Pioglitazone (Pioglitazone)

Hoʻomoe ʻia ka lāʻau lapaʻau i ke ʻano o nā papa: mai kokoke ke keʻokeʻo a keʻokeʻo, puni, 15 mg - biconvex, i kahakaha ʻia ma kekahi ʻaoʻao o "15", 30 mg - papalaha, me kahi bevel, i kahakaha ʻia ma kekahi ʻaoʻao o "30" (10 pcs. i nā blister, 1, 3 a i 5 paha blister a me nā ʻōlelo e hoʻohana ai iā Pioglara i kahi pahu pahu).

Pākaukau 1 papa:

• mea kūlohelohe: pioglitazone hydrochloride - 16,53 a i ʻole 33.07 mg, kahi mea e kū like ai me ka pioglitazone ma ka nui o 15 a 30 mg, kēlā me kēia
• Nā kumuhana hou: calcium carboxymethyl cellulose, magnesium stearate, hydroxypropyl cellulose (haʻahaʻa haʻahaʻa), lactose, wai maʻemaʻe.

Lapaʻau lāʻau

ʻO Pioglitazone kahi mea lawaiʻa waha hypoglycemic a, kahi kahi o ka series thiazolidinedione, kahi mea hoʻonaninani i ka ʻγ e ʻāpono i hoʻāla ʻia e ka peroxisome proliferator (PPARγ). Hoʻokumu ʻia nā mea hoʻokalakupua a PPAR tiss i nā ʻili na mea i ʻoi aku ka mea nui o ka hana o ka insuline (kaʻe ʻuhane, ke kiko adipose a me nā leʻa). ʻO ke ʻoliʻoli o nā mea uʻi o nā nuklepika o PPARγ ka hoʻololi ʻana i ka helu o ka nui o nā ʻano maʻi i ʻike i ka insulin a pili i ka kaohi o ke koko a me ka metabolism lipid. Hāʻawi ʻo Pioglitazone i ka hoʻēmi i ka pale ʻana i ka insulin, ma muli o ke kīhina ʻana o ka hoʻohana ʻana i ka glucose i hilinaʻi ʻia o ka insulin, ka nui o ka glucose a me kona hoʻokuʻu mai ka puʻuwai. Ke kōkua nei ka mea hana e hōʻemi i ka triglycerides, hoʻonui i ka manaʻo o nā lipoproteins density kiʻekiʻe (HDL) a me ka cholesterol. ʻAʻole hiki i ka Pioglar ke hoʻoikaika i ka hana o nā insulin, e like me nā derivatives o sulfonylurea.

Lapaʻau lāʻau

Ma hope o ka lawelawe waha, ua ʻike ʻia kahi kukuna o ka pioglitazone, i loko o ke koko koko ka mea i ʻike ʻia ma hope o 30 mau minuke, ka nui o ke kūpaʻa nui (C_max) ua loaʻa ma hope o 2 mau hola, a ma hope o ka ʻai - ma hope o 3-4 mau hola. Hiki kokoke loa i ke aikini i nā protein plasma - e ka 99%, ka nui o ka hoʻoili (V_{e d}) aia 0.22–1.04 l / kg. Hoʻomili nui ʻo Pioglitazone e ka hydroxylation a me ka oxidation, nā metabolites i kūkulu ʻia ma muli o ka biotransformation o ka mea hana e hoʻohuli pū kekahi i nā konohiki sulfate / glucuronide.

Kuhi i ka pioglitazone hydroxide (nā metabolites M-II a me M-IV) a me ka keto-derivative pioglitazone (metabolite M-III) e hōʻike i ka hana lāʻau lapaʻau. Ma ke kaʻina o ka hepatic metabolism o ka lāʻau lapaʻau, ʻo ka hana nui ka mea i hoʻopili i ka isoenzymes o ka cytochrome P450 - CYP3A4 a me CYP2C8. I kekahi wahi, ʻoi aku ka nui o nā isoenzymes i komo pū kekahi i ka metabolism o ka lāʻau, ʻo ka mea nui o ka extrahepatic isoenzyme CYP1A1.

Ma ka hihia o kēlā me kēia lā i hoʻohana ai ʻo Pioglar i plasma, ʻo ka ʻike o ka pioglitazone holoʻokoʻa (pioglitazone me nā metabolite ikaika) hiki ke loaʻa ma hope o 24 hola. Ke kikowaena paʻa (C_{ai ʻo ss}) i ka plasma o nā pioglitazone ʻelua a me nā pioglitazone i nānā ʻia ma hope o 7 mau lā.

Hoʻopau nui ʻia ka lāʻau lapaʻau me ka bile i kahi ʻano i hoʻololi ʻole ʻia a me ke ʻano o nā metabolites, a hoʻopau ʻia me nā feces. 15-30 ka mea i hoʻohālikelike ʻia e nā keiki ma nā ʻano o nā metabolites a me nā ʻolihi. Ka hapalua ola (T_½) pioglitazone a me ka pioglitazone keu he 3-7 mau hola a he 16-24 mau hola, kēlā.

Nā hōʻailona no ka hoʻohana ʻana

Noi ʻia ʻo Pioglar no ka hoʻohana ʻana i ka mellitus type 2 (ʻoiai he lāʻau lapaʻau monotherapy a i hui pū pū me ka metformin, i ʻole a me ke kōmia o ka hoʻokuʻukū ʻia a i loaʻa i ka wā e hoʻomaʻamaʻa ʻia, kaʻai ʻana a me ka monotherapy me kekahi o nā lāʻau antidiabetic i luna.

Nā Hoʻohui

• Helu III - IV ka hewa o ka puʻuwai, e like me ka helu ʻana o ka New York Association of Cardiology (NYHA),
• maʻi ketoacidosis maʻi, type 1 diabetes mellitus,
• ʻoi aku ka nui o ka hana o ka ate, ka hana o ka nui o nā enzyme o ke koena ma mua o 2.5 mau manawa o ka palena o ka maʻamau.
• macrohematuria o kahi kumu ʻike,
• maʻi ʻohiola ʻaʻa manuʻa (me nā moʻolelo)
• makahiki i 18 makahiki
• hapai a me lactation,
• glucose-galactose malabsorption, hemahema lactase, galactose intolerance,
• hypersensitivity o kekahi o nā lāʻau o ka lāʻau.

Hoʻohana (pono e hoʻohana ʻia nā papa Pioglar me ka makaʻala nui).

