🦋 Flashcards
Which anticonvulsive requires therapeutic monitoring of phenobarbital serum levels in addition to its own?
A- Carbamazepine B- Clonazepam C- Ethosuximide D- Phenytoin E- Primidone
E- Primidone
Which anticonvulsive is most likely to cause kidney stones?
Topiramate
Which antiepileptics are likely to cause hyponatraemia?
Carbamazepine
Eslicarbamazepine
Oxcarbamazepine
Sodium valproate
If patient reports a sore throat after carbimazole use, what blood test should be ordered?
Neutrophil count
Reasons to stop HRT therapy for further investigation
Severe abdominal pain
Swelling or pain in calf muscle
Sudden breathlessness
Prolonged headache
Counselling advice for GTN tablets
If symptoms don’t resolve after 3 doses, call an ambulance
May be used as prophylaxis before exercise
Discard 8 weeks after opening
Throbbing headache and flushing are common side effects
Aqueous creams
Aqueous creams as leave-on emollients may increase the risk of skin reactions
Who is the prophylaxis of meningococcal disease indicated for?
Those with prolonged close contact with a case of meningococcal disease
- during the 7 days before onset of disease
- if they had transient close contact and have been directly exposed to large respiratory droplets/secretions around the time of hospital admission
Appropriate antibiotic therapy for patient presenting with cut on arm. The wound is oozing yellow and crusty with localised erythema.
Flucloxacilin 500mg QDS for 7 days
Which lab test would confirm if a patient is suffering from a hypersensitivity reaction?
FBC and differential
At risk groups for seasonal influenza vaccines
Respiratory conditions- asthma (needing steroid inhaler or tabs), COPD (including emphysema and bronchitis)
Diabetes
Heart conditions
Being very overweight- BMI of 40 or above
CKD
Liver disease e.g. hepatitis
Neurological conditions e.g. Parkinson’s, MS
Learning disability
Problems with the spleen e.g. spleen removal or sickle cell disease
Weakened immune system e.g. due to AIDS or HIV or taking steroid tabs or chemo
How is the absolute bioavailability of a drug given as an oral extended release tablet determined?
By comparing it to the bioavailability of the parenteral solution of the drug given as IV bolus or IV infusion
What drug can cause weight loss, tachycardia and waking through the night due to stress?
Levothyroxine
How long should a child with measles stay off school from when the symptoms first appear?
4 days
Complications of measles
1 in 20 people experience ear infections
Other complications: Bronchitis Convulsions Pneumonia Encephalitis
MMR vaccine
May be administered by IM or SC injection.
Administered at 12 months, then a booster shot is given 3 years later.
May be given to children that have had a previous anaphylactic reaction to eggs.
Patients of Chinese ethinicity are at greatest risk for genetic polymorphisms in which CYP50 isoenzyme?
CYPD2D6
How long can doxycycline be used for the prophylaxis of malaria?
2 years
Diethyltoluamide (DEET) 20-50% in lotions, sprays, or roll-on formulations is safe and effective when applied to the skin of adults and children over 2 months of age. True or False?
True
Diethyltoluamide (DEET) 20-50% cannot be used during pregnancy and breast-feeding. True or False?
False
When sunscreen is needed in addition to DEET, DEET should be applied after the sunscreen. DEET reduces the SPF of sunscreen so a sunscreen should also be applied.
Mosquito nets impregnated with permethrin provide the most effective barrier protection against insects. Mats and vaporised insecticides are also useful.
If 24 month old baby has oral thrush, what OTC product can be given?
Daktarin oral gel
Suitable for aged 4 months and over.
Which inhaler is a LAMA that is effective for the management of COPD, but cannot be used for relief of acute bronchospasm?
Spiriva (tiotropium)
The CHM has advised that this inhaler should be introduced at a low dose and the effect properly monitored prior to dose increase.
Serevent (salmeterol)
Which inhaler provide short term relief in mild COPD. Its maximal effect occurs 30-60 mins after use.
Atrovent (Ipratropium)
What are symptoms of reactivation of latent TB?
Breathlessness, night sweats, fatigue and weight loss.
Anti-TNF therapies- esp. monoclonal antibody preparations- e.g. infliximab are associated with risk of reactivating TB. This usually occurs within 3-6 months of commencing infliximab.
What is the antibiotic used to treat pneumonia that is caused by Pneumocystis jirovecii (Pneumocystis carinii)?
Co-trimoxazole (can also be used prophylactically)
If CI, then atovaquone
Which antibiotic should not be given with isotretinoin?
Doxycycline
Isotretinoin increases the risk of benign intracranial hypertension when given with doxycycline.
