Chapter 8, 9, 10 (medium weighted) Flashcards
ANAEMIA
> A condition in which there is a deficiency of red cells or haemoglobin in the blood.
There are about six types of anaemia.
You should know about 4: sickle cell anaemia, iron deficiency anaemia, haemolytic, vitamin deficient anaemia i.e megaloblastic anaemia (lack of B12, B9)
SICKLE CELL ANAEMIA – hereditary (two parent carriers)=>suffer from a crisis that causes a lot of pain as new red blood cells are being produced as they have irregular shape
Occurs due to a structural abnormality of haemoglobin. Can lead to increase in folic acid requirement.
*Phenoxymethylpenicillin (antibiotic) is used in prophylaxis of infection. (6+: 250 BD prevent/treatment QDS, under 6: 125mg)
folic acid, B9
**Hydroxycarbamide is used to reduce frequency of crisis and need for blood transfusion.
HAEMOLYTIC ANAEMIA
*Epoetins (synthetic of erythropoietin) are used to treat the anaemia associated with
erythropoetin deficiency in chronic kidney failure
(erythropoetin stimulates the bone-marrow to produce more red blood cells)
*MHRA warns about severe reactions in patients being treated with erythropoetins. Some cases were fatal
*It can also affect blood pressure and lead to hypertensive crisis.
Which drug is used in the prophylaxis of minor infections in patients with sickle cell anaemia?
A. Hydroxycloroquine
B. Amoxicillin
C. Ciprofloxacin
D. Phenoxymethylpenicllin E. Methotrexate
D. Phenoxymethylpenicllin
IRON DEFICIENCY ANAEMIA
> blood test to find out type of anaemia
Give iron supplementation only if there is demonstrable iron-deficiency state. This is to avoid iron overdose=>toxic.
Antidote: desferoxamine
Take extra care if patient is pregnant (do not dispense OTC, unless prescribed and check SCR) and severe asthma
100mg to 200mg of elemental iron usual daily dose for treatment of iron -deficient anaemia.
***Familiarize yourself with ferrous table
Iron can discolour stools, altered taste (metallic), abdominal discomfort, after last iron injection must wait 5 days to take oral iron
Iron can cause constipation as a side-effect. Give with vitamin C (glass of orange juice) to increase absorption=>less constipation issues; ferrogotC
Iron can cause GI side-effects. Consider taking after food if this occurs
See interactions such as iron and tetracyclines, chloramphenicol etc=>min of 2 hrs with other meds (levo, quinolones)
MEGALOBLASTIC ANAEMIA (vitamin deficiency: B12, B9)
*Occurs due to lack of vitamin B12 or (B9) folic acid.
*Hydroxocobalamin (injection) has completely replaced cyanocobalamin as the vit B12 form of choice for therapy in the UK
*Hydroxocobalamin is retained in the body alotl onger and can be given
Every 12 weeks/3 months
VI TAMINS
ADEK – Fat soluble
Which drugs can lead to loss of fat soluble vitamin? Orlistat
>celiac disease=>can cause low levels of ADEK
CB – water soluble; metformin causes low B12
VITAMIN A
Found in liver pate, liver sausage, fish liver, palm oil, carrots.
Can improve vision.
High doses can lead to toxicity: excess of vitamin A or D are more likely to lead to toxicity
VERY IMPORTANT – vitamin A may be teratogenic in pregnancy (amount not known to consume that would cause this). Advice pregnant women to avoid Vitamin A except on doctor’s advice.
Note- ISOTRETINOIN (a drug used to treat acne) is a vitamin A analogue. Pregnancy prevention programme (PPP) applies: (sodium valproate, vitamin A analogues, mycophenalate motil, thalidomide), rule out pregnancy/pregnancy test (ideally 2 tests, min 1), rx needs date as cannot be more than 7 days old with negative test result (day rx prescribed is day 1), 30 day quantity, patient becomes pregnant: if taking SV, keep taking but refer urgent to gp, stop taking other drugs and refer urgent, contraception.
VITAMIN C
Ascorbic acid
Found in fruits etc (oranges, lemon, lime)
Deficiency can lead to scurvy – swollen gums and bleeding margins.
Vitamin C increases iron absorption.
There is no evidence to show that vitamin C (anti-oxidant) ameliorate cold and flu symptoms.
Vitamin C is contraindicated in cardiac dysfunction: HF
VITAMIN D
Sun vital in production of vitmin D
Many people in the UK are vit D deficient. Lack of vit D can cause rickets (low metabolism and low vitamin D)
Supplements are readily available: maintenance dose 1000units in regular vitamin D levels
High doses can lead to toxicity!
High vit D levels can lead to hypercalcaemia: drugs affected by high levels of calcium=>digoxin
WHAT ADVICE WOULD YOU GIVE TO DARKER SKIN PATIENTS IN THE UK REGARDING VITAMIN D INTAKE REQUIREMENT ?
