18 month exam revision Flashcards
In patients with ACS, we are looking for raised troponin levels to aid diagnosis. What other conditions could raise troponin?
AF
Poor Renal Function
Drug eluting stents contain antiproliferative agents such as _____ to stop cells growing around the stent
Paclitaxel
What is referred to as high dose ICS in terms of BDP equivalence?
1,200–2,000 micrograms per day in 2 divided doses of Beclomethasone Dipropionate
Budesonide: 1,000–1,600 micrograms per day in 2 divided doses
When critically appraising a randomised control trial using the CASP tool, what is most important to consider?
Whether the results are statistically significant
What is paroxysmal AF as per NICE?
Paroxysmal atrial fibrillation spontaneously terminates within 7 days, usually within 48 hours
Which of the following side effects of amiodarone is listed as common?
Nausea + vomitting
Liver toxicity
Thyroid disorders
Corneal microdeposits
Thyroid disorders
In a patient with severe hyperkalemia (K+ of 6.6 & ECG changes present), what is the primary focus for management?
In patients with severe hyperkalemia, treatment focuses on immediate stabilization of the heart using calcium gluconate:
10–20 mL, calcium gluconate 10% over 3-5 minutes
What is the mechanism of action of Aminoglycosides?
bind to the 30s ribosomal sub-unit and inhibit protein synthesis
Patients with CAP and a CURB score of 3-5 are classed as having severe pneumonia. What treatment is indicated here?
IV treatment
Co-amoxiclav 1.2 g tds IV plus
clarithromycin 500 mg bd IV
Patients classed as having moderate severity CAP (CURB score = 2) are treated how?
Amoxicillin 500 mg – 1.0g tds orally plus clarithromycin 500 mg bd orally
alternative: Doxycycline 200 mg loading dose then 100 mg
Rash is considered a Type __ reaction to Phenytoin
Type B
What are the risks with NG tubes? state two potential risks
Infection risk
Dislodging/ aspiration
What happens with grade 4 (severe) hypovolaemic shock?
> 2L of fluids lost
Severe hypotension
Anuria (no unrine output)
Being female and a non-smoker puts you more at risk of what condition?
Post operative nausea and vomitting
These two factors along with history or PONV & post-op opioid administration are all factors in the Apfel scoring system for PONV.
If any opioid is used during surgery, patients are considered high risk
Gynae, abdominal, ear/ ENT surgery all pose a greater risk of what?
Post op nausea and vomitting
What was the name of the case-control study that found 10 different risk factors to account for 90% of strokes?
INTERSTROKE
Alteplase is proven to significantly reduce death and disability at 90 days.
What is the time window in which Alteplase can be administered? The ISHT-3 trial showed similar efficacy if Alteplase is administered to those under 80 years old and also over 80 (showed to be safe). It showed that greatest benefit is seen if Alteplase is administered within __ hours.
Should be administered within 4.5 hours
Greatest benefit if administered within 3 hours
What does the ABCD(^2) tool show?
It estimates the risk of recurrence of stroke at 2 days and 7 days post TIA. Those with scores of over 5 are at 10x greater of having a recurrent stroke than those with scores under 4. Those with scores of >4 should have a same day assessment in the stroke unit (within 24 hours)
What trial supports the use of Aspirin 300mg OD for 2 weeks post stroke?
CAST
IST
What trial supports the use of Aspirin to Clopidogrel switch after 14 days post stroke?
PROFESS
What type of lipoproteins should be reduced in patients with ischaemic stroke or TIA caused by athersclerosis?
Low density Lipoprotein cholesterol
Target LDL: <2mmol/L
Reducing LDL level by 1mmol/L reduces risk of recurrent stroke by 12% and all strokes by 21%
Reducing LDL level by 2-3mmol/L reduces risk of stroke by 40-50%
What statin/ dose should be considered for patients with TIA or ischeamic stroke?