Which drug can increase the likelihood of thrush and UTI episodes to occur?
Dapagliflozin
Which antidiabetic drug can increase the risk of lactic acidosis?
Metformin
Which drug can help with insulin resistance as it works by increasing insulin utilisation in the body, thereby helping her lose weight and reduce her insulin dose?
Metformin
Which antidiabetic drug should be avoided in chronic heart failure?
Pioglitazone
What use of amitriptyline is off-license?
Neuropathic pain
Which opioid is less suitable for prescribing?
Kaolin and Morphine Mixture, BP (Kaolin and Morphine Oral Suspension) is less suitable for prescribing.
Fluoxetine 10mg tablets
Unlicensed
Symptoms of mumps
Swelling of the parotid glands headache joint pain feeling sick dry mouth mild abdominal pain feeling tired loss of appetite a high temperature (fever) of 38C or above
Which antimuscarininc bronchodilators is licensed for twice daily use?
Aclidinium bromide
What are signs of anaphylaxis?
Difficulty breathing
Dizziness
Pale skin
Swelling of tongue
Questions to ask patient who comes in with primary dysmenorrhoea (period pain)
Age
Nature of pain
Onset of pain
Severity of pain
Pseudoephedrine
Dose: ONE tablet every 4-6hrs upto 4 times a day
It is licensed from 12 years old
It can cause sleep disturbances
Can be used in the manufacture of crystal methamphetamine
Each tablet has a strength of 60mg. Max OTC sale of 720mg (12 tabs).
Dioralyte sachets
Dissolve in 200ml of fresh water or freshly boiled and cooled water
Discard an hour after it’s been made up, or after 24 hours if kept in the fridge
Can be given to 3 months old and over
Dose: One sachet after each loose stool, can take upto 5 sachets in 24 hours.
What dose of paracetamol should be given to a 26 month old toddler?
7.5ml QDS PRN
What time gap would you recommend between hypromellose and lacrilube eye drops?
5 minutes
Which inhaler has a dose indicator that changes colour from green to red to show that the dose had been inhaled correctly?
Genuair
Which inhaler does not have a dose counter?
Easi-breathe
Preparations that do NOT contain which sugars can be classed as sugar free?
Fructose, glucose and sucrose
What is the mechanism of action of EllaOne?
Primary mechanism for ellaOne is inhibition or delay of ovulation
Driving and diabetes
Check your blood glucose no longer than 2 hours before driving
Check your blood every 2 hours if you’re on a long journey
Travel with sugary snacks and snacks with long-lasting carbs, like a cereal bar or banana
If you feel your levels are low:
Stop the car when it’s safe
Remove the keys from the ignition
Get out of the driver’s seat
Check your blood glucose and treat your hypo
Do not drive for 45 minutes after you start to feel better
What can the dispensing technician do before the RP comes into work?
DIspense prescriptions
What are referral points to a Dr for a patient who may have piles?
Sharp stabbing pain on defecation
Blood mixed in the stools, giving them a tarry red or black appearance
Symptoms present after 1 week OTC treatment
Haemorrhoid symptoms with nausea and vomiting
Side effects of Buscopan (hyoscine butylbromide)
Pupil Dilatation Dry mouth Urinary retention Constipation Blurred vision
Symptoms of digoxin toxicity
Diarrhoea Nausea Palpitations Blurred vision Yellow vision
Digoxin toxicity
Most common trigger: hypokalemia, which may occur as a result of diuretic therapy. Dosing errors are also a common cause of toxicity in the younger population.
Factors that increase the risk of digoxin toxicity include: Hypothyroidism/hyperthyroidism.
How long should a thermometer be placed under the tongue for an accurate oral temperature?
3-4 minutes
Cause of warts and veruccas
Infection of the skin with the human papilloma virus (HPV).
Treatment of warts/veruccas
Topical salicylic acid (15-50%) should be applied daily for up to 12 weeks
Cryotherapy with liquid nitrogen can be carried out for a maximum of 6 treatments
Without any treatment warts and verrucae may spontaneously resolve within two years.
What age group have the highest incidence of warts and veruccas?
16-18 year age group
How long do you have immunity from the Yellow Fever vaccine before requiring re-vaccination?
10 years
Which drug requires referral to hospital immediately if there is any redness, pain or swelling of the leg?
Tamoxifen
What parameter should be monitored 2 weeks after commencing Fluoxetine?
Assessment for signs of suicidal ideation
What is the MHRA alert on SSRIs?
