1st/2nd Line Treatment Flashcards
TTP
1st: Plasma Exchange
2nd: Steroids, rituximab
3nd: Splenectomy
Type 2 Diabetes Mellitus
1st: Metformin (Biguanide)
2nd: Add one:
- Want to lose weight / Heart disease: Dapagliflozin (SGL2-I)
- Can gain weight: Gliclazide (Sulfanylurea)
- Weight-Neutral: Sitagliptin (DPP4)
3rd line: Add another of the above
4th line: Swap one of the above for another.
5th line: Insulin
Hyperthyroidism
1st line: Multiple, depends on the patient.
- Radioactive Iodine: Don’t use in pregnancy
- Thyroidectomy + Levothyroxine
- Carbimazole +- Levothyroxine.
Hypothyroidism
1st line: Titrate levothyroxine.
Prolactinoma
1st line: Cabergoline (Dopamine agonist).
Gold standard: Transsphenoidal surgery.
Acromegaly
Gold standard and 1st line:
Transsphenoidal surgery
2nd line(surgery refused):
SST analogue (Octreotide)
3rd line: Cabergoline/Bromocriptine (Dopamine agonist).
Neurogenic Diabetes Insipidus
1st line: Desmopressin + Thiazide.
Renal Colic
1st line:
IM Diclofenac
Expectant +-tamsulosin (∂-blocker) considered for stones <5mm
2nd line (Post NC-CTKUB):
-Lithotripsy if the stone is 5-20mm
-Uteroscopy if stones 10-20mm (overlap)
-Percutaneous Lithotomy if stones >20mm.
Pyelonephritis / Hydronephrosis:
-Emergency decompression
Gout
Acute 1st line: Colchicine (Anti-inflammatory)
Long-term 1st line: Allopurinol
Rheumatoid arthritis
1st: DMARD:
Methotrexate / Leflunomide / Sulfasalazine (pregnant)
(NSAIDs and steroids while initiating MTX “Bridging”).
2nd: TNF-Blockers e.g., Infliximab
Glucocorticoids for flare-ups
ITP
No treatment required for children.
1st: glucocorticoids - prednisolone, IV IgG
2nd: Rituximab / High dose dexamethasone
Final resort: Splenectomy
Asthma
1st: SABA e.g. Salbutamol
2nd: Weak ICS e.g. Beclamethosone
3rd: LTRA e.g. Montelukast
4th: Stop LTRA and go for LABA e.g. Salmeterol
5th: Strong ICS e.g Beclamethosone
Migraine
-Mild-Moderate: Paracetamol and NSAIDs
-With Aura: Sumatriptan (Serotonin Agonist)
-Vomiting: Metoclopramide (Anti-Emetic)
-Prophylaxis:
1st line: Propanolol
(Avoid asthma)
2nd line: Topirimate
(Avoid Preg)
3rd line: Amitryptaline
Failure: 10 sessions of acupuncture.
Menstrual Migraines: Triptan mini-prophylaxis
Other: Riboflavin (vB2) OD
Polycythaemia
1st line:
-Aspirin OD
-Regular venesection
Other:
-Allopurinol (Gout prophylaxis)
-Hydroxycarbamide
Hypocalcaemia
1st: IV Calcium gluconate 10mL 10% over 10 mins if severe.
2nd: AdCal + Treat underlying.
Addison’s disease
1st line: oral glucocorticoids
Adrenal crisis - IV saline and hydrocortisone
Hypoglycaemia
1st:
Glucogel 10-20g PO if they have a safe-swallow.
2nd:
-IV Glucose 20% (If you have access)
3rd:
IM Glucagon if no IV access (LESS EFFECTIVE IF ON SULFANYLUREA)
Heart Failure (Reduced EF)
1st: ACE-I and Beta-Blocker (No mortality benefit in PRESERVED-EF)
2nd/Preserved EF: Spironolactone +-SGLT2-Inhibitors
3rd: Possibly Ivabradine (If HR >75 and LVEF < 35%) / Digoxin
Always add some furosemide if symptoms; no good for mortality.
Heart Failure (Preserved EF)
1st: SGLT-Inhibitor; Dapagliflozin
(ACE-Is and Beta-Blockers have no mortality benefit)
Always add furosemide for symptoms; no mortality benefit.
May deteriorate to reduced EF; Go to that treatment then.
Paget’s disease
1st: Analgesia & bisphosphonates
2nd: Surgery to correct bone deformities
Osteoporosis
1st line: AdCal-D3 & bisphosphonates
2nd line: Denosumab – monoclonal antibody to RANK ligand
Supraventricular tachycardia
Acute:
- Valsalval maneuver
- Adenosine (or Verapamil in asthmatic pt)
Long term: ß-blockers, Ca-blockers, Amiodarone (K+ blocker)
Tension pneumothorax
1st: Needle decompression - 2nd intercostal space, midclavicular
2nd: Chest drain
Simple Pneumothorax
1st:
-No Symptoms: even if large: Observe +-O2 over 4-6 hours and discharge.