Asian/Olive-tone:
Black: risk of low levels vitamin D bc more melanin, more melanin the less likely vitamin D is absorbed into the skin, more melanin less likely to get burned=>advice regarding vitamin D; take all year long
White: needs to cover her skin from sun to avoid burn, wear sunscreen
**all races must use sunscreen
MANAGEMENT OF VITAMIN D DEFICIENCY OR INSUFFICIENCY FOR CHILDREN
Link/NICE Management
VITAMIN D AND SKIN TONE
Darker skin patients are at higher risk of vitamin D deficiency in the UK.
Light skin can produce up to five times the amount of vitamin D compared to dark skin tones. However, light-skinned individuals have less melanin and are at a higher risk of sunburn and skin cancer.
A mother wants to know which vitamins are safe for her 4-year-old son. Which vitamins are safest in young children?
A. A, B, C, D
B. A, B, E
C. A, C, D
D. A, B, E
E. B, D, K
**can’t give E and K
**vitamin D doses in young children table: allowance for 1.5-yr old?
C. A, C, D=>6 months-5yrs
VITAMIN K
> Vit K is necessary for the production of blood clotting factors.
Oral anticoagulants antagonise the effects of vitamin K (warfarin)
Vitamin K is given to newborn infants after birth via injection for example if the mother is on antiepileptic medication: risk of bleeding, haemoraggic newborn disease.
Green leafy vegetables (kale, spinach, Brussel sprouts, broccoli, collard greens) contain vitamin K. Caution patients whilst taking which drug ????
Vitamin E is essential for skin care
> VITAMIN B
Thiamine (B1) – is most common vitamin B lacked by alcoholics. Rx in Wernicke ebcephalopathy
Mothers who are severely deficient in thiamine should avoid breast feeding due toxic methyl-glyoxal present in their breast milk. >Pyridoxine (B6)– doses over 200mg daily can lead to neuropathy.
Folic Acid (B9)
Hydroxycalabin (B12)
B2, riboflavin
B3, niacin
Isoniazide (TB treatment) can reduce pyridoxine levels and lead to neuropathy=>B6 given as a supplement
Cyanocobalamin / B12 –
Deficiency of B12 can lead to megaloblastic anaemia.
FOLIC ACID
For conception(planning to conceive) and pregnancy
Dose for conception and up to 3 months of pregnancy is 400mcg.
Folic acid 5mg and higher required for –
Patients taking antiepileptic medication
Patient who are diabetic
Patients who have sickle cell anaemia
It Prevents methotrexate induced side-effects. (take folic acid on a different day than when you take the methotrexate)
>smoking/obese
>neural tube defects
FOLIC ACID DOSES
Folic acid Dose is from 5mg
How should folic acid be taken in methotrexate rx
case? different day to methotrexate, if methotrexate taken on Monday, take folic acid any other day
Lack of folic acid can lead to megaloblastic anaemia
Prevention of neural tube defects
Neural tube defects tend to occur within 28 days of pregnancy.
***ELECTROLYTES (will come on exam, drug, symptoms, solution)
Electrolytes Ranges
Sodium: 135 –145mmol/L
Potassium: 3.5 –5.0mmol/L – over 5.5 is usually considered hyperkalaemia
Calcium: 2.1 –2.6mmol/L
Magnesium: 0.7 –1.0mmol/L
Urea: 2.5 –6.4mmol/L
Creatinine clearance (CCL) Men: 97 –140ml/min, Women: 85 – 125ml/min
DIRECTED STUDY QUESTION
Which drugs can cause hypokalaemia?
Which drugs can cause hyperkalaemia?
Which drugs can cause hyponatraemia? what can cause the problem: SSRI, diuertics, carbamazepine, desmopressin; drug that will be affected by low levels od sodium is lithium, symptoms: dizzy, drowsy, low BP, confusion, seizure, solution: withhold medication, give supplements like slow sodium chloride tablets
Which drug can cause hypomagnesaemia?
Which drug can cause hypercalcaemia?
Which drug does not carry a risk of haemolysis (bleeding) in G6PD deficient patients.
A. Gliclazide
B. Dapsone
C. Ciprofloxacin
D. Phenoxymethylpenicllin
E. Aspirin
D. Phenoxymethylpenicllin
G6PD DEFICIENCY
> Glucose 6-phosphate dehydrogenase deficiency
glucose 6-phosphate dehydrogenase deficiency can lead to acute haemolytic anaemia which can occur from taking certain drugs. Ingestion of fava beans (especially raw) and broad beans can also cause the deficiency.
DRUGS: 3Q SANDIP=>quinine (leg cramps, 4 weeks), quinolones, quinidine (malaria), sulphonyureas/sulfasalzin, aspirin, nitrofurantoin, dapsone, isoniazid, primaquine
ACUTE POPHYRIAS: susceptible to increase risk of bleeding=>Anti-depressants, amiodarone, nitrofurantoin, carbamazepine , erythromycin
GOUT - INTRO
Gout is a type of arthritis in which small crystals form inside and around the joints. It causes sudden attacks of severe pain and swelling.
