Chapter 11-15 (low weighted) Flashcards
CHAPTER 11: Eye
How should eye drops be applied?
Instill into the pocket formed by gently pulling down the lower eye-lid, blinking a few times to ensure even spread and then close the eye.
Eye ointment should be applied in a similar fashion inside the lower eye lid , blinking a few times to ensure even spread and then close the eye
Eye ointments can for a film and can cause blurry vision and affect driving.
Leave 5 minutes between eye preparations.
Always apply eye drops BEFORE eye ointments (more viscous).
Eye drops can cause systemic side-effects as they can be absorbed into the blood stream
Discard eye drop bottles after 4 weeks unless stated otherwise by manufacturer.
*hylo-forte/hylo-tear: longer shelf-life but otherwise 28 days max
*chloramphenical eye drops only use for course of 7 day treatment, discard afterwards (eye drops not to be shared, reduce contamination, separate eye drops per person)
Contact Lenses
> TWO TYPES – Hard and Soft lenses.
Most patients use soft lenses
Advice the need to maintain good hygiene.
Patients who use soft contact lenses are susceptible to Acanthamoeba Keratitis mostly due to poor hygiene.
Only use PRESERVATIVE FREE EYE DROPS with contact lenses. (preservative interacts with lens, also pts who have had eye surgeries, use glasses if product contains preservative)
DO not use eye ointment with contact lenses. (if using, use glasses)
Some drugs can discolour contact lenses . E.g. sulfasalazine can change colour to orange=>reassure discolouration is from a known side effect, use eye glasses during use of medications
Eye Infections
> CONJUNTIVITIS – self limiting (advise to use warm flannel and water for 72hrs and can get treatment if symptoms still exist), chloramphenicol (2 days, 2hrs+3 days, 4hrs+2 days, 4 hrs), fusidic acid drops (after treatment, pt still complains but could be adherence, but can advise one more course (2 max), after 2, refer to get fuscidic eye drops) (if pregnant/breastfeeding, can’t treat=>grey baby syndrome, under 2 need rx)
STYE - self limiting (warm flannel for 72hrs), chloramphenicol ointment (5 days TDS+2days TDS)
BLEPHARITIS– wipes/lotion (blephaclean & blephasol brand=>reduces symptoms not treat), chloramphenicol eyedrops, tetracyclines orally
KERATITIS – specialist treatment
CORNEAL ULCERS – specialist treatment
Each patient must use individual eye drop containers to avoid cross contamination.
Glaucoma
●Glaucoma - Increased intraocular pressure → optic nerve damage and vision loss Primary open angle - most common type, develops slowly. (causes: genetics, hypertension, lifestyle=>reduce salt intake, lose weight/exercise, cut alcohol intake)
Angle closure - rare, more common in Asians, more severe form of Glaucoma
For Treatment: N/B - Combination of treatments may be used
Drugs, Side effects and cautions
Prostaglandin analogues (-prost) (eg: Latanoprost) Browning/ change in colour of iris , Increase in eyelash
Beta Blockers (-lol) (eg: Timolol) Contraindicated for cardiac conditions in asthma/ COPD
Carbonic anhydrase inhibitors (- zolamide)(eg: Dorzolamide)
Alpha 2 agonist/ sympathomimetics(-monidines) (eg: Brimonidine) can cause Palpitations, headaches, hypertension
Cholinergics (eg: Pilocarpine) - Can cause ciliary spasms affecting night vision and Headache
**salbutamol inhaler (beta agonist) + timolol (beta antagonist)=>increase breathing difficulties and they are fighting for the receptors
Dry eyes
More common in elderly and women, certain seasons
Causes ● Ageing , Underlying medical conditions such as blepharitis (inflammation of eyelids) , Hormonal changes in women/menopause, pregnancy, Hot or windy climate, using computer screens.
