100 Most Commonly Prescribed Drugs Flashcards
Acetlycystine
Use
Caution
SE
Dose
Precursor of glutathione, detoxifies metabolites of paracetamol
Use in paracetamol OD, look at the graph to determine if needed
Caution in asthma and atopy
SE: allergy - rash, bronchospasm, anaphylaxis if pushed too quick
Dose: if above treatment line at 4hrs or >8hrs post ingestion
Initially 150mg/kg in 200ml 5% glucose over 1 hr
Then 50mg/kg in 500ml over 4hrs
Then 100mg/ kg in 1L over 16hrs
Activated Charcoal
Use
Caution
Dose
Binds and decreases absorption of tablets and poisons
Used in ODs up to 1hr post ingestion (longer if antimuscarinic drugs)
Decreases GI motility so can cause obstruction.
Don’t use if low GCS unless have ET tube (risk of aspiration)
50g PO stat. Repeated doses 4hrly for barbiturates, carbamazepine, phenytoin, digoxin, dapsone, Paraguay, quinine, salicyates, theophylline.
Naloxone
Use
Caution
Dose
Opioid receptor antagonist for opiate reversal if OD to over Rx
Caution if pt has cardiovascular disease, if they are taking cardio toxic drugs or if they have a physical dependence on opioids.
Dose: 0.4-2 mg IV (s/c or IM).
Tramadol may need much larger doses. repeat after 2 mins if not response.
Very short half life so may been evert 2-3 mins, to max of 10mg. then r/v and consider IVI: 10mg with 40ml of %% dextrose, start at 60% of initial dose over 1hr.
Gaviscon
Use
Caution
Dose
Alginate raft-forming oral suspension for acid reflux
Ensure pts are well hydrated especially if elderly, have GI narrowing, or decreased GI motility
Dose: 5-10ml or 1-2 tablets after meals and at bedtime
NB:
- 3mmol Na and 1mmol K in 5ml
- 25mmol Na and 1mmol K in 1 tablet
Hyoscine Butlybromide (buscopan)
Use CI Caution SE Interactions Dose
Antimuscarinic: decreases GI motility (does not cross BBB)
Used to treat smooth muscle spasm - biliary colic, diverticulitis, IBS
CI: closed angle glaucoma, myasthenia gravis, megacolon, increased prostate
Caution in: GI obstruction, urinary retention, tachycardia
SE: antimuscarinic: decrease secretions, drowsiness, confusion
Interactions:
decreases effects of metaclopramide and sublingual nitrates.
increases tachycardic effect of B agonists
Dose: 20mg QDS PO or 20mg IM/IV. max 100mg/day
Hyoscine Hydrobromide
Use CI Caution SE Warnings Interactions Dose
Antimuscarinic - predominantly effects on CNS.
Decreases vestibular activity and respiratory/ oral secretions
Used in: motion sickness, terminal care and chronic bad swallow. unlicensed for hypersalivation secondary to antipsychotics
CI: closed angle glaucoma
Caution in: GI obstruction, urinary retention, CVD, porphyria, Downs syndrome, myasthenia gravis
SE: Antimuscarinic: decresed secretions, sedative
Warning: driving may be impaired
Interactions: decreases effect of sublingual nitrates
Dose: 300micrograms 6-hrly PO (max 3 doses) for motion sickness
0.6-2.4mg/ 24hr s/c infusion for secretions
300 micrograms BD PO with antipsychotics
Atropine
Use CI Caution SE Dose
Muscarinic antagnoist - blocks vagal SAN and AVN, bronchodilates, and decreases oropharyneal secretions
Used in severe bradycardia or heart block, organophosphate/ anticholinesterase OD
CI: closed angle glaucoma, myasthenia gravis, paralytic ileus, pyloric stenosis, bladder neck obstruction
Caution: down’s syndrome, GORD, diarrhoea, UC, acute MI, HTN, increased HR, pyrexia
SE: transient decrease in HR, antimuscarnic symptoms, N&V, confusion, dizziness
Dose: 0.3- 0.6 mg IV for bradycardia, 1-2mg IV every 10-30 mins to a max 100mg in 24hrs for poisoning.
Mebeverine
Use CI Caution SE Dose
Antispasmodic - direct action on GI muscle
Use: GI smooth muscle cramps
CI: ileus,
Caution: porphyria
SE: hypersensitivity, skin reactions
Dose: 135 - 150mg TDS, 20mins before food
Ranitidine
Use
Caution
SE
Dose
H2 antagonist - decreases H+ secretion from parietal cells
Used in peptic ulcer disease and reflux oseophagitis . Can be used along side long term NSAID use
Caution in acute porphyria and all the failures and pregnancy
Side effects are rare but include: GI upset (diarrhoea) dizziness, confusion, fatigue, blurred vision, headache, rash.
V rarely arrhythmias, hypersensitivity and blood disorders
Dose: 150mg BD PO initially (can have 300mg nocte) can increase to 600mg/day.
50mg TDS/QDS IV
Omeprazole
Use Caution SE Interactions Dose
Proton pump inhibitor - inhibits H+/K+ ATPase of parietal cells so decreases the acid secretion
Used in peptic ulcer disease and prevention if on NSAIDs, GORD, H.Plyori eradiction, Zollinger-Ellison syndrome
Caution - can mask symptoms of gastric malignancy,
Side effects include GI upset and headaches most commonly. Also dizziness, arthralgia, weakness and skin reactions.
Rarely hepatoxicity, blood disorders,
Interactions:
Decreases P450 - therefore increases levels of phenytoin, cilostazol, diazepam, raltegravir and digoxin.
Increases effects of warfarin
Dose: 20mg OD PO initially. Can increase to 40mg if severe disease, and decrease to 10mg OD if symptoms stable.
20mg BD for H.pylori eradication
max dose 20mg if liver failure
Can be used for acute GI bleeds.
Lansoprazole
PPI - same as omeprazole
fewer interactions
Dose: 15-30mg OD PO, can decrease to 15mg for maintenance
Loperamide
Use CI Caution SE Dose
Antimotility agent: synthetic opiod analogue. binds to receptors in the GI muscle so decreases peristalisis, increasing transit time and therefore resorption of water
Used in diarrhoea
CI: constipation, ileus, megacolon, bacterial enterocolitis secondary to salmonella, shigella, campylobacter, abdominal distension, active IBD, pseudomembranous colitis.
Caution in the young as can lead to fluid depletion.
SE: constipation, abdominal cramps, bloating, dizziness, drowsiness, fatigue.
Dose: 4mg initially, then 2mg after each loose stool (max 16mg/day for 5 days)
Sulfasalazine
Use CI SE Monitoring Dose
Aminosalicylate - combintation of the immune modulator 5-aminosalicylic acid (5-ASA) and the anti bacterial sulfapyridine
Used in RA, UC,
CI: hypersensitivity, renal failure
SE:GI upset (decreased appetite), hepatotoxicity, blood disorders, hypersensitivity, sezuires, lupus
LFTs, U&Es and FBC need monitoring
Dose: 500mg/day increaseing to a max of 3g/day
Mesalazine is similar but hasfewer side effects. the effects are decreased by lactulose. if used with NSAIDS and azathioprine nephrotoxicity may increase.
Fybogel
Use
CI
Dose
Bulking agent laxative - Ispaghula husk
Used for constipation including IBS
CI: decreased swallow, GI obstruction, faecal impaction, colonic atony
Dose: 1 sachet or 10ml BD after meals with water
Senna
USE CI Caution SE Dose
Stimulant laxative. Takes 8-12 hrs to work
Used for constipation
CI: GI obstruction
Caution in pregancy, try a bulk forming or osmotic first
SE: GI cramps, if used chronically: atonic non functioning colon, hypokalaemia.
Dose: 2 tablets nocte
Lactulose
Use CI Caution SE Dose
Osmotic laxative and decreases the growth of NH4 producing bacteria
Used in constipation and hepatic encephalopathy
CI: GI obstruction, glactosamia
Caution is pt lactose intolerant
SE: flatulence, distension, abdominal pains
Dose: 15ml OD/BD for constipation (can take 2 days to work) and 30-50ml TDS for HE
Movicol is also an osmotic laxative
Digoxin
Use CI Caution SE Monitor Interactions Dose
Cardiac glycoside. Decreases heart rate by slowing down AVN conduction and increasing vagal tone
Used in AF and heart failure
CI in heart block, VF, VT, HOCM, SVTs secondary to WPW
Caution in recent MI, hypokalaemia and hypothyroidism, in renal and liver failure decrease the dose
Side effects: mild unless toxicity (there is a small therapeutic window)
GI upset, arrhythmias, visual disturbances (blurred vision and yellow halos), fatigue, weakness, confusion, hallucinations, mood changes.
Rarely decreased platelets, rash, increased esinophils
Monitor U&Es, digoxin levels (6hrs post dose
Interactions: toxicity is increased by Ca2+ (especially verapamil), amiodarone, antimalarials, ciclosporin, St Johns wart, diuretics ( via K+ depletion), ACE inhibitors and sprionolactone.