• puʻuwai paʻakikī
• anemia
• ka leo edematous
• nā hana maʻi o ka ate.

Pioglar, nā ʻōlelo e pili ana i ka hoʻohana ʻana: ke ʻano a me ka helu ʻana

Lawe ʻia nā papa Pioglar i 1 mau manawa i ka lā, me ke ʻano o ka manawa ʻaina.

Ke lawe nei i ka monotherapy, e hōʻike ʻia e inu i ka lāʻau lapaʻau ma loko o kahi hapa o 15-30 mg, ʻoi ka nui o kēlā me kēia lā he 45 mg.

I ka hui hui pū ʻana me nā derivatives metformin a i ʻole olonylurea, pono e hoʻohana ʻia ka pioglitazone ma kahi pākuʻi mua o 15 a 30 mg; inā hele mai ka hypoglycemia, ʻike ʻia ka nui o ka hoʻomākaukau ʻana o ka metformin a i ʻole ka hoʻoponopono ʻana i ka sulfonylurea.

Me ka hoʻohana pū ʻana o Pioglar me ka insulin, ʻo ka pioglitazone mua o kēlā me kēia lā e pono ai he 15-30 mg, waiho ʻia ka nui o ka insulin a i hōʻemi ʻia paha e 10-25% inā hōʻike nā mea maʻi i ka hypoglycemia a i ʻole ka hoʻoliʻi ʻana o ka plasma glucose i kahi pae ʻaʻole iʻoi aku ma mua o 100 mg. / dl.

Nā hopena hopena

• ea kalepa: sinusitis, pharyngitis,
• nā hana a me nā mea hoʻonaninani: ʻeha, hōʻeha, ʻeha, hyposthesia, ʻike maka (ʻike pinepine ʻia i ka hoʻomaka ʻana o ka mālama ʻana a pili pū me nā loli o ka pae glucose plasma, e like me nā lāʻau antidiabetic).
• hematopoietic ʻōnaehana: anemia,
• metabolism: hypoglycemia, kaupaona momona,
• gastrointestinal tract: lemulence,
• ʻōpū a i ʻole nā ​​maʻi kaulike: ke kino o ka maʻi ʻaila, nā hōʻailona o ke kūkulu ʻana i nā maʻi e koi pinepine i ka urinate, macrohematuria, ʻeha i ka wā o ka urination, ʻeha ma ka ʻōpū o ka ʻōpū a i ʻole ka lumbar o ke ʻano (ʻo ke ʻano o kēia mau pilikia e hōʻike koke ʻia i ke kauka).
• musculoskeletal system: myalgia, arthralgia,
• na haina ʻona o ka laboratorium: hoʻonui i ka hana o ka alanine aminotransferase (ALT) a me ka phosphokinase creatine, he kaila o nā pae hemoglobin a me ka hoʻohaʻahaʻa ʻana hematocrit (ʻo ka mea maʻamau i hana ʻole ʻia, ma muli o ka hoʻonui i ka nui o ka plasma a ʻaʻole i hōʻike i ka hoʻomohala o nā hopena lapaʻau hematological koʻikoʻi).

Me ka wā mālama i ʻoi aku ma mua o ka 1 makahiki, i ka 69% o nā hihia, hiki ke nānā ʻia ke ʻano o ka edema ʻoluʻolu a me ke ʻano, ka mea pinepine ʻole e koi i ke kāpae ʻana iā Pioglar, hiki ke hoʻopaʻa ʻia i nā maʻi.

I ka wā o ka maʻi maʻi, i kekahi mau hihia, hiki i ka uluʻana o ka puʻuwai puʻuwai.

Nā ʻōlelo kikoʻī

I ka poʻe maʻi me ka manawa anovulatory i ka manawa premenopausal a me ke kū'ē i ka insulin ma muli o ka mālama ʻana me ka pioglitazone, ʻike ʻia ka hoʻōla ʻana o ka maʻi ovulation. Ma muli o ka hoʻonui nui ʻana o kēia mau mea maʻi i ka insulin i ka ʻole o ka hoʻohana ʻana i nā contraceptives kūpono, e hoʻonui ʻia ka nui o ka hāpai ʻana. Inā hele mai ka hapai i ka wā o ka hoʻomanawanui a ke hoʻolālā nei ka mea maʻi i ka wā hapai, pono e hoʻokuʻu ʻia ka pioglitazone.

E like me nā hopena o nā noi preclinical, ʻo thiazolidinediones, me ka pioglitazone, i alakaʻi i ka hoʻonui ʻana o ka nui plasma a me ka hoʻomohala ʻana i ka myocardial hypertrophy, ma muli o ka preload. I nā hoʻokolohua lapaʻau i ʻike ʻole ʻia e nā maʻi me ka papa III a me IV mau paʻakikī (NYHA), ʻaʻohe nui o ka piʻi ʻana o nā hopena ʻino loa mai ka ʻōnaehana cardiovascular, pili i ka hoʻonui o ka nui o ka plasma (paleka o ka naʻau paʻakikī).

ʻO nā hualoaʻa o nā hoʻokolohua lapaʻau e mālama ʻia ana, a me ka ʻikepili epidemiological ʻ availablelelo, hōʻike i ka hoʻonui ʻana i ka hoʻoweliweli o ka hoʻoweliweli o ka maʻi pākīpī i nā mea maʻi me ka maʻi diabetes ua lawe i ka pioglitazone i nā hōkeo kiʻekiʻe i kēlā me kēia lā no ka manawa lōʻihi. Eia nō naʻe, ʻaʻole ka mea i loaʻa i kēia mau ʻike ke kāpae i ka nui o ka maʻi kōpipi i ka wā o ka manawa pōkole me ka lāʻau lapaʻau. ʻO nā mea aʻe i pili paha i ka pilikia o ke kanesa o ka pōpoki: ʻōpio kahiko, ka ulaula (me ka wā ma mua), chemotherapy (me ka hoʻohana ʻana o ka cyclophosphamide), radiation radiation o nā pelvic organitions, a me kekahi mau pilikia hana. Ma mua o ka hoʻomaka ʻana o ka papa o ka hoʻōla, pono ʻia nā haʻawina macroscopic e hoʻokumu i kekahi macrohematuria. Pono e hoʻākāka koke i ke kauka e pili ana i nā hōʻailona āpau o ka dysuria a me kahi hoʻomohala kino ʻana i nā hōʻailona mai ka urinary tract a me / a i nā mea ʻaihue.