Atorvastatin 80mg
THIS IS SECONDARY PREVENTION
If patients are intolerant to aspirin, then clopidogrel 300mg OD can be used for 14 days post stroke then 75mg OD thereafter
Which Trials support this?
CARESS
CAPRIE
PROFESS
What did the stroke trial ‘INTERACT 2’ show?
ANTIHYPERTENSIVES TRIAL:
In patients with intracerebral heamorrhage, intensive lowering of blood pressure did not result in a significant reduction in the rate of death or severe disability
The PROGRESS Trial involved
Preventing Strokes by Lowering Blood Pressure in Patients with Cerebral Ischemia.
What was the first line ACEi used in this trial?It was shown to be effective in combination with which diuretic to lower BP?
Perindopril
In combo with Indapamide
Why should we hold of antihypertensives in the acute phase of stroke?
IF the clot is still in place, only a tiny amount of blood will be getting through, therefore we dont want to hypoperfuse the brain even further
Can consider starting statins/ BP meds 48 hours after symptom onset/ initial treatment and after imaging confirms clot has gone.
Megans notes: after 10 - 14 days antihypertensive treatment can be started if BP greater than 140/85
What is target BP post TIA?
What class of medicines should be avoided to assist in lowering BP post stroke?
under 130/80
Avoid use of beta blockers
Diltiazem is often seen used in patients with persistent / permanent AF. What type of drug is this?
Why should this never be used in combo with a beta blocker?
Rate limiting calcium channel blocker
Other rate limiting CCB: Verapamil
Beta blocker + Diltiazem/ Verapamil= potential to cause heart block if used together
What is the difference between Paroxysmal, Permanent and Persistent AF?
Paroxysmal: This is an episode of atrial fibrillation that lasts less than a week, usually resolves within 48 hours
Commonly manages with ‘Pill in the pocket’- Flecainide, sotolol, amiodarone
Persistent: Usually, this lasts longer than a week
Permanent: AF symptoms that do not go away
What levels of BP are classified as STAGE 1, 2, and 3 hypertension?
1: BP= 140/90mmHg and above
2: BP= 160/100mmHg and above
3: BP= 180/ 110mmHg and above
Do we ever combine both an ACE inhibitor plus an ARB to control hypertension?
NO- its only either or used
Black afro-carribean: consider using an ARB at step 2 over ACE inhibitor treatment (use a CCB first line)
What are the preferred diuretics of choice used for Hypertension?
Thiazide like diuretics
Namely Indapamide or Chlortalidone
Why are beta blockers contra-indicated in patients with diabetes?
As they may block signs of low blood sugar, such as rapid heartbeat
What is the name of the assessment tool to assess Cardiovascular Disease Risk (CVD risk) for the primary prevention of CVD in people up to 84 years old?
This tool estimates the risk of a CV event occuring in the next ___ years.
QRISK2
Estimates the risk of a CVD event happening in the next 10 years
What is the difference between Type A and Type B adverse drug reactions?
Type A are predictable, dose-related toxicities, often identified in preclinical or clinical trials, and usually occur in overdose settings or with pre-existing hepatic impairment- e.g. respiratory depression with opioids
Type B are not clearly related to increasing dose and are associated with drug-specific and patient-specific characteristics. Hypersensitivity (allergic) reactions to drugs are examples of type B ADRs- e.g. rash/ anaphylaxis with penicillins
Which cholesterol (HDL/ non-HDL/ LDL) is the bad stuff?
HDL= GOOD cholesterol
non HDL/ LDL= BAD cholesterol. Statin therapy aims to reduce this level
Non HDL(bad) = Total Cholesterol minus HDL (good) cholesterol
What level of statin therapy should be used for patients with a 10% or greater 10-year risk of developing CVD? Should this be used first line?
Atorvastatin 20mg
PRIMARY PREVENTION
Advice on lifestyle changes should be used first line
Statin therapy should be second line
What organ may statins affect and therefore what should be monitored?