Cholestyramine and antacids decrease absorption
Dose: non acute AF/SVT: load with 125-250 microgram bd PO and then maintain with 62.5-250 micrograms OD heart failure: 62.5 - 125 micrograms OD Decrease does in renal failure P
Bendroflumethiazide
Use CI Caution SE Interactions Dose
Thiazide Diuretic - decreases Na+ (and Cl-) reabsorption from the DCT so causes Na and H2O loss and stimulates K+ excretion
Used for Oedema (due to heart failure and low protein states) HTN (third line, it decreases fluid volume and CO in the short term and then decreases TPR in the long term)
Can also be used to prevent renal stones in hypercalcuria
CI: hypokalaemia, hyponatremia, hypercalcaemia, addisons disease, severe liver and renal failure.
Caution in porphyria, can worse gout, DM and SLE
SE: dehydration, hypokalaemia, GI upset, impotence, hyponatriumia, metabolic disturbance, pancreatitis
Interactions:
increases lithium levels, effect is decreased by NSAIDs, and oestrogens.
If causes hypokaleamia can increase the toxic effects of digoxin, NSAIDs, steroids, and antiarrhythmics.
There is an increased risk of hyponatraemia when use with carbamazepine.
Dose: 5mg -10 mg OD PO then decrease dose frequency if possible.
Indapamide
Use CI Caution SE Monitor Interactions Dose
Thiazide derivative diuretic - same as bendroflumethiazide
Used in HTN third line
CI: hx of sulphonamide derivative allergy, hypokalaemia, hyponatriumia, hypercalcaemia, severe liver or renal failure.
Caution hyperparathyroidism, gout, porphyria
SE: fewer metabolic disturbances than bendroflumethiazide.
dehydration, hypokalaemia, impotence
Monitor: U&Es and urate
Interactions: increases lithium levels and toxicity of digoxin
Dose: 2.5mg OD PO (in the morning)
Furosmide
Use CI Caution SE Interactions Monitor Dose
Loop diuretic - inhibits Na/K pump in the ascending loop of Henle. It decreases the resorption of Na and therefore H20.
Used in LVF, resistant hypertension, oliguria secondary to AKI ( only if volume has been replaced)
CI: hypokalaemia, hyponatriumia, Addisons, cirrhosis, renal failure.
Caution if hypotension, BPH, porphyria, diabetes
SE: hypotension, hypokalaemia, hyponatremia, other metabolic disturbances. Increased urate/ gout.
Rarely BM supression, renal failure, rash, pancreatitis.
Interactions: increases the toxicity of digoxin, flecanide, solatol, NSAIDs, vancomycin, gent, and lithium.
decreases the effect of antidiabetics
NSAIDs may decrease the diuretic response
Monitor: U&Es
Dose: 40mg po/iv/im in acute LVF
Sprionolactone
Use CI SE Monitor Interactions Dose
Potassium sparing duiretic.
Aldosterone antagonist at distal tube.
Potentiates loop and thaizide diuretics
Used in ascities, oedema, HF, nephrotic syndrome and primary aldosteronism
CI: hyperkalaemia, hyponatreamia, Addisons,
SE: hyperkalaemia, gynaecomasti, N&V, impotence,
Monitor: U&Es
Interactions: increases digoxin and lithium levels.
Increased risk of renal failure with NSAIDs
Dose: 100-400mg/ day PO.
25mg OD if for HF
Adenosine
Use CI Caution SE Warn Interactions Dose
Purine nucleoside. Slows AVN conduction, dilates coronary arteries
used in the treatment of SVT and the slowing down of SVT to see underlying rhythm.
CI: asthma, COPD, heart failure (can cause death), hyppotension, increased QTc, heart block
Caution: heart transplants, AF/ atrial flutter
SE: bronchospasm, decreased heart rate, asystole, angina, resp failure
Warn that can make you feel like you are going to die, sick, pain in chest, dyspnoea
Interactions: effects increased by dipyridamole: decrease initial dose to 0.5-1mg and watch for bleeding as adenosine also increases the anti-platelet effects of dipyridamole.
effect decreased by theophyllines and caffeine.
If used with digoxin can increase risk of VF
Dose: 6mg IV over 2sec, then 12mg IV after 1-2 x2. Cardiac monitor NEEDs to be attached, and needs to be given through large peripheral or central and then flushed.
t1/2 <10 sec
Amiodarone
Use CI Caution SE Monitor Warn Interactions Dose
Class III antiarrhythmic: increases refractory period of conducting system, useful as has a less negative inotropic effect than other drugs
Used in tachyarrhythmias especially SVT, AF, atrial flutter, nodal tachycardias, VT and VF
CI: sinus bradycardia, heart block, thyroid disease
Caution: hypokalaemia there is an increased risk of torsades
SE: Acute; nausea and vomiting, bradycardia, hypotension
Chronic: intersitial lung disease, changes to thyroid function, hepatotoxicity, conduction disturbances, malaise, fatigue, night glare, grey slate skin
Monitor: TFTs, LFTs, K+ and CXR
Warn: avoid sunlight and use sun cream
Interactions: increases the effects of phenytoin and digoxin.
Drugs that can cause an increase risk of VT: other antiarrhythmics, antipsychotics, TCAs, lithium, erythromycin
Drugs that can cause bradycardia and heart block: verapamil, diltiazem and B blockers
Increases effect of warfarin
Dose: PO load with 200mg TDS for 1/52, 200mg BD for 1/52 and then 200mg OD maintenance.
IV (in emergencies) 150-300mg in 10-20ml of 5% glucose over >3mins (see ALS guidelines)
Lidocaine
Use CI Caution SE Monitor Interactions Dose
Class Ib antiarrhythmic - decreases conduction in Purkinje and ventricular muscle fibres.
Local anaesthetic - blocks Na+ channels
Used in ventricular arrhythmias
CI: myocardial depression, heart block
Caution: epilepsy, hypoxia, hypovolaemia, bradycardia
SE: dizziness, drowiness, confusion, tinnitus, blurred vision. rarely resp depression, seizures, anaphylaxis
Monitor ECG when giving IV
Interactions: increased risk of arrhythmias with antipsychotics
increased myocardia depression with other antiarrhythmics and B blockers
levels increased by propranolol, ataza/ lopinavir and cimetidine.
Prolongs the action of suxamethonium
Dose (for ventricular arrhythmias): 50-100mg IV followed immediately by IVI as short t1/2.
Propranolol
Use CI Caution SE Interactions Dose
B blocker - non selective
B1 = decrease heart rate and contractility
B2 = vasodilation, bronchoconstriction, and glucose release from the liver
Blocks effects of catecholamines, decreases renin and slows SAN/AVN conduction
Used in hypertension, IHD, portal hypertension, essential tremor, symptom relief of anxiety and hyperthyroidism
CI: asthma, peripheral arterial disease, bradycardia, hypotension, heart block,
Caution: COPD, diabetes, mysthenia
SE: bradycardia, hypotension, peripheral vasoconstriction, fatigue, depression, sleep disturbances, hyperglycaemia, GI upset
Interactions: Verapamil ad diltiazem can cause heart block and death!!
Risk of hypotension and heart failure with nifedipine.
Increase risk of lidocaine toxicity.
Dose: variable depending on use.
HTN: 80-160mg PO
Post MI: 40mg QDS for 2-3 days then 80mgBD PO
dose needs to be decreased in liver and renal failure
Bisoprolol
Differences to Propranolol
Cardio selective B1 > B2
CI in heart failure, if SAN block and caution in poriasis
Dose: 10mg OD PO
Atenolol
Differences to Propranolol
Mildly cardioselective (B1 > B2), increased H2O soluble so less effects centrally, and increased renal secretion
Can be used within 12hrs of an MI
Causes less bronchospasm and less sleep disturbances
Dose: HTN 25-50 mg OD PO
Doxazonsin
Use CI Caution SE Interactions Dose
A1 blocker = systemic vasodilation and relaxation of internal urethral sphincter. Decreases TPR and increases bladder outflow.
Used in hypertension and BPH
CI; postural hypotension, anuria
Caution: micturition syncope
SE: postural hypotensin, dizziness, headache, urinary incontinence. Increases HDL ratio
Interactions: increases hypotensive effects of diuretics, B blockers, calcium channel blockers, general anaesthetics, and antidepressants
Dose: 1mg OD then increase to max 16mg/day in hypertension and 8mg/day in BPH
Ramipril
Use CI Caution SE Monitor Interactions Dose
ACE inhibitor
Used in hypertension, heart failure, post MI
CI: renovascular disease
Caution: sympotmatic aortic stenosis, hx of angioedema, if taking drugs that increase potassium
SE: hypotension, renal failure, dry cough, hyperkalaemia,
hypersensitivity, pancreatitis
Monitor: U&Es - baseline and then 2 weeks after starting
Interactions: effect decreased by NSAIDs (also increases renal failure),
Diuretics, TCAs, and antipsychotics increase the risk of hypotension.