Me ka hana pūpū hemahema

I ka wā o ka papa maʻi, ua hoʻolako ʻia e mālama pinepine i nā neʻe o nā enzyme o ke aʻai i ke koko. I ka maʻi āpau, ma mua o ka hoʻomaka ʻana o ka mālama ʻana me ka pioglitazone, kēlā me kēia mau mahina 2 i ka makahiki mua o ka loaʻa ʻana o Pioglar a me ka manawa maʻamau i nā makahiki o ka hana o ka hoʻomaʻamaʻa ʻia, pono ia e hoʻoholo i ke kiʻekiʻe o ALT. Pono hoʻi e nānā i ka hana o ke ate i ka wā e ʻike ʻia ai nā hōʻailona o ka palaleka o ka ate, e like me ka ʻōpū o ka ʻōpū, ke ala, ka luaʻi, ke anorexia, nā nāwaliwali, nā pōʻeleʻele. Inā hele mai ka jaundice, kāpae i ka lawe ʻana iā Pioglar.

Hoʻohana ʻia ka hoʻohana ʻana o kahi laikini hypoglycemic i loko o nā mea maʻi me nā maʻi pūpū ikaika a i ʻole e kūlike ana i ke ʻano o ka hoʻonui ʻana i nā hōʻailona ALT ma mua o 2 mau manawa ʻo VGN.

Me ka piʻi liʻiliʻi o nā pae ALT (12.5 mau manawa kiʻekiʻe ma mua o ka papa maʻamau) ma mua o ka papa a i ka wā e hoʻōla ai, pono ʻia kahi hoʻokolokolo e hoʻokumu i nā kumu o kēia kipi. E hoʻomaka a hoʻomau i ka mālama ʻana me Pioglar ma ka hiki ʻana o ka hoʻonui haʻahaʻa ʻana i ka hana o nā huina o ka ate me ka mālama nui loa, ka hoʻokau ʻana i ka nānā pinepine ʻana o kā lākou hana.

Ma ka hihia i ʻike ʻia ai ka piʻi ʻana o ka hana o nā transaminases hepatic ma mua o 2 mau manawa i hoʻohālikelike ʻia me VGN, pono e kiaʻi pinepine i ka pae o nā enzymes, a hiki i nā hōʻailona ke hoʻēmi i ka maʻamau a i ʻole nā ​​mua. Inā ʻoi aku ka nui o ka pae ALT ma mua o nā manawa maʻamau ma mua o ka 3 mau manawa a i ʻole ka jaundice i mālama ʻia, pono e haʻalele ʻia ka hoʻohana ʻana o ka pioglitazone.

Hoʻohana i ka wā kahiko

I ka poʻe ʻelemakule, ma mua a i ka wā o ka mālama ʻana, ma muli o ka ulu ʻana o ka hoʻoweliweli ʻana o ka pōpilikia, nā maʻi o ka ʻōnaehana cardiovascular a me nā pōpoki pale i nā maʻi o nā ʻōpio o kēia makahiki, kahi loiloi e pili pono ana i ka pōmaikaʻi me ka hopena o ka hopena o ka mālama ʻana me Pioglar e hana.

Hoʻohui nūhou

• nā hana hoʻohālikelike waha ʻole - nā haʻawina ʻo pharmacokinetic o ka hoʻohana pono ʻana i kēia mau lāʻau a me ka pioglitazone ʻaʻole i mālama, akā naʻe, i ka hoʻohana ʻana o nā thiazolidinediones ʻē aʻe i hui pū me nā ʻaina waha, e loaʻa pū ana i ka ethinyl estradiol / norethindrone, i hoʻopiʻi i ka hōʻemi ʻana i ka pae plasma o nā hormones a ʻelua i ka 30%, kahi e hiki ai i ka nāwaliwali nui o nā hopena contraceptive. E makaʻala kēia hui
• warfarin, digoxin, metformin, glipizide - ʻaʻohe hoʻololi i ka pharmacokinetics o pioglitazone,
• ketoconazole - pioglitazone metabolism ua pale ʻia, e like me nā haʻawina in vitro, me kēia hui hui pono e kiaʻi pono ai i ka ʻike o ke koko glucose,
• nā lāʻau lapaʻau antidiabetic ʻē aʻe: ʻaʻohe ʻikepili ma ka hoʻohana ʻana i ka pioglitazone ma ka hoʻohui triple me kēia mau lāʻau.

ʻO nā hui o Pioglar nā: Astrozone, Diab-norm, Piouno, Amalvia, Diaglitazone, Piogli.

Nā loiloi Pioglar

Wahi a nā loiloi, ʻo Pioglar kahi loea hypoglycemic maikaʻi i hoʻohana ʻia no ka mālama ʻana o ka mellitus type type 2, i ka wā monotherapy a me ka hoʻohui pū me nā mea hana hypoglycemic ʻē aʻe, me ka insulin. Hoʻomaopopo nā mea maʻi e hoʻomaikaʻi ka lāʻau lapaʻau i ka kaohi o ka glucose a hoʻonui i ka pale ʻana i nā maʻi i ka insulin, akā ua ʻōlelo kekahi i ka hoʻohana ʻana iā Pioglar wale nō e like me ka ʻōlelo a ke kauka.

Loaʻa nā hemahema o Pioglar i ka hele mai o contraindications a me ka hoʻomohala ʻana o nā hopena ʻokoʻa, ʻoi aku ka nui o ka paona ʻana, ke poʻo, ka ʻulunu.

ʻO ke kumu kūʻai o Pioglar i loko o nā lāʻau lapaʻau

ʻAʻohe ʻike kūpono mau e pili ana i ke kumukūʻai o Pioglar, no ka mea, ʻaʻole i kūʻai ʻia kēia lāʻau lapaʻau i nā hale kūʻai.

Ka hoʻonaʻauao: ʻO ke Kulanui Kauka Kahikole ma Moscow i kapa ʻia ma hope o I.M. Sechenov, hoʻolālā "General Medicine".

Hōʻike nui ʻia ka ʻike e pili ana i ka lāʻau lapaʻau, i hoʻolako ʻia no ka hana ʻike a ʻaʻole hoʻololi i nā ʻōlelo aʻoaʻo. Hoʻopilikia ka lāʻau-pono iā ia ke olakino!