Small increased risk of postpartum haemorrhage when used in the month before delivery
There is a small increased risk of congenital heart defects when taken during early pregnancy. If used during the third trimester there is a risk of neonatal withdrawal symptoms, and persistent pulmonary hypertension in the newborn has been reported.
Common symptoms of abrupt withdrawal of SSRIs
Gastro-intestinal disturbances Headache Anxiety Dizziness Paraesthesia Electric shock sensation in the head, neck, and spine Tinnitus Sleep disturbances Fatigue Influenza-like symptoms Sweating
Within how long can antidepressant withdrawal occur?
Within 5 days of stopping treatment.
The risk of withdrawal symptoms is increased if the antidepressant is stopped suddenly after regular administration for 8 weeks or more.
Which is the best research methodology for making evidence based clinical decisions, according to the Cochrane Collaboration?
Meta-analysis studies
Benzoyl peroxide
Adults and children over 12 years old
Takes around 4 weeks to start working
Not suitable for very bad acne with nodules (large, hard lumps that build up beneath the surface of the skin and can be painful) or cysts (large, pus-filled lumps that look similar to boils).
Can bleach or discolour your hair, as well as clothes, towels and bedding. Keep it away from hair and coloured fabrics.
Try to avoid strong sunlight while using benzoyl peroxide gel, wear sunscreen.
What can cause neutropenia in a patient?
Viral infection
Patient presents with scalp ringworm
If a pet is the source of the fungal infection, then it should be assessed and treated by a vet
What requires urgent referral in people with dyspepsia?
Iron deficiency anaemia
Advice with the COC
Blood pressure may increase
Studies also show that it decreases risk of ovarian and womb cancer, but can increase the risk of breast cancer
If a patient presents with sneezing, rhinorrhoea, congestion and itch and watery, red eyes, what medicine could help to relieve their symptoms?
Nasal beclometasone
Reporting your concerns
The Public Disclosure Act exists to protect you should you raise a concern
Failure to disclose concerns may constitute a failure of your own fitness to practice
You should keep a personal record of the concerns you have and who you have raised
them with
You should try to maintain confidentiality where appropriate when raising concerns
Handling of waste medicines returned to pharmacies in England
Liquid waste should not be decanted into a waste container
Waste should not be stored for longer than three months
All waste must be stored in a designated area away from medicines that are fit for use
No more than 5 cubic meters of hazardous waste can be stored at any one time
A prescription for a Veterinary Medicinal
Product (VMP) which is also a Schedule 2 Controlled Drug must be written on a Standardised Controlled drug form. True or False?
False
Advanced services provided by community pharmacies
Stoma Appliance Customisation
New Medicines Service
Flu Vaccination
Medicines Use Review
Drug Driving code
The new offence covers blood levels of specific medicines classified as Controlled Drugs in the body.
Drivers can invoke a specific defence, which covers Controlled Drugs taken in accordance with medical advice.
A separate offence exists of driving while impaired through drugs – and this applies to driving while impaired by any type of drug.
Cannabis is an example of a drug covered by the new legislation
According to the new Drug Driving offence legislation, the police DO NOT need to prove impairment case-by-case where a specified drug has been detected above the specified limit.
The contactable pharmacist may be the contactable pharmacist for more than one
pharmacy at the same time. True or False?
True
What can staff do while the RP is not physically present on the premises?
Accuracy checking
Concomitant use of clozapine and co-trimoxazole may result in what?
Bone marrow suppression
What medication is there legislation for that prohibits you from administering the medicine without instruction from an appropriate practitioner?
Soluble Insulin 100units/mL injection
Not legislation is required for: Diazepam 10mg/2. 5mL rectal solution Salbutamol 100mcg inhaler Adrenaline 1mg/mL injection Midazolam 5mg/mL buccal solution
Pharmacy record
RP must ensure it’s correctly mainained
Electronic copy must be kept for 5 days from the date it was first created
All pharmacy staff have the right to view this record
An entry can be made remotely as long as it fulfils all legal requirements.
CPDs
A minimum of nine relevant entries per year must be made
CPD entries can be stored securely online
CPD requirements apply equally to all pharmacy professionals
Handwritten records must be written in an approved format
What electrolyte imbalance can indapamide cause?
Hypomagnesaemia
Hypokalaemia
Hyponatraemia
Hypokalaemia is dangerous in severe cardiovascular disease and in patients also being treated with cardiac glycosides.
In hepatic impairment, hypokalaemia caused by diuretics can precipitate encephalopathy.
Why should thiazides and thiazide-like diuretics not be used to treat gestational diabetes?