Increases effects of lithium
Dose: 1.25mg OD increase to max 10mg OD
post MI: 2.5mg BD then increase to 5mg BD after 2 days and then maintain
- captopril is a short acting ACEi*
Lostartan
Use CI Caution SE Interactions Dose
Angiotensin II receptor antagonist - specifically blocks then renin- angiotensin system not anything to do with Bradykinin
Use: Hypertension, prevention of diabetic induced nephropathy if an ACEi not tolerated
CI: pregnancy and breast feeding
Caution: renal artery stenosis, HOCM, mitral or aortic stenosis, if taking drugs that increase potassium
SE: same as ramipril but not s dry cough
Interactions: can cause hyperkalaemia if used with drugs that increase potassium
Dose: 25-50mg OD increasing to a max of 100mg OD.
reduce dose in renal or liver failure
Glyceryl Trinitrate
Use CI Caution SE Interactions Warn Dose
Nitrate: coronary artery and systemic vein dilation = increased oxygen supply to the myocardium and decreased preload = decreased oxygen demand of the myocardium
Used in angina and LVF
CI; hypotension, anaemia, AS/MS, constrictive pericarditis, tamponade, HCOM, glaucoma, hypovolaemia, increased ICP
Caution: recent MI, hypothyrodism, head trauma, cerebral haemorrhage, malnutrition,
SE: hypotension, headache, dizziness, flushing, tachycardia
Interactions:
Sildenafil, tadalafil and vardenafil are CI due to +++ hypotension
reduced effect of heparins
Dose: 2 sprays or sublingual tabs PRN
in acute MI/ KVF 10-200micrograms/min IV
Isosorbide mononitrate = a nitrate but PO not sublingual - gives less of a headache than GTN.
10 - 40mg bd PO
Nicorandil
Use CI Caution SE Interactions Dose
Potassium channel activator - arterial dilation which decreases afterload with a nitrate component - venous dilatation decreasing preload
Used to treat angina which is unresponsive to other Rx
CI: hypotension, LVF with low filling pressures
Caution: hypovolaemia, acute pulmonary oedema, ACS with LVF,
SE: headache, flushing, dizziness, weakness, N+V, hypotension and tachycardia.
Rarely GI/ perianal ulcers
Interactions, risk of ++hypotension when used with sildenafil etc
Dose: 5-30mg BD
Adrenaline
Use Caution SE Interactions Dose
Sympathamimetric - powerful stimulation of alpha (vasoconstriction), beta 1 (increase HR, increase contractility) and beta 2 (vasodilation broncodilation, and uterine relaxation).
Also decreases mast cell cytokine release immediately
Used in CPR, anaphylaxis
Caution: cerebralvascular and heart disease
SE: tachycardia, hypertension, anxiety, sweats etc
Interactions: effect is increased by dopexamine, TCAs, ergotamine and oxytocin.
Risk of ++ hypertension and bradycardia with B blockers, TCAs, MAOIs.
Risk of arrhythmias with digoxin, quinidine, and volatile liquid anaesthetics
Dose:
CPR: 1mg IV (10mls of 1 in 10000) then flush with 20mls saline,
Anaphylaxis: 0.5mg im (0.5ml of 1 in 1000)
Enoxaparin
Use CI Caution SE Monitoring Interactions Dose
Low molecular weight heparin - anticoagulant. Potentiates protease inhibitor antithrombin III which inactivates thrombin.
Used in DVT/ PE treatment and prevention and in ACS
CI: haemorrhagic disorders (haemophilia), low platelets, severe hypertension, acute bacterial endocarditis, recent spinal (can give therapeutic doses)
Caution: hyperkalaemia, renal failure
SE: haemorrhage, low platelets, hypersensitivity, hyperkalaemia (inhibits aldosterone so increased risk if diabetic, chronic renal failure, acidosis or on potassium sparing drugs) osteoporosis
Monitor: FBC, U&E
Interactions: effect may be reduced by GTN ivi. increased bleeding risk with NSAIDs
Dose: subcut 1mg = 100 units DVT/ PE treatment = 1.5mg/kg OD ACS treatment = 1mg/kg BD Prophyalxis = 40mg OD (half for renal failure)
Warfarin
Use CI Caution SE Warn Dose
Vitamin K antagonist - blocks the synthesis of vitamin K dependent factors (II, VII, IX, X) and protein C and S
Used to prevent thrombo embolisms in AF, recurrent DVTs/PE, new heart valves
CI: severe hypertension, peptic ulcers, severe bleeding, haemorrhagic CVA, pregnancy
Caution: recent surgery, bacterial endocarditis, 48 hr post partum
SE: haemorrhage, rash, fever, diarrhoea, purple toe syndrome, skin necrosis, heptotoxicity
Warn: effects are increased by alcohol, cranberry juice,
Interactions: antibiotics and drugs that affect cytochrome P450
Dose: monitor INR - aim for 2.5 in most cases except for mechanic heart valve where 3.5 is needed.
Need to give a loading dose (10mg) and then check INR every day for 4 days and adjust dose accordingly and then continue to monitor in the community.
When starting need to give LMWH for 5 days as it is prothrombotic to start with.
Need to reduce doses for: >80yrs, liver failure, heart failure, post op, poor nutrition, or taking drugs that increase the effect of it.
Amlodipine
Use CI Caution SE Interactions Dose
Ca2+ channel blocker - cause vasodilatation and reduce the oxygen consumption of the myocardium.
Dihydropyridine - mainly peripheral vasodilators, and cause reflex tachycardia.
Used for hypertension, and angina.
CI: ACS, cardiogenic shock, clinically significant aortic stenosis
Caution in heart failure, BPH,
SE: flushing, headache, ankle oedema, dizziness, hypotension, palpitations, poly/nocturia, rash, GI upset, weakness, myalgia, gum hyperplasia,
Interactions: may increase the effect of theophyllines, care should be taken with inducers of cytochrome 3A4, decrease simvastatin dose to max 20mg OD
Dose: initially 5mg PO
Verapamil
Use CI Caution SE Interactions Dose
Calcium channel blocker - promotes vasodilatation and reduces myocardial oxygen consumption.
Non - dihydropyridines - slow conduction at the AV and SAN.
Used for hypertension, angina, arrhythmias
CI: hypotension, bradycardia, heart block, decreased LV function, AF,
Caution: ACS,
SE: Constipation, hear failure, hypotension, heart block, headache, dizziness, fatigue ankle oedma, hypersensitivity, skin reactions
Aspirin
Use CI Caution SE Interactions Dose
NSAID - inhibits COX1 and COX2 - decreases prostaglandin synthesis (anti-inflammatory and antipyrexial) and decreases thromboxane A2 (anti platelet aggregation)
Used for mild pain and as an anti platelet in IHD
CI in children <10ml/min
Caution in asthma,
SE: GI irritation, bleeding. rarely hypersensitivity, AKI, hepatotoxicity and ototoxic in OD
Interactions: increased GI bleeding when used with other anticoagulants, other NSAIDs, SSRIs and venlafaxine.
Increases the effect of warfarin.
Can increase the levels of methotrexate, increase the effects of anticonvulsants and decrease the effects of spironolactone.
Dose:
For analgesia: 300-900mg 4-6hrly, for IHD prevention 75mg OD, for treatment of ACS 300mg stat.
Clopidogrel
Use CI Caution SE Monitor Dose
Antiplatelet - ADP receptor antagonist (works with aspirin to have ++ anticoagulation as both on similar pathway)
Used post MI for 12months
CI: active bleeding,
Caution: increased bleeding risk, trauma, surgery.
effects decreased by omeprazole etc
SE: haemorrhage, GI upset, pancreatitis, headache, fatigue, dizziness etc
monitor FBC and signs of occult bleeding
Dose: 75mg OD - load with 300mg
Dipyridamole
Use Caution SE Interactions Dose
Antiplatelet agent - inhibits platelet aggregation, adhesion and survival. Also dilates arteries, including coronaries.
Used for secondary prevention of ischemic TIA/CVA, and in prevention of thromboembolism in prosthetic valves (as an adjunct to warfarin)
Caution in recent MI, angina, aortic stenosis, myasthenia gravis
SE: GI upset, dizziness, myalgia, headache, hypotension,
Interactions: decreases the effects of cholinesterase inhibitors, increases the effects of adenosine, increases the effects of warfarin
Dose: 200mg BD PO - must be taken with food.