Symptoms
● Usually mild - but more severe cases can be painful and lead to complications
● Usually affects both eyes
● Eyelids stick together when waking up
● Feelings of dryness, grittiness or soreness that gets worse throughout the day
● Some people may have episodes of watering eyes - occurs because eye tries to relieve irritation by producing tears
How to distinguish dry eyes from conjunctivitis? **dry eyes (affects both eyes) vs conjunctivitis (usually one eyes, purulent mucous)
● Should not have purulent discharge or small corneal infiltrates
● Usually affects both eyes as opposed to just one eye
Treatment
● Ocular lubricants - different treatment regimes for different stages of dry eye (mild, moderate and severe)
»hypromellose 0.3, 0.5, carbomer
»hylotear/hyloforte
»if had surgery, give preservative free
SUBCONJUNTIVAL HAEMORRAGE
SYMPTOMS
blood shot eye accompanied with lack of coordination, loss of vision, nausea and vomiting , confusion, pain in the eyes=>red flag
**first line: self-liming measure (warm flannel), second line: optrex blood shot eyes=>sooth eye and speed healing
**different reasons: minor tear to blood vessels due to stress, physical cause to cause rupture (rubbing)
if has red flag symptoms with blood shot eyes=>REFER patient to A/E can be a serious indicator of bleeding in brain that has lead to this condition
- EAR, NOSE, AND OROPHARYNX
EAR
Otitis externa Infection (can be managed OTC) of the ear canal, a topical anti-infective such as neomycin or clioquinol may be used, but for only about a week. Acetic acid 2% (Ear Calm) acts as an antifungal and antibacterial in the external ear canal and may be used to treat mild cases. In more severe cases an anti-inflammatory preparation with or without an antibiotics is required (otomize, fluclox/clarithromycin).
Otitis media (pharmacy 1st scheme, diagnose using otoscope) Most common cause of severe ear pain in small children. Many infections are caused by viruses, and uncomplicated cases resolve without antibacterial treatment. In children with systemic features, **antibacterial treatment (amoxicillin) may be started after 72 hours if no improvement. See pharmacy first scheme
Removal of earwax - Wax provides a protective film on the ear canal, and only needs to be removed if it causes hearing loss. Wax can be softened using olive or almond oil, or ear drops; ear drops are also effective, but may cause dryness of the ear canal. If necessary, wax may be removed by irrigation with warm water. (sodium bicarbonate, OTEX eardrops=>dont need syringe or irrigation, if not able to help natural removal they will need to be referred to get irrigation)
***red flag: discharge, blood, loss of hearing (after rule out earwax), sharp pain, medication (bisphosphonates: alendronic acid/risidronate=>otonecrosis of ear canal)
Nose
> > blocked nose/runny nose from cold/flu can manage in pharmacy, if infection like polyp needs to be referred=>treatment for infection: naseptin cream (contains neomycin, chlorhexidine), ask if allergic to nuts bc contains peanut oil/arachis oil
Allergic rhinitis is self-limiting but can be controlled with antihistamines (e.g. azelastine), or nasal corticosteroids (e.g. beclomethasone, mometasone). Sodium cromoglicate is an alternative but may be less effective. If necessary, a pregnant woman can use nasal beclometasone, budesonide, fluticasone, or sodium cromoglicate.
Bacterial sinusitis may require treatment with antibacterials (amoxicillin or doxycycline). There is no evidence that topical anti-infective nasal preparations have any therapeutic value in rhinitis or sinusitis. However, Naseptin and Bactroban are licensed for the eradication of nasal carriage of staphylococci.
Nasal polyps can be treated with short-term use of corticosteroid (e.g. beclomethasone, mometasone)
OROPHARYNX
Dry mouth - Often caused by antimuscarinic drugs (oxybutinin),diuretics (hypovolaemia: low water=>dehydration=>dry mouth) OR surgery (neck and throat cancer: first line treatment, pilocarpine, radiotherapy=>can affect/destroy salivary glands).
May be relieved by simple measures such as frequent sips of cool drinks or sucking pieces of ice or sugarfree fruit pastilles. Sugar-free chewing gum stimulates salivation in patients with residual salivary function. Artificial saliva can provide useful relief of dry mouth.
> DENTAL / Oral hygiene (should see dentist 1-2 times a year especially for those on biphosphonates to maintain dental/oral hygiene)
There is no convincing evidence that antiseptic lozenges and sprays have a beneficial action, they can irritate and cause sore tongue and sore lips. A warm saline mouthwash is ideal for superficial infections and can be prepared by dissolving half a teaspoonful of salt in a glassful of warm water.
Hydrogen peroxide, may be useful in the treatment of acute ulcerative gingivitis. Chlorhexidine (can discolour teeth to brown, reversible as soon as treatment is stopped) is an effective antiseptic which has the advantage of limited inhibition of plaque formation on the teeth. Fluoride toothpaste is used in the prophylaxis of dental caries.