May cause neonatal thrombocytopenia, bone marrow suppression, jaundice, electrolyte disturbances, and hypoglycaemia; placental perfusion may also be reduced. Stimulation of labour, uterine inertia, and meconium staining have also been reported.
To identify signs of agranulocytosis or neutropenia in patients taking clozapine, how often should this particular patient have his blood counts monitored?
Weekly leucocyte and differential blood counts for 18 weeks, then at least every 2 weeks and if clozapine continued and blood count stable after 1 year at least every 4 weeks (and 4 weeks after discontinuation)
If leucocyte count below 3000 /mm3 or if absolute neutrophil count below 1500 /mm3 discontinue permanently and refer to haematologist.
Patients who have a low white blood cell count because of benign ethnic neutropenia may be started on clozapine with the agreement of a haematologist.
In addition to agranulocytosis or neutropenia, what other adverse effects can occur?
Fatal myocarditis (most commonly in first 2 months) and cardiomyopathy reported. Persistent tachycardia especially in first 2 months should prompt observation for other indicators for myocarditis or cardiomyopathy.
Impairment of intestinal peristalsis, including constipation, intestinal obstruction, faecal impaction, and paralytic ileus, (including fatal cases) reported.
Clozapine dose adjustment
Clozapine dose adjustment might be necessary if smoking started or stopped during treatment.
Monitoring for clozapine
Monitor prolactin concentration at the start of therapy, at 6 months, and then yearly.
Annual cardiovascular health monitoring
Monitor leucocyte and neutrophil count
Blood lipids and weight should be measured at baseline, every 3 months for the first year, then yearly.
Fasting blood glucose should be measured at baseline, after one months’ treatment, then every 4–6 months.
Foods to avoid with MAOIs e.g. phenelzine
Potentially life-threatening hypertensive crisis can develop in those taking MAOIs who eat tyramine-rich food (such as mature cheese, salami, pickled herring, Bovril®, Oxo®, Marmite® or any similar meat or yeast extract or fermented soya bean extract, and some beers, lagers or wines) or foods containing dopa (such as broad bean pods).
Avoid tyramine-rich or dopa-rich food or drinks with, or for 2 to 3 weeks after stopping, the MAOI.
What treatment would be considered for a 10 year old with major depression?
Fluoxetine
Which sulphonylurea carries the greatest risk of hypoglycaemia, so should be avoided in the elderly?
Gilbenclamide
Reasons to stop combined hormonal contraceptive
An unusual, severe, prolonged headache
Unexplained swelling of calf in one leg
Severe stomach pain
Sudden breathlessness
Adrenaline injection advice
If you still feel unwell after the first injection, use a second injector 5 to 15 minutes after
the first.
An ambulance should be called after each administration.
The individual should lie down with their legs raised (unless they have breathing difficulties, in which case they should sit up) and should not be left alone.
Always carry 2 pens with you at all times.
Inject (intramuscularly) into the anterolateral aspect of the middle third of the thigh
Monitoring parameters for antipsychotics
Blood lipids and weight should be measured at baseline, at 3 months (weight should be measured at frequent intervals during the first 3 months), and then yearly with antipsychotic drugs. Patients taking olanzapine require more frequent monitoring of these parameters: every 3 months for the first year, then yearly.
Fasting blood glucose should be measured at baseline, at 4–6 months, and then yearly. Patients taking olanzapine should have fasting blood glucose tested at baseline, after one months’ treatment, then every 4–6 months.
Monitoring with statins
Before starting treatment with statins, at least one full lipid profile (non-fasting) should be measured, triglyceride concentrations, thyroid-stimulating hormone, and renal function should also be assessed.
NICE suggests that liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment.
Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy.
Before initiation of statin treatment, creatine kinase concentration should be measured in patients who have had persistent, generalised, unexplained muscle pain.
If the concentration is more than 5 times the upper limit of normal, a repeat measurement should be taken after 7 days. If it still remains above 5 times, statin treatment should not be started; if concentrations are still raised but less than 5 times the upper limit, the statin should be started at a lower dose.
Patients at high risk of diabetes mellitus should have fasting blood-glucose concentration or HbA1C checked before starting statin treatment, and then repeated after 3 months.
Monitoring for ACE inhibitors
Renal function and electrolytes should be checked before starting ACE inhibitors (or increasing the dose) and monitored during treatment (more frequently if side effects mentioned are present).
Monitoring for sodium valproate
Monitor liver function before therapy and during first 6 months especially in patients most at risk.
Measure full blood count and ensure no undue potential for bleeding before starting and before surgery.