Simvastatin
Use CI Caution SE Monitor Interactions Dose
HMC-CoA reductase inhibitor - decreases cholesterol synthesis and increases LDL uptake (so decreases amount) and decreases triglyceride
Used to reduce cholesterol, prevent atherosclerotic disease
CI: acute porphyria, liver failure, pregnancy (contraception must be used during and for 1 month after)
Caution in hypothyroidism, alcohol abuse, hx of liver disease
SE: hepatitis and myositis (rhabdo) headache, GI upset, pancreatitis
Monitor: LFTs and CK if symptoms develop
Interactions: increased risk of myositis when used with fibrates, clarithromycin etc, ketoconazole etc, ciclosporin, protease inhibitors, nicotinic acid, fusidic acid, amiodarone, verapamil, amlodipine, and grapefruit juice.
Mildly increases effect if warfarin
Dose: 10-80mg at night
decrease if renal failure or increased risk of myositis
Salbutamol
Use Caution SE Monitor Interactions Dose
B2 agonist - short acting.
Dilates bronchial smooth muscle and endometrium.
Also inhibits mast cells mediator release.
Used in asthma, in hyperkalamia, and premature labour (IV)
Caution: CVD (especially arrhythmias, increased QTc and hypertension,) diabetes, hyperthyroidism
SE:
neurological - fine tremor, headache, nervousness
CVS: tachycardia, palpitations, increased QTc
other: hypokalaemia, muscle cramps, rarely paradoxical bronchospasm
Monitor: K and glucose
Interactions: with IV salbutamol +++ hypotension if used with methyldopa
Dose: 100-200 microgram inhaler PRN for chronic asthma
In acute asthma attack 2.5-5 mg PRN via neb (can give up to every 15mins)
Salmeterol
Use
Caution/ SE/ Monitor
Dose
Bronchodilator - long acting B2 agonist
Used in step 3 of asthma treatment
Caution: CVD (especially arrhythmias, increased QTc and hypertension,) diabetes, hyperthyroidism
SE:
neurological - fine tremor, headache, nervousness
CVS: tachycardia, palpitations, increased QTc
other: hypokalaemia, muscle cramps, rarely paradoxical bronchospasm
Monitor: K and glucose
Dose: 50 - 100 micrograms BD inhaler
Ipratropium
Use
SE
Caution
Dose
Inhaled muscarinic antagonist - bronchodilator and increases bronchial secretions
Used in chronic and acute bronchospasm (COPD > Asthma)
SE: antimuscarinic - decrease secretions: constipation, urinary retention, drowsiness, dry eyes dry skin
Caution: glaucoma (if has angle closure need to protect patients eyes from the drug) bladder outflow obstruction.
Dose: 20- 400 microgram TDS inhaler 250 - 500 microgram QDS nebs
Beclometasone
Use
Caution
SE
Dose
Inhaled corticosteroid - decreases airway oedema and mucous secretions
Used for chronic asthma not controlled by PRN salbutamol - step 2
Caution in TB
SE: oral candidiasis, hoarse voice. high doses may cause adrenal suppression, Cushing’s, decreased bone density,
Dose: 200 - 2000 micrograms daily inhaler
Seratide
What is in it?
long acting B2 agonist + fluticasone (in varying amounts)
Chlorphenamine
Use CI Caution SE Warn Interactions Dose
Anithistamine: H1 antagonist (peripheral and central so sedating)
Used in allergies
CI; hypersensitivity to any antihistamine
Caution: pylorodudodenal obstruction, urinary retention, thrytoxicosis, asthma, bronchitis, severe hypertension, CVD, glaucoma, epilepsy
SE: drowsiness, antimuscarinic (deceased secretions) GI upset,
Warn that driving may be impaired
Interactions: can increase pheytonin levels, MAOIs can increase + antimuscarinic levels
Dose: 4mg 4-6hrly PO
Diazepam
Use CI Caution SE Warn Interactions Dose
Long acting benzodiazepine
Used in seizures, for alcohol withdrawal, anxiety, insomnia, muscle spasm
CI: respiratory depression, marked neuromuscular respiratory weakness, sleep apnoea, acute pulmonary insufficiency, chronic psychosis, depression
Caution: respiratory disease, muscle weakness, hx of drug and alcohol abuse, personality disorder, porphyria.
SE: respiratory depression, drowsiness, dependence.
Warn: sedation is increased by alcohol
Interactions: metabolised by P40 so there are many!!
Erythromycin etc, ketoconazole etc can increase levels.
Sedative effect is increased by antipsychotics, antidepressants, antiepileptics, and anti retrovirals.
Risk of bradycardia and hypotension when used with IM olanzapine.
Dose:
4mg IV lorazepam in status epilepticus
30mg chlordiazepoxide QDS to start with for alcohol withdrawal (15mg QDS diazepam)
Zopiclone
Use CI Caution SE Interactions Dose
Short acting hypnotic - potentiates GABA pathways the same as benzos but NOT a benzo.
Used for insomnia but not long term due to dependence
CI: respiratory failure, sleep apnoea, marked neuromuscular respiratory weakness
Caution: psych disorders, hx of drug abuse,
SE: rare.
Interactions: levels are increased by ritonavir, erythromycin and other enzyme inhibitors.
Sedation is increased by alcohol
Dose: 7.5mg at night (can go up to 15mg)
Haloperidol
Use CI Caution SE Interactions Dose
Typical antipsychotic - Dopamine anatgonist D1 and D3 > than D2 and D4. Also blocks 5HT2A and H1, adrenergic and muscarinic receptors.
Used for acute sedation, in schizophrenia and bipolar disorder and for nausea and vomiting.
CI: CNS depression, elderly patients with dementia, history of blood dyscarsis, severe CVD
Caution: Parkinson’s, drugs that increase the QTc, epilepsy, myasthenia, phaeo, glaucoma, BPH, respiratory disease, jaundice, blood disorders, photosensitivity in sunlight
SE: sedation, extrapyramidal effects ( parkinsonisms, dyskinesias, akathesia), hypoglyceamia, SIADH, weight gain, ECH changes, neuroleptic malignant syndrome.
Interactions: risk of CNS toxicity with lithium.
metabolised by P450 - levels increases by fluoxetine, venlafaxine, quinidine, buspirone, and ritonavir.
Levels decreased by carbamazepine, phenytoin, rifampicin.
Increased risk of arrhythmias with amioderone, and it decreases the effects of anticonvulsants.
Dose: for acute sedation and psych - 1.5 - 5mg PO BD/ TDS (max 30mg a day) 2-10mg im/ iv 2-4hrly (max 18mg/day)
For nausea and vomiting: 0.5 - 2mg TDS im/sc/iv
Chlorpromazine
Use CI Caution SE Warn Monitor Interactions Dose
Typical antipsychotic - dopamine antagonist D1 and D3 > D2 and D4. Also blocks 5HT2A, H1 adrenergic and muscarinic receptors.
Used in schizophrenia, acute sedation and intractable hiccups.
CI: CNS depression, elderly patients with dementia, hx of blood dyscarisais, severe CVD
Caution: Parkinson’s, drugs that increase the QTc, epilepsy, myasthenia, phaeo, glaucoma, BPH, severe respiratory disease, jaundice, blood disorders, postural hypotension. Avoid sunlight as causes photosensitivity.
SE: sedation, extrapyramidal effects (parkinsons, dyskinesais, akathesia) antimuscarinic (decreased secretions), seizures, weight gain, hypotension, ECG changes, endocrine effects ( menstrual changes, galactorrhoea, gynaecomastia, sexual dysfunction) changes to LFTs, agranulocytosis, low WCC, neuroleptic malignant syndrome.
Warn: avoid alcohol and direct sunlight
Monitor: FBC and BP
Interactions: sedation may be increased by alcohol. may increase hypotension caused by other medications.
Effects increased by TCAs, lithium, ritonavir, cimetidine and B blockers.
Increased risk of CNS toxicity with sibutramine.
Dose: 25 - 300mg TDS PO
decrease if elderly or renal failure
Olanzapine
Use CI Caution SE Monitor Interactions Dose
Atypical antipsychotic - D1, D2, D4 and 5HT2 antagonist (has mild antimuscarnic effects)
Used in schizophrenia, mania, bipolar and for acute sedation (IM)
CI: breast feeding.
If giving IM: acute MI/ ACS, hypotension and bradycardia, recent heart surgery
Caution: drugs that increase QTc, dementia, cardiovascular disease, DM, BPH, glaucoma, Parkinson’s, Hx of epilepsy, blood disorders, paralytic ileus.
SE: Sedation, weight gain, ankle oedema, change in LFTs, postural hypotension, increase glucose (diabetes and DKA).
Transient extrapyramdial and anticholinergic effects) rarely neuroleptic malignant syndrome
Monitor: blood glucose, LFTs, U&Es, FBCs, prolactin , weight, lipids.
Interactions: metabolised by P450 - levels decreased by carbamazepine and smoking. Increased risk of low neutrophils when used with valporate.
Levels increased by ciprofloxacin.
Increased risk of CNS toxicity with sibutramine.
Increased risk of arrhythmias when used with drugs that increase the QTc.
