Chapter 7 Qs: Prescribing: doing it yourself

Question 1

PReSCRIBER

Answer 1

PReSCRIBER = patient details, reaction (allergy + reaction), sign front of chart, contraindications to each drug, route of each drug, IV fluids, blood clot prophylaxis, antiemetic, pain-relief.

Question 2

Every drug prescription must be

Answer 2

Every drug prescription must be:

• Legible + unambiguous (e.g. not range of doses such as 30-60mg codeine).
• Approved (generic) name: e.g. salbutamol not Ventolin.
• In CAPITALS.
• Instructional if drug to be used ‘as required’ i.e. provide (1) indication + (2) maximum frequency.
• Without abbreviations.
• Signed + bleep number.
• Inclusive of indication + stop/review date if antibiotic being prescribed.
• Inclusive of treatment duration i_f treatment not long-term_ (e.g. antibiotics) or if GP setting (e.g. 7 or 28 days).
  
  • BNF states duration of antibiotic course under each indication.
  • General rule # 1 = most courses for 5 days except female UTIs (3 days), bone infections + endocarditis (+++ weeks).
  • General rule # 2 = once patient clinically improving, convert IV antibiotics to oral route where possible.

Question 3

Q7.2 What to REMEMBER re treating a VTE

Answer 3

• Treatment is with DALTEPARIN
• The treatment dose for VTE should be continued until warfarin has achieved a therapeutic INR (i.e. >2).
• Other options are enoxaparin or tinzaparin.
• Thrombolysis in PE (e.g. with alteplase) is reserved for those in cardiac arrest or cardiogenic shock resistant to IV fluids + inotropes.

Question 4

Q7.3 What is the first line treatment of HF

Answer 4

ACE-i + B-blocker is 1st line for chronic HF.

Select ACE-i if pt has asthma.

ACE-i can cause postural hypotension so best given in evening.

For perindopril, state which type being used – erbumine or arginine, as have different doses.

Furosemide has no effect on mortality – give in AM as subsequent diuresis.

Spironolactone used as adjunct in mod/severe HF when ACE-i + B-blockers inadequate – give in AM as diuresis.

Question 5

Q7.4 What is the first line treatment of Hypertension

Answer 5

ACE-i e.g. Ramipril 1st-line for HTN <55years.

Perindopril only ACE-i recommended to be given in the morning, all other’s at night (due to postural hypotension)

ARBs 2nd line.

Question 6

Q7.5 What is the first line treatment of acute Asthma

Answer 6

• After O2,
• salbutamol + ipratropium nebulisers.
• Unlike salbutamol which may be given back-to-back and whose total dose is only limited by side-effects (tachycardia + tremor), ipratropium should only be given x4-6/day.

Question 7

Q7.6 What is the first line treatment to relieve pain in stable angina

Answer 7

GTN i 0.3-1MG… SUBLINGUAL TABLET/2 sprays sublingual– this would be correct as only 1 strength (concentration) of spray available, so don’t need to write 400micrograms/metered dose – but if you wish, it should go with the drug name i.e. GTN spray 400 micrograms/metered dose, then 2 sprays in the dose box. GTN sublingual tablets given as 0.3-1mg sublingual – but must pick a dose!

Question 8

Q7.7 What is the first line treatment of AF to control the rhythm

Answer 8

1st line rate control = beta-blocker (CI as has asthma) or rate-limiting CCB e.g. diltiazem or verapamil.

Question 9

Q7.8 What is the first line treatment in hyperkalaemia which lowers the potassium

Answer 9

ACTRAPID… 10 UNITS IN 100ML OF 20% DEXTROSE OVER 30 MINUTES… IV

short-acting insulin (e.g. actrapid or novorapid) with glucose – insulin causes cellular uptake of K+ and dextrose given to prevent subsequent hypoglycaemia.

Standard is 5-10 units of actrapid (or novorapid) in 50ml of 50% dextrose over 5-15 minutes IV – but this can irritate veins so some elect lower concentration of dextrose.

Question 10

Q7.9 What is the first line prophylaxis medication for complex partial seizures in a women

Answer 10

Focal epilepsy (e.g. multiple complex partial seizures) is best managed with lamotrigine or carbamazepine (the latter causes SIADH). Lamotrigine also has best safety profile in pregnancy of all AEDs.

Question 11

Q7.10 What is the first line treatment of TDM2 (overweight vs normal/under)

Answer 11

When selecting 1st oral hypoglycaemic drug for diabetic patients, generally pick metformin if overweight or sulphonylurea if N/underweight. Creatinine >150 umol/L should also preclude using metformin.