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Medicine Extras > 1st/2nd Line Treatment > Flashcards

1st/2nd Line Treatment Flashcards

1
Q

TTP

A

1st: Plasma Exchange
2nd: Steroids, rituximab
3nd: Splenectomy

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2
Q

Type 2 Diabetes Mellitus

A

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

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3
Q

Hyperthyroidism

A

1st line: Multiple, depends on the patient.

  • Radioactive Iodine: Don’t use in pregnancy
  • Thyroidectomy + Levothyroxine
  • Carbimazole +- Levothyroxine.
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4
Q

Hypothyroidism

A

1st line: Titrate levothyroxine.

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5
Q

Prolactinoma

A

1st line: Cabergoline (Dopamine agonist).

Gold standard: Transsphenoidal surgery.

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6
Q

Acromegaly

A

Gold standard and 1st line:
Transsphenoidal surgery

2nd line(surgery refused):
SST analogue (Octreotide)

3rd line: Cabergoline/Bromocriptine (Dopamine agonist).

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7
Q

Neurogenic Diabetes Insipidus

A

1st line: Desmopressin + Thiazide.

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8
Q

Renal Colic

A

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

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9
Q

Gout

A

Acute 1st line: Colchicine (Anti-inflammatory)

Long-term 1st line: Allopurinol

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10
Q

Rheumatoid arthritis

A

1st: DMARD:
Methotrexate / Leflunomide / Sulfasalazine (pregnant)

(NSAIDs and steroids while initiating MTX “Bridging”).

2nd: TNF-Blockers e.g., Infliximab

Glucocorticoids for flare-ups

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11
Q

ITP

A

No treatment required for children.

1st: glucocorticoids - prednisolone, IV IgG
2nd: Rituximab / High dose dexamethasone

Final resort: Splenectomy

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12
Q

Asthma

A

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

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13
Q

Migraine

A

-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

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14
Q

Polycythaemia

A

1st line:
-Aspirin OD
-Regular venesection

Other:
-Allopurinol (Gout prophylaxis)
-Hydroxycarbamide

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15
Q

Hypocalcaemia

A

1st: IV Calcium gluconate 10mL 10% over 10 mins if severe.

2nd: AdCal + Treat underlying.

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16
Q

Addison’s disease

A

1st line: oral glucocorticoids

Adrenal crisis - IV saline and hydrocortisone

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17
Q

Hypoglycaemia

A

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)

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18
Q

Heart Failure (Reduced EF)

A

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.

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19
Q

Heart Failure (Preserved EF)

A

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.

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20
Q

Paget’s disease

A

1st: Analgesia & bisphosphonates
2nd: Surgery to correct bone deformities

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21
Q

Osteoporosis

A

1st line: AdCal-D3 & bisphosphonates

2nd line: Denosumab – monoclonal antibody to RANK ligand

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22
Q

Supraventricular tachycardia

A

Acute:

  • Valsalval maneuver
  • Adenosine (or Verapamil in asthmatic pt)

Long term: ß-blockers, Ca-blockers, Amiodarone (K+ blocker)

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23
Q

Tension pneumothorax

A

1st: Needle decompression - 2nd intercostal space, midclavicular
2nd: Chest drain

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24
Q

Simple Pneumothorax

A

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.

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25
Q

Oesophageal varices

A

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.

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26
Q

Infective Endocarditis

A

1st: (Before Cultures) Amoxicillin

Streptococci: Benzylpenicillin + Gentamicin

Staphylococci: Flucloxacillin
—-Prosthetic: Add rifampicin + gentamicin

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27
Q

Lupus

A

1st: NSAIDs to control pain
2nd: Hydroxychloroquine / Azothioprine / DMARDs.

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28
Q

Testicular Cancer

A

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.

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29
Q

Erectile Dysfunction

A

1st: PDE4-Inhibitors e.g. Viagra (Vasodilation) + Educate about lifestyle changes.
2nd: Prostaglandin Intracavernous injections OR Vacuum pump.

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30
Q

Neisserial Infection

A

In hospital / Meningitis: Cefotaxime

Primary Care / Community: Benzylpenicillin

Prophylaxis (To close-contacts): Ciprofloxacin/ Rifampcin

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31
Q

Minimal Change Disease

A

1st: Prednisolone
2nd: (If Steroid-resistant) Rituximab / Tacrolimus

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32
Q

Trigeminal Neuralgia

A

1st: Anticonvulsants e.g. carbamazepine, gabapentin, lamotrigine.

