Treating and Monitoring ...... 100 Preventing NSAID-Induced Gastropathy ...... 130 Adaptation Phase ...... 100 Conclusion ...... 131 Nutrition ...... 100 Annotated Bibliography ...... 132 Trophic Factors ...... 101 Self-Assessment Questions ...... 135 Maintenance Phase ...... 102 Patient Education ...... 102 Nutrition I Early Complications ...... 103 Fluids and Electrolytes ...... 103 NUTRITION MANAGEMENT IN THE INTENSIVE Vitamins and Minerals ...... 103 CARE UNIT Diarrhea ...... 104 Learning Objectives ...... 141 Hypergastrinemia ...... 106 Introduction ...... 141 Central Venous Catheter-related Complications . . .106 Malnutrition in the Intensive Care Unit ...... 141 Late Complications ...... 106 Nutrition Support Goals ...... 141 Hyperoxaluria ...... 106 Physiological Changes ...... 141 Cholelithiasis ...... 107 Starvation ...... 141 D-Lactic Acidosis ...... 107 Critical Illness ...... 142 Liver Disease ...... 109 Ebb and Flow Physiology ...... 142 Other Complications ...... 109 Protein Metabolism ...... 142 Surgery ...... 109 Carbohydrate Metabolism ...... 142 Nontransplant Surgery ...... 109 Lipid Metabolism ...... 142 Transplant Surgery ...... 109 Fluid Changes ...... 143 Stoma Management ...... 110 Electrolyte Changes ...... 143 Skin Care ...... 110 Nutritional Assessment ...... 143 Complications ...... 111 Clinical Assessment ...... 143 Psychosocial Concerns ...... 111 Weight History ...... 143 Pharmacists’ Role ...... 111 Clinical History and Physical Examination ...... 143 Conclusion ...... 112 Bowel Function ...... 143 Annotated Bibliography ...... 112 Injury and Illness Type and Severity ...... 143 Self-Assessment Questions ...... 113 Laboratory Assessment ...... 144 Serum Proteins ...... 144 NSAID-INDUCED GASTROPATHY Albumin ...... 144 Learning Objectives ...... 117 Prealbumin ...... 144 Introduction ...... 117 Retinol-binding Protein ...... 144 Pathogenesis ...... 117 Transferrin ...... 144 Risk Factors ...... 119 Nutritional Requirements ...... 144 Aspirin as a Risk Factor ...... 120 Energy Requirements ...... 144

Table of Contents xviii Pharmacotherapy Self-Assessment Program, 5th Edition Predictive Equations ...... 144 CHRONIC PARENTERAL NUTRITION-ASSOCIATED Harris-Benedict Equations ...... 144 METABOLIC COMPLICATIONS Ireton-Jones Equations ...... 145 Learning Objectives ...... 163 Other Equations ...... 145 Introduction ...... 163 Weight-based Estimates ...... 145 Liver Complications ...... 163 Indirect Calorimetry ...... 146 Cholestasis ...... 163 Protein Requirements ...... 146 Etiology and Predisposing Factors ...... 164 Weight Determination ...... 146 Biochemical Abnormalities ...... 164 Nitrogen Balance ...... 146 Clinical Symptoms ...... 164 Fluid Requirements ...... 147 Management ...... 164 Electrolyte Requirements ...... 147 Non-pharmacological Approaches ...... 164 Vitamin and Trace Element Requirements ...... 147 Pharmacological Approaches ...... 164 Nutritional Intervention ...... 147 Ursodiol ...... 164 Timing of Intervention ...... 147 Sincalide ...... 165 Route of Intervention ...... 148 Oral Antibiotic Drugs ...... 165 Physiology ...... 148 Cholestyramine ...... 165 Clinical Studies Comparing EN to PN ...... 148 Enzyme Inducers ...... 165 Enteral Nutrition ...... 149 Cholelithiasis ...... 165 Enteral Access ...... 149 Etiology and Predisposing Factors ...... 165 Enteral Administration Techniques ...... 149 Management ...... 166 Enteral Formula Selection ...... 150 Hepatic Steatosis ...... 166 Immune-enhancing Formulations ...... 150 Etiology ...... 166 Arginine ...... 150 Dextrose ...... 166 Glutamine ...... 150 Lipid Emulsions ...... 166 Complications of EN ...... 150 Choline Deficiency ...... 166 Mechanical Complications ...... 150 Carnitine Deficiency ...... 166 Infectious Complications ...... 