BPS Mocks Flashcards
Which treatment summary has information on vaginal thrush?
Antifungals, systemic use
How can vaginal candidiasis be treated?
may be treated with locally acting antifungals, fluconazole given by mouth or itraconazole by mouth for resistant organisms.
Itraconazole for likely immunosuppressed patients
For uncomplicated vulvovaginal thrush, treatment choice and formulation depend on the patient’s age, personal preference and contra-indications / cautions. An initial course of an intravaginal antifungal cream or pessary, or an oral antifungal is appropriate for most women.
Clotrimazole, econazole nitrate or miconazole can be used vaginally.
Fenticonazole could be used but is not available in the UK. Fluconazole or itraconazole can be used orally. Fluconazole 150 mg PO can be given as a single dose for vaginal candidiasis.
Which treatment option should be used for vaginal candidiasis if the patient is likely to be immunosuppressed?
Oral itraconazole
Check if the patient is taking systemic corticosteroids (immunosuppressed then!)
Which SINGLE USE vaginal option for thrush treatment is there?
As a single dose is requested,** clotrimazole 10% cream or 500 mg pessary** should be prescribed. Clotrimazole 100 mg and 200 mg pessaries are used nighty for 6 nights or 3 nights respectively. Clotrimazole 1% and 2% cream are suitable for superficial sites of infection in vaginal and vulval candidiasis but require 2-3 times daily application. A single application of lower strengths of cream or pessaries is not appropriate.
Alternative: Econazole nitrate as single dose 150mg pessary (gyno-pevaryl once)
What is the standard dose of alteplase for ischaemic stroke?
900 micrograms/kg (max. 90mg)
The first 10% of the dose is given by IV injection
The remaining 90% is given by IV infusion
Which medication should be given in ischaemic stroke to improve OUTCOMES (most appropriate to increase th elikelihood of recovery)?
Alteplase
Urgent thrombolysis recommended as early as possible within 4.5 hours of onset of symptoms.
Which drugs are recommended for VTE prophylaxis following elective knee replacement surgery?
Any of aspirin, LMWH or rivaroxaban
Alternatives where first lines are contraindicated: apixaban and dabigatran
Specifically:
* low-molecular-weight heparin (LMWH) for 14 days;
* aspirin 75 mg or 150 mg PO daily for 14 days;
* rivaroxaban 10 mg PO daily for 14 days;
* apixaban 2.5 mg PO twice daily for 10-14 or dabigatran etexilate 220 mg PO once daily for 10 days if none of the above options can be used.
If a patient is started on tinzaparin sodium for VTE prophylaxis, what should be monitored?
The platelet count should be monitored periodically following discharge on LMWH due to the risk of heparin-induced thrombocytopenia.
Treatment of choice for patients WITH visual loss assocaited with giant cell arteritis?
Immediate treatment with methylprednisolone
dose of 0.5-1 g IV daily for 3 days initially. High dose therapy should be given until remission of symptoms, until maintenence therapy with prednisolone (PO) canbe acheived.
If IV glucocorticoid therapy is not available for giant cell arteritis with visual loss, what is the SECOND best treatment option?
prednisolone 60-100 mg PO daily can be given for up to 3 consecutive days pending referral to a rheumatologist.
Low dose is FIRST line for patients without visual loss
How long do patients with GCA stay on prednisolone for?
A maintenance dose of prednisolone 7.5-10 mg PO daily is continued for at least 2 years or longer in some patients.
How should methylprednisolone be prescribed for GCA with visual loss?
500mg - 1 g intravenous daily
For 3 days
Methylprednisolone sodium succinate
Methylprednisolone must be prescribed as the sodium succinate salt for this indication. Methylprednisolone acetate injection is a suspension intended for IM or intra-articular depot injection only
Which fluid should be administered ALONGSIDE variable rate IV insulin induction for diabetics undergoing surgery?
sodium chloride 0.45% / glucose 5%/ potassium chloride 0.15% solution
Glucose and potassium are required to provide a substrate for insulin when a VRIII is running to reduce the risk of hypoglycaemia and hypokalaemia.
At what rate should X be given alongside VRIII (diabetic undergoing surgery)?
IV fluid at a rate of 1 litre over 8 to 12 hours (83 to 125 mL/h)
Which fluid is recommended for resuscitation in children?
Glucose-free crystalloids that contain sodium in the range 131-154 mmol/L, with a bolus of 10 mL/kg over less than 10 minutes, in children aged 29 days and older.