>patients with certain type of diet/medication, rich man’s disease: only rich people could afford foods that increase the risk ie red meat, alcohol, high in sugar, processed foods
>lifestyle changes can reduce the incedence of gout
It’s estimated that between one and two in every 100 people in the UK are affected by gout.
The condition mainly affects men over 30 and women after
the menopause. Overall, gout is more common in men than women.
Gout can be extremely painful and debilitating, but treatments are available to help relieve the symptoms and prevent further attacks.
SIGNS AND SYMPTOMS
- severe pain in one or more joints
- the joint feeling hot and very tender
- swelling in and around the affected joint
- red, shiny skin over the affected joint
GOUT CAUSES
Genetics
DIET – Red meat=>protein=>amino acids=>purines and pyridamines=>purines turn into uric acid=>accumulation of uric acid=>gout, sea food, alcohol, certain sugary drinks
may also increase risk of gout.
AMINO ACIDS
PURINES
URIC ACID
SOME Drugs can exacerbate gout: loop/thiazide diuretics,
T YPES
> Acute Gout Attack: NSAIDs (gi irritation/ulcers/increase risk of bleeding/interacts with wrafarin/anticoagulants, HF: increase fluid overload, uncontrolled BP, asthma)(naproxen, diclofenac, NOT ibuprofen too weak), colchicine (can interact with statins, stop statin while on colchicine as it is used for 3-7 days), canakinumab (always screen for TB before prescribed, rx by specialist), experiences once in a while
Chronic long-term gout: allopurinol (1st line, prevents build-up of uric acid, drink plenty of water, interacts with azothiaprin=>reduce axothiaprin to 25%, rashes developed=>stop and refer to GP, can be a sign of toxicity), febuxostat (1st line, history of CVD avoid this med), sulphinepirazone, 2 or more acute attacks in a year or presence of tophi
acute gout attack treatment to chronic/long-term gout=>need to wait 1-2 weeks before start second medication
if patient is taking allopurinol and develop an acute gout attack=>take both allopurinol and colchicine
PRESENCE OF TOPHI
nubby of toe, start treating patient for long-term management of gout
THERAPY
ACUTE GOUT
NSAIDs
COLCHICINE avoid in Egfr less than 10ml/min and adjust if between 10 to 50 ml/ min
CANAKINUMAB
Therapy
CHRONIC GOUT
ALLOPURINOL – rashes,water intake
FEBUXOSTAT – mhra: monitor for st. johns syndrome (severe skin rash) and CVD
SULFINPYRAZONE – acute porphyria
Drugs to Avoid
If a patient is being treated for acute how long before starting long-term treatment ?
AVOID DEHYDRATION
Diuretics
ASPIRIN
CICLOSPORIN interact with colchicine
NIACIN – VIT B3
WHICH DRUG DOES NOT REQUIRE PREGNANCY PREVENTION PROGRAMME
A. MYCOPHENOLATE MOPHETIL
B. THALIDOMIDE
C. ISOTRETINOIN
D. SODIUM VALPROATE
E. AZATHIOPRINE
E. AZATHIOPRINE
METHOTREXATE
DIHYDROFOLATE REDUCTASE (folate antagonist)
TAKE WEEKLY (once weekly)
2.5MG STRENGTH VS 10MG STRENGTH: increased risk of dispensing errors, so keep in separate places
HOW TO TAKE FOLIC ACID ?? take on a different day to methotrexate
do not Handle with bare hands: cytotoxic, use gloves, separate tweezer and counting tray
COUNSEL PATIENTS ON HOW TO TAKE
METHOTREXATE ADVERSE EFFECTS
BLOOD DISORDER: carbimazole, sulfasalizin, trimethoprim, phenytoin, mirtazipine, carbamazepine, methotrexate
LIVER TOXICITY: dark urine, jaundice, increase in bilirubin levels and AST/ALT, nausea, vomitting, fatigue
RESPIRATORY EFFECTS: SOB, wheezing, difficulty breathing
PHOTOSENSITIVITY
DEHYDRATION: drink plenty of water
ASCITES: type of liver disease, should not initiate treatment until ascites is managed
CONTRACEPTION AND CONCEPTION: both men and woman, wait 6 months after stopping methotrexate in order to start trying to concieve
OTHER SIDE-EFFECTS: G.I IRRITATION, TOXICITY withdraw if stomatitis, ANAEMIA, taste disturbance,
dyspnoea
GIVE CALCIUM FOLINATE (folinic acid) IN ACUTE TOXICITY
Methotrexate Caution
Blood count: factors which increase bone marrow suppression (age, renal impairment, trimethoprim (antifolate)
GI toxicity: withdraw treatment if stomatitis
Liver toxicity: do not start treatment or discontinue if abnormal liver function test results
Pulmonary toxicity: special problem in rheumatoid arthritis. Seek medical attention if (dyspnoea, cough or fever. Monitor symptoms at each visit and discontinue if pneumonitis suspected=>refer!
Which drug to avoid with methotrexate:
Colchicine
Naproxen: reduces eGFR
Trimethoprim: can never take 2 antifolate drugs at same time=>increase risk of mylosuppresion
Amlodipine
Co-Codamol