2nd line: microvascular decompression/ablative. surgery

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33
Q

Polymyalgia Rheumatica

A

1st: Prednisolone (Reduce dose over time and watch bones)

34
Q

Testicular torsion

A

1st: Urgent surgical exploration

BILATERAL orchidoplexy

35
Q

Malaria

A

Uncomplicated:
Artemisinin — or — Quinine and Doxycycline

Complicated / Severe:
24h Artensuate then the above treatment.

36
Q

Ulcerative Colitis

A

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.

37
Q

Crohn’s

A

Induce Remission:

1st: Prednisolone
2nd: Infliximab (or other anti-TNF antibodies)

Maintain Remission:

1st: Mercaptopurine then Azathioprine (Thiopurines)
2nd: Methotrexate

38
Q

Mallory-Weiss Tear

A

1st: ABCDE + Telipressin
2nd: Urgent Endoscopy + Banding + Adrenaline

39
Q

Barret’s Oesophagus

A

1st: LOTS of lifestyle advice + GORD control + Endoscopic surveillance.
2nd: Resection of dysplastic lesions.

40
Q

Carcinoid syndrome

A

1st:
Surgical resection
Octreotide (Somatostatin analogue)

Metastases: Additional radiofrequency ablation

41
Q

COPD

A

1st: QUIT SMOKING (+Vaccines)
2nd: Either SABA or SAMA
3nd: Stop SAMA and add LAMA and LABA
4th: Add ICS
5th: Consider Oxygen

42
Q

Hepatic Encephalopathy

A

1st Lactulose (Non-Absorbable Sugar)

2nd: Non-absorbable antibiotics (e.g Rifaxamin)

The aim is to kill or reduce gut-produced ammonia,

43
Q

Legionella

A

1st: Clarithromycin / Erythromycin (Macrolides)
2nd: Ciprofloxacin (Quinilones)

DO NOT USE B-LACTAMS

44
Q

Giant-Cell Arteritis

A

1st: IV Methylprednisolone then switch to PO.
2nd: 75mg daily aspirin
3rd: Toxcilzumab (IL-6 Antagonist) for remission.

45
Q

Meningitis

A

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.

46
Q

Autoimmune hepatitis

A

1st and GOLD: corticosteroids e.g. prednisolone

47
Q

CML with Philadelphia Chromosome

ALL with Philadelphia Chromosome

A

1st and GOLD: Imatinib (Tyrosine Kinase Inhibitor)

48
Q

Diabetic ketoacidosis

A

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

49
Q

Cluster headache

A

1st line (acute):
100% O2 for 15 mins
SC triptans

Prophylaxis: Verapamil

50
Q

Rhabdomyolysis

A

1st: IV Fluid

No great 2nd line- Difficult to manage

51
Q

SEPSIS (6)

A

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

52
Q

Antiphospholipid Syndrome

A

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.

53
Q

Essential Tremor

A

1st: Do nothing
2nd: Problematic? Propanolol.

54
Q

Hodgkin’s Lymphoma

Non-Hodkin’s Lymphoma

A

Hodgkin’s: ABVD
Non-Hodgkin’s: RCHOP

+Radiotherapy in both

55
Q

Lead poisoning

A

1st line: remove the exposure

2nd line: chelating agent - calcium disodium edetate

Depends on severity.

56
Q

Beta thalassaemia

A

1st line: regular blood transfusions + iron chelating agent (deferipone) to prevent iron overload

2nd line: bone marrow transplant

57
Q

Sickle cell anaemia

A

Vaso-occlusive crisis: IV fluids & analgesia

Prophylaxis: Hydroxyurea/hydroxycarbamide + folic acid supplementation
OR regular blood transfusion

Bone marrow transplant in severe disease

58
Q

Peripheral vascular disease

A

1st line: Risk factor modification

2nd line: Revascularisation

3rd line: Amputation (when there is foot pain at rest)

AVOID beta blockers

59
Q

Second degree heart block

A

Mobitz I
-No treatment required ;)