Options: Hartmann’s solution, Plasma-Lyte, sodum chloride 0.9%, Ringer’s solution
First line drug for hyperemesis gravidarum?
Antihistamine (oral cyclizine or promethazine) or a phenothiazine (oral prochlorperazine)
The patient should be reassessed after 24 hours then the chosen anti-emetic continued if response is good.
Drugs that may cause tremor?
Haloperidol 1.5 mg oral (PO) nightly
Salbutamol 2.5 mg nebulised (NEB) as required
Theophylline m/r 200 mg oral (PO) twice daily (12-hrly)
Haloperidol, like most antipsychotic drugs, may be associated with the development of a tremor. This may be of a Parkinsonian-type because of the dopaminergic antagonism that is characteristic of this type of drugs. They also cause other movement disorders such as ‘tardive dyskinesia’ after long-term usage. Theophylline and its derivatives are indicated for the treatment of reversible airways obstruction. They act by inhibiting phosphodiesterase and thereby potentiating the actions of cyclic adenosine monophosphate, the secondary messenger involved in beta-adrenergic transmission. This promotes bronchodilatation but also tends to cause tremor in the peripheral musculature. B-agonists such as salbutamol also cause tremor as a common adverse effect. It is particularly common when high doses are used as is the case with nebulised treatment. Tremor is also a potential adverse effect of lansoprazole but this is rare…
Which lung condition is associated with nitrofurantoin?
Pulmonary toxicity
Nitrofurantoin is an uncommon but important cause of pulmonary toxicity that may present as acute, subacute, and chronic reactions. The most common manifestation is acute toxicity which may develop within a week of initiation of nitrofurantoin but may also appear a few hours to a month after the first dose. Nitrofurantoin may exert its toxic effects through a hypersensitivity reaction (acute form), or more slowly developing oxidant-mediated tissue injury (chronic form). Longer-term effects of nitrofurantoin include the development of pulmonary fibrosis.
Which antibiotic interacts with sodium valproate to increase the risk of seizures?
Meropenem
The BNF lists an interaction between doxycycline and sodium valproate causing an increased risk of hepatotoxicity, but not an increased risk of fitting.
What is the result of the interaction between doxycycline and sodium valproate?
Increased risk of hepatotoxicity
What is the starting dose for bisoprolol?
For hypertension: 5-10mg PO daily (max. 20mg)
Heart failure: 1.25mg PO daily (max. 10mg)
NOTE: other beta-blockers such as atenolol may have other doses
What is the recommended dose of rivaroxaban for atrial fibrillation?
20 mg PO daily
What is the recommended dose of rivaroxaban for prophylaxis of atherothrombotic effects following ACS with elevated biomarkers?
2.5 mg PO twice daily (usually for 12 months) in combination with aspirin and/or clopidogrel
Which drugs are known to exacerbate/cause gout? (6)
- Aspirin
- Ticagrelor
- Bumetanide (and all other loop diuretics)
- Calcineurin inhibitors e.g. ciclosporin
- Pyrazinamide
- Antineoplastic drugs
Who is Sacubitril/Valsartan indicated for?
NICE recommend sacubitril/valsartan as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people with NYHA class II to IV symptoms and with a left ventricular ejection fraction of 35% or less and who are already taking a stable dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). This patient is taking 10 mg daily of ramipril which is the maximum licensed dose for symptomatic heart failure.
Sacubitril/valsartan should not be co-administered with what?
an ACE inhibitor or an ARB.
Due to the potential risk of angioedema when used concomitantly with an ACE inhibitor, sacubitril/valsartan must not be started until at least 36 hours after discontinuing ACE inhibitor therapy. As this patient is currently prescribed ramipril, sacubitril/valsartan should not be started until 36 hours after discontinuing ramipril.
The use of sacubitril/valsartan in combination with what drugs can increase the risk of hypotension?
carvedilol, eplerenone and empagliflozin
Which drug commonly used in psychiatry can result in raised CK levels?
Haloperidol (through side effect of rhabdomyolysis)
Although: NMS is most likely to cause raised CK
Which drugs can cause NMS?
any anti-dopaminergic medicine, such as antipsychotics or metoclopramide
Neuroleptic malignant syndrome (NMS) is a rare, but life-threatening complication of treatment with any anti-dopaminergic medicine, such as antipsychotics or metoclopramide. NMS can also be caused by abrupt withdrawal of anti-Parkinsonian medication. First generation antipsychotics such as haloperidol carry the greatest risk. Features include muscle rigidity, hyperthermia, and autonomic instability, with a raised serum creatine kinase, and often delirium. Management is typically supportive, with treatment of the rhabdomyolysis, acute kidney injury, and hyperkalaemia. Aggressive correction of hyperthermia in intensive care is sometimes necessary, as well as management of agitation with benzodiazepines. Dantrolene and bromocriptine are occasionally used in the management of NMS. Stopping the causative agent is critical. Mortality can be as high as 10-20%, although this is reduced by early recognition and treatment. This is a potential cause of this patient’s symptoms, including the raised creatine kinase.