FLUORIDE supplementation (min age to quality: 6 months, 2 strengths 2800ppm/5000ppm that children under 10 can’t use): scenario different parts of the UK=>amount of fluoride would be given in each of these areas=>which part of these areas require fluoride supplementation? min of 700mcg/L
Ulceration and inflammation
**acute sore throat under pharmacy first scheme
Important to establish the diagnosis, as each case will require specific management. Unexplained mouth ulcer of more than 3 weeks requires urgent referral to hospital to exclude oral cancer. Preparations include saline mouthwash, chlorhexidine mouthwash, oral corticosteroids, benzydamine (difflam), flurbiprofen (sore throat), and choline salicylate, bonjela (GSL to P=>contains lidocaine, affects growth/development of children) bonjela adults, bonjela children (P, contains lidocaine, only if tried every other option, last line), bonjela infants (GSL, no lidocaine)
Chapter 13: Skin
DRY SKIN
EMOLLIENTS (hydromoor, E45, epaderm, aqueous cream=>flammable) Hydrate the skin; their effects are short-lived and should be applied frequently and regularly. Some preparations contain urea to relive itching & hydrate the skin. Emollients should be applied in the direction of hair growth to reduce the risk of folliculitis. Safety information Emollients soak into fabric and can become a fire hazard. Patients should be advised not to smoke, use naked flames (or be near people who are smoking or using naked flames), or go near anything that may cause a fire while emollients are in contact with their medical dressings or clothing.
STEROIDS – mild, moderate, potent and very potent (1st line for contact dermatitis: hydrocortisone not used for face, broken/bleeding skin, private areas, min age 10 yrs, less than 10yrs see GP), eumovate OTC: 12 yrs+
ACNE (presence of comedones, 12yrs+ OTC: freedom, ancecide; if OTC doesnt help, refer to GP=>zimerat on Rx needs to be made up, how does does it last for?)– RETINOIDS = ISOTRETINOIN, ACRTRETIN
>antibiotics can be used as well=>doxycycline, macrolides
Female/childbearing age for vitamin A agonist: PPP, isotret can cause MOOD CHANGE, 30 day supply, 7 day expiry on Rx, pregnancy test taken before Rx given, ensure contraception, cannot donate blood while on medication
Skin
Topical corticosteroid preparation potencies
Potency of a topical corticosteroid preparation is a result of the formulation as well as the corticosteroid. Therefore,
proprietary names are shown.
Mild
Hydrocortisone 0.1–2.5%
Dioderm
Mildison
Synalar 1 in 10 dilution
Mild with antimicrobials
Canesten HC
Daktacort
Econacort
Fucidin H
Hydrocortisone with chlorhexidine hydrochloride and nystatin
Terra-Cortril
Timodine
Skin
Moderate
* Betnovate-RD (0.025%)
* Eumovate
* Haelan
* Modrasone
* synalar 1 in 4 dilution
* Ultralanum Plain
Moderate with antimicrobials
* Trimovate (kept in fridge)
Moderate with urea
* Alphaderm
Skin
Potent
*beclometasone dipropionate 0.025%
* Betamethasone valerate (benovate) 0.1%
* Betacap
* Betesil
* Bettamousse
* Betnovate
* Cutivate
* Diprosone
* Elocon: mometasone
* Hydrocortisone butyrate
* Locoid
* Locoid Crelo
* Metosyn
* Mometasone furoate 0.1%
* Synalar
Skin
Potent with antimicrobials
* Aureocort
* Betamethasone and clioquinol
* Betamethasone and neomycin
* Fucibet
* Lotriderm
Potent with salicylic acid
* Diprosalic
Verypotent
* Clarelux
* Dermovate: clobetasol (eumovate=clobetasone)
* Etrivex
Very potent with antimicrobials
* Clobetasol with neomycin and nystatin
Chapter 14: Vaccines
Immunoglobulins:
Passive immunity (only lasts for a few weeks)-
Immunity with protection against certain infective organisms can be obtained by injecting preparations made from plasma of immune individuals with adequate levels of antibody to the disease for which protection is sought.
The duration of this passive immunity varies according to the dose and type of immunoglobulin.
Passive immunity only lasts a few weeks, when necessary, it can be repeated.
Antibodies of human origin are usually termed immunoglobulins. The term antiserum is
applied to material prepared in animals.
Two types of immunoglobulin are available: normal immunoglobulin and disease-specific immunoglobulins.
Skin Infections (photos, min of 2 pic questions)
Review photo conditions
White coating on tongue: oral thrush/candiadasis
Bump on eye: stye
circle splotch on skin: ringworm, tinea coporus (capitus=>head, cruis=>jock itch)
Flushed cheeks: slapped cheek syndrome is self-limiting (antihistamines, simple analgesics: paracetamol/ibuprofen), can take 2 weeks to disappear
molloscum: looks like skin tags/skin coloured moles, caused by a virus, self-limiting
Active Immunity
ACTIVE IMMUNITY:
Acquired by natural disease or vaccination. Vaccines stimulate production of antibodies and other components of the immune system.