Mobitz II
-Pacemaker

60
Q

Third degree heart block

A

1st line: IV atropine

GOLD: Permanent pacemaker insertion

61
Q

Irritable bowel syndrome

A

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

62
Q

Pheochromocytoma

A

1st line and gold: Phenoxybenzamine (∂-Blocker) + Surgical resection

63
Q

Duchenne muscular dystrophy

A

Multiple supportive therapies:

  • Wheelchair for mobility
  • Orthopaedic care - orthotics/surgery for contractures/scolisos
  • Cardiac and resp surveillance

Medication:
1st line and gold: corticosteroids

64
Q

Disseminated Intravascular Coagulation (DIC)

A

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
65
Q

Osteoarthritis

A

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

66
Q

Urinary incontinence

A

1st: Bladder training
2nd: Oxybutinin (muscarinic antagonist)

67
Q

Ankylosing Spondylitis

A

1st: Ibuprofen for pain
2nd: Infliximab for disease modifying

Other: Steroid injection for acute flare up

68
Q

Septic Arthritis

A

2 weeks IV antibiotics
2-4 weeks oral Abx

69
Q

Sarcoidosis

A

Oral prednisolone if:

1- Hilar Infiltrates AND symptoms
2- Any pulmonary infiltrates
3- Hypercalcaemia
4- Eye/Neuro/Heart involvement.

Otherwise: Supportive management, should remit.

70
Q

Type 1 Diabetes

A

1: Insulin (Basal bolus regime, then adding meal-time regimes)
-4 daily glucose measurements.

If BMI >25 consider adding Metformin.

71
Q

Myocardial Infarction

A
  1. Aspirin + either
    -Ticegrelor if all is normal OR
    -Prasugrel to PCI OR
    -Clopi to Cloti (High Bleed RIsk)
  2. Isosorbide Mononitrate / GTN
  3. Acutely; Morphine / Oxygen IF required.
  4. STEMI:
    -PCI + Heparin/LMWH if available within 2h (OR AFTER 12h)
    -Thrombolysis - Tinectaplase/Alteplase within 12h

NSTEMI:
GRACE: >3% = PCI : <3% = Dual AP.

  1. After: Secondary Prevention (DABS):
    -Above dual antiplatelet choice.
    -Beta-blocker + ACE-Inhibitor.
    -Statin.
72
Q

Obesity

A

1.
BMI >40 : Early bariatric surgery

BMI >30 OR >28 + Risk Factors:
-Orlistat (Pancreatic Lipase Inhibitor) for <1 year.

  1. 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.
  2. BMI >30: Bariatric surgery as third line.
73
Q

Atrial Fibrilation

A

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.

74
Q

Ectopic Pregnancy

A

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)

75
Q

Inguinal Hernia

A
  1. Surgery In all patients (unless not fit for surgery):
    -Laparoscopic in bilateral
    -Open mesh surgery in unilateral

Strangulated: Immediate surgery

76
Q

Peri-Anal Fistulae

A

(IE, in Crohn’s)

1: Oral Metronidazole (Should close spontaneously if infection subsides)

  1. Complex: Surgical closure.

Steroids play no role unless there is an actual flare of the disease.

77
Q

Hiatus Hernia

A
  1. Lifestyle advice (Lose weight, quit alcohol/smoking, sit up after meals, don’t eat before bed etc).
  2. PPI
  3. Surgery (Fundoplication): Mostly for symptomatic “Rollling” Hernias where a bit of the stomach recurrs over the gastro-oesophageal junction and above the diaphragm.
78
Q

Ischaemic Stroke / TIA

A

After confirmed no haemorrhage:

  1. Aspirin 300mg
  2. (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.
  3. No glucose for 24 hours
  4. (Secondary Prevention)
    -AF: CHADSVaSc/ORBIT then Rivaroxaban if ok.

-No AF:
—-Switch Aspirin to Clopidogrel
—-No clopidogrel? ADD dipyridamol

-High-dose statin (80mg OD)

  1. Carotid Endarterectomy if >50-70% stenosed.
79
Q

Prostate Cancer

A

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).

80
Q

Achalasia

A
  1. 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.

81
Q

ALS / Unconscious Cardiogenic Patient

A

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)

82
Q

Urticaria

A
  1. Non-Sedating Antihistamine (Cetirizine or Loratidine)
  2. Sedating antihistamine on top of non-sedating for night-time use
  3. Severe/Resistant: 5 day course of oral steroids.

Medicine Extras (24 decks)

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