Ke "holo" nei ke koko o ke kanaka ma o nā moku ma lalo o ka pīhoihoi nui a, inā e hoʻokaʻawale ʻia kona kūpaʻa, hiki ke pana i ka 10 mau mika.

ʻOi aku ka ikaika o nā iwi kanaka ʻehā ma mua o ka konihi.

Inā oki ka hana o kou ate, e make ka make i loko o ka lā.

Uaʻoi aku ma mua o $ 500 miliona i kēlā me kēia makahiki nā lāʻau lapaʻau wale nō i ʻAmelika Hui Pū ʻIa. Ke manaʻoʻiʻo nei nei ʻoe i kahi ala e pau ai nā allergy e loaʻa?

Aia nā mea lapaʻau maʻi keu nui loa, e like me ka nānā ʻana o nā mea nānā. Ma ka ʻōpū o kahi mea hoʻomanawanui e loaʻa ana i kēia mania, ua loaʻa nā mea 2500 mau mea ʻē.

I 5% o nā mea maʻi, ʻo ka clomipramine antidepressant e hōʻeha i kahi orgasm.

Me ka kipa pinepine ʻana i ka moena maka, hiki i ka manawa o ka loaʻa ʻana o ka maʻi maʻi kino e hoʻonui ʻia e 60%.

I ka wā hake, hoʻopau kā mākou kino i ka hana. Holo ka naʻau.

Inā ʻoe e minoʻaka a ʻelua wale i ka lā, hiki iā ʻoe ke hoʻohaʻahaʻa i ke koko a hōʻemi i ka hopena o nā hōʻeha o ka naʻau a me nā kī.

Wahi a nā helu helu, ma Lāpule, piʻi ka nui o nā hōʻeha o hope i ka 25%, a me ka hopena o ka hōʻeha ʻana o ka puʻuwai - ma ka 33%. E makaʻala.

Wahi a WHO noiʻi, ʻo ke kūkākūkā o kēlā me kēia hola i kēlā me kēia hola kelepona i hoʻonui ʻia i ka ulu ʻana o ka ulu ʻana o ka lolo ma o 40%.

ʻO James Harrison kahi kanaka 74 o kāna makahiki o Australia, ua lilo ia i mea honi koko ma kahi o 1,000 mau manawa. Loaʻa iā ia kekahi ʻano koko nui, nā antibodies o nā mea kōkua i nā pēpē hou me ke anemia koʻikoʻi. No laila, ua mālama ʻo Australia i kahi miliona miliona keiki.

ʻAʻole loaʻa nā manamana lima pilikino wale nō, akā he ʻōlelo nō hoʻi.

ʻO ka mea ma mua, ʻo ia ka hana ʻana i ke kino me ka oxygen. Akā, ua kolohe ʻole kēia ʻike. Ua hōʻoia nā ʻepekemaʻepekema i ka yawning, hoʻokaʻawale kahi kanaka i ka lolo a hoʻomaikaʻi i ka hana ʻana.

Ua hana ʻia ka vibrator mua i ka kenekulia 19. Ua hana ʻo ia ma ka mokuahi kahi i manaʻo ʻia no ka mālama ʻana i ka hysteria wahine.

ʻO ka nalu mua o ka pua e hele mai ana i kahi hopena, akā e hoʻohuli ʻia nā lāʻau pua i nā mauʻu mai ka hoʻomaka ʻana o Iune, ʻo ia ka mea e hoʻopilikia ai i nā maʻi āpau.

Lapaʻau

Hoʻowaliwaleʻi maikaʻi ia i nā receptors gamma i hoʻoneʻe ʻia e ka proliferator peroxisome (gamma PPAR). Hoʻololi ia i ka hoʻohalike o nā genes e pili ana i ka insulin a komo i ka kaohi o ke kūpaʻa o ka glucose a me ka lipid metabolism i loko o ka adipose, ka mōʻīpū a me nā puʻupaʻa. ʻAʻole ia e hoʻoulu i ka ulu o ka insulin, eia nō naʻe, ke hoʻoikaika nei ia i ka wā e mālama ʻia ka hana o ka insulin-synthetic o ka pancreas. Hoʻēmi i ka pale ʻana o ka insulin i nā kiko peripheral a me ka leʻa, hoʻonui i ka ʻai o nā glucose i hilinaʻi ʻia o ka insulin, e hōʻemi ana i ka pae o ka glucose mai ka ate, e hoʻoneʻe ana i ka pae o ka glucose, insulin a me ka hemoglobin glycosylated i loko o ke koko. I nā mea maʻi me ka protein metabolism maʻi ʻole, e hōʻemi ana ia i ka triglycerides a hoʻonui i ka HDL me ka ʻole o ka hoʻololi ʻana o ka LDL a me ka kolamu holoʻokoʻa.

Ma nā hoʻokolohua hoʻokolohua, ʻaʻohe ona ka maʻi carcinogenic a me nā mutagenic. Ke hoʻolako ʻia i nā lā wahine a me nā kāne a i ka 40 mg / kg / lā, pioglitazone (ʻo 9 mau manawa he kiʻekiʻe ma mua o ka MPDC, ma nā ʻōlelo o 1 m 2 o ka ʻōpū o ke kino) ʻaʻole ʻike ka hopena ma ka huaʻai.

Kuhi ʻia i ke koko 30 min ma hope o ka hoʻokūkū waha, C_max Loaʻa ma hope o 2 mau hola_max ua hoʻopaʻa ʻia ma hope o 3-4 mau hola), ʻaʻole naʻe i pili i ka hoʻopau ʻana. Hoʻohālikelike ia i nā protein plasma koko, ʻoi loa me ka albumin, ma mua o 99%. ʻO ka awelika helu hoʻoili helu he 0.63 l / kg. Ke hoʻomau nei ke koʻikoʻi nui i ke koko no nā hola 24 ma hope o hoʻokahi paona. T_1/2 ka manawa 3-7 (pioglitazone) a me 16-24 mau hola (metabolites). Hoʻomili ʻia ia i ka puʻuwai me ke komo ʻana o ka cytochrome P450 me ka hoʻokumu ʻana o ʻelua mau metabolite ikaika, ka hui like me ka glucuronic a me ka waikawa sulfuric. Hoʻokuʻu ʻia ia i loko o ka bile i loli ʻole a ma ke ʻano o nā metabolites, a hoʻoulu ʻia mai ke kino me nā feces a me ka urine (15-30%). ʻO ka hoʻomaʻemaʻe i kaʻeleʻele he 5-7 l / h.