Common side effects of beta blockers
Abdominal discomfort; bradycardia; confusion; depression; diarrhoea; dizziness; dry eye (reversible on discontinuation); dyspnoea; erectile dysfunction; fatigue; headache; heart failure; nausea; paraesthesia; peripheral coldness; peripheral vascular disease; rash (reversible on discontinuation); sleep disorders; syncope; visual impairment; vomiting
Signs of lithium toxicity
Signs of intoxication require withdrawal of treatment and include increasing gastro-intestinal disturbances (vomiting, diarrhoea), visual disturbances, polyuria, muscle weakness, fine tremor increasing to coarse tremor, CNS disturbances (confusion and drowsiness increasing to lack of coordination, restlessness, stupor); abnormal reflexes, myoclonus, incontinence, hypernatraemia.
With severe overdosage seizures, cardiac arrhythmias (including sino-atrial block, bradycardia and first-degree heart block), blood pressure changes, circulatory failure, renal failure, coma and sudden death reported.
What are potential side effects of doxorubicin?
Diarrhoea, dehydration, and red colouration of the urine can commonly occur with this cytotoxic antibiotic
What is the dosing limit for doxorubicin?
Higher cumulative doses are associated with cardiomyopathy and it is usual to limit total cumulative doses to 450 mg/m2 because symptomatic and potentially fatal heart failure is common above this dose.
Which cytotoxic drug can result in progressive pulmonary fibrosis?
Bleomycin
This is dose-related, occurring more commonly at cumulative doses greater than 300 000 units. Basal lung crepitations or suspicious chest C-ray changes are an indication to stop therapy with this drug.
Which analgesic should be voided if at all possible in patients with a history of epilepsy or susceptibility to seizures?
Tramadol
The duration the responsible pharmacist records must be kept for
5 years
The duration that CD requisition forms must be kept for.
2 years
The duration that CD registers must be kept for, following the final entry and issue of a new register.
2 years
Permethrin 5% cream
Apply all over the body including the head (BNF), SPC states to exclude the head
Legal requirements
The AGE of patient on prescription if under 12
For an emergency supply at request of a doctor, the prescription must be
received within 72 hours
Diamorphine is the preferred opioid in palliative care because:
Its greater solubility allows effective doses to be given in a small volume
What is the mechanism of action of canagliflozin?
Canagliflozin reversibly inhibits sodium-glucose cotransporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce glucose
reabsorption and increase urinary glucose excretion.
Why are tetracyclines contraindicated for under 12s?
Deposition of tetracyclines in growing bone and teeth (by binding to calcium) causes
staining and occasionally dental hypoplasia.
Consider stopping use of the suspected drug with all ADRs. True or False?
False.
Only stop use of the suspected drug if the
ADR is serious or at the request of the individual, and avoid its use in future
What counts as a missed pill with combined oral contraceptives?
A missed
pill is one that is 24 or more hours late
Emergency contraception is recommended if 2
or more combined oral contraceptive tablets are missed from the first 7 tablets in a
packet and unprotected intercourse has occurred since finishing the last packet.
What counts as a missed pill for a woman taking Qlaira® [dienogest with estradiol valerate], or Zoely® [Estradiol with nomegestrol]?
12 hours or more late
What to do if you forget to take a progestogen-only contraceptive?
Take it as soon as you remember and take the next pill at the right time. If the pill was more
than 3 hours (12 hours for desogestrel) overdue you are not protected.
Signs and symptoms of hand, foot and mouth disease
Fever, loss of appetite, sore throat, raised spots on mouth, throat and skin and feeling unwell.
After 12 to 36 hours, the red spots develop into yellowy-red ulcers in your mouth, on your tongue and inside your cheeks.
After one to two days, sores may start on hands and feet.
When to refer for hand, foot and mouth disease
Make a GP appointment if symptoms do not resolve in 10 days
What antidiabetic medicine should not be used in patients with a history of bladder cancer?
Pioglitazone
In England, Northern Ireland and Wales, what is the automatic age of screening for bowel cancer?
60 years old
What should you do if a patient taking Madopar has felt an overpowering
urge to buy unnecessary things?
BNF states that review of medication should be sought if worrying psychological changes occur relating to impulse control disorders. So the dose of Madopar may need to be decreased.
What is the definition for morbidity rate?
Refers to the incidence rate of disease within a population
When is the rotavirus vaccine given?
It is given at 8 and 12 weeks of age.
Rotavirus is a common cause of childhood diarrhoea and sickness.
The vaccine is administered orally to young infants.
Which act protects whistleblowers in the workplace to come forward about negligence and other issues?
Disclosure Act 1998
What is a root cause analysis?