1) A live attenuated (MMR- viral) (BCG- bacterial)
2) Inactivated preparation (influenza vaccine)
3) Detoxified exotoxins produced by a micro-organism (tetanus vaccine)
4) Extracts of a micro-organism, which may be derived from the organism
(pneumococcal vaccine) or produced from recombinant DNA (hep B vaccine)
Live attenuated vaccines usually produce durable immunity, but not always as long as natural infection.
Inactivated vaccines may require a primary series of injections of vaccine to produce an adequate antibody response, and in most cases booster injections are required.
**if patient is taking an immunosuppressant drug (cyclosporine/mexotrexate): avoid live vaccines=>further impairs patients immunes system
Routine Immunisation Schedule
**general population
**prison immunisations
You work as a pharmacist in HM prisons. You are asked to give a presentation to the inmates regarding prison vaccination schedules. As regards hepatitis B vaccines, how many doses are recommended for inmates in the resource provided.
A. Hepatitis B vaccines are available to all ages and 3 doses are recommended.
B. Hepatitis B vaccines are available to inmates over 18 years and 3 doses are recommended.
C. Hepatitis B vaccines are available to all ages and 4 doses are recommended.
D. Hepatitis B vaccines are available to males of all ages and 3 doses are recommended.
E. Hepatitis B vaccines are available to all ages and 2 doses are recommended.
C. Hepatitis B vaccines are available to all ages and 4 doses are recommended.
**MEP course: green book (details on individual vaccines ie if there is an egg allergy, dont give yellow fever, flu jab), pink book (if condition has an available vaccine)
Chapter 15: Anaethetics
LOCAL ANESTHETICS (lidocaine: emla cream, blocks sensation to a specific area) AND GENERAL ANAESTHETICS (due to deliver/surgery)
CAN CAUSE SEDATION. WARN ABOUT DRIVING.
MHRA wanring: no aesthetics products to pregnant woman, no piles treatment (anusol, preparation H)
Anaethesia
**skipped slide…
Stop Before Surgery
Combined Oral Contraceptives: stop 4 weeks before major surgery and all surgery to legs or surgery that involves immobilisation due to risk of venous thromboembolism
Hormone Replacement Therapy: stop 4 to 6 weeks before surgery and restart on full mobilisation
Antidepressants: MAOI: gradually withdraw 2 weeks before surgery, TCA: inform anaesthetist if continued, risk of arrhythmia and hypotension
Lithium: stop 24 hours before major surgery (constant fluid and electrolyte balance to avoid toxicity)
Potassium-Sparing Drugs: AVE inhibitors/ARBs (also cause severe hypotension), Potassium-sparing diuretics as risk of hyperkalemia if renal perfusion is impaired or if there is tissue damage
Antiplatelet/Oral Anticoagulants: consider stopping if increases risk of bleeding and convert to Heparin for during surgery
Diabetes: switch patient to insulin during surgery, give infusion of glucose with potassium and insulin on a sliding scale, once patient begins to eat, start SC insulin before breakfast and stop IV insulin 30 minutes after
May Continue During Surgery
Anti-Epileptics
AntiParkinson
Antipsychotics
Anxiolytics
Bronchodilators
Cardiovascular Drugs (except K+ sparing diuretics)
Glaucoma Drugs
Immunosuppressants
Progesterone Only Contraceptives
Thyroid and Antithyroid Drugs
Drugs and Antidotes
FOR EACH DRUG, PLEASE STATE THE ANTIDOTE IN CASES OF OVERDOSE OR TOXICITY
1. THEOPHYLINE = activated charcoal
2. HEPARIN = Protamine Sulphate
3. DABIGATRAN = idaricuzimab
4. ASPIRIN = sodium bicarbonate
5. WARFARIN = vitamin k
6. IRON = dexferboxamine
7. APIXABAN/ RIVAROXABAN = andaxanet alfa
8. BENZODIAZEPINES = flumenazil
9. PARACETAMOL = acetyl ceistine
10. OPIOIDS = naloxone
Fluid Therapy: Lithium
Nalaxone: Opioids
A 16-year-old patient was sustained a 1st-degree burn to his hand whilst ironing his shirt. His mother phones your pharmacy to ask for advice on what to do next. She explains that she has instructed his son to run tap water on the burn area. What is the correct next line of action in this situation?
A. Call 999 immediately
B. cool the burn with Ice
C. Remove anything that’s stuck to the skin.
D. cover the burn by placing a layer of cling film over it.
E. Apply Vaseline on the affected area.