Hoʻohui

ʻO nā hua o ka sulfonamides, metformin a me ka potentiate insulin (kūoʻi) hypoglycemia. Hiki i nā nāwaliwali o ka hopena o ka hopena o ka waha.

ʻAʻole i hana ʻia ka haʻawina ʻo Pharmacokinetic ma ka hoʻohana ʻana i ka pioglitazone a me nā kūmole waha. ʻO ka hoʻohana ʻana o nā thiazolidinediones ʻē aʻe me ka hana o ka waha e loaʻa ana i ka etinyl estradiol a i ʻole norethindrone i ukali ʻia me ka hoʻokaʻawale ʻana o ka 30% o nā ʻaina o nā lua i ka plasma, hiki iā ia ke alakaʻi i ka nui o ka hopena o ka hopena. No laila, e hana pono ka akahele i ka hoʻohana ʻana i ka pioglitazone a me nā mea hoʻohālikelike waha.

Hoʻopili pū me nā Induct CYP2C8

Hiki i nā mea hoʻohālikelike o ka CYP2C8 isoenzyme o ka cytochrome P450 (e.g. rifampicin) hiki ke hoʻemi nui i ka pioglitazone AUC. No laila, i ka hoʻomaka a i ka hoʻopau ʻana o ka hopena me ka inducers CYP2C8, pono paha ka hoʻoponopono ʻana o ka pioglitazone.

Pākuʻi no ka waiwai Pioglitazone

Me ka mālama aka, ua kuhikuhi ʻia nā mea maʻi me ka edema a me ka hoʻonui ʻana i ka nui o ka pae o nā enzyme o ka ate. ʻO ka hoʻomohala ʻana o ka hypoglycemia i ka wā hui hoʻohui pono me ka hoʻokaʻawale ʻana i ka pakanā o ka conphitant sulfonamides a i ʻole insulin. E pale aku i ke kua o ke aloha ʻole, ʻaʻole i koi ʻia ka hoʻoponopono ʻana. Inā hele mai ka jaundice, ua kau ʻia ka mālama ʻana. I ka poʻe maʻi me ka manawa o ke anovulatory i ka manawa premenopausal, hiki i ka komo ke hoʻokomo i ka ovulation a hoʻonui i ka nui o ka hāpai ʻana (e pono ana nā hana contraceptive kūpono).

ʻO ka pilikia o ka hoʻomohala ʻana i ka maʻi kanesa.

ʻO ka hoʻohana ʻana o ka pioglitazone no ka ʻoi aku ma mua o 1 makahiki e pili ana i ka mahuahua o ka hoʻonui ʻana i ka maʻi kanesa.

Ke koho ʻana i ka pioglitazone, pono e ʻike ka mea maʻi i ka hopena o ka hoʻomohala ʻana i ke kanesa pale maʻi a i ʻole ke kuhikuhi ʻana iā ia i ka poʻe maʻi me ka maʻi maʻi maʻi kīnā, e komo pū ana ma kahi moʻolelo ʻohana.
Kuhi ʻia kēia ʻikepili palekana no ka pioglitazone ma nā hualoaʻa o ʻelua mau haʻawina neʻe i ka maʻi ma mua o ka 40 me kahi maʻi maʻi o ka maʻi mellitus.
I loko o ka hoʻopaʻa kālā cohort moʻo he ʻumi makahiki (Ianuali 1997 - ʻApelila 2008) i alakaʻi ʻia i USA, ʻoi aku ka nui o 193,000 mau mea maʻi i hoʻohui. Ua hōʻike ʻia kahi loiloi o ka ʻikepili mai kēia noiʻi i ka wā o ka makahiki, ke kāne wahine, ka uahi ʻana, ka lawe ʻana i nā lāʻau lapaʻau no ka maʻi maʻi a me nā mea ʻē aʻe i ka nui o ka hopena i ka hopena nui o ka hoʻomohala ʻana i ka maʻi palaka i nā maʻi e lawe ana i ka pioglitazone hoʻohālikelike i nā poʻe maʻi ʻole loa. pili (odds ratio OR = 1.2, 95% interval pagsalig CI = 0.9-1.5). Eia nō naʻe, pili ka lōʻihi o ka mālama ʻana me ka pioglitazone (ʻoi aku ma mua o 12 mau mahina) e pili ana i ka hopena o 40% i ka ulu ʻana o ka maʻi pā ʻana o ka maʻi pale (OS = 1.4, 95% CI = 1.03-2.0)
ʻO nā hualoaʻa o kahi noiʻi cohort retrospective i hana ʻia ma Farani (2006-2009), ka mea e pili ana ma kahi o 1,5 miliona mau maʻi me ka maʻi maʻi maʻi, ka hōʻike ʻana i ka nui o ka nui o ka loaʻa ʻana o nā maʻi o ka maʻi puhipuhi me ka nui o ka pioglitazone ma mua o 28 mg (OS = 1.75, 95 % CI = 1.22-2.5) a i ka wā i lawe ʻia ai ma luna o 1 makahiki (OS = 1.34, 95% CI = 1.02-1.75), ʻoi aku ka nui o ka hōʻeha o nā kāne ma mua o nā wahine (OS = 1.28, 95% CI = 1.09-1.51).
Ma muli o ka ʻikepili mai kēia mau noiʻi, ua hoʻokuʻu ʻia ka hoʻohana ʻana o ka pioglitazone ma Farani, a ʻo i Kelemānia ua hoʻomaka ʻia e hoʻomaka i ka therapy pioglitazone i nā maʻi hou.
Pono e paipai ʻia nā mea maʻi o kekahi mau hōʻailona o ka maʻi pale ʻaʻai, e like me hematuria, urination, ʻeha i ka wā urination, ʻeha ma ke kua a i ʻole ʻōpū paha.

Hoʻomākaukau kaʻaila glitazone hou

ʻO nā lāʻau āpau ma ka mākeke, nā pioglitazone wale nō (Aktos, Diab-norm, Pioglar) a me rosiglitazone (Roglit) e kūʻai aku nei i kēia manawa.

ʻO nā lāʻau ʻē aʻe ua haʻalele ʻia ma muli o nā hopena hopena o ka mālama ʻana.