Liver
LFT’s - baseline, 3 months, 12 months
In patients with T1DM, when should statins be used?
Primary prevention (atorvastatin 20mg) should be used in patients with type 1 diabetes who are:
Over 40 years old
Had diabetes for >10 years
Have established nephropathy
Have other CVD risk factors
Adults newly diagnosed with CVD are offered atorvastatin at what dose?
atorvastatin 80mg
What is the name of the trial that showed the role of Spironolactone to improve mortality in patients with HF?
RALES trial
Spironolactone at a dose of 25mg on alternate days, increased to 50mg OD if tolerated
It is an aldosterone antagonist, it should be administered within 3-14 days of a Heart Attack, preferably after an ACEi has been started
In patients with Heart Failure, what drug combination is a suitable alternative to an ACE inhibitor and an ARB for those that are intolerant?
Hydrazaline in combination with a nitrate!!!
When should Digoxin be used in patients with HF?
Used for worsening or severe Heart Failure due to LVSD despite first or second line Tx
When should patients undergoing surgery have their warfarin stopped?
All patients requiring surgery should have their warfarin stopped 5 days before the operation
Give phytomenadione (po VitK) day before if INR ≥ 1.5
Patients on warfarin need their therapy bridging if undergoing surgery. We tell them to stop taking warfarin 4 days before treatment
How do we bridge patients deemed low risk?
How do we bridge patients deemed intermediate risk?
Low risk: no bridging required
Intermediate Risk- Bridge with PROPHYLACTIC enoxaparin 3 days pre-operatively at 9.00am. Miss on the morning of surgery and resume 6 hours post-operatively until patient reaches and INR of 2
Patients on warfarin need their therapy bridging if undergoing surgery. We tell them to stop taking warfarin 4 days before treatment
How do we bridge patients deemed highrisk?
High Risk- Bridge with TREATMENT dose enoxaparin at 9am 3 days pre-operatively, miss on the morning of the operation and resume 6 to 24 hours post-op once haemostasis is secure until the patient reaches an INR of 2.
When should we consider stopping oestrogen containing oral contraceptives/HRT before surgery due to increased clot risk?
Consider stopping oestrogen containing oral contraceptives/HRT 4 weeks before elective surgery with alternative contraception
Anesthetics carry a risk of VTE/DVT.
What carries increased risk?
General over Local anaesthetic
Surgical Procedure with a total anaesthetic and surgical time >90 minutes, or 60 minutes if surgery involves the pelvis or lower limb
VTE prophylaxis recommended for __ weeks following:
Total Hip Replacement?
Total Knee Replacement?
Fractured neck of femur (#NOF)?
Total Hip Replacement and #NOF= 4-5 weeks
Total Knee Replacement= 2 weeks
What is DKA?
Insulin deficiency results in ketone production in the liver.
Ketones are excreted by the kidneys and are initially buffered in the blood, however once the system fails then metabolic acidosis occurs.
How should patients on sulphonylureas undergoing LONG surgeries be managed?
Pre-surgery intervention is not usually required for short-medium surgery
For longer surgeries, short-acting sulphonylureas (gliclazide and tolbutamide) should be omitted on the morning of the surgery to reduce the risk of hypoglycaemia that can occur in the NBM patient.
Longer-acting sulphonylureas (e.g. glibenclamide) should be stopped two to three days before surgery and can be converted to either short-acting sulphonylureas or insulin.
How is metformin manged pre-surgery?
For longer surgeries or surgeries using contrast media metformin should be stopped 48 hours before surgery with general anaesthesia
It should not be started for at least 48 hours after to reduce the risk of lactic acidosis
What is the GLIK regimen?
GLIK is basically insulin administered as a single dose as an infusion with glucose and potassium
Suitable for patients likely to be NBM for <48 hours
It is not as flexible as a sliding scale, but is easy to control on a busy surgical ward
Sliding scale is more appropriate if NBM >48 hours, its more titratable and provides more stable blood glucose levels
At what level eGFR should metformin be re-commenced after surgery?