151 Signs and Symptoms ...... 166 Underfeeding and Therapy Interruptions ...... 151 Management ...... 167 Feeding Protocols ...... 151 Metabolic Bone Disease ...... 167 Diarrhea ...... 151 Etiology ...... 167 Delayed Gastric Emptying ...... 151 Calcium and Phosphorus Deficiencies ...... 167 Prokinetic Drugs ...... 152 Calcium and Phosphorus Intake ...... 167 Postpyloric Tube Placement ...... 152 Amino Acids and Hypercalciuria ...... 167 Parenteral Nutrition ...... 152 Metabolic Acidosis and Calcium Deficiency . . .167 Parenteral Access ...... 152 Parenteral Nutrition Cycling and Administering PN ...... 152 Hypercalciuria ...... 167 Complications of PN ...... 152 Aluminum Toxicity ...... 168 Metabolic Complications ...... 152 Vitamin D ...... 168 Overfeeding ...... 152 Signs and Symptoms ...... 168 Overfeeding Protein ...... 152 Management ...... 168 Overfeeding Carbohydrates and Hyperglycemia 152 Trace Mineral Abnormalities ...... 169 Overfeeding Lipid ...... 153 Manganese ...... 169 Refeeding Syndrome ...... 153 Manganese Toxicity ...... 169 Monitoring Nutrition Support ...... 153 Management ...... 170 Monitoring for Effectiveness ...... 153 Copper ...... 170 Monitoring for Complications ...... 153 Copper Deficiency ...... 170 Specific Disease States ...... 154 Management ...... 170 Burns ...... 154 Zinc ...... 170 Postresuscitation EN (Timing, Complications, Zinc Deficiency ...... 170 and Overall Need for PN) ...... 155 Management ...... 170 Trauma ...... 155 Selenium ...... 170 Acute Lung Injury and Acute Respiratory Selenium Deficiency ...... 171 Distress Syndrome ...... 155 Management ...... 171 Conclusion ...... 156 Iron ...... 171 Annotated Bibliography ...... 156 Iron Deficiency ...... 171 Self-Assessment Questions ...... 159 Management ...... 171

Pharmacotherapy Self-Assessment Program, 5th Edition xix Table of Contents Electrolyte Abnormalities ...... 171 Indications for Parenteral Nutrition ...... 193 Sodium ...... 172 Role of Exogenous Pancreatic Enzyme Hyponatremia ...... 172 Supplementation in Chronic Pancreatitis ...... 194 Hypernatremia ...... 172 Therapeutic Goals and Desired Outcomes in Acute Potassium ...... 172 and Chronic Pancreatitis ...... 195 Hypokalemia ...... 172 Conclusion ...... 195 Hyperkalemia ...... 173 Annotated Bibliography ...... 195 Magnesium ...... 173 Self-Assessment Questions ...... 197 Hypomagnesemia ...... 173 Hypermagnesemia ...... 173 OVERWEIGHT AND OBESITY Phosphorus ...... 173 Learning Objectives ...... 201 Hypophosphatemia ...... 173 Introduction ...... 201 Hyperphosphatemia ...... 174 Definitions ...... 201 Calcium ...... 174 Epidemiology ...... 201 Hypocalcemia ...... 174 Adults ...... 201 Hypercalcemia ...... 174 Children and Adolescents ...... 202 Chloride and Acetate ...... 174 Diagnosis and Patient Assessment ...... 202 Conclusion ...... 174 Pathophysiology ...... 203 Annotated Bibliography ...... 175 Energy Balance ...... 203 Self-Assessment Questions ...... 177 Genetics and Chemical Mediators of Weight Regulation ...... 204 Nutrition II Environmental Factors ...... 204 Relationship of Obesity to Other Disorders ...... 205 NUTRITIONAL MANAGEMENT IN ACUTE Introduction ...... 205 AND CHRONIC PANCREATITIS Mortality ...... 205 Learning Objectives ...... 183 Cardiovascular Disease ...... 206 Introduction to Acute and Chronic Pancreatitis . . . . .183 Type 2 DM ...... 206 Epidemiology of Acute and Chronic Pancreatitis . .183 Cancer ...... 206 Classifying and Diagnosing Pancreatitis ...... 183 Other Disorders ...... 206 Etiology and Clinical Manifestations of Treatment Goals ...... 207 Pancreatitis ...... 185 Weight Loss ...... 207 Nutritional Pathophysiology in Pancreatitis ...... 185 Weight Maintenance ...... 207 Nutritional Pathophysiology in Acute Quality of Life/Functional Status ...... 