Hoʻom hoʻomākaukau a Thiazolidinedione

ʻO Troglitazone (Rezulin) ka lāʻau o ka hanauna mua o kēia hui. Hoʻomau ʻia ʻo ia mai ke kūʻai aku ʻana, ʻoiai he hopena maikaʻi loa kona hopena i ka ate.

ʻO Rosiglitazone (Avandia) kahi lāʻau lapaʻau hanana kolu i kēia pūʻulu. Ua paʻa i ka hoʻohana ʻia ma ka 2010 (ua pāpā ʻia i loko o ka European Union) ma hope o kona hōʻoia ʻia ʻana e hoʻonui i ka nui o ka maʻi o ka maʻi maʻi.

ʻO ka hana o ka hana pioglitazone

ʻO ka hana o ka pioglitazone e hoʻopili i kahi mea hōʻiliʻili PPAR-gamma kūikawā, aia i ka sela o ka paena. No laila, ʻo ka lāʻau lapaʻau e hoʻopilikia i ka hana o nā pūlima e pili ana i ka hoʻoili ʻana o ka glucose. Pono ka ate, ma lalo o kona mana, e hoʻoulu nui ʻia. I ka manawa like, hoʻonui ka naʻau i ka insulin.

Hoʻopau maoli kēia i nā momona, nā ʻāʻī a me nā pili o ke ake. A laila, aia ka emi o ka wikiwiki o ka glucose glucose glucose a me ka loaʻa o ke kaona glucose postprandial.

Hoʻohana ikaika

Eia kekahi, ua hōʻike ʻia he lāʻau lapaʻau kekahi mau mea pōmaikaʻi hou.

• Hoemi ke koko
• Hoʻopilikia i ka pae o ka cholesterol (hoʻonui i ke alo o ka "cholesterol maikaʻi", ʻo ia hoʻi, HDL, a ʻaʻole e hoʻonui i ka "kino kino" - LDL),
• Mālama i ka hoʻokumu a me ka ulu ʻana o ka atherosclerosis,
• Hoʻemi i ka hōʻeha o ka maʻi naʻau (e.g., hōʻeha ka naʻau, ka ʻoka).

ʻO nā pioglitazone e kuhikuhi ʻia

Hiki ke hoʻohana ʻia Pioglitazone ma ke ʻano he lāʻau ʻai hoʻokahi, i.e. monotherapy. Eia kekahi, inā ʻoe i ka maʻi mellitus type 2, ʻo kou mau loli i ke ola e hāʻawi i nā hopena i manaʻo ʻia a aia nō nā contraindications to metformin, ʻo kona palaka maikaʻi ʻole a me nā hopena hopena paha.

Hiki ke hoʻohana ʻia ka pioglitazone me ka hoʻohui i nā lāʻau antidiabetic e like me ka laʻana, ka acarbose) a me ka metformin inā ʻaʻole i lawe ʻia nā hana ʻē i ka kūleʻa.

Hiki ke hoʻohana ʻia ʻo Pioglitazone me ka insulin, e ʻike pū i nā poʻe e kūleʻa ke kino i ka metformin.

Pehea e lawe ai i ka pioglitazone

Pono ka lāʻau lapaʻau ʻia i hoʻokahi manawa i ka lā, ma ke ʻano, i ka manawa paʻa. Hiki i kēia ke hana ma mua a ma hope o ka ʻai, no ka mea ʻaʻole i pili ka meaʻai i ka hoʻopili ʻana o ka lāʻau. ʻO ka maʻamau, hoʻomaka ka hoʻomaʻamaʻa me ka liʻiliʻi haʻahaʻa. I nā wahi i loaʻa ʻole ka hopena o ka mālama ʻana, hiki ke hoʻonui iki ʻia.

Hoʻohana ʻia ka hopena o ka lāʻau i nā hihia i kahi e pono ai e mālama i ka maʻi diabetes type 2, akā ʻaʻole hiki ke hoʻohana ʻia ka metformin, monotherapy me hoʻokahi lāʻau lapaʻau i ʻae ʻia.

I ka ʻoi aʻe o ka pioglitazone e hōʻemi i ka glycemia postprandial, ka glucose o ka plasma a hoʻopaʻa hou i ka hemoglobin glycated, he hopena hou nō hoʻi ia ma ke kaʻe o ke koko a me ka kolamu koko. Eia kekahi, ʻaʻole ia e hoʻomaka i nā anomalies.

Nā hopena hopena

ʻO nā hopena ʻokoʻa e kū pū me ka terapi pioglitazone e komo ana i loko:

• Hoʻonui ka ʻike wai i loko o ke kino (ʻoi aku ka hoʻohana ʻia me ka insulin)
• I ka hoʻonui ʻia ʻana o ka hana palupalu, kahi i hoʻopiʻi ʻia me nā hōʻeha ʻana,
• ʻO nā maʻi hou o nā mea hanu maʻamau
• ʻO ka loaʻa kālā.
• ʻO ka haunaele hiamoe.
• Polōpiopio.

ʻO ka lawe ʻana i ka lāʻau lapaʻau ka mea e hoʻonui i ka hopena o ka macular edema (ʻo ke ʻano mua ka mea hōʻino i ka acuity ʻike, pono hoʻi e hōʻike koke ʻia i ka ophthalmologist) a me ka hopena o ka hoʻomohala ʻana i ka maʻi maʻi kīnā.

ʻAʻole kēia lāʻau lāʻau i ka hypoglycemia, akā hoʻonui i ka pilikia o kāna hōʻeha inā hoʻohana ʻia me nā lāʻau lapaʻau i loaʻa mai i ka insulin a i ʻole ka sulfonylurea.

ʻLoe a me ke kākele

Pioglitazone (Aktos, Diab-norm, Pioglar) lawe ʻia ma ke kino, 1 ka manawa i kēlā lā i kēia lā, heʻe ʻole ko kahi meaʻai. ʻO ka dosis mua he 15-30 mg, ʻo ka nui loa ma mua o kēlā me kēia lā he 45 mg, a ʻo ka nui loa ma ke ʻano he therapy 30 mg / lā.

Rosiglitazone (Avandia, Roglite) lawe ʻia i 1-2 mau manawa i ka lā, me ke ʻano o ka komo ʻana o ka meaʻai. ʻO ka ma mua mau lā he 4 mg / lā, ʻo ka nui loa ma kēlā me kēia lā he 8 mg, a ʻo ka nui loa ma ke ʻano he hopena ʻo 4 mg / lā.