What are the features of NMS?
muscle rigidity, hyperthermia, and autonomic instability, with a raised serum creatine kinase, and often delirium.
Combining statins with what classes of medications increases the risk of rhabdomyolysis?
fibrates, or niacin (vitamin B3)
Management of statin-induced rhabdomyolysis involves suppo njury and hyperkalaemia, and stopping the causative agent.
Where in BNFc can information about the expected body weight be found?
In the BNF for Children, the expected body weight for children of different ages is found under ‘About BNFc’; ‘Approximate Conversions and Units’; ‘Prescribing for children: weight, height, gender’.
Which weight should be used for a patient (child) who is obese?
IDEAL body weight for their height (to avoid overdosing them)
Which analgesic should be avoided in patients with asthma?
Ibuprofen is not an appropriate choice of treatment in view of the patient’s history of asthma and presentation with chicken pox.
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may induce bronchospasm causing worsening of asthma, either acutely or through gradual worsening of symptoms when used for longer periods.
Which antiemetic is not commonly used in children?
Metoclopramide hydrochloride
Under ‘Important safety information’, the BNF for Children warns that metoclopramide is associated with an increased risk of neurological adverse effects in children and young adults, including extra-pyramidal reactions and tardive dyskinesia.
As a result metoclopramde is only licensed for use in children aged 1-18 years for the prevention of delayed chemotherapy induced nausea and vomiting or as second-line treatment of post-operative nausea and vomiting.
How do omeprazole and clopidogrel interact?
Omeprazole is predicted to reduce the efficacy of clopidogrel.
How do ACE inhibitors affect sodium levels?
Cause HYPOnatraemia
Hyperkalaemia is the most common electrolyte disturbnce
What doses of DAPT are used in patients with ACS?
Dual anti-platelet therapy (DAT) is initiated in patients with acute coronary syndrome (ACS) and is usually for up to 12 months in patients who have had a myocardial infarction with percutaneous coronary intervention, unless it is contra-indicated.
In patients weighing <60 kg or aged ≥75 years, the treatment of choice is aspirin 75 mg PO daily with prasugrel 60 mg PO as a single dose then 5 mg PO daily.
In patients aged 18-74 weighing ≥60 kg the dose of prasugrel is 60 mg PO as a single dose then 10 mg PO daily.
If a patient has been on the maximum dose of an SSRI for 4 weeks and is not seeing improvement, what should be done?
Change to a different drug
What needs to be monitored when LMWHs are used in patients with renal impairment?
anti-Xa concentrations approximately 7 days after starting (to monitor for drug accumulation)
Also monitor for: morbidly obese or very thin, pregnant patients or those at increased risk of bleeding or rethrombosis.
What are the benefits of unfractionated heparin over LMWH?
short half-life and reversibility with protamine
HOWEVER: LMWH has more predictable pharmacokinetics and a once daily administration regimen.
What is the first line option for moderate/severe restless legs syndrome?
pramipexole 88 micrograms PO nightly
The first-line treatment for patients with moderate to severe RLS is a non-ergot dopamine-receptor agonist, particularly ropinirole, pramipexole or rotigotine. An alpha-2-delta ligand such as pregabalin or gabapentin may also be used, particularly if sleep disturbance is a problem as sedation is a common adverse effect. However, neither drug is licensed for this indication in the UK.
Which diabetes drug should be avoided in patients with obesity?
Sulfonylureas such as gliclazide
What would prevent a patient from being prescribed pioglitazone?
Heart failure
If metformin is contraindicated/ineffective, what monotherapy options are there for T2DM?
For patients with HbA1c ≥48 mmol/mol the BNF and NICE guidance both recommend:
* a dipeptidy peptidase-4 inhibitor (DPP-4i) (e.g. alogliptin, linagliptin, sitagliptin, saxagliptin, vildagliptin), or
* pioglitazone, or
* a sulfonylurea (SU) (e.g. glibenclamide, gliclazide, glimepiride, glipizide, tolbutamide)
a sodium-glucose co-transporter 2 inhibitor (SGLT-2i) (e.g. dapagliflozin, canagliflozin and empagliflozin) instead of a DPP-4i if an SU or pioglitazone are not appropriate.