207 Pancreatitis ...... 185 Non-pharmacological Therapy ...... 207 Nutritional Pathophysiology in Chronic Diets to Induce Weight Loss ...... 207 Pancreatitis ...... 186 Traditional Low-calorie, Low-fat Diets ...... 207 Physiology of Exocrine Pancreatic Function ...... 187 Very Low-calorie Diets ...... 208 Low-carbohydrate Diets ...... 208 Nutritional Assessment in Acute Pancreatitis ...... 187 Other Diets ...... 209 Macronutrient Requirements in Severe Acute Commercial Weight Loss Programs ...... 209 Pancreatitis ...... 187 Meal Replacement Therapy and Structured Protein ...... 187 Meal Plans ...... 209 Carbohydrate ...... 188 Fat Substitutes ...... 209 Lipid ...... 188 Sugar Substitutes ...... 209 Role of Nutrition Support Therapy in Severe Acute Physical Activity ...... 210 and Chronic Pancreatitis ...... 189 Behavioral Therapy ...... 210 Role of Nutrition Support in Mild Acute Pharmacological Therapy ...... 210 Pancreatitis ...... 189 Nonprescription Therapy ...... 210 Role of Nutrition Support in Severe Acute Over-the-counter Drugs ...... 210 Pancreatitis ...... 189 Dietary Supplements ...... 211 Role of Nutrition Support in Chronic Pancreatitis . .190 Prescription Therapy ...... 211 Indications for EN ...... 190 History and Present Usage ...... 211 Selecting EN Formulas ...... 191 Orlistat ...... 212 Selecting EN Formulas in Acute Pancreatitis . . .191 Sibutramine ...... 213 Selecting EN Formulas in Chronic Pancreatitis . .191 Unlabeled Drugs ...... 215 Optimal EN Feeding Tube Placement ...... 192 Investigational Drugs ...... 216

Table of Contents xx Pharmacotherapy Self-Assessment Program, 5th Edition Surgical Therapy ...... 216 Patient Populations at Risk ...... 242 Treatment Plan ...... 217 Calculating the Al Load in PN ...... 242 Economic Issues ...... 219 Di-(2-ethylhexyl) Phthalate Toxicity ...... 242 Quality of Life Issues ...... 219 Adverse Effects Associated with DEHP ...... 243 Pharmacists’ Role ...... 219 Patient Populations at Risk ...... 243 Conclusion ...... 219 Methods to Limit DEHP Exposure ...... 243 Annotated Bibliography ...... 219 Photodegradation ...... 243 Self-Assessment Questions ...... 223 Methods to Minimize Peroxidation ...... 244 Conclusion ...... 244 SPECIAL CHALLENGES IN PEDIATRIC Annotated Bibliography ...... 244 NUTRITION: CLINICAL ISSUES AND Self-Assessment Questions ...... 247 COMPOUNDING CONSIDERATIONS Learning Objectives ...... 227 Introduction ...... 227 Essential Fatty Acid Deficiency ...... 227 Patient Populations at Risk ...... 228 Consequences of EFAD ...... 228 Signs and Symptoms of EFAD ...... 228 Treatment Options ...... 229 Nutritional Issues in CHD ...... 231 Growth Failure ...... 231 Causes of Growth Failure ...... 231 Nutritional Assessment ...... 232 Energy Requirements ...... 232 Feeding Options ...... 232 Enteral Nutrition ...... 232 Parenteral Nutrition ...... 233 Special Conditions ...... 233 The Ketogenic Diet ...... 233 Mechanism of Action ...... 234 Other Indications ...... 234 Contraindications ...... 234 Initiation and Maintenance of the Diet ...... 235 Monitoring ...... 235 Effectiveness of the Diet ...... 235 Drug Use ...... 235 Intercurrent Illness ...... 236 Complications ...... 236 Discontinuing the Diet ...... 236 Protective Nutrients and Functional Foods ...... 237 Probiotics ...... 237 Rationale for Use ...... 238 Indications ...... 238 Product Concerns ...... 239 Prebiotics ...... 239 Amino Acids ...... 239 Glutamine ...... 239 Glutamine Research ...... 240 Arginine ...... 240 Summary ...... 241 Current Controversies in PN Preparation ...... 241 Aluminum ...... 241 Aluminum Toxicity ...... 241 Diagnosis ...... 242 Treatment ...... 242 Food and Drug Administration Mandate ...... 242

Pharmacotherapy Self-Assessment Program, 5th Edition xxi Table of Contents