Clinical Pharmacology and Toxicology Flashcards
Carbon Monoxide Poisoning
- Features
- Investigation
- Treatment
Falsely Normal SpO2
Low PaO2
ECG
Flattening of Oxygen Dissociation Curve
100% oxygen
P450 Enzyme INHIBITOR Mnemonic
SICKFACES.COM
Sodium Valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol Binge Drinking
Chloramphenicol
Erythromycin
Sulphanamides
Ciprofloxacin
Omeprazole
Metronidazole
Grape Fruit Juice
P450 Enzyme Inducer Mnemonic
CRAP GPS
Carbamezepine
Rifampicin
Alcohol (Chronic)
Phenytoin
St John Warts
Greiosulvin
Phenobarbitone
Sulphonyl urea / SMOKING
Which CCB causes Gingival Hyperplasia
Amlodipine
Teratogenic Drugs Menmomnic
SAFE Moms Take Really
Good Care = WIN
Sulphonamides/ Statins
Aminoglycosides/ACEi
Fluoroquinolones
Erythromycin/Estradiol
Metronidazole
Tetracyclines/Trimethoprim
Ribavirin/Retinoids
Griseofulvin
Chloramphenicol/Clomiphene citrate
Warfarin
Isoniazid
Nitroimidazole
Metformin MOA
Biguanide
activation of the AMP-activated protein kinase (AMPK)
Increasing Glucose Sensitivity and Decreasing Hepatic Gluconeogenesis
Contraindications for Metformin
eGFR < 30 or Creat > 130
Reviewed if eGFR < 45 and Creat > 130
Contraindicated if Tissue Hypoxia States (precipitate Lactic Acidosis) - Recent MI , Sepsis , AKI etc ….
Side Effects of Metformin
GI Upset and Lactic Acidosis
How long should you leave before you increase dose of Metformin ?
1 week
If patients develop side effects on Immediate Release Metformin then what ?
Switch to Modified Release
Gentamicin
If the Peak Level is High = What to do ?
If the Trough Level is High = What to do ?
Peak High = Reduce Dose
Trough Level is High = Increase the Gap between doses
Contraindication for Gentamicin ?
MG
Quinolones MOA
inhibit topoisomerase 2 (DNA gyrase) and topoisomerase 4
Mechanism of Resistance of Quinolones
Mutations to DNA gyrase
Efflux pumps which reduce intracellular quinolone concentration
Side Effects of Quinolones
Lower Seizure Threshold
Tendon Rupture (Especially if on Steroids)
QT Prolongation
When to Avoid Quinolones ?
G6PD
Pregnancy / Breastfeeding
When to give Hyperbaric Oxygen in CO Poisoning ?
- CO level >25 percent
- CO level >20 percent in pregnant patient
- Loss of consciousness
- Severe metabolic acidosis (pH <7.1)
- Evidence of end-organ ischemia (eg, ECG changes, chest pain, or altered mental status)
Motion Sickness What Sequence of Drugs ?
Hyoscine
Cyclizine
Promethazine
Digoxin MOA ?
Inhibition of the Na+/K+ ATPase pump in
Cardiac Muscle
Features of Digoxin Toxicity ?
Yellow Green Vision
Gynecomastia
BRADYCARDIA
Check Digoxin Levels in Patients with Digoxin Toxicity how often ?
8 to 12 hours after last dose
What Precipitates Digoxin Toxicity ?
Digoxin competes for same site as K at ATPase
Hypokalemia → digoxin more easily bind to the ATPase pump → increased inhibitory effects
Which Drugs Precipitate Digoxin Toxicity ?
Amiadorone
Diltiazem
Verapamil
Quinidine
Ciclosporin
Precipitants of Digoxin Toxicity ?
Half Empty (MT) Packet of Chips (PKT)
Mg , Temp , pH, K, Thyroid
Full Can of Coke (CaN)
High Ca and Na
Ethylene Glycol Poisoning Treatment?
Fomepizole - Inhibit Alcohol Dehydrogenase
BUT Ethanol in the past competes for Alcohol Dehydrogenase
Traztusumab MOA and Side Effect
HER 2 Receptor blocker
Cardiotoxicity so do Echo before starting
Ethambutol MOA ?