Nā ʻōkuhi no ka hoʻohana ʻana i ka lāʻau lapaʻau

Hoʻomaopopo wale ka lawelawe ʻana o ka lāʻau lapaʻau ma hope o ke kūkākūkā ʻana me ke kauka hele mai, ka mea i kuhikuhi i ka dosis kūpono, me ka noʻonoʻo ʻana i nā hiʻohiʻona pilikino o ka mea maʻi. Ma ka hihia o ka hoʻohana pono ʻana i ka waiwai Pioglitazone, pono e ʻike pono ʻia nā ʻōkuhi no ka lāʻau lapaʻau e pale aku i nā hoʻopiʻi ʻana.

Hōʻike ʻia ka lāʻau lapaʻau no ka hoʻohana ʻana inā he maʻa ka 15 a hiki i ka 30 mg, a me ke kiʻekiʻe (ma kēlā me kēia lā) he 45 mg. Inā ʻoe e hoʻohui i ka mea me nā lāʻau lapaʻau ʻē aʻe, pono eʻoi aku ka make ma mua o 30 mg. Hoʻomaopopo ʻia ʻo Pioglitazone no ka hoʻohana hoʻokahi ʻana i ka lā.

I ka wā o ka hoʻōla, pono ʻoe e hoʻomau i ka hahai ʻana i ka meaʻai a me ka hoʻomaʻamaʻa. He mea nui loa ia e nānā i ke kiʻekiʻe o ka hemoglobin i ke koko.

Hōʻike ʻia ʻo Pioglitazone me ka mālama kūikawā no ka poʻe maʻi e huehue ana, a loaʻa ka nui i ka nui o nā enzymes. Me ka hoʻomohala ʻana o ka hypoglycemia i ka wā hui hui pono i hoʻemi ʻia ma ka nui o ka dosis o ka insulin a i sulfonamides paha. Inā he jaundice ka mea maʻi, hiki ke hoʻopilikia maikaʻi ʻia i ke kino, no laila e hoʻōki ʻia ka mālama ʻana. ʻO nā mea maʻi e loaʻa ana kahi anovulatory i ka wā premenopausal e pili pono ana i ka wā hāpai, no laila e pono e hoʻohana ʻia ka ʻahaʻā.

ʻO ka lōʻihi o nā lāʻau lapaʻau i hoʻohana ʻia i ka maʻi diabetes, ʻaʻole i palena iki i ka insulin.

Hāʻawi ʻo Pharmacology i kēia lā i kahi ākea o nā pono hana e kōkua i ke hoʻohaʻahaʻa i ke kō i ke kōpaʻa type 2. ʻO kahi ʻāpana koʻikoʻi o lākou he synthesized artificially, as Pioglitazone (Pioglitazone).

Hōʻike, hoʻokuʻu i ke ʻano

Ke hele nei ka lāʻau lapaʻau i kūʻai ʻia i loko o nā pahu pahu pepa o nā papa 3 a i ʻole 10 paha, aia i nā papa he ʻumikūmālua o kahi ʻano puni a me ka ʻulaʻula. Hiki ke kau ʻia ka mea ola i loko o lākou i ka paʻa o 15, 30 a 45 mau mg.

ʻO ka waihona kumu o ka lāʻau, ka pioglitazone hydrochloride, e hōʻemi ana i ka hoʻowalewale ʻana o ka ate a me nā ʻōpala i ka hana o ka hormone, ma muli o ka nui o ka hōʻila o ka glucose, e māhuahua, a me ka hoʻoneʻe ʻana i ka ate i ka emi ʻana.

ʻO kaʻoi aʻe i ka mea nui, aia nā papa i nā māhele hoʻohui aʻe:

• laktosa lactose,
• konekena stearate,
• hydroxypropyl cellulose,
• kalepuleta carboxymethyl cellulose.

Ka hana lāʻau lapaʻau

ʻO Pioglitazone e pili ana i nā huila hypoglycemic waha e pili ana i ka thiazolidindine. Hoʻokomo ʻia ka waiwai i ka kaohi o ke koko me ka lipid metabolism. ʻO ka hōʻemi ʻana i ka pale o nā kola o ke kino a me ka lewa i ka insulin, e alakaʻi ana i ka hoʻonui ʻana o ka hoʻonui ʻia ʻana o ka glucose ka hilinaʻi o ka insulin a me ka hoʻemi ʻana i nā mea hoʻihoʻi mai ka ate.

Eia naʻe, ʻaʻole ia e hoʻolaha i ka hoʻoulu hou ʻana o nā β-cell o ka pancreas, kahi e mālama ai iā lākou mai ka wikiwiki. ʻO ka hopena o ka lāʻau i ka maʻi type 2 e alakaʻi i kahi hāʻule o ke kō o ke glucose a me ka hemoglobin glycosylated. Hiki i ka huahana ke hoʻohana wale ʻia a i ʻole me ka hoʻohui pū ʻana me nā lāʻau lapaʻau haʻahaʻa.

Ke kōkua nei ka hoʻohana ʻana i ka lāʻau lapaʻau e hoʻomaʻamaʻa i ka hana lipid metabolism, ke alakaʻi nei i ka hōʻemi o nā pae a me ka hoʻonui o HDL me ka hoʻopiʻi ʻole ʻana i ka kolamu a me LDL.

Nā hōʻailona a me nā contraindications

Kuhi ʻia ʻo Pioglitazone e like me ke ʻano o ka kaohi ʻana i ka maʻi diabetes 2 ʻano. Hiki ke hoʻohana ia e like me ka lāʻau hoʻokahi, ʻo ia ka mea i hōʻike pinepine ʻia i ka poʻe maʻi maʻi pākaha i keu nui a i ke kuhi ʻia hoʻi o Metformin.

ʻOi aku ka ikaika, hoʻohana ʻia ka lāʻau lapaʻau i loko o ka ʻoihana paʻakikī i nā kiʻi e hiki mai nei.

• hui pū pālua me nā metformin a i ʻole ka hopena sulfonylurea,
• triple hui pū me nā hui ʻelua o nā lāʻau

E like me nā contraindications:

• ka mālamalama nui loa i kekahi ʻāpana o ka lāʻau,
• ka mōʻaukala o nā ala cardiovascular,
• naakou o ka pili luhi,
• maʻi diabetes type 1
• maʻi maʻamau ketoacidosis,
• ka loaʻa ʻana o nā maʻi maʻi
• ka loaʻa ʻana o ka hemro macroscopic o ka kumu maopopo ʻole.