A root cause analysis is used to identify all factors that could have contributed to
this error for analysis
When can Buccastem M be given?
Buccastem M (prochlorperazine) is only licensed for nausea and vomiting in previously diagnosed migraine, in adults aged 18 years and over.
Age restrictions for pholcodine 5mg/5mL and dextromethorphan
12 years and over (but pholcodine can be given at 2mg/5ml- Galenphol Paediatric Linctus- from the age of 6)
Age limit for Covonia syrup
1 year and over
Age limit for Beconase nasal spray
P version can be bought OTC but is only suitable for adults aged 18 and over.
Age limit for Cetirizine 5mg/5ml liquid
2 years and over
Pseudoephedrine and phenelzine
Pseudoephedrine would not be appropriate – there is a risk of hypertensive
crisis when pseudoephedrine is given with Monoamine oxidase inhibitors (MAOIs)
avoid pseudoephedrine for at least 2 weeks after stopping MAOI.
Patient taking pioglitazone presenting with vomiting and abdominal pain
Seek immediate medical attention as nausea, vomiting, abdominal pain, fatigue and dark urine may indicate liver toxicity
Methadone and quetiapine
There is an increased risk of ventricular arrhythmias when antipsychotics that prolong the QT interval are given with methadone
Vitamin A in pregnancy
Vitamin A may cause birth defects, women who are (or may become) pregnant are advised not to take vitamin A supplements (including tablets and fish-liver oil drops), except on the advice of a doctor or an antenatal clinic; nor should they eat liver or products such as liver paté or liver sausage.
What is given to prevent haemorrhagic disease of newborns?
All newborn babies should receive vitamin K
to prevent vitamin K deficiency bleeding (previously termed haemorrhagic disease of the newborn)
Pregnancy prescription exemption
While pregnant and for 12 months after
Co-beneldopa
Levodopa helps the Parkinson’s symptoms, benserazide prevents the breakdown of levodopa in other parts of the body
Supply of unlicensed meds
Record must be kept for 5 years
Responsible Pharmacist records
Need to be personally made by the RP themselves
Max oral dose of aspirin
4g
When to take theophylline levels
5 days after starting
4-6 hours after a dose
Naproxen (1 g daily)
Associated with a lower thrombotic risk
Carbimazole
Report sore throat immediately
Folinic acid
Suspected methotrexate overdose
Mebendazole
Not to be used in children under 2 years
CE on licensed devices
Conformite Europeenne
Max number of days for methadone prescriptions
14 days
Rifampicin-simvastatin
Decreased control of hypercholesterolaemia as rifampicin can induce the metabolism of simvastatin
Methotrexate monitoring
Full blood count and renal and liver function tests repeated every 1–2 weeks until therapy stabilised, thereafter patients should be monitored every 2–3 months.
Advise to report all symptoms and signs suggestive of infection, especially sore throat
Leflunomide-warfarin
Leflunomide inhibits the enzyme that metabolises warfarin, leading to bleeding
Prescribing of ciclosporin
Must be brand specific
Side effect of ciclosporin
Hypertension
Interactions with ciclosporin
Pomelo juice is predicted to increase ciclosporin exposure, and purple grape juice is predicted to decrease ciclosporin exposure.
Monitoring for ciclosporin
Liver function, serum potassium (especially in renal dysfunction- risk of hyperkalaemia), serum magnesium, blood lipids before treatment and after the first month of treatment.
Monitor kidney function—dose dependent increase in serum creatinine and urea during first few weeks may necessitate dose reduction in transplant patients
Monitor blood pressure—discontinue if hypertension develops that cannot be controlled by antihypertensives.
In rheumatoid arthritis measure serum creatinine at least twice before treatment. During treatment, monitor serum creatinine every 2 weeks for first 3 months, then every month for a further 3 months, then every 4–8 weeks depending on the stability of the disease, concomitant medication, and concomitant diseases (or more frequently if dose increased or concomitant NSAIDs introduced or increased).
How do advanced services work?
Contractors are paid monthly based on the MURs claimed for
Doxycycline for malaria prophylaxis
100mg daily, starting 2 days before entering area and continuing for 4 weeks after leaving
Monitoring adverse effects of atorvastatin
Alanine transaminase and creatinine kinase
Most people are able to use NRT, including:
Adults and children over 12 years of age – although children under 18 should not use the lozenges without getting medical advice first
Pregnant women
Breastfeeding women
Isoniazid co-therapy with pyridoxine
Pyridoxine hydrochloride should be given prophylactically in all patients from the start of treatment. Peripheral neuropathy is more likely to occur where there are pre-existing risk factors such as diabetes, alcohol dependence, chronic renal failure, pregnancy, malnutrition and HIV infection.