-Symptoms AND >2cm (or safe to intervene):
Assess high-risk characteristics:
Smoke and >50, Hypoxia / Haemodynamic Instab, Bilateral, or SECONDARY, or FAILED NEEDLE.
Present = CHEST DRAIN
Not Present = NEEDLE
-Success when <2cm afterwards.
-EVERY secondary patient will get admitted for monitoring.
-All patients followed-up in 2-4 weeks.
Oesophageal varices
1st: ABCDE: IV Fluids + Telipressin + Prophylactic Abx
+- Blood transufsion
2nd: Urgent Endoscopy:
-Band ligation if possible
-Sansken-Blakemore Tube/Baloon if bleeding doesn’t stop
3rd: TIPS (Transjugular Intrahepatic Portal Shunt) if above fails.
Infective Endocarditis
1st: (Before Cultures) Amoxicillin
Streptococci: Benzylpenicillin + Gentamicin
Staphylococci: Flucloxacillin
—-Prosthetic: Add rifampicin + gentamicin
Lupus
1st: NSAIDs to control pain
2nd: Hydroxychloroquine / Azothioprine / DMARDs.
Testicular Cancer
1st:
- Seminoma (ß-HCG[+]): Orchidectomy + Chemo
- Non-Seminoma (∂FP[+]): Chemotherapy
2nd:
- Seminoma: Radiotherapy.
- Non-Seminoma: Surgery may be needed.
3rd:
- Both, in the presence of metastasis: Lots of chemo.
Erectile Dysfunction
1st: PDE4-Inhibitors e.g. Viagra (Vasodilation) + Educate about lifestyle changes.
2nd: Prostaglandin Intracavernous injections OR Vacuum pump.
Neisserial Infection
In hospital / Meningitis: Cefotaxime
Primary Care / Community: Benzylpenicillin
Prophylaxis (To close-contacts): Ciprofloxacin/ Rifampcin
Minimal Change Disease
1st: Prednisolone
2nd: (If Steroid-resistant) Rituximab / Tacrolimus
Trigeminal Neuralgia
1st: Anticonvulsants e.g. carbamazepine, gabapentin, lamotrigine.
2nd line: microvascular decompression/ablative. surgery
Polymyalgia Rheumatica
1st: Prednisolone (Reduce dose over time and watch bones)
Testicular torsion
1st: Urgent surgical exploration
BILATERAL orchidoplexy
Malaria
Uncomplicated:
Artemisinin — or — Quinine and Doxycycline
Complicated / Severe:
24h Artensuate then the above treatment.
Ulcerative Colitis
Induce Remission:
1st: Rectal Sulfasalazine (Aminosalicylates)
2nd: 4w failure: Oral Sulfasalazine
3nd: Oral Pred
Severe: IV Steroid.
Maintain Remission:
1st: Sulfasalazine (PO or topical or both)
2nd: (2+ relapses per year):
Azathioprine / Mercaptopurine (Thiopurines)
Last resort: Full colotomy.
Crohn’s
Induce Remission:
1st: Prednisolone
2nd: Infliximab (or other anti-TNF antibodies)
Maintain Remission:
1st: Mercaptopurine then Azathioprine (Thiopurines)
2nd: Methotrexate
Mallory-Weiss Tear
1st: ABCDE + Telipressin
2nd: Urgent Endoscopy + Banding + Adrenaline
Barret’s Oesophagus
1st: LOTS of lifestyle advice + GORD control + Endoscopic surveillance.
2nd: Resection of dysplastic lesions.
Carcinoid syndrome
1st:
Surgical resection
Octreotide (Somatostatin analogue)
Metastases: Additional radiofrequency ablation
COPD
1st: QUIT SMOKING (+Vaccines)
2nd: Either SABA or SAMA
3nd: Stop SAMA and add LAMA and LABA
4th: Add ICS
5th: Consider Oxygen
Hepatic Encephalopathy
1st Lactulose (Non-Absorbable Sugar)
2nd: Non-absorbable antibiotics (e.g Rifaxamin)
The aim is to kill or reduce gut-produced ammonia,
Legionella
1st: Clarithromycin / Erythromycin (Macrolides)
2nd: Ciprofloxacin (Quinilones)
DO NOT USE B-LACTAMS
Giant-Cell Arteritis
1st: IV Methylprednisolone then switch to PO.
2nd: 75mg daily aspirin
3rd: Toxcilzumab (IL-6 Antagonist) for remission.
Meningitis
1st/Empirical:
-Benzylpenicillin (in the community).