I kēia mau hihia, ua hoʻololi ʻia ka lāʻau lapaʻau me nā analogue e loaʻa kahi ʻano like a me ka hana o ka hana.

Nā Noi a me nā Kūlana Kūʻai

No nā poʻe kahiko, ʻaʻohe mau koi kūikawā dosage. Hoʻomaka pū kekahi me kahi liʻiliʻi, e hoʻonui mālie.

I ka wā hapai, ʻaʻole i ʻae ʻia ka lāʻau lapaʻau no ka hoʻohana ʻana, ʻaʻole i maopopo loa kona hopena i ka ʻōpio, no laila ua paʻakikī ke wānana i nā hopena. I ka wā lactation, inā pono ka wahine i ka hoʻohana ʻana i kēia lāʻau lapaʻau, pono ʻo ia e hōʻole i ka hānai i ka pēpē.

ʻO nā mea maʻi me nā maʻi o ka puʻuwai a me nā moku koko ke hoʻohana i ka palena liʻiliʻi loa, ʻoiai he mea pono ke nānā i ke kūlana o nā pilikia pilikia i ka wā o ka hoʻokele ʻana o Pioglitazone.

ʻO ka lawe ʻana iā Pioglitazone hiki ke hoʻonui i ka hōʻemi o ka hoʻomohala ʻana i ka maʻi kanesa i ka 0,06 pakeneka, e pili ana i ke kauka e hōʻomaʻomaʻi i ka mea maʻi a ʻōlelo i ka hoʻemi ʻana i nā mea pilikia ʻē aʻe.

No nā poʻe maʻi me ka hikiʻole o ka puʻuwai, ua contraindicated ka lāʻau, a me ka hōʻemi ʻeha, hiki ke hoʻohana me ka mālama aka. I kēia hihia, pono ia e hoʻomalu i ka pae o nā enzyme o ka ate, inā ʻoi aku lākou i kēlā me kēiaʻano i ʻekolu mau manawa, ua hoʻopau ʻia ka lāʻau lapaʻau.

Video e pili ana i nā hopena o nā lāʻau lapaʻau maʻi ma ke kino:

ʻO ka hoʻomākaukau ʻana i kahi hana like

Hāʻawi ʻia nā analogs Pioglitazone ma luna o ka mākeke me ka nui o nā meaʻokoʻa.

ʻO nā mea hana e like me ka hoʻolālā like ʻana:

• ʻO Pioglar ka lāʻau Inia,
• Nā Lūkini Lūkini o Diaglitazone, Astrozone, Diab-Norm,
• Papa ʻ Actlelo Laws,
• Kelemania hoʻomaʻemaʻe ʻo Amalvia,
• Pioglite
• ʻO Piouno a me nā mea ʻē aʻe.

ʻO kēia mau lāʻau āpau e pili ana i ka pūʻulu o ka hoʻomākaukau glitazone, ka mea pū me ka troglitazone a me ka rosiglitazone, kahi ʻano hana like ʻole, akā ʻokoʻa i ka ʻano kemika, no laila hiki ke hoʻohana ʻia inā hōʻole ʻia ka pioglitazone e ke kino. Loaʻa iā lākou kekahi pono ponoʻī a me nā mea e pono ai, i hiki ke loaʻa i nā ʻōlelo i nā lāʻau lapaʻau.

Eia kekahi, nā analogues e loaʻa i kahi waihona ʻokoʻa e hiki ke lawelawe e like me nā analogues: Glucofage, Siofor, Bagomet, NovoFormin.

He mea pono ia e like me nā ʻokoʻa o nā loiloi o nā poʻe maʻi i hoʻohana iā Pioglitazone a me kāna mau ʻano. No laila, e pili ana i ka lāʻau lapaʻau ponoʻī, pane nā mea maʻi i ka maikaʻi loa, e loaʻa ana i nā mea liʻiliʻi loa.

Hoʻomaʻamaʻa pinepine ʻia nā ʻike analogues me nā hopena maikaʻi ʻole, e like me ka paona ʻana, edema, ka palena hemoglobin.

E like me ka hōʻike ʻana, hōʻike pono ka lāʻau lapaʻau i ka hōʻemi o nā pae gula a hiki ke hoʻohana maikaʻi ʻia i ka mālama ʻana i ka maʻi diabetes 2 ʻano. Eia nō naʻe, he mea nui e koho i ke ʻano kūpono o ka lāʻau lapaʻau a me keʻano.

ʻO nā kumukūʻai maoli

Mai ka hiki ke hua ʻia ka hāmeʻa ma lalo o nā inoa like ʻole, e pili ana i ka mea hana, ʻano nui ka nui o kāna kumukūʻai. Kuhi o Pioglitazone i loko o nā lāʻau lapaʻau ʻokoʻa i kona ʻano maʻa he pilikia, hana ʻia ma ke ʻano o ka lāʻau me nā inoa ʻē aʻe.Loaʻa ʻia ma lalo o ka inoa ʻo Pioglitazone Asset, ke kumukūʻai o ke ana ma ke ʻano o 45 mg ka 2 mano rubles.

E kūʻai ʻo Pioglar i ka 600 a me kekahi mau rubles no 30 mau papa me ka nui o ka 15 mg a me ka liʻiliʻi o ke kumukūʻai ma mua o hoʻokahi kaukani no ka huina like me ka nui o ka 30 mg.

ʻO ke kumukūʻai o Aktos, ma nā ʻōlelo i kuhikuhi ʻia i kēia mau ʻano hana like, mai kēlā me kēia 800 a me 3000 rubles.

E kūʻai aku ʻo Amalvia i ka 900 rubles no kahi laʻa o 30 mg, a me Diaglitazone - mai 300 mau rubles no kahi maʻi o 15 mg.

ʻO ka holomua lāʻau lapaʻau hou e hiki i ka mea e hiki ai ke loaʻa i nā hopena i ʻoi aku ka nui o ka nānā ʻana a me ka hoʻoponopono ʻana i ke kō. ʻO ka hoʻohana ʻana i nā lāʻau lapaʻau hou e hiki ke hoʻokō me kēia a me ka maikaʻi, ʻoiai ʻaʻole lākou me ka loaʻa ʻole o ka drawback, kahi āu e ʻike pono ai ma mua o ka hoʻomaka ʻana o ka lāʻau lapaʻau.