BRAINS and AIMS

Question 1

BRAINS AIMS

-what does this stand for

Answer 1

Benefits
Risks
Adverse effects
Interactions
Necessary prophylaxis
Susceptible groups

Administering
Informing
Monitoring
Stopping

Question 2

What are the risks involved in drug prescribing

Answer 2

Overdosing
Contraindications
Costs
Resistance to medication

Question 3

How to deal with adverse reactions

Answer 3

Is it time or dose dependent
What drug is responsible
How would you correct the ADR
Stop ADR 
Report

Question 4

What is a dose dependent adverse reaction

-what are the 3 types

Answer 4

Adverse reaction that is dependent on the amount of drug given

Supratherapeutic - toxic
-paracetamol OD
Therapeutic - side effects
-NSAID renal failure
-ACEi cough
Subtherapeutic - Hypersusceptible
-allergy

Question 5

What are the dose dependent drugs that cause hepatitis

How would you recognise this?

Answer 5

Increase in ALT
Azathiopurine
Paracetamol

Question 6

What are the dose independent drugs that cause hepatitis

How would you recognise this

Answer 6

Increase in ALT
Isoniazide, Pyrazinamide
Valproate
Methyldopa
Statins
NSAIDS
Phenytoin

Question 7

What are the dose dependent drugs that cause cholestasis

How would you recognise this

Answer 7

Increase in AST and bilirubin
Rifampicin
Estrogen+Anabolic steroids

Question 8

What are the dose independent drugs that cause cholestasis

How would you remember this
How would you recognise this

Answer 8

Increase in AST and bilirubin - Cl/Chl
Chlorpromazine - antipsychotic

Clarythromycin - ABx
Clavulanate-amox
Cloxacilin (flu)

Cimetidine - SSRI

Carbimazole - antithyroid

Chlorpropamide - sulphonylurea

Question 9

What are the drugs that cause microvesicular steatosis

How would you remember this

Answer 9

VAT
Valproate
Aspirin
Tetracyclines

Question 10

What are the drugs that cause macrovesicular steatosis

How would you remember this

Answer 10

Fatty liver, cirrhosis
AMA

Alcoholic hepatitis
Methotrexate
Amiodarone

Question 11

What are time dependent ADRs

• rapid
• first dose
• risk increases at first then decreaess
• risk increases with time
• withdrawal
• delayed

What are examples of each one
How would you manage each type

Answer 11

Rapid - administer slowly
-IV vancomycin => Red man syndrome (systemic histamine release)

First dose - careful monitoring

• ACEi => hypotension
• penicilin => allergy

Risk increases at first then diminishes - warn patients of possible ADRs
-carbimazole, 5ASA (-salazines) => agranulocytosis (sore throat, increased bleeding risk, anemia)

Late - warn, monitor, prophylaxis if possible
-CS => osteoporosis

Withdrawal - warn, replace with longer acting drug if withdrawal not possible
-opiates, BZ, methyldopa(HTN), Bb => withdrawal symptoms

Delayed - avoid, screen, warn
-ciclosporin => carcinogen

Question 12

What are the time independent ADRs

• due to change in dose
• due to change on concentration
• due to neither

What are examples of each one
How would you manage each type

Answer 12

Change in dose from changed formulations
-stick to 1 brand for a patient

Change in concentration
-warn, monitor, reduce dosage, avoid interacting drugs

Due to neither
-warn, monitor, avoid interacting drugs

Question 13

What are common examples of drugs that affect PO absorption

• decrease GI motility
• increase GI motility

Answer 13

Decrease GI motility

• opiates
• TCA

Increase GI motility
-metoclopromide (antiemetic)

Alter rate of absorption of other drugs

Question 14

Describe the significance of displacement

-possible outcomes

Answer 14

Displaced drug => metabolised and excreted

Displaced from plasma proteins => increased toxicity, potency

• ASA+NSAIDs => methotrexate toxicity if secretion impaired
• ASA+NSAID+warfarin => increase bleeding risk

Question 15

What are the methods of excretion

Answer 15

Glomerular filtration of unbound drug

Active tubular secretion
-ability reduced in renal failure

Passive tubular reabsorption

Question 16

What are liver enzyme inducers
What do they do?