-Cefotaxime (In hospital)
-Additionally Amoxicillin if Listeria suspected (Patient under 3 months, or over 50 years).
2nd: Sensitivity Antibiotics
Close-contact Prophylaxis:
Ciprofloxacin or Rifampcin.
Autoimmune hepatitis
1st and GOLD: corticosteroids e.g. prednisolone
CML with Philadelphia Chromosome
ALL with Philadelphia Chromosome
1st and GOLD: Imatinib (Tyrosine Kinase Inhibitor)
Diabetic ketoacidosis
1st: IV fluids. (Especially if SBP <90mmHg)
2nd: Fixed-Rate 0.1U/kg/h Insulin
3rd: Glucose IV when <14mmol/L
4th: Careful Potassium Replacement
Cluster headache
1st line (acute):
100% O2 for 15 mins
SC triptans
Prophylaxis: Verapamil
Rhabdomyolysis
1st: IV Fluid
No great 2nd line- Difficult to manage
SEPSIS (6)
GIve 3:
1: Fluids IV
2: Administer Oxygen
3: Empiric Antibiotics IV
Take 3:
1: Take blood cultures
2: Check lactate
3: Check urine output
Antiphospholipid Syndrome
Before any events occur: 75mg Aspirin OD
After an event, lifelong: Warfarin (INR 2-3) or LMWH if pregnant.
After recurrent events: Warfarin with INR 3-4 +- Aspirin.
Essential Tremor
1st: Do nothing
2nd: Problematic? Propanolol.
Hodgkin’s Lymphoma
Non-Hodkin’s Lymphoma
Hodgkin’s: ABVD
Non-Hodgkin’s: RCHOP
+Radiotherapy in both
Lead poisoning
1st line: remove the exposure
2nd line: chelating agent - calcium disodium edetate
Depends on severity.
Beta thalassaemia
1st line: regular blood transfusions + iron chelating agent (deferipone) to prevent iron overload
2nd line: bone marrow transplant
Sickle cell anaemia
Vaso-occlusive crisis: IV fluids & analgesia
Prophylaxis: Hydroxyurea/hydroxycarbamide + folic acid supplementation
OR regular blood transfusion
Bone marrow transplant in severe disease
Peripheral vascular disease
1st line: Risk factor modification
2nd line: Revascularisation
3rd line: Amputation (when there is foot pain at rest)
AVOID beta blockers
Second degree heart block
Mobitz I
-No treatment required ;)
Mobitz II
-Pacemaker
Third degree heart block
1st line: IV atropine
GOLD: Permanent pacemaker insertion
Irritable bowel syndrome
1st line: Dietary modification to avoid triggers
2nd line: Antispasmodics
3rd line: Antimotility agents - loperamide
4th line: TCA or SSRI (if TCA ineffective)
Other: CBT, hypnotherapy etc
Pheochromocytoma
1st line and gold: Phenoxybenzamine (∂-Blocker) + Surgical resection
Duchenne muscular dystrophy
Multiple supportive therapies:
- Wheelchair for mobility
- Orthopaedic care - orthotics/surgery for contractures/scolisos
- Cardiac and resp surveillance
Medication:
1st line and gold: corticosteroids
Disseminated Intravascular Coagulation (DIC)
When SLOWLY EVOLVING and NON-BLEEDING
-Consider Heparin (to prevent platelet loss)
When BLEEDING:
- Specifically low fibrinogen:
- —–Cryoprecipitate (Replace Fibrinogen)
- Specifically low clotting factors:
- —–FFP
- Specifically low platelets:
- —–Platelets
Osteoarthritis
1st line: topical NSAIDs + paracetamol
2nd line: oral NSAIDs + PPI
3rd line: Paracetemol / Weak opioids [ONLY if all other treatments have failed and the course will be short].
4th line: intra-articular steroid injections if all else fails
Final resort: complete joint replacement
Urinary incontinence
1st: Bladder training
2nd: Oxybutinin (muscarinic antagonist)
Ankylosing Spondylitis
1st: Ibuprofen for pain
2nd: Infliximab for disease modifying
Other: Steroid injection for acute flare up
Septic Arthritis
2 weeks IV antibiotics
2-4 weeks oral Abx
Sarcoidosis
Oral prednisolone if:
1- Hilar Infiltrates AND symptoms
2- Any pulmonary infiltrates
3- Hypercalcaemia
4- Eye/Neuro/Heart involvement.
Otherwise: Supportive management, should remit.
Type 1 Diabetes
1: Insulin (Basal bolus regime, then adding meal-time regimes)
-4 daily glucose measurements.
If BMI >25 consider adding Metformin.
Myocardial Infarction
- Aspirin + either
-Ticegrelor if all is normal OR
-Prasugrel to PCI OR
-Clopi to Cloti (High Bleed RIsk) - Isosorbide Mononitrate / GTN
- Acutely; Morphine / Oxygen IF required.