How should you switch from a subcutaneous anticoagulant (e.g. enoxaparin sodium) to edoxaban?
Discontinue the subcutaneous (SC) anticoagulant and start edoxaban at the time of the next scheduled SC anticoagulant dose.
What might low BP indicate in an opioid user?
Dependence (however may also be an adverse effect of opioids or simply a low baseline BP)
Confusion, sweating and bruising are possible signs of intoxication.
What should a patient be told when starting gentamicin?
should report any hearing loss immediately
Gentamicin may cause both nephrotoxicity and ototoxicity.
Although nephrotoxicity is a key adverse effect of gentamicin that requires close monitoring, reduced urine output is a very late sign. Any kidney injury should be detected long before this point through regular monitoring of serum gentamicin and creatinine concentrations. Therefore, there is no need to tell the patient to report reduced urine output.
Why is gentamicin contraindicated in blind people?
Because any hearing loss could profoundly impact their quality of life
When a patient is started on cetirizine what should they be informed about?
Cetirizine may cause increased sleepiness
NOTE: Cetirizine hydrochloride may affect performance of skilled tasks (e.g. cycling or driving) and cause somnolence but it would be inappropriate to discourage a healthy activity altogether. The patient should be warned of the potential for these problems to emerge and report them if they do. However, in the absence of any problematic symptoms she should be encouraged to continue with health promoting sporting activities.
What is the most important information option that should be provided for the patient and his partner about the naloxone kit?
His partner should phone emergency services as soon as signs of overdose are identified before administration of naloxone.
The patient’s partner must be told to call the emergency service as soon as signs of overdose (being unresponsive are recognised, after shaking the patient and shouting his name. Any delay in receiving expert medical attention increases the risk of death or serious brain damage.
What does a typical naloxone kit contain?
2 doses of naloxone IM injection 400 micrograms/mL as well as instructions for use, a rescue breathing barrier, non-latex gloves, an ampoule snapper and syringes with needles attached.
Kits may also be available containing intranasal or sublingual naloxone which may be easier for a lay person to use and have the advantage of avoiding IM injection in a potentially unhygenic pre-hospital environment. The absorption of naloxone from the IM route may also be reduced if the patient is peripherally shut down.
When a treatment self administers enoxaparin sodium, what should they be told?
Hold the syringe at a right angle to the skin and insert the full length of the needle
What advice should be given for patients taking insulin about treatment the day before admission for surgery?
continue the usual bolus insulin doses at meal times and reduce the night time basal insulin dose by 20%
Most likely FIRST sign of systemic lidocaine toxicity
circumoral numbness/tingling
Also: tongue paraesthesia, and dizziness.
Why is concomitant use of isotretinoin with tetracyclines (e.g. demeclocycline hydrochloride, doxycycline, lymecycline, minocycline, oxytetracycline, tigecycline) is contraindicated?
Increased risk of developing benign intracranial hypertension
What should be monitored weekly for linezolid?
Full blood count - due to risk of myelosuppression.
Most appropriate option to monitor for beneficial effects of the dalteparin sodium prescrintion after 72 hours of treatment?
peak anti-Xa concentration
How are the beneficial effects of Addison’s treatment assessed?
The effectiveness of treatment in Addison’s disease is usually assessed by monitoring for resolution of symptoms e.g. malaise, salt cravings, hypotension, anorexia, electrolyte disturbances.
This includes measurements such as blood pressure, electrolytes and WEIGHT.
How often should plasma renin levels be monitored in Addison’s disease?
Annually
What measure can be used to assess degree of anticoagulation in patients on unfractionated heparin in pregnancy?
APTT
Ratio of current vs baseline is used to decide on dose changes.
In what units is colchicine prescribed?
MICROGRAMS
During the postpartum period, how is the dose of LMWH for VTE prophylaxis calculated?
Based on pre-pregnancy (booking) weight
For 50-90kg, this is 5000 units SC daily
What are recognised side effects of all insulins?
When is dose reduction (after 21 days) of rivaroxaban indicated?
In patients with severe renal impairment (creatinine clearance <30 mL/min)
Drugs that can CAUSE DKA
SGLT-2 inhibitors e.g. dapagliflozin
How should severe hypercalcaemia be managed initially?
sodium chloride 0.9% IV infusion
then investigate and manage the cause