Increased risk of hypotension with GA
Decreases the effects of anticonvulsants
Dose: 5-20mg PO daily
IM form used for acute sedation 5-10mg - max daily dose 20mg per day (including PO doses)
NOT recommended to be used with benzos as increased risk of respiratory depression
Quetiapine
Use CI Caution SE Interactions Monitor Dose
Atypical antipsychotic
Used in schizophrenia, mania, depression in bipolar disorder
Off licence is used for psychosis in dementia
CI: breast feeding.
Caution: drugs that increase QTc, cardiovascular disease, Hx of epilepsy
SE: Sedation, weight gain, ankle oedema, change in LFTs, postural hypotension, increase glucose (diabetes and DKA).
Transient extrapyramdial and anticholinergic effects) rarely neuroleptic malignant syndrome
Interactions: metabolised by P450.
Levels decreased by carbamazepine and smoking.
Increased risk of low neutrophils when used with valporate.
Levels increased by ciprofloxacin, and clarithromycin etc
Increased risk of CNS toxicity with sibutramine
Increased risk of arrhythmias with drugs that increase QTc
Increased risk of hypotension with GA
Decreases the effects of anticonvulsant
Dose: needs titration - start low 25mg BD increasing to a max of 750mg/ day
Monitor: blood glucose, LFTs, U&Es, FBCs, prolactin , weight, lipids.
Amitriptyline
Use CI Caution SE Warn Interactions Dose
Tricyclic antidepressant: blocks reuptake of NA and 5HT.
Used in depression, neuropathic pain and in migraine prophylaxis
CI: recent MI, arrhythmias, mania and liver failure
Caution: cardio/ thyroid disease, epilepsy, glaucoma, PBH, phaeo, porphyria. Hx of mania, psychosis or urinary retention.
SE: antimuscarinic ( decreased secretions) cardiac effects (arrhythmias, heart block, postural hypotension, dizziness, syncope), weight gain, sedation, seizures.
Rarely: mania, fever, blood disorders, hypersensitivity, change in LFTs, hyponatreamia, neuroleptic malignant syndrome
Warn: higher doses may impair driving
Interactions:
MAOIs - never give with or within 2 weeks of having one. causes hypertension and CNS excitation and death.
Levels increased by SSRIs, phenothiazines, and cimetidine.
Increased risk of arrhythmias with amiodarone and pimozide (CI)
Increased risk of paralytic ileus with antimuscarinics
Increased sedative effect when taken with alcohol
Increased CNS toxicity with sibutramine (CI)
Dose: for depression initially 75mg at night up to a max of 200mg/ day.
For pain initially 10mg at night increasing to 75mg if needed
Fluoxetine
Use CI Caution SE Warn Interactions Dose
Serotonin specific reuptake inhibitor - has long t1/2 compared to the others
Used in depression, and other psych disorders including bulimia and OCD
CI: active mania
Caution: epilepsy, receiving ECT, hx of mania or bleeding disorders, heart disease, diabetes, glaucoma
SE:
Class - GI upset, weight loss, insomnia, aggitation, headache, hypersensitivity. withdrawal when stop suddenly (flu like symptoms, shock like sensations, dizziness, anxiety, irritability, insomnia, vivd dreams). Rarely extrapyramidal and antimuscarinic effects, sexual dysfunction, convulsions, hyponatreamia, blood disorders, serotonin syndrome
Specific: hypoglycaemia, vasculitis
Warn: dont stop suddenly!!
Interactions: decreases P450 - increases levels of TCAs, benzos, clozapine, and haloperidol.
Increases lithium toxicity.
Increases hypertension and CNS effects with dopaminergics.
Increases risk of CNS toxicity with drugs that increase 5HT ( tramadol, sibutramine, sumatriptan and st johns wort).
Increased risk of bleeding with aspirin and NSAIDs.
Levels increased by ritonavir.
Antagnoises antiepiletpics but increases levels of carbamazepine and phenytoin.
Avoid with tamoxifen
Never give with or 2 weeks after MAOIs.
Increases warfarin effect mildly
Dose: 20mg in the morning initially increase to a max of 60mg OD
Cyclizine
Use CI Caution SE Warn Dose
Antihistamine antiemetic
Used in nausea and vomiting (especially secondary to opioids), vertigo, motion sickness, labyrinthine disorders
CI: hypersensitivity to any antihistamine
Caution: severe heart failure, pyloroduodenal obstruction, urinary retention, thyrotoxicosis, asthma, bronchitis, severe hypertension, CVD, glaucoma, epilepsy
SE: antimuscarinic, drowsiness
Warn: may impair driving
Dose: 50mg po/ im/ iv TDS
Metoclopramide
Use CI Caution SE Interactions Dose
Anti emetic dopamine blocker - acts on central chemoreceptor trigger zone and directly stimulates GI tract
Used in nausea and vomiting, especially GI or opiate induced
CI: GI obstruction, perforation or haemorrhage - including 2-4 days post op GI surgery, phaeo
Caution: epilepsy, porphyria
SE: extrapyramidal (especially in elderly and young females) drowsiness, restlessness, mood changes, increased prolactin.
Rarely skin reactions and neuroleptic malignant syndrome
Interactions: increases the effect of NSAIDs, and ciclosporin levels.
Increases the risk extrapyramidal effects of antipsychotics, SSRIs and TCAs
Dose: 10mg TDS PO/IM/IV
decrease dose in renal and liver failure, 5-19yrs or weight < 60kg
Domperidone
Use CI Caution SE Dose
Anti-emetic D2 antagonist, inhibits central nausea chemoreceptor trigger zone.
Has poor BBB penetration so fewer central side effects
Used in nausea and vomiting, secondary to chemotherapy, and in parkinson’s disease and migraines.
CI: prolactinoma, when GI obstruction is harmful, with drugs that increased QTc.
Caution: GI obstruction
SE: increased QTc, rash, allergy, increase prolactin (gynaecomastia, galactorrhoea, and hyperprolactinoma).
Rarely decreased libido, dystonia and extrapyramidal effects
Dose: 10mg TDS PO or 60mg BD PR
Ondansetron
Use Caution SE Interactions Dose
Antiemetic 5HT3 antagonist. Acts on central and GI receptors.
Used in nausea and vomiting especially post op and if resistant to other treatment.
Caution in GI obstruction, long QTc, liver failure, pregnancy and breast feeding.
SE: constipation, headache, sedation, fatigue an dizziness.
Rarely seizures, chest pain, hypotension, change in LFTs, rash and hypersensitivity
Interactions: metabolised by P450.
Levels decreased by rifampicin, carbamazepine and phenytoin.
Decreased the effects of tramadol.
Dose: 8mg BD PO, 16mg OD PR, 8mg 2-8 hrly IV/IM
Max 24mg/ day
Prochlorperazine
Use
Dose
Antiemetic: DA antagonist
Used for nausea and vomiting especially in labyrinthine disorders
CI/ caution/ SE etc - same as chlorpromazine
Dose: PO - acutely 20mg, then 10mg 2 hr later, can give initial dose IM (12.5mg) and then PO doses there after.
Paracetamol
Use Caution SE Interactions Dose
Antipyretic and mild analgesic - has no anti inflammatory effects
Used in mild pain or in moderate and severe in combination with other treatments and pyrexia
Caution: alcohol dependence
SE: ALL are RARE.
rash, blood disorders, hepatic failure ( if OD)
Interactions: may increase the effects of warfarin
Dose: 0.5 - 1g PO/ PR or 15mg/kg if <50kg. 4-6hrly, max of 4g/ day.
Max 6g/ day IV in LF, dehydration, chronic alcoholism or chronic malnutrition,
Minimum iv dosing interval in renal failure 6hrly.
Children: 3-6mnths 60mg, 6-24mnths 120mg, 2-4yrs 180mg, 6-8yrs 250mg, 8-10yrs 375mg, 10-12yrs 500mg, 12-16yrs 480-750mg
Codine
Use CI Caution SE Interactions Dose
Weak Opiate analgesic - mainly metabolised to morphine
Used in mild/ moderate pain, diarrhoea and anti-tussive
CI: acute respiratory depression, risk of ileus, increased ICP/ head injury/ coma
Caution: all other condition whee morphine is either contraindicated or cautioned:
Bilary colic, acute alcoholism, phaeo, renal failure, pancreatitis, bowel obstruction, large prostate or urethral stricture, arrhythmias, hypothyroidism, adrenocorticoid insufficiency, myasthenia
SE: constipation, respiratory depression, sedation
Interactions: dont not give within 2 weeks of an MAOI - can cause death.
Increased sedative effect with antihistamines, alcohol, TCAs, antipsychotics, anxiolytics, moclobemide.
Increases the effect of sodium oxybate
Dose: 30-60mg up to 4hrly (max 240mg/ 24hr)
Can be give as co-codamol ( paracetamol + codeine phosphate) or co-dydramol (paracetamol + dihydrocodeine)
Tramadol
Use CI/ Caution SE Interactions Dose
Opioid. Also decreases pain by increasing 5HT/ NA transmission
Used in moderate/ severe pain
CI/ caution: same a codeine but also CI in uncontrolld epilepsy, pregnancy and breast feeding
SE: as morphine but less respiratory depression, less constipation, leaa addiction, more confusion compared to codiene.
