Clinical pharmacology Flashcards by caitlin stewart

What is CAM?

Complementary and alternative medicine

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What is the issue with CAM?

Lack of scientifically valid safety and efficacy data

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What are the high risk groups for taking CAMs?

Children
Pregnant
Polypharmacy
Prescribed medicines

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Give 3 examples of CAM.

Herbals 
Homeopathy 
Acupuncture
Aromatherapy 
Chiropractor 
Hypnosis
Chinese medicine
Vitamins and minerals

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What are concerns around CAMs?

Implausibility 
Lack of evidence of benefit 
Lack of safety data
Evidence of harm 
Adverse effects/ herb-drug interactions 
Unqualified practitioners/missed diagnoses
Stopping conventional medicines

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What percentage of the population use CAM?

80%

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Who commonly take CAM?

Affluent
Educated
Family and friends also

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Why do people use CAM?

Desire to control own health 
Disatisfaction with conventional treatment (not for majority) 
Concerns about SEs of prescribed meds
Chronic symptoms
"Hollistic approach"
Relatives use them

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Why do healthcare professionals recommend CAM?

Experience - seeing is believing
Genuine belief in therapy
Use CAM themselves
“Feel good” factor in terminal illness

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What are the issues surrounding herbals?

Active components - heavy metals, bacteria, medicines

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Why is it an issue that women are using CAM during earlyand late pregnancy?

Most use herbals and we don’t know if they have teratogenic effects

No safety or efficacy data

Drug-herb interactions

Fetogenesis

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What is the issue 70% of breast cancer patients using CAM?

Supplement estrogenic activity

Possible herb-drug interactions

e.g soya, evening primrose, chamomile, garlic

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Give an example of a well known drug-herb interaction.

St John’s wort and warfarin

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Discuss KAVA and consequences.

Used for anxiety and stress. Documented cases of hepatotoxicity

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What is homeopathy?

a “treatment” based on “like cures like” by using of highly diluted substance,

One part toxin mixed with 10 parts water - potentiation (promote active “water memory”)

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Discuss efficacy of homeopathy.

Scientifically implausible
Issues with quality of studies
No convincing evidence

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What are issues with homeopathy?

Missed diagnosis
Inappropriate treatment
Adulteration (can contain other compounds that can kill you)

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What is acupuncture?

Traditional Chinese medicine

Vital force (“Qi”) - circulates along “meridians” (12 which correspond to 12 major functions or organs o the body). Trigger points targeted for needling to deal with pain

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What happens during acupuncture?

4-10 points are needled
Left in for 10-30 minutes

For chronic conditions - 6-12 sessions every 3 months

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Discuss efficacy of acupuncture.

Partially explained by physiology of pain - stimulate fibres entering dorsal horn of spinal cord, inhibit impulses. Stimulate release endogenous opioid and other neurotransmitters e.g serotonin

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What are serious risks of acupuncture?

Similar to any harm with needle use e.g infection, pneumothorax, pneumopericardium, organ puncture

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What is aromatherapy?

Use of essential oils extracted from herbs, flowers and other plants to treat diseases. Commonly administered by massage

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Can aromatherapy be harmful?

Yes e.g inhalation can cause bronchospasm in asthma.

Skin irritation 
Allergies
Photosensitivity 
Insomnia
Abortifacient if taken in pregnancy

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Why is aromatherapy used for cancer patients?

Short term benefits on psychological wellbeing
Effect on anxiety
Improve physical symptoms

Lack of evidence for all

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What are the main concerns of CAMs?

Efficacy Cost effectiveness Safety Increasing availability

What do the MHRA do?

License medicines

What is pharmacovigilance?

Process involving detection, assessment, understanding and prevention of ADRs

What is the main method of post-marketing surveillance of ARDs in the UK?

Yellow card scheme

What is the MHRA yellow card scheme?

Collects info on suspected problems or incidents involving SEs, medical devices, defective medicines, counterfeit or fake medicines or medical devices, safety concerns

Who can file a yellow card report?

Voluntary scheme | Healthcare professionals and members of the public

What drugs should healthcare professionals report if suspected adverse reactions.

New drug Black triangle drug Children (mostly off license) Serious ADRs for established drugs e.g anaphylaxis

What info should be included in a yellow card report?

Side effects Info about person who has experienced se Name of medicine Your name and full address

Would you report vomiting after a new vaccine?

