Chapter 4 - Chronic Flashcards
Planning Management
At what level do you treat hypertension?
> 150/95mmHg
If existing/high risk of stroke, IHD, PVD or if evidence of hypertensive organ damage - CKD, retinopathy, LVH or intracerebral bleed
>135/85mmHg
Target BPs for those on antihypertensives
<80 Clinic - <140/85
Home - <135/85
>80 Clinic - <150/85
Home - <145/85
Draw out the treatment diagram for antihypertensives
Over 55/Afro caribbean - C
Under 55 - A
A + C
A + C + D
A + C + D + (other diuretic, beta blocker, alpha blocker)
Chronic management: Heart failure
- ACEi + Beta blocker
- Increase dose as tolerated
- Mild - add ARB (candesartan)
Mod/sev+afro caribbean - add hydralazine + isosorbide mononitrate
Mod/sev other patients - add spironolactone
ACEi ARB if ACEi not tolerated Hydralazine + isosorbide mononitrate if neither ARB nor ACEi tolerated Beta blocker - start low and go slow Spironolactone
Chronic management: Stable angina
- GTN spray PRN
- Beta blocker +/- CCB
Inadequate control - add isosorbide mononitrate or nicorandil
Inadequate control - PCI/CABG - Secondary prevention - aspirin + statin
Stable angina - symptom control
GTN spray PRN
Stable angina - anti-anginal
Beta blocker +/- CCB
increase dose
add isosorbide mononitrate or nicorandil
PCI/CABG
Stable angina - secondary prevention
Aspirin + statin
Chronic management - 3 areas of AF management
- Rhythm control
- Rate control
- Stroke prevention
AF - how do you see if they require stroke prevention and what are the results?
CHADSVAS Congestive HF Hypertension Age >75 (2) Diabetes Stroke or TIA before (2) Vascular disease - PAD/IHD Age (65-74) Sex (female)
0 (or 1 if female) - NO ANTICOAGULATION
1 (if male) = condiser antiplatelet or anticoagulant: aspirin OR warfarin
2 or more = anticoagulation - warfarin - aim for INR 2.5
Who do you cardiovert in AF? (5)
What does the cardioversion involve?
- Young
- First episode
- Symptomatic
- Reversible cause
IF IT HAS BEEN LESS THAN 48 HOURS
If not, they require anticoagulation
Electrical
Pharmacological - Amioderone 5mg/kg IV over 20-120 minutes
Asthma - Step 0
Monitored initiation of treatment with LOW DOSE ICS
Asthma - Step 1
Regular preventer - LOW DOSE ICS
Asthma - Step 2
Initial add-on - add inhaled LABA - usually in a combination inhaler like fostair or seretide
Asthma - Step 3
Additional add-on
No response to LABA - stop LABA, increase ICS to MEDIUM DOSE
LABA benefit:
1. Continue LABA, increase ICS to MEDIUM DOSE
or
2. Continue LABA, continue ICS, add (theophylline, montelukast, LAMA)
Asthma - Step 4
- Increase ICS to HIGH DOSE
or - Trial 4th drug (theophylline, montelukast, LAMA, Beta agonist tablet)
Asthma - Step 5
Continued oral steroids
When should you consider moving up the asthma management ladder?
Using SABA 3 or more times a week for relief of symptoms
Draw out COPD guidelines
SABA or SAMA PRN
exacerbations: no asthmatic features or no steroid responsiveness
add LABA + LAMA
exacerbations: asthmatic features or steroid responsiveness:
add LABA + ICS
persistent exacerbations: asthmatic features or steroid responsiveness:
triple therapyLABA + LAMA + ICS
What should diabetics have checked annually to monitor nephropathy? Results mean what?
AlbuminCreatinineRatio - >3mg/mmol = give ACEi
What should diabetics be on to avoid CV risks?
Statin
What is the target HbA1c in type 2 diabetics?
<48mmol/mol
Type 2 diabetes drug regime if overweight + creatinine <150
- standard release metformin 500mg then increase slowly to reduce GI SEs
- If GI SEs - modified release metformin 500mg then increase slowly
- metformin + gliclazide
metformin + sitagliptin
metformin + pioglitazone
metformin + empaglifozin - metformin + gliclazide + sitagliptin
metformin + gliclazide + pioglitazone - insulin
What is the most common first line drug for Parkinson’s?
Co-careldopa
Levodopa + carbidopa
(also co-beneldopa - levodopa + benserazide)
What are 2 alternative drug groups and examples in Parkinson’s and who would you consider giving it to?
Dompamine AGONISTS
rotigotine, ropinirole, pramipexole
MAO-B inhibitors - selegiline, rasagiline
Consider giving these to patients with mild symptoms whose quality of life is not really that affected.
Also if concerned about finite period of benefit from levodopa
Drug of choice in epilepsy: focal seizures
Carbamazepine or lamotrigine
Drug of choice in epilepsy: tonic clonic
Sodium valproate
Drug of choice in epilepsy: absence
Sodium valproate or ethosuximide
Drug of choice in epilepsy: myoclonic
Sodium valproate
Drug of choice in epilepsy: tonic/atonic
Sodium valproate
What is the drug group of choice & examples for
mild/moderate Alzheimer’s?
Achesterase inhibs
Rivastigmine, donepezil, galantamine
What is the drug group of choice & examples for
moderate/severe Alzheimer’s?
NMDA antagonists
Memantine
What would you use to induce remission in Crohn’s in
a) mild
b) severe
a) prednisolone 30mg PO OD
b) hydrocortisone 500mg IV 6 hourly
What 3 drugs would you use to maintain remission in Crohn’s?
1) Steroids
2) Azathioprine/mercaptopurine - IF TPMT deficient, methotrexate
3) Infliximab
What is a definite contraindication to a certain drug used to treat IBD and why? which drug? alternative?
Azathioprine, mercaptopurine
TPMT deficiency
Liver and bone marrow toxicity
Methotrexate alternative
If diarrhoea is non-infective, what would you treat it with?
Loperamide or codeine
Stool softeners (2) - what are they good for? Contraindications?
Docusate sodium
Arachis oil (PR)
Good for impaction
Arachis oil - nut allergy
Bulking agents (1) - problem? Contraindications?
Isphagula hulk
Can take days to work
Impaction, colonic atony
Stimulants (2) - problem? Contraindications?
Senna
Bisacodyl
May exacerbate cramps
Bisacodyl - acute abdomen
Osmotic laxatives (2) - problem? Contraindications?
Lactulose
Phosphate enema
May exacerbate bloating
Phosphate - acute abdomen
First line treatment for insomnia
Zopiclone
What is the standard treatment for rheumatoid arthritis?
Methotrexate + DMARD (hydroxychloroquine or sulfasalazine)
2 DMARDs you might use in treatment of RA
Hydroxychloroquine, sulfasalazine
What would you use to treat flare ups of RA?
short term glucocorticoids - IM methylprednisolone
NSAIDs - ibu + lansoprazole
What would you use to treat RA that fails to respond to 2 DMARDs?
Infliximab (TNFa inhibitor)
