Chapyter 8

Question 1

What needs to be checked before starting vancomycin?

Answer 1

Serum Creatinine - renal function must be taken into account when deciding on dosing regimen

Question 2

What needs to be checked before starting a statin and why?

Answer 2

Transaminases need to be checked - if 3x normal range statin is CI/ should be stopped.
Recheck 3m and 12m after starting

This is because they are metabolised by liver –> if hepatic impairment –> higher risk myopathy

Question 3

When should CK be checked in those starting a statin?

Answer 3

Creatine kinase need only be checked at baseline in patients who are considered to be at increased risk of the rare side effect of myopathy i.e. a personal or
family history of muscular disorders, previous history of muscular
toxicity, a high alcohol intake, renal impairment, hypothyroidism
and in the elderly

Question 4

How are phenytoin levels checked?

Answer 4

At day 14 of treatment a pre-dose ‘trough’ phenytoin level is requested
in order to ensure that it is within the normal reference range. T

Question 5

What are the monitoring requirements for lithium? Before and during

Answer 5

Before: renal, cardiac, thyroid function, BMI, U+E, FBC

Every 6m monitor BMI, U+E, eGFR, TFT

Question 6

What is the therapeutic window for lithium?

Answer 6

0.9-1mmol/ litre

Around 1.5mmol/ L expect to see toxicity

Question 7

When should lithium concentration be measured

Answer 7

12 hrs after dose

weekly upon inititiation, every 3m for first year and every 6m after that

Question 8

What are the monitoring requirements for methotrexate?

Answer 8

FBC, U+E, LFT every 1-2 weeks until therapy stable and then every 2-3m after that

Question 9

What are the adverse effects of methotrexate

Answer 9

Bone marrow suppression
GI toxicity (diarrhoea/ stomatitis)
Liver cirrhosis
Pulmonary toxicity (fever, cough, dyspnoea)

Question 10

What are the different colours and doses of warfarin tablets?

Answer 10

Warfarin tablets are colour coded to aid recognition and to allow dose management. White (0.5mg), brown (1mg), blue (3mg) and pink (5mg).

Question 11

What monitoring is required for antipsychotics?

Answer 11

PL at start, 6m and yearly

Lipids, BMI, BP, blood glucose at start, 3m and yearly

FBC, U+Es, LFTs every 12m

ECG for haloperidol

Question 12

What are the monitoring requirements for amiodarone?

Answer 12

TFTs, LFTs baseline and every 6m
CXR and K+ levels (wary of hypokalaemia) at baseline
If done IV needs ECG monitoring

Question 13

What needs to be measured in any patient with carbimazole and a suspected infection?

Answer 13

Neutrophil count as can cause bone marrow suppression

Question 14

What is the multiple daily dose regimen for gentamicin normally/ in endocarditis?

Answer 14

For multiple daily dose regimen, one-hour (‘peak’) serum concentration should be 5–10 mg/litre; pre-dose (‘trough’) concentration should be less than 2 mg/litre.

For multiple daily dose regimen in endocarditis, one-hour (‘peak’) serum concentration should be 3–5 mg/litre; pre-dose (‘trough’) concentration should be less than 1 mg/litr

Question 15

What is the most important monitoring parameter for digoxin?

Answer 15

digoxin is predominantly renally excreted and patients with renal dysfunction are at increased risk of
toxicity.

Question 16

What is the most important monitoring parameter for sodium valproate?

Answer 16

sodium valproate therapy is associated with hepatotoxicity and liver function should be measured at
baseline as well as at regular intervals throughout the duration of therapy.

Question 17

What monitoring is required in particular for clozapine

Answer 17

Due to the risk of neutropenia and potentially fatal agranulocytosis, routine monitoring of full blood
count is required weekly for 18 weeks, then fortnightly for up to one year, and then monthly

Question 18

When do U+E levels need to be checked for ACE-i?

Answer 18

U+Es before, after 1-2 weeks, Once treatment is stable, measure renal function and serum electrolytes at least every monthly for 3 months and then at least every six months and at any time if the person becomes acutely unwell.

Question 19

What drugs interact with statins?

Answer 19

statins should be stopped while taking clarithromycin (a CYP3A4 inhibitor) as they increase toxicity
and associated side effects.

Question 20

When is a tacrolimus level checked?

Answer 20

measuring a trough level before the morning or evening dose is the correct way to check a tacrolimus
level. At this stage after transplant we would be aiming for a level of 6–10 ng/mL. This info is on the BNF.

Question 21

What is the best way to monitor resolution of \DKA?

Answer 21

normalisation of serum ketones

serum glucose normalises rapidly after insulin is given but this does not mean DKA resolution necessarily

Question 22

Best way to monitor a chest infections response to abx?

Answer 22

RR

resolution of CXR and crackles take longer to normalie and respond to abx

Question 23

If someone on an ACE-i presents with malaise what should you check?

Answer 23

serum creatinine! AKI can be difficult to spot clinically and may present vaguely.