What are the drugs that do this
How would you remember this

Answer 16

Increase activity of liver enzymes
=> active drug broken down so less potent
=> inactive drug activated so more potent

PCBRAS
Phenytoin (antiepileptic)
Carbamazepine
Barbiturates, BBQ foods
Rifampicin
Alcohol (chronic)
St Johns Wort

Question 17

What are liver enzyme inhibitors
What do they do

What are the drugs that do this
How would you remember this

Answer 17

Decrease activity of liver enzymes
=> active drug not broken down
=> inactive drug not activated

GODEVICES
Grapefruit juice
Omeprazole
Disulfriam
Erythromycin
Valproate, 
Isoniazid
Cimetidine, 
Ethanol (acute)
Sulphonamides, 

Allopurinol
Metronidazole, ketoconazole
Ciprofloxacin
Verapamil, diltaizam, amiodarone
Chloramphenicol
SSRIs

Question 18

What are the clinically significant drugs with a narrow therapeutic range

How would you remember this

Answer 18

Small range where the drug concentration is safe and toxic

WAC STOPS
Warfarin
Antiarrythmics
Ciclosporin
Sulphonylureas
Theophyllines
Oral Contraceptives
Phenytoin
Steroids, statins

Question 19

Describe the interaction between SSRIs and liver enzymes

What is the danger when prescribing SSRIs and opioid pain relief

Answer 19

SSRIs (eg, fluoxetine, paroxetine) inhibit CYP2D6

Many opioids need to be activated by CYP2D6 => less effective if inhibited

Tramadol also has SNRI properties => increased risk of seretonin syndrome if coadministered with SSRIs

Question 20

What are the common interactions with warfarin

Answer 20

Protein binding displacement
-NSAIDs

Inhibit metabolism
-amiodarone, metronidazole, acute alcohol

Induction of liver metabolism

• phenytoin
• carbimazepine
• barbiturates, BBQ
• Rifampicin
• Alcohol
• St Johns Wort

Cranberry juice => increased INR

Question 21

Necassery prophylaxis for

• NSAIDs
• opioids
• CS

Answer 21

NSAIDs => PPI (lansoprazole)

Opioids => laxatives, antiemetics

CS - if 3months, 7.5mg+ => alendronate

Question 22

Susceptibility mnemonic

-ASADGAP

Answer 22

Allergy
Sex
Age
Disease
Genetic
Altered physiology
Pregnancy, breast feeding

Question 23

What are women and men more susceptible to?

How would you reduce this risk

Answer 23

Use lower doses

Women

• alcohol
• ACEi cough
• drug induced lupus
• hepatitis - methyldopa
• cholestasis - flucloxacilin

Men
-cholestasis - coamox

Question 24

What common drugs are older adults more susceptible to

How would you reduce this risk

Answer 24

Lower doses, monitor carefully but avoid where possible

Diuretics, antiHTN, Bb
Digoxin
NSAIDs
CNS drugs (BZ)
TCA
H1 antihistamines (chlorpheniramine)
H2 antagonists (ranitidine)
Opiates

Question 25

Describe how renal impairment may affect drugs

How would you approach this

Answer 25

Accummulation of renally cleared drugs

• avoid drugs/reduced dose with narrow therapeutic range
• increased nephrotoxicity of NSAIDs

Question 26

Describe how hepatic impairment may affect drugs

What drugs would this affect

Answer 26

CAFE METRO - altered PK, PD

Clotting reduced - warfarin, aspirin, NSAID
Albumin reduced - phenytoin, prednisolone toxicity
Fluid retention
Electrolyte imbalance - NSAIDs, steroids, furosemide
Metabolism reduced - opioids not activated or broken down
Encephalopathy - sedatives, hypoK (diuretics), opioids, constipators
Toxic liver drugs - NSAIDs => hepatitis, cholestasis, steatosis
Renal function impacted - NSAIDs

Question 27

Altered physiology susceptibility

• pregnancy
• drugs to avoid

Answer 27

Increased renal clearance of
-lithium, digoxin, penicillins => need to increase dose

Risk to fetus

• thalidomide
• phenytoin, valproate
• warfarin, lithium
• retinoids