Interactions: as codiene but also increased risk of convulsions with SSRIs, TCAs, and antipsychotics.
Increased risk of sertonin syndrome with SSRIs.
Carbmanzepine and ondansetron decrease its effects
Increases the effect of warfarin
Dose: 50 - 100mg up to 4hrly, max 400mg/ day
Morphine Sulphate
Use CI Caution SE Interactions Dose
Opiate analgesic
Used for severe pain
CI: acute respiratory depression, risk of paralytic ileus, delayed gastric emptying, bilary colic, acute alcoholism, increases ICP/ head injury, phaeo,
Caution: decrease resp reserve, hypotension, shock, acute abdomen, biliary tract disorders, pancreatitis, bowel obstrution, IBD, BPH/ urethral stricture, arrhythmias, hypothyroidism, addrenocorticoid insufficency, myasthenia
SE: nausea and vomiting, constipation, respiratory depression, dependence (lots more see pg 112 of pocket prescriber)
Interactions: DO NOT GIVE WITHIN 2 weeks of MAOI
Levels decreased by ritonavir.
Decreases levels of ciprofloxacin
increased sedative effects with antihistamines, baclofen, alcohol, TCAs, antipsychotics, anxiolytics, and moclobemide
Increased effects of sodium oxybate and gabapentin
Dose: Acute pain 5-20mg SC/ IM 4 hrly (IV is half the dose) Acute MI 5-10mg IV Acute LVF 5- 10mg IV Chronic pain use PO
Carbamazepine
Use CI Caution Monitor Warn Interactions Dose
Antiepileptic, mood stabiliser, analgesic, decreases synaptic transmission.
Used for epilepsy - generalised tonic clonic and partial but may exacerbate absence and myoclonic. To treat bipolar if lithium doesnt work and in post herpatic neuralgia.
CI: unpaced AV conduction problems, hx of bone marrow supression, acute porpyria.
Caution: cardiac disease, hx of skin disorders (HLA - B1502 have increased risk of SJS) haematological drug reactions.
Need to take high dose folate if pregancy as ++ risk of neural tube defects.
SE:
Dose related - nausea and vomiting, headache, drowsiness, dizziness, vertigo, ataxia, visual disturbances (double vision) - can be improved by decreasing the dose or spacing out the times
Other: skin reactions, blood disorders (low WCC), increased gamma GT, oedema, hyponatreamia,
Monitor: U&Es, LFTs, FBC, serum levels, vit D level
Warn: driving may be impaired,
Interactions: increases P450 - may cause failure in OCP.
Effect is increased by clarithromycin etc, isoniazid, verapamil and diltiazem,
Effects are decreased by phenytoin, and phenobarbitone
CI wirh MAOIs
Decreases effect of warfarin
Dose: 100-200mg OD increase slowly to a max of 1.6g/day
Phenytoin
Use CI Caution SE acute SE chronic Monitor Warn Interactions Dose
Antiepileptic - blocks Na channels so stabilises neuronal membranes
Used in all forms of epilepsy
CI: (only if giving IV) sinus brady, heart block,
Caution: diabetes, porphyria, hypotension, pregnancy
SE acute: drowsiness, cerebellar effects, rash, nausea and vomiting, diplopia. If given IV risk of hypotension, arrhythmias, purple glove syndrome, CNS/ resp depression
SE chronic: gum hypertrophy, coarse faces, hirsutism, acne, reduced folate, peripheral neuropathy, rickets,
Monitor: FBC, serum levels ( narrow therapeutic range)
Warn: report any rash, mouth ulcers, sore throat, fever, bruising, bleeding immediately
Interactions: metabolised and increases p450 so has lots of interactions.
Decreases the effects of OCP, doxycycline, ca2 blockers, steriods (lots more see page 129 of PP)
Levels decreased by rifampicin, theophylline, antipsychotics, TCAs, St Johns wort.
Levels increased by NSAIDs, fluoxetine, trimethoprim, amioderone, metronidazole, clarithromycin, +++ ( see PP)
Decreases the effect of warfarin
Dose: PO 150 - 500mg
Sodium Valporate
Use CI Caution SE Warn Monitor Interactions Dose
Antiepileptic and mood stabiliser - potentiates and increases GABA levels.
Used in epilepsy and mania
CI: acute porhyria and personal or family hx of severe liver dysfunction
Caution: SLE, increased bleeding risk, pregnancy (needs high dose folate as increases neural tube defects)
SE: sedation, cerebellar effects, headache, GI upset, weight gain.
Rarely hepatoxocity, blood disorders (decreased platelets), pancreatitis
Warn of the clinical features of pancreatitis and liver/ blood disorders. Inform women of child baring age about teratogenicity
Monitor: LFTs, FBC + serum levels pre dose
Interactions: effects decreased by antimalarials, antidepressants, st john wort, antipsychotics, and some antiepileptics.
Levels increased by cimetidine and carbopenems.
Increases effects of aspirin and primidone.
Increased risk of low neutrophils with olanzopine
Increases the effect of warfarin
Dose: initially 300mg BD increasing to a max of 2.5g/day
** can give a false positive urine dipstick for ketones**
Gabapentin
Use Caution SE Interactions Dose
Antiepileptic - similar structure to GABA but mechanism of action is different from drugs affecting GABA receptors
Use: neuropathic pain and epilepsy (as an adjunct)
Caution: hx of psychosis or DM
SE: fatigue, dizziness, cerebellar effects, eye changes, headache, rhinitis.
Rarely low WCC, GI upset, arthralgia, skin reactions, suicide ideation.
Interactions: effects decreased by antidepressants and antimalarials.
Antipsychotics reduce seizure threshold.
Dose: initally 300mg OD, increasing by 300mg/day to a max of 3.6g daily in 3 divided doses. DO NOT JUST STOP, decrease over a week
** can give false positive urine dipstick for protein**
Levodopa
Use CI Caution SE Warn Interactions Dose
Precursor of dopamine: needs concomitant peripheral dopa decarboxylase inhibitor such as benserazide (co -beneldopa) or carbidopa (co- careldopa) to limit the side effects
Use: parkinsonism
CI: glaucoma, MAO-A inhibitors, melanoma
Caution: Pulmonary/ cardiovascular/ psych disease, endocrine disorders, osetomalacia, hx of peptic ulcers or convulsions, ventricular arrhythmias
SE: dyskineasias, abdominal upset, postural hypotension, drwsiness, aggression, psych (confusion, depression, suicide, hallucinations, psychosis, hypomania), can reactivate melanoma, peripheral neuropathy, changes in taste
Warn can cause daytime sleepiness, and reduce ability to operate machinery
Interactions: effects decreased by neuroleptics,
risk hypertension crisis with MAOIs (but can give with MAOB inhibitors)
risk of arrhythmias with halothane
Dose: 125- 500mg daily, after food
abrupt withdrawal can induce neuroleptic like syndrome
Benzylpencillin
Use CI Caution SE Interactions Dose
Beta lactam antibiotic - poor PO absorption so only given IV/ IM.
Used mostly against strep and neisserial infections. Usually in conjuction with other agents - severe skin infections, menigitis, endocarditis, ENT, pneumococcal pneumonia
CI: allergy,
Caution: hx of allergy, false +ve glycosuria
SE: allergy, diarrhoea.
Rarely blood disorders (low platelets, neutrophils), CNS toxicity, hypokalaemia and hyponatreamia in high doses
Interactions: levels increased by probenecid.
increased risk of rash with allopurinol.
Dose: 0.6 - 1.2g QDS IV
Flucloxacillin
Use CI Caution SE Interactions Dose
Beta - lactam, penicillin (penicillinase resistant)
Use: penicillin resistant (B lactam producing) staph especially skin and osteomyelilites and endocarditis
CI: allergy,
Caution: hx of allergy, false +ve glycosuria
SE: allergy, diarrhoea.
Rarely blood disorders (low platelets, neutrophils), CNS toxicity, hypokalaemia and hyponatreamia in high doses
Interactions: levels increased by probenecid.
increased risk of rash with allopurinol.
Dose: 250 - 500mg QDS po (or up to 2g QDS iv)
decrease dose in severe renal failure
Ampicillin
Use CI Caution SE Interactions Dose
Broad spectrum penicillin for PO and IV use - has good GI absoprtion
Use: mild pneumonias, see trust guidelines.
CI: Penicillin hypersensitivity
Caution: EBV/ CMV infections, ALL, CLL - causes a raash
SE: rash - erythematous, maculopapular (often doesnt reflect allergy), commoner in renal failure.
Nausea and vomiting and diarrhoea.
Hypersensitivity
Interactions: levels increased by probenecid.