Metformin should only be recommenced if the eGFR is > 50mls/min
(Contra-indicated if eGFR <45)
Can you think of three SICK DAY rules for diabetic patients?
Never stop taking insulin or tablets- illness increases your need for insulin
Test blood glucose levels every 2 hours, day and night
Test urine for ketones every 2 hours
Eat normally + stay hydrated
How is an intravenous aminophylline dose converted to an oral aminophylline or theophylline dose?
If the IV aminophylline dose is 35mg/hr and the dosing interval for oral aminophylline and oral theophylline is every 12 hours, calculate the appropriate BD oral doses
The conversion from IV aminophylline to oral aminophylline is just a straight conversion so
1) work out the total daily IV dose: 840mg
2) divide by 2 to get BD dosing= 420mg BD
3) work out what the nearest dose according to tablet strength is (225mg tabs) = Phyllocontin Continus® 450mg PO BD
The salt factor for aminophylline to oral theophylline is approximately 0.8
Therefore in this case you need to times the totally IV dose by 0.8= 672mg
Could therefore give Uniphyllin Continus® 300mg in the morning and 400mg in the evening
Describe the different types of Enteral Nutrition Tubes:
NG NJ PEG RIG PEJ
See notes
Explain what Type C, D and E ADR’s are
Type C Reactions= ‘continuing’ reactions, persist for a relatively long time. An example is osteonecrosis of the jaw with bisphosphonates.
Type D Reactions+‘delayed’ reactions, become apparent some time after the use of a medicine. The timing of these may make them more difficult to detect. An example is leucopoenia, which can occur up to six weeks after a dose of lomustine.
Type E Reaction= ‘end-of-use’ reactions, are associated with the withdrawal of a medicine. An example is insomnia, anxiety and perceptual disturbances following the withdrawal of benzodiazepines.
What are the three different types of incompatibility of drugs administered down tubes?
Therapeutic incompatibility- i.e. drug interactions, pH changes, altered renal excretion by one drug effecting another, enzyme induction resulting in altered metabolisms
Physical incompatibility: Interaction between 2 substances leading to change in colour, odor, taste, viscosity. Examples: insolubility, immiscibility (two liquid drugs wont mix)
Chemical incompatibility:
chemical reaction occurs between two substances changing its chemical properties e.g. oxidation, hydrolysis
Describe the differences in IV access:
Peripheral line
Central line/ Hickmann line
PICC line
See notes
What two vaccines are required for patients with COPD?
pneumococcal and influenza
What criteria must be met to move up a step from 1 to 2 in the NICE/BNF asthma guidelines?
Using salbutamol inhaler three times a week or more
Having symptoms three times a week or more
Experiencing night time symptoms once a week or more
Had an asthma attack in the last two years
What happens to Theophylline in smokers and alcohol users?
What is the target concentration for theophylline?
The plasma-theophylline concentration is decreased in smokers, and by alcohol consumption
10–20 mg/litre
Plasma-theophylline concentration is measured 5 days after starting oral treatment and at least 3 days after any dose adjustment. A blood sample should usually be taken 4–6 hours after an oral dose of a modified-release preparation
Theophylline has a narrow therapeutic window, target plasma conc is 10-20 mg/L
What are signs of theophylline toxicity?
vomiting, agitation, restlessness, dilated pupils, tachycardia, and hyperglycaemia, also hyperkaleamia
What conditions is theophylline levels increased by?
What conditions are levels decreased by?
The plasma-theophylline concentration is increased in heart failure, hepatic impairment, and in viral infections.
It is decreased in smokers, and by alcohol consumption.
