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PRE REG > Clinical Powerpoint > Flashcards

Clinical Powerpoint Flashcards

1
Q

Which drugs increase the anticoagulant effect of warfarin (INR increased\0

A

SSRIs, PPIs, Statins

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2
Q

Which drugs increase the INR by enzyme inhibition

A

erythromycin, miconazole, amiodarone, cimetidine

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3
Q

Which drugs decrease the INR by enzyme induction

A

St John’s wort, carbamazepine, rifampicin, phenytoin

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4
Q

How can antibacterials affect INR

A

Unpredictable but in practice all can effect. Monitor more frequently

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5
Q

Which juice affects INR

A

Cranberry juice - enhances the anticoagulant effect

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6
Q

How does Vitamin K interact with warfarin?

A

Antagonises the effect

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7
Q

How do NSAIDs interact with warfarin?

A

Will not necessarily alter INR but bleed risk is increased significantly. Same for antiplatelets

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8
Q

What are the enzyme INhibitors? (INcrease)

A

Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole

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9
Q

What are the enzyme inDUCErs? (REDUCE)

A

Carbamazepine
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbital
Sulphonylureas

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10
Q

What is the starting dose for apixaban?

A

Treatment of DVT/PE: 10mg daily for 7 days then 5mg daily
Stroke prophylaxis in AF: 5mg BD or 2.5mg bd in over 80, bw less than 60 or renal impairment

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11
Q

What is the starting dose for rivaroxaban?

A

Treatment of dvt/pe:
15mg bd for 21 days then 20mg daily with food
prophylaxis of dvt/pe recurrent: 10mg daily or 20mg in high risk
af: 20mg daily

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12
Q

What is the starting dose for edoxaban?

A

BW below 60 = 30mg od
BW above 60 = 60mg od

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13
Q

what is the starting dose for dabigatran

A

under 75 - 150mg bd
75-79 - 110-150mg bd
80+ 110mg bd

following 5 days with a parenteral anticoagulant

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14
Q

What is the common interactions with NOACs

A

Increased risk of haemorrhage with NSAIDs, other anticoagulants, antiplatelets, SSRIs, systemic steroids

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15
Q

Which drugs can increase the plasma concentration of NOACs

A

antifungals, diltiazem, verapamil, amiodarone, dronaderone

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16
Q

Which drugs can decrease the plasma conc of NOACs

A

rifampicin, carbamazepine, phenytoin, phenobarbital, st johns wort

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17
Q

What is the antidote for dabigatran

A

idacalizumab

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18
Q

What is the antidote for rivaroxaban/edoxaban/apixaban