Increases the effects of warfarin
Increased risk of rash with allopurinol
Increases levels of methotrexate
Dose: 500 - 1000mg TDS PO/IV
Co - Amoxiclav
Use CI Caution SE Interactions Dose
Combination of amoxicillin and clavulanic acid ( B lactamase inhibitor) to overcome resistance
Used in UTIs, and lots of other infections. Broad spectrum.
CI: Penicillin hypersensitivity
Caution: EBV/ CMV infections, ALL, CLL - causes a raash
SE: rash - erythematous, maculopapular (often doesnt reflect allergy), commoner in renal failure.
Nausea and vomiting and diarrhoea.
Hypersensitivity
Interactions: levels increased by probenecid.
Increases the effects of warfarin
Increased risk of rash with allopurinol
Increases levels of methotrexate
Dose: 250mg TDS PO
Tazocin
Use CI Caution SE Interactions Dose
Combination of peperacillin (antipseudomonal penicillin) and tazobactam ( B lactamase inhibitor)
Used in severe infections
CI: allergy,
Caution: hx of allergy, false +ve glycosuria
SE: allergy, diarrhoea.
Rarely blood disorders (low platelets, neutrophils), CNS toxicity, hypokalaemia and hyponatreamia in high doses
Interactions: levels increased by probenecid.
increased risk of rash with allopurinol.
Dose: 2.25 - 4.5 g TDS/ QDS IV
Cefuroxime
Use CI Caution SE Interaction Dose
2nd generation cephalosporin ( 3rd generation = ceftriaxone)
Good for gram -ve (h. infulenzea and n. gonorrhoeae) and gram +ve (s aureus)
CI: cephalosporin hypersensitivy
Caution: if at increased risk of antibiotic aquired colitis (recent antibiotic use, elderly, severe underlyng disease, long hospital stay, GI surgery, drugs that reduce the gastric acidity) penicillin hypersensitivity ( 10% also allergic to cephalosporins)
SE: GI upset, allergy, AKI, intersitial nephritis, hepatic dysfunction, blood disorders, CNS disturbance
Interactions: levels increased by probenecid, increases warfarin effects.
Dose: 250mg TDS PO
** can give false positive coombs and urine glucose test**
Doxycycline
Use CI Caution SE Interactions Warn Dose
Tetracycline antibiotic - inhibits ribosomal (30S) subunit. Has longest t1/2 of all tetracyclines
Used in genital infection, malaria, COPD exacerbation
CI: <12 yrs, acute porphyria, pregnancy
Caution: may worsen myasthenia, or SLE
SE: Gi upset, oesphageal irritation, heahache, dyshagia, hepatoxicity, blood disorders, photosensitivity, anorexia, flushing, tinnitus
Interactions: decreased absorption with milk, antacids, FE, AL, Ca, Mg, Zn salts.
Increased risk of BIH with retinoids
Increases effect of warfarin
Can increase ciclosporin strain
Warn: avoid UV light and ZN/ Fe containing products
Dose: 100 - 200mg od/bd
Gentamicin
Use CI Caution SE Monitor Interactions Dose
Aminoglycoside: broad spectrum - inhibits ribosomal 30S subunit.
Good gram -ve aerobe cover. Often needs cover with metronidazole or penicillin
Used in severe infections
CI: Myasthenia gravis
Caution: obesity
SE: ototoxicity, nephrotoxic, hypersensitivity, rash, decreased Mg if long treatment
Monitor: serum levels aftr 3-4 doses (early in renal failure) measure 1 hr post dose (ideally 5-10mg/l) and trough immediately predose (ideally <2mg/l). If levels are high can increase spacing between doses as well as decreasing dose.
Interactions: effects increased by loop diuretics, cephalosporins, vanc, ciclosporins, ( space as far from gent dose as possible)
increases effects of muscle relaxanrs and anticholinesterases
Dose: once only initally 5-7mg/kg
lower in renal failure
Erythromycin
Use CI Caution SE Interactions Dose
Macrolide antibiotic - binds to 50S ribosome
Used in atypical pneumonias
CI: macrolide hypersensitivity or if taking terfenadine, pimozide, ergotamine or dihydroerotamine
Caution: increase QTc
SE: GI upset, dry itchy skin, hypersensitivity, arrhythmias, chest pain, reversibe hearing loss, cholestatic jaundice
Interactions: decreases P450 - increases levels of ciclosporins, digoxin, theophyllines, carbamazepine and warfarin.
Dose: 500mg QDS PO
Can give IV but is a venous irritant
Vancomycin
Use Caution SE Monitor Interactions Dose
Glycopeptide antibiotic. has poor PO absorption unless the bowel is inflammed so given IV.
Used in serious gram +ve infections and for C.diff (PO)
Caution: hx of deafness, IBD, avoid rapid infusion, can cause anaphylaxis
SE: nephrotoxicity, ototoxicity, blood disorders, rash, hypersensitivity, nausea, fever,
Monitor: serum levels - keep predose trough 10-15mg/l, start to monitor after third dose (first if renal failure).
Also monitor U+Es, FBC, urinalysis
Interactions: Increased nephrotoxicity with ciclosporin.
increased ototoxicity with loop diuretics
increases the effects of suxamethonium
Dose: 1 - 1.5g BD IVI or 125mg QDS PO for Cdiff
Trimethoprim
Use CI Caution SE Warn Interactions Dose
Antifolate antibiotic - inhibits dihydrofolate reductase
Used in UTIs
CI: blood disorders
Caution: low folate, porphyria, pregnancy
SE: rare - skin reactions, blood disorders, GI upset, rash
Warn: those on long term treatment to look for signs of blood disorders and to report fever, sore throat etc
Interactions: increases phenytoin levels.
Increases risk of arrhythmias with amiodarone.
Antifolate effects with pyrimethamne and methotrexate
Increases efffects of warfarin
Dose: 200mg BD PO
Metronidazole
Use Caution SE Interactions Dose
Antibiotic - binds to DNA of anaerobic bacteria and protozoa
Caution: avoid with alcohol ( has disfulfiram like reaction)
SE: GI upset, disturbed taste, skin reactions
Rarely: drowsiness, headache, dizziness, dark urine, hepatotoxicity, myalgia, arthralgia, seizures, ataxia, peripheral neuropathy
Interactions: ca increase busulfan, lithium, ciclosporin and phenytoin levels
Increases warfarin
Dose: 500mg TDS ivi
Ciprofloxacin
Use CI Caution SE Warn Interactions Dose
Quinolone antibiotic: inhibits DNA gyrase, broad spectrum with extra good cover for gram -ve infections
Used for GI and resp infections
CI: hypersensitivity to any quinolone
Caution: hx of seizures, myasthenia gravis, G6PD deficiency, young people. avoid if dehydrated or urine pH increased.
SE: GI upset, pancreatitis, neuro/psych effects (confusion, seizures, headaches, dizziness, hallucinations, sleep disorders) tendinitis (epec if taking steroids), hypersensitivity, crystalluria, increased glucose, skin reactions,
Warn: avoid sun light (can cause photosensitivity)
avoid ingesting Fe and Zn containing products (antacids)
Interactions: increases levels of theophyllines,
NSAIDs increase the risk of seizures
Increases nephrotoxicity of ciclosporins
FeSO4 and antacids reduce the absorption
Dose: 250 - 750mg bd PO,
** MUST STOP if get tendinitis, severe neuro/ psych or hypersensitivity**
Nitrofurantoin
Use CI Caution SE Dose
Antibiotic only present in urine, no systemic effects.
Used for UTIs not for pyelonephritis
CI: C6PD deficiency, acute porphyria, renal failure, < 3yrs, pregnancy
Caution: diabetes, lung disease, low Hb, low vitamin B, low folate, electrolyte imbalance, susceptibility to peripheral neuropathy,
SE: GI upset, pulmonary reactions, peripheral neuropathy, hypersensitivity,
Rarely: hepatoxicity, cholestasis, pancreatitis, arthralgia, alopecia, skin reactions, blood disorders.
Dose: 50mg QDS PO, OD nocte if for prevention
** can cause a false positive urine dipstick for glucose and discolour of urine**
Nystatin
Use
SE
Dose
Polyene antifungal
Used in candida infections - topically for skin and mucous membranes and PO for GI infections (its not absorbed)
SE: GI upset at high doses
Dose: PO suspension 100, 000 units QDS for 1 week. After food!
Clotrimazole
Use
Caution
Dose
Canesten. Imdazole antifungal (topical)
Used for external candida infections
Caution: can damage condoms and diaphragms
Dose: 2-3 applications/ day of 1% cream for 14 days.
Gliclazide
Use CI Caution SE Interactions Dose
Short acting sulphoneurea - increases the pancreatic release of insulin. Stimulates B islet cell receptors and inhibits gluconeogenesis
Used in T2DM - must have endogenous insulin to work.
Not recommended in obesity
CI: ketoacidosis, acute porphyria, severe liver or renal failure
Caution: may need to replace with insulin during intercurrent illness/ surgery
SE: hypoglycaemia, GI upset, weight gain.
Rarely: hypersensitivity, blood disorders, hepatotxicity, transient visual changes
Interactions: effects increased by chlorampenicol, sulphonamides, sulfinpyranzone, antifungals, warfarin, fibrates and NSAIDs.
Levels decreased by ricampicin
Increased risk of hepatoxicity with bosentan
Dose: initially 40-80mg in the morning with food increasing to a max of 320mg/ day.
Comes in long acting modified release form
Metformin
Use
CI
SE
Dose
Oral antidiabetic - biguanide. Increases insulin sensitivity without effecting the levels - decreased gluconeogensis, GI absorption of glucose and increases peripheral use of glucose. Only active in the presence of endogenous insulin
Used in T2DM (causes less weight gain the SUs) and in PCOS
CI: DKA, increased risk of lactic acidosis - renal failure, severe dehydration, infection, periperhal vasc disease, shock, major trauma, resp failure, alcohol dependence, recent MI, GA, iodine containing radiology contrast media
SE: GI upset, taste disturbance,
rarely: decreased vit B12 absorption, lactic acidosis (must stop drug)
Dose: 500mg OD in the morning, increasing to max 2g/day over divided doses
decrease dose in renal failure, do not use in severe renal failure
- when having coronary angiogram - stop on the day and restart 48hrs later, may need insulin cover**
- when having operation stop of day and restart again when renal function back to baseline**
Pioglitazone
Use CI Caution SE Monitor Interactions Dose
Thiazolidinedione (glitazone) antidiabetic - decreases peripheral insulin resistance and hepatic gluconeogenesis
Used in T2DM in combination with a sulphonylurea or metformin, or both (if obese)
CI: ACS, bladder cancer (previous or active) heart failure, liver failure, pregnancy, breast feeding.
Caution: peri operatively - omit as insulin will be needed.
SE: oedema, low Hb, weight gain, GI upset, headache, hypoglycaemia, increased risk of distal #.
Rarely hepatotoxicity
Monitor: LFTs (stop if jaundice) and for signs of heart failure
Interactions: levels decreased by rifampicin
levels increased by gemfibrozil
Dose: initally 15-30mg OD to a max of 45mg OD
Levothyroxine
Use CI Caution SE Interactions Monitor Dose
Synthetic T4.
Used in hypothyroidism
CI: hyperthyroidism
Caution: panhypopituitarism/ other predisposition to adrenal insufficiency (need to replace corticosteroids first), chronic hypothyroidism, CVD, diabetes
SE: features of hyperthryoidism: D&V, tremors, restlessness, headache, flushing, sweating, etc
Osteoporosis if high doses are given
Interactions: can change digoxin and diabetic requirements
Increases the effects of TCAs
Decreases the level of propranolol
Increases effect of warfarin
Monitor: baseline of ECG to help distinguish changes due to ischemia and hypothroidism
Dose: 25 - 200 micrograms in the morning – titrate up slowly
Alendronic acid
Use CI Caution SE Warn Dose
Bisphosphonate - decreases osteoclastic bone resorption
Used in osteoporosis treatment and prevention
CI: delayed GI emptying, low calcium, unable to sit/ sand for > 30mins
Caution: upper G disorders
SE: oesphageal reactions, GI upset, low calcium, low phosphate, peptic ulcer, hypersensitivity, myalgia.
Rarely: osteonecrosis and femoral stress #
Warn: take upright with a full glass of water on an empty stomach, and stay upright for 30mins until breakfast or other oral medicine.
Stop tablets and seek medical attention if symptoms of oesphageal irritation
Dose: 10mg in the morning (or more commonly 70mg once a week)
Finsteride
Use
Caution
SE
Dose
Antindrogen - 5areductase inhibitor. dereases testosterone conversion to more potent dihydrotestosterone
Used in BPH - decreases the prostate size and reduces the symptoms, and in male pattern baldness
Caution: prostate cancer - can lower the PSA and mask it, obstructive uropathy
In pregnancy women must avoid handling tablets and men must be a condom if pregnant or likely to become as it is teratogenic and present in the semen
SE: sexual dysfunction, testicular pain, gynaecmastia, hypersensitivity
Dose: 5mg OD for BPH, 1mg OD for baldness
Oxybutynin
Use CI Caution SE Dose
Anticholinergic - selective M3 anatagoist: antispasmodic (decreases bladder muscle contractions)
Used in detrusor instability
CI: bladder outflow or GI obstruction, urinary retention, severe UC/ toxic megacolon, glaucoma, myasthenia, breastfeeding
Caution: large prostate, autonomic neuropathy, hiatus hernia, hyperthyroid, ischemic heart disease, arrhythmias,
SE: antimuscarinic (dryness) GI upset, palpitations, skin reactions - all mostly dose dependent and less with modified release preps
Dose: 5mg BD/TDS increase up to 5mgnQDS max
Available in patches
Sildenafil
Use CI Caution SE Interactions Dose
Phosphodiesterase type 5 inhibitor increases the local effects of NO (smooth musle relaxation increases and therefore increased blood into the corpus cavernosum)
Used in erectile dysfunction, pulmonary artery hypertension, and digital ulceration under specialist supervision
CI: recent CVA, MI, ACS, low blood pressure (systolic <90), hereditary degenerative retinal disorders. Hx of non arteritic anterior ischemic optic neuropathy, conditions where vasodilatation or sexual activity is not advised.
Caution: CVD, LV outflow obstruction, bleeding disorders, anatomical deformation of the penis, predispostion to prolonged erection (multiple myloma, leukaemia, sickle cell)
SE: headache, flushing, GI upset, dizziness, visual distrubances, nasal congestion, hypersensitivity
Rarely: serious cardiovascular events, priapism, red eyes
Interactions: ** NEVER give with nitrates or nicorandil - can cause +++ hypotension and death **
Antivirals increase levels.
Increases hypotensive effects of B blockers - avoid concomitant use
Levels increased by ketoconazole
Dose: initially 50mg approx 1hr before sexual intercourse, adjusting to response. Max 1 dose in 24hrs
For pulmonary hypertension 20mg TDS
Ferrous sulphate
Use
Caution
SE
Dose
Oral Fe preparation
Used in iron deficiency aneamia - to treat or to prevent
Caution in pregnancy
SE: dark stools, GI upset, change in bowel habit
Dose: to treat - 200mg BD/ TDS, prevention 200mg OD
Diclofenac
Use CI Caution SE Interactions Dose
Medium strength NSAID - non selective COX inhibitor
Used in pain and inflammation in especially musculoskeletal pain
CI/ Caution/ SE/ interactions: the same as ibuprofen but higher chance of bleeding and thrombotic risks
Dose: 25 - 50mg TDS PO
Allopurinol
Use CI Caution SE Warn Interactions Dose
Xanthine oxidase inhibitor: decreases uric acid synthesis
Used in the prevention of gout, renal stones and other increase urate states
CI: acute goat - can worsen, DO NOT start it but dont have to stop it if already taking it when attack flares up
SE: GI upset, severe skin reactions.
Rarely: neuropathy, blood disorders, renal failure, hepatotoxicity, gynaecomastia, vasculitis
Warn: report rashes and maintain good hydration
Interactions: increases the effects and toxicity of azathioprine, chlorproamide and theophyllines.
Levels decreased by salicylates, and probenecid
Increase likelihood of rash with ampicillin and amoxicillin
Increases warfarin
Dose: initally 100mg OD PO, can increase to max of 900mg/ day in devided doses of up to 300mg after food.
Decrease dose if it increases the effects of other drugs or in renal or liver failure,
Quinine Sulphate
Use CI Caution SE Monitor Interactions Dose
Antimalarial
Used in malaria and for nocturnal cramps
CI: optic neuritis, tinnitus, haemoglobinuria, myasthenia gravis
Caution: cardiac disease, G6PD deficiency
SE: visual changes, tinnitus, GI upset, headache, rash/ flushing, hypersensitivity, confusion, hypoglycaemia,
Rarely: blood disorders, AKI, cardiovascular (low BP in OD)
Monitor: BMs, ECG, electrolytes
Interactions: increases the levels of flecanide and digoxin.
Increased risk of arrhythmias with pimozide, moxifloxacin, and amiodarone.
Increased risk of seizures with mefloquine.
Avoid artemether
Dose: 200 - 300mg notc PO for leg cramps
Lantanoprost
Use Caution SE Warn Dose
Topical PG analogue: increases uveoscleral outflow
Used for increased optic pressure in glaucoma and ocular hypertension
Caution: asthma, aphakia (loss of lens of eye), pseudophakia, uveitis, macular oedema
SE: change in colour of iris (increased brown), blurred vision, local reactions. Darkening of periorbital skin and increased eyelash length.
Rarely: cystoid macular oedema, uveitis, angina
Warn: can change colour of iris
Dose: 1 drop of 0.01% OD