Plasma _____ levels should be monitored in patients with severe asthma, because beta 2 agonists, theophylline, corticosteroids can all cause ________
Potassium levels
Hypokaleamia
remember that these asthma medications all cause LOW potassium
Preparations containing Phenytoin sodium are not equivalent to those containing Phenytoin Base. 100mg of Phenytoin Sodium is equivalent to ___mg of phenytoin base
Equivalent to 92mg
Do aspirin / Nsaids increase the risk of Upper or lower GI bleeds?
Lower GI bleeds
The Blatchford score and the Rockall score are measures for what?
For patients with acute upper GI bleeding
Blatchford score for first assessment
Full Rockall score after the endoscopy
What clotting factors does warfarin inhibit?
Factor 2, 7, 9 and 10
Remember 2 + 7 = 9 then 10
Clopidogrel interacts with PPI’s.. therefore what do we advised if these are to be given together?
Separate their administration by 2 hours
Why do we assess the levels of the TPMT enzyme before starting therapy with azathioprine/ mercaptopurine in patient with Chrons ?
These drugs work by interfering with DNA synthesis and inhibiting proliferation of quickly growing cells.
TPMT is an enzyme that increases the metabolism of these drugs, so low levels of TPMT= more exposure to azathioprine/ mercaptopurine = risk of myelosuppression
Mesalasine and sulfasalasine are used in which GI disorder?
Ulcerative colitis
Why is chlordiazepoxide the benzodiazepine of choice in alcohol withdrawal?
It has a low dependent forming potential compared to other benzodiazepines
Alternative- diazepam
If severe/acute liver impairment= use lorazepam- so ask about LFTS, as impairment of liver will impair the metabolism of Chlordiazepoxide
What is Terlipressin used for?
Variceal bleeding
Where do Glycopeptides exert their action on bacterial cells? What are some examples?
GlycoPEPTIDes inhibit PEPTIDoglycan cross-links in the cell wall
E.g: Vancomycin, Teicoplanin
What is the mechanism of Penicillins?
Inhibit enzymes that are responsible for cross linking peptidoglycans in bacterial cell walls
How do Macrolides exert their bacteriostatic effects?
Macrolides:
Clarithromycin
Azithromycin
Erythromycin
Bind to 50S subunit of ribosomes inhibiting protein synthesis (similar to Aminoglycosides: bind to 30S subunit)
Which conditions are Beta blockers used as secondary prevention;
NSTEMI
STEMI
Unstable Angina (all 3= ACS)
Stroke
All ACS conditions (STEMI, NSTEMI, unstable angina) involve a Beta blocker as secondary prevention
Beta blockers are contra-indicated in Stroke, however they can be continued if they are for another condition
Co-careldopa contains Levodopa and Carbidopa
Co-beneldopa contains Levodopa and Benserazide
What are the roles of these different drugs in Parkinsons?
Levodopa= replenishes depleted striatal dopamine
Benserazide + Carbidopa= dopa-decarboxylase enzyme inhibitors, reduce the peripheral conversion of levodopa to dopamine BEFORE they cross the Blood Brain Barrier, hence limit side effects such as Nausea + Vomitting
Dopamine in the periphery= nausea/ vomitting. Metoclopramide= antisickeness= a dopamine anatagonist, but it crosses the BBB so shouldn’t be given in Parkinsons as it will increase PD symptoms! Use Domperidone to control N&V in Parkinsons patients
Antimuscarinic drugs such as Procyclidine can be used in ________ Parkinsons disease
Drug-induced
remember procyclidine was always used to control EPSE’s in mental health patients as a result of their anti-psychotics
Stalevo contains Levodopa Carbidopa and Entacapone. What is Entacapone for?
Its a COMT enzyme inhibitor which stops the peripheral breakdown of levodopa, similar to carbidopa which inhibitor dopa-decarboxylase enzyme
What is the mechanism of Parkinsons drug Pramipexole and what can it cause if titrated too quickly?
Its a dopamine receptor agonist
Can cause dopamine excess- symptoms= nausea, vomiting, irregular heartbeat, anxiety