- STEMI:
-PCI + Heparin/LMWH if available within 2h (OR AFTER 12h)
-Thrombolysis - Tinectaplase/Alteplase within 12h
NSTEMI:
GRACE: >3% = PCI : <3% = Dual AP.
- After: Secondary Prevention (DABS):
-Above dual antiplatelet choice.
-Beta-blocker + ACE-Inhibitor.
-Statin.
Obesity
1.
BMI >40 : Early bariatric surgery
BMI >30 OR >28 + Risk Factors:
-Orlistat (Pancreatic Lipase Inhibitor) for <1 year.
- BMI >35 (or 32.5 if high-risk ethnic group, or any BMI with signs of non-diabetic hyperglycaemia):
-GLP-Agonist (E.g Semaglutide) for <2 years. - BMI >30: Bariatric surgery as third line.
Atrial Fibrilation
RATE CONTROL:
-48h+ Symptoms
RHYTHM CONTROL:
-(Under 48h Symptoms
OR >3w DOAC
OR TO-Echocardiogram of LAA with no thrombus found)
-Concurrent Heart Failure
-First episode of AF
-Reversible Cause
Rate:
-Bisoprolol / Verapamil / Diltiazem
-DOAC (CHADSVaSc)
Rhythm:
-LMWH +
-Flecainide (Don’t use if structural heart disease)
-Amiodarone (Don’t use if hypothyroid)
-DC-Cardioversion IF HAEMDYN UNSTABLE.
-4 WEEKS DOAC.
Ectopic Pregnancy
NON-SURGICAL if ALL THREE:
<35mm
No or minimal pain
hCG <5000
SURGICAL IF ANY:
>35mm
Ruptured
Intolerable Pain
Visible Heartbeat
hCG >5000
Details:
Non-Surgical:
-hCG < 1500 and no pain = Expectant
-hCG > 1500 = Methotrexate 50mg + Followup (+- second dose MTX)
Surgical:
-1: Salpingectomy
-2: Salpingotomy (If previous removal a tube/ovary)
Inguinal Hernia
- Surgery In all patients (unless not fit for surgery):
-Laparoscopic in bilateral
-Open mesh surgery in unilateral
Strangulated: Immediate surgery
Peri-Anal Fistulae
(IE, in Crohn’s)
1: Oral Metronidazole (Should close spontaneously if infection subsides)
- Complex: Surgical closure.
Steroids play no role unless there is an actual flare of the disease.
Hiatus Hernia
- Lifestyle advice (Lose weight, quit alcohol/smoking, sit up after meals, don’t eat before bed etc).
- PPI
- Surgery (Fundoplication): Mostly for symptomatic “Rollling” Hernias where a bit of the stomach recurrs over the gastro-oesophageal junction and above the diaphragm.
Ischaemic Stroke / TIA
After confirmed no haemorrhage:
- Aspirin 300mg
- (Only for actual strokes)
-Alteplase in 4.5 hours if no haemorrhage or bleeding risk WITH thrombectomy within 6 hours.
-Thrombectomy alone 6-24 hours. - No glucose for 24 hours
- (Secondary Prevention)
-AF: CHADSVaSc/ORBIT then Rivaroxaban if ok.
-No AF:
—-Switch Aspirin to Clopidogrel
—-No clopidogrel? ADD dipyridamol
-High-dose statin (80mg OD)
- Carotid Endarterectomy if >50-70% stenosed.
Prostate Cancer
T1/T2 (Both lobes, but within capsule):
-Watchful waiting (Mostly in the old)
-Radical prostatectomy
-Brachytherapy
T3/4 (Penetration into areas around prostate):
-Radiotherapy
-Endocrine therapy (Gozerellin [GNRHAg] + short Cyproterone [Anti-androgen] course)
-Radical prostatectomy.
Metastatic:
-Endocrine therapy (Gozerellin [GNRHAg] + short Cyproterone [Anti-androgen] course).
Achalasia
- Nitrate or CCB before meals to reduce symptoms (Helps sphincter relax) while awaiting definitive management.
Definitive:
-Tolerate surgery: Pneumatic dilateion or Cardiomyotomy
-Not tolerate surgery: Botox injections.
ALS / Unconscious Cardiogenic Patient
Strategy:
-CPR + Help immediately
-Shock (3x if monitored) ASAP and every two mins
-Adrenaline (ASAP if PEA/Asystole) every 3 mins + 3rd shock
-Amiodarone every 3 shocks.
-Oxygen
-Reverse causes (e.g PE = Alteplase)
Urticaria
- Non-Sedating Antihistamine (Cetirizine or Loratidine)
- Sedating antihistamine on top of non-sedating for night-time use
- Severe/Resistant: 5 day course of oral steroids.