Yes as it is a new vaccine

Well established drug. Neutropenia following tow weeks treatment (Already mentioned as SE in BNF). Would you report?

Yes

Would you report sleep disturbance following two weeks administration of a well established drug?

What does off-label drug mean?

Licensed but prescribed outwith the terms of marketing authorisation

What are 'specials' in relation to drugs?

Special formulations of medicines made of clinical reasons when existing formulation of an available licensed product is not suitable for patient = unlicensed

What is an unlicensed drug?

No marketing authorisation

What are the classifications of medicines (human medicines regulations 2012)?

Prescription only medicine (POM) Over the counter (OTC)

What are general sales list medicines?

Can be sold in registered pharmacies but also in other retail outlets e.g paracetamol

What can controlled drugs cause?

Dependency

What are 'P' drugs?

Pharmacy only

Give examples of controlled drugs.

Opiates Temazepam Tramadol

How do you write drugs if less than 1g?

Write as mg, avoid decimal points! i.e 500mg NOT 0.5g

How do you write drugs less than 1mg?

Write as mcg, avoid decimal points! i.e 500mcg NOT 0.5mg

What should you do before prescribing?

Medicines reconciliation Decide/discuss with seniors if medicine is to continue/change dose, be stopped - record on medicines reconciliation form Check BNF if unsure of drug/dose/frequency

What is a PAR?

Kardex

What exerts tonicity?

Sodium which disrupts how body handles fluid

What body compartments does fluid end up in?

Plasma --> then redistribute

How do you estimate patient volume load?

Take history, ask about thirst (low intravascular volume if thirsty), check temp, CRT, leg raise and BP measurement, BP, vital signs, skin turgor, weigh, measure UO

What is one of the most validated ways to assess intravascular volume?

CRT

What are the three Rs of fluid administration?

Resuscitation Routine maintenance Replacement

What does maintenance fluid usually contain?

Sodium, potassium, little bit of glucose, water

What would happen if given patient 5% glucose overnight at 100ml/hour?

Cerebral oedema and death. Glucose metabolise, free water will distribute through all body compartments including brain.

What questions should you consider when prescribing fluid?

1. What is my patients volume status?Does my patient need IV fluids 2. Does my patient need IV fluids 3. How much fluid do they need? 4. What type of fluid do they need?

What types of fluid do they need?

Crystalloids e.g Hartmanns, plasmalite, 0.9% NaCl Colloids e.g blood, albumin

What is the patient's volume status?

If acutely unwell - A-E

Do hypovolamic patients need fluid?

Yes

Do euvolaemic patients need fluid?

No unless electrolyte deplete or low BP

Do hypervolaemic patients need fluid?

Might paradoxically need fluid , may have lots of oedema but are hypotensive and tachycardic

What are signs of euvolaemia?

``` Feels well Not thirsty Warm extremities Mild sweat Normal BP and HR Normal urine ```

What are signs of hypovolaemia?

``` Feels nauseous, thirsty Flat veins Cool peripheries No sweat Low or postural BP and high HR Concentrate oliguria Responds to SLR ```

What do hypovolameic patients need?

Resuscitation fluids | Rehydration fluids

What are signs of hypervolaemia?

``` Breathless Not thirsty Distended veins Warm or oedematous extremities Sweaty High BP and High HR Dilute urine ```

What do hypervolaemic patients need?

No more fluid Possible diuretics (if respiratory compromise) Haemofiltration

When do things get tricky when prescribing fluids?

Low oncotic pressure | Heart failure

How do you work out water deficit?

Catheters, drains , input charts, vomit bowls, sputum pot, stool charts

What are crystalloids useful for?

Acute dehydration, AKI, resuscitation

What are crystalloids not useful for?

Long term maintenance Hypernatraemic --? remain in ECF, usually high Na load which can cause problems over time

When are plasma expanders useful?

Liver patients | Select intra-operative

Where do colloids stay?

Exclusively in IVS.

How do you assess fluids status?

History and vital signs

How much fluid and mineral are needed in 24 hours?

Water = 25-30ml/kg/day Sodium = 1mmol/kg/day Potassium = 1mmol/kg/day Glucose = 50-100mg/day

What routes should be first line for fluid administration?

Oral and NG

What is the recommended fluid bolus needed in resuscitation?

3-10ml/kg e.g start with 250ml then repeat