Inhibits Arabinose Transferase
which converts Arabinose to Arabinan
Which TB drug has renal dosing ?
Ethambutol
eGFR<30
Lithium Side Effects ?
Leukocytosis
Increased Urine (Nephrogenic DI)
Thirst/Tremor (Coarse vs Tremor (when in therapeutic levels))
Hypothyroidism
Upset Stomach
Mental (Seizures/Coma)
Lithium Treatment
3C’s - confusion convulsion coma
if present, along with lithium =
ABC + emergent hemodialysis
if not,
ABC + IV Saline + check lithium levels (4 hourly if DI) + assess for DR. DAMN
DR. DAMN - dehydration + renal fail + diuret. + acei + metronid. + nsaids
Lithium Toxicity (>1.5) Precipitants ?
Drugs (ACEi, Thiazide, NSAID’s, Metronidazole)
AKI
Dehydration
Caustic Agent Ingestion Treatment
Urgent OGD if Symptomatic (drooling, vomiting, dysphagia, odynophagia, chest pain)
IV PPI
If Asymptomatic - Trial Oral Fluid and Discharge
If Signs of Perf (Mediastinal Widening or Surgical Emphysema) = Upper GI Referral
Side Effect of Hydrofluoric Acid ingestion ?
Hypocalcemia
How often to Monitor
Lithium
Ciclosporin
Digoxin
Phenytoin
6 hours Post Dose
Immediately Before Dose
12 hours Post Dose
Immediately Before Dose
Cyanide Poisoning MOA ?
Cyanide Inhibits Cytochrome C which results in halting of the Mitochondrial ETC
Cyanide Poisoning Treatment ?
Hydroxocobalamin
Combination of Inhaled Amyl Nitrite + IV Sodium Nitrite + Sodium Thiosulfate
Adrenaline Induced Digital Ischemia Treatment ?
Topical Application of Nitroglycerin then
Phentolamine - Short Acting Alpha Blocker
Ciclosporin Side Effects
CiclosporINCREASES everything:
fluid, BP, K+, hair, gums, glucose, creatinine, lipids, infections.
Only 2 toxicities (nephro and hepatic)
What increases level of Ciclosporin ?
Cannabinoid
Drugs having Zero Order Kinetics ?
High Dose Aspirin
Phenytoin
Heparin
Ethanol
Drugs affected by Acetylator Status ?
Isoniazid
Procainamide
Hydralazine
Dapsone
Sulfasalazine
SHIP - D
Drugs undergoing First Pass Metabolism ?
Aspirin
Isosorbide dinitrate
GTN
Lidocaine
Propranolol
Verapamil
Isoprenaline
Testosterone
Hydrocortisone
Which Drug causes Anal Ulceration ?
Nicorandil
Which Anti-Anginal Causes Sleep Disturbance
(vivid dreams) ?
Beta Blocker
DRESS Syndrome Diagnostic Criteria ?
Triad of Skin Rash + Fever + Organ Involvement
At least 3 of the following:
- Hospitalization
- Reaction suspected to be drug related
- Acute skin rash
- Fever about 38ºC
- Enlarged lymph nodes at two sites
- Involvement of at least one internal organ
- Blood count abnormalities such as low platelets, raised eosinophils or abnormal lymphocyte count.
Phase 1 Reactions
Hydrolysis , Reduction and Oxidation
Caused by Enzymes : P450 or Alcohol Dehydrogenase or Xanthine Oxidase
Side Effects of Sildanefil (PDE5i)
NOID
(Non-Arteritic Anterior Ischaemic neuropathy)
Bluish Discoloration of Vision
Nasal Congestion
Flushing
When not to take Sildanefil ?
Concomitant Nitrates
Recent MI (wait 6 months)
Cannabis Toxicity
- Features
Coronary
Neurological
Psychiatric
Other -
Ischemic Colitis
Rhabdomyolysis
Metabolic Acidosis
Hyperthermia
Cannabis Toxicity
- Treatment
NSTEMI - IV Benzo + GTN
STEMI - PCI STAT !!!!
HTN - Nitroprusside + BZD
Drugs Causing Impaired Glucose Tolerance
TASTINg Sugar
Thiazides,
Antipsychotics,
Steroids,
T cell in inhibitors (tacrolimus |&| cyclosporin),
interferon alpha,
Nicotinic acid.
Sugar = impaired glucose tolerance
Most Common Side Effect of Finasteride ?
Gynecomastia
Drugs causing Gynecomastia
DISCO with GF
Digoxin
Isoniazid
Spironolactone
Cimetidine
OEstrogen
Goserlin
Finasteride
What drug can be discontinued abruptly when starting Sildenafil ?
Alpha Blockers Stopped for 4 hours AFTER Sildenafil
Nateglinide used in Diabetic Control
Doxazosin would need to be adjusted because the time taken will need to be changed.
Heparin Induced Thrombocytopenia
See Note from HaemoOncology !!!
Which Factor does LMWH inhibit ? vs Standard Heparin ?
LMWH - Antithrombin III but SPECIFICALLY 10a
Standard - Antithrombin III (10 2,7,11,12,9)
Side Effects of Heparins ?
Osteoporosis
Thrombocytopenia (HIT)
Hyperkalemia (inhibition of aldosterone secretion)
MOA
- Statins (Myositis)
- Ezetimibe
- Nicotinic acid (Myositis)
- Fibrates (Myositis)
- Cholestyramine
HMG CoA Reductase inhibitor
Decreases Cholesterol Absorption via NPC1L1 (Niemann-Pick 1 like 1)
Decreases Hepatic VLDL Secretion
PAPP-R agonist –> Increasing Lipoprotein Synthesis
Bile Acid Sequestrant
Which Anti - Lipid Drug Potentiates Myositis from Statins ?
Fibrates !!!
Tacrolimus MOA and how is it different to Ciclosporin ?
Bind to FKMB –> Inhibit Calcineurin –> Prevent Dephosphorylation of Transcription Factor NF-AT –> Inhibit release of IL-2
Vs
Ciclosporin
Bind to cyclophilin –> Inhibit release of IL-2
MOA of MMF ?
Inhibits inosine monophosphate dehydrogenase –> Decreasing G base pairs for DNA / RNA Synthesis
Drugs that can be cleared by Hemodialysis ?
Barbiturate
Lithium
Alcohol (Methanol and Ethylene Glycol)
Salicylate
Theophylline (Charcoal Hemodialysis)
Drugs that CANNOT be cleared by hemodialysis ?
TCA
BB
Digoxin
BZD
Dextropropoxyphene (Co-proxamol)
Drugs causing Urticaria ?
P(I)ANO
penicillin’s
aspirin
NSAIDs
opiates
MDMA associated with which electrolyte derangement ?
Hyponatremia
Drugs causing Photosensitivity Rash ?
SAN LIGHT
Sulphanamides
Amiodarone
NSAIDs
Loop Diuretics
Isoniazid
Griseofulvin
Hydrochlorothiazide
Tetracyclines
OR
PQRST AND CNG
P- Psoralens
Q- Quinine, Quinolones, Quinidine
R- Retinoids
S- Sulphonamides, Sulfonylureas
T- Tetracyclines, Thiazides
A- Amiodarone
N- NSAID’S– Ibuprofen, naproxen, celecoxib
D- Dapsone
C- Chloroquine, Chlorpromazine
N- Nalidixic acid
G- Griseofulvin
Cetuximab (Anti Epidermal Growth Factor)
Alemtuzumab (Anti CD52)
Abciximab (Anti Glycoprotein IIb/IIIa)
OKT3 (Anti - CD3)
Monoclonal Antibodies Created via STEM CELL HYBRIDIZATION
Myeloma Cells + Mouse Spleen Cells sensitivised for Antigens = Hybridoma
Humanising is when Fc Portion from Human is attached to the Mice FaB
Drugs causing Thrombocytopenia ?