Isoniazid food/drink interactions
Avoid tyramine-rich foods (such as mature cheeses, salami, pickled herring, Bovril®, Oxo®, Marmite® or any similar meat or yeast extract or fermented soya bean extract, and some beers, lagers or wines) or histamine-rich foods (such as very mature cheese or fish from the scromboid family (e.g. tuna, mackerel, salmon)) with isoniazid, as tachycardia, palpitation, hypotension, flushing, headache, dizziness, and sweating reported.
How long do women need to wait after taking ulipristal acetate before starting suitable hormonal contraception?
5 days
One missed contraceptive pill dose
Take the last pill you missed now, even if this means taking 2 pills in 1 day
Carry on taking the rest of the pack as normal
Take your 7-day pill-free break as normal, or if you’re on an everyday (ED) pill, take your dummy (inactive) pills
Two or more missed contraceptive pill doses
Take the last pill you missed now, even if this means taking 2 pills in 1 day
leave any earlier missed pills
carry on taking the rest of the pack as normal
use extra contraception, such as condoms, for the next 7 days
When you come to the end of your pill pack, after missing 2 or more pills:
if there are 7 or more pills left in the pack after the last missed pill – finish the pack, take your 7-day pill-free break as normal, or take your inactive pills before you start your next pack
if there are less than 7 pills left in the pack after the missed pill – finish the pack and start a new pack the next day; this means missing out the pill-free break or not taking your inactive pills
SLS endorsement on Nizoral cream
Nizoral® cream is not prescribable in NHS primary care except for the treatment of seborrhoeic dermatitis and pityriasis versicolor; endorse prescription ‘SLS’.
Contraindications of antimuscarinics
Angle-closure glaucoma; gastro-intestinal obstruction; intestinal atony; myasthenia gravis (but some antimuscarinics may be used to decrease muscarinic side-effects of anticholinesterases); paralytic ileus; pyloric stenosis; severe ulcerative colitis; significant bladder outflow obstruction; toxic megacolon; urinary retention
Quinolones
can prolong the QT interval; conditions that predispose to seizures; diabetes (may affect blood glucose); exposure to excessive sunlight and UV radiation should be avoided during treatment and for 48 hours after stopping treatment; G6PD deficiency; history of epilepsy; myasthenia gravis (risk of exacerbation); psychiatric disorders
Lithium-ramipril
Ramipril is predicted to increase the concentration of lithium.
Acid reflux OTC treatment in pregnancy
Gaviscon Advance
Age for OTC cystitis treatment
16 to 65 (not including 65)
Meningitis symptoms
The first symptoms are usually fever, vomiting, headache and feeling unwell. Limb pain, pale skin, and cold hands and feet often appear earlier than the rash, neck stiffness, dislike of bright lights and confusion.
Lithium toxicity symptoms
Signs of intoxication require withdrawal of treatment and include increasing gastro-intestinal disturbances (vomiting, diarrhoea), visual disturbances, polyuria, muscle weakness, fine tremor increasing to coarse tremor, CNS disturbances (confusion and drowsiness increasing to lack of coordination, restlessness, stupor); abnormal reflexes, myoclonus, incontinence, hypernatraemia.
With severe overdosage seizures, cardiac arrhythmias (including sino-atrial block, bradycardia and first-degree heart block), blood pressure changes, circulatory failure, renal failure, coma and sudden death reported.
GLP-1 agonists prescribing
Only if triple therapy with metformin hydrochloride and two other oral drugs is tried and is not effective
only for patients who have a BMI of 35 kg/m2 or above (adjusted for ethnicity) and who also have specific psychological or medical problems associated with obesity;
or for those who have a BMI lower than 35 kg/m2 but for whom insulin therapy would have significant occupational implications or if the weight loss associated with glucagon-like peptide-1 receptor agonists would benefit other significant obesity-related comorbidities.
After 6 months, the drug should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight).
Eumovate (clobetasone 0.05%)
Moderate potency
Apply BD for max 7 days
GTN SL tabs
Tablets should be discarded after 8 weeks in use
Monitoring of aminosalicylates
Renal function should be monitored before starting an oral aminosalicylate, at 3 months of treatment, and then annually during treatment.
Maintenance dose of rivaroxaban in AF
20mg OD
Treatment of DVT dosing for rivaroxaban
Initially 15 mg twice daily for 21 days, then maintenance 20 mg once daily
Prophylaxis of DVT dosing for rivaroxaban
10mg OD
Post ACS rivaroxaban (in combo with aspirin or aspirin and clopidogrel)
2.5 mg twice daily usual duration 12 months
Common side effects of rivaroxaban
Constipation
Diarrhoea
Headache
Rash
Adrenaline anaphylaxis dose for 1 month-5 years
150 micrograms
Adrenaline anaphylaxis dose for 6-11 years
300 micrograms
Adrenaline anaphylaxis dose for 12-17 years
500 micrograms
Adrenaline anaphylaxis dose for adults
500 micrograms
Recommended injection site for adrenaline injection
Anterolateral aspect of the middle third of the thigh
Which vitamin should be avoided with spironolactone?
Vitamin K
Thalidomide
Thromboprophylaxis is recommended for at least the first 5 months of treatment, especially in patients with additional thrombotic risk factors.
Patients with pre-existing peripheral neuropathy should not be treated with thalidomide unless the potential clinical benefits outweigh the risk.
Thalidomide and women of child-bearing age
A medically supervised pregnancy test should be performed on, or within 3 days prior to, initiation and repeated every 4 weeks thereafter (including 4 weeks after the last dose).
Females of childbearing potential must use effective contraception for at least 4 weeks before, during, and for at least 4 weeks after stopping treatment (including during dose interruptions).
Oral combined hormonal contraceptives and copper-releasing intrauterine devices are not recommended.
Male patients, even after successful vasectomy, must use condoms during treatment (including during dose interruptions) and for at least 1 week after stopping, if their partner is pregnant or is of childbearing potential and not using effective contraception.
Bulk forming laxatives onset of action
Ispaghula husk, methylcellulose and sterculia
2-3 days
Stimulant laxatives onset of action
Bisacodyl, docusate sodium, glycerol, senna, and sodium picosulfate
6-12 hours
Suppositories 15-60 minutes
Faecal softeners onset of action
Liquid paraffin
1-2 days
Liquid paraffin not recommended for use as faecal softener
Can cause anal seepage and irritation, granulomatous reactions caused by absorption of small quantities of liquid paraffin, lipoid pneumonia, and malabsorption of fat-soluble vitamins
Osmotic laxatives onset of action
Lactulose, macrogols and magnesium salts
1-3 days
Pramipexole (dopamine-receptor agonist)
Associated with impulse control disorders, including pathological gambling, binge eating, and hypersexuality.
Risk of postural hypotension (especially on initiation)—monitor blood pressure.
Antiparkinsonian drug therapy should never be stopped abruptly as this carries a small risk of neuroleptic malignant syndrome.
Excessive daytime sleepiness and sudden onset of sleep can occur with dopamine-receptor agonists.
Review of Parkinson’s disease after diagnosis
6-12 months
Formulations fo co-beneldopa
When switching from modified-release levodopa to dispersible co-beneldopa, reduce dose by approximately 30%.
Apomorphine HCL
SC into lower abdomen
Disulfram reaction
Full body rash, feeling and being sick, stomach pain, hot flushes, a pounding heartbeat (palpitations) and a headache
Metronidazole with alcohol
Do not drink alcohol while taking a course of metronidazole tablets, liquid, suppositories or vaginal gel, or for 2 days after finishing treatment
How often should the need for oxybutynin therapy be reviewed?
Every 4-6 weeks until symptoms stabilise then every 6-12 months
Norethisterone dosing
1 tablet TDS
When is the most appropriate time to start taking norethisterone?
3 days before menstruation is due
When is menstruation likely to start after stopping norethisterone?
2-3 days after stopping
Ciprofloxacin-ibuprofen
Increased risk of convulsions
Treatment of clindamycin exceeds 10 days
Monitor renal and liver function
Vancomycin trough conc
15-20 mg/L
Monitoring of vancomycin
renal function, urinalysis and blood counts
Treating hypersalivation
Glycopyrronium bromide
Unlicensed: antimuscarinic drugs (amitriptyline, atropine, benzatropine, trihexyphenidyl hydrochloride, hyoscine hydrobromide)
Beta-blockers
Botulinum toxin
Mefloquine for malaria
Mefloquine is associated with potentially serious neuropsychiatric reactions. Abnormal dreams, insomnia, anxiety, and depression occur commonly. Psychosis, suicidal ideation, and suicide have also been reported. Psychiatric symptoms such as insomnia, nightmares, acute anxiety, depression, restlessness, or confusion should be regarded as potentially prodromal for a more serious event.
Solifenacin-itraconazole
Itraconazole (CYP3A4 inhibitor) is predicted to increase the exposure to solifenacin.