HARDPANS Q (kinda looks like a pan)
- Heparin
- Anticonvulsants: carbamazepine, valproate
- Rifampicin
- Diuretics: furosemide
- Penicillin
- Abciximab
- NSAIDs
- Sulphonamide
- Quinine
Drugs precipitating AIP ?
Induce P450 –> Increasing Heme Synthesis –> Depleting Heme Storage –> Attack
SHABOB
Sulphanamide
Halothane
Alcohol
Barbiturates
Ora Contraceptive Pill
BZD
Methanol vs Ethylene Glycol Poisoning
How to differentiate
Vision Disturbance in Methanol but not in Ethylene Glycol
Which drug causes Corneal Opacification ?
Corneal opacification –> Amiodarone , Indomethacin
Lens opacification –> Steroids
Local Anesthetic Toxicity Antidote ?
IV Lipid Emulsion 20%
MOA of Ketamine ?
NMDA Antagonist
BarbiDurates=increase Duration
Frenzodiazipine=increase frequency
Is Aspirin a Reversible or Non Reversible COX 1 and 2 inhibitor ?
IRREVERSIBLE
Mercury Poisoning Features ?
M - Muscle weakness + PN
E - Eye (Visual field defect) + Ear (SNHL)
R - RTA-P → Hyperchloraemic metabolic acidosis
C - aCrodynia → Pain + Pink discoloration → Hand + Foot
U - ↓Urine → Renal impairment
R - Restless → Irritability
Y - enzYme - Inhibition of selenoenzyme → end-organ oxidative damage
MDMA + SSRI = Which Crisis ?
Serotonin Crisis
Cyanide Poisoning
Read Attached Note and Watch Medicosis
Alpha 1 = Phenylephrine
Alpha 2 = Clonidine
Beta 1 = Dobutamine
Beta 2 = Salbutamol
Beta 3 = Mirabegron
When to give IV HCO3- in TCA OD ?
pH <7.1
QRS >160 ms
Arrhythmias
Hypotension
MOST COMMON Side effect of Progesterone Only Pill ?
endometrium pops (irregular periods)
BUT also
Head pops (headache), breasts pop (breast tenderness), Tummy pops (weight gain) and skin pops (acne),
TB Drugs Side Effects
Rifampicin - Orange
Isoniazid - Peripheral Neuro
Pyrazinamide - Gout , Hepatitis
Ethambutol - RBR
Amiodarone Induced Hypothyroidism
vs
Amiodarone Induced Thyrotoxicosis
Continue Amiodarone
Add Levothyroxine
Stop Amiodarone
AIT Type 1 (Excess Iodine) - Carbimazole or Potassium Perchlorate
AIT Type 2 (Destructive Thyroiditis) - Corticosteroids
Difference between AIT Type 1 and Type 2
Which has Goitre ?
Type 1 has Goitre
Drugs NOT safe in Pregnancy ?
Sulphanamides/Statins
Aminoglycosides/ACEi (Renal Agenesis)
Fluroquinolones
Erythromycin/Estadiol
Metronidazole
Tetracyclines (Discoloured Teeth)
Rivabarin/Retinoids
Griseofulvin
Chlormphenicol (Gray Baby Syndrome)
Diethylstilbesterol - Vaginal Clear Cell Adenocarcinoma
Methadone MOA
Buprenorphine MOA
Methadone - Full agonist of the mu-opioid receptor
Buprenorphine - Full Kappa and Partial Mu
Detoxification Monitored via How ? for How Long ?
Urinalysis
4 weeks in Hospital
12 weeks in Community
Side Effect of Octreotide ?
Biliary Stasis
Treatment for Methanol Poisoning
fomepizole (competitive inhibitor of alcohol dehydrogenase)
Ethanol
Haemodialysis
cofactor therapy with folinic acid to reduce ophthalmological complications
Upper Extremity Nerve Injury Video to Watch
ARM - U
NAMe SOME
Watch https://www.youtube.com/watch?v=Orr4KPUr9Ck&t=302s
Cinconism
Tinnitus
Hypoglycemia
Flash Pulmonary Edema
Prolonged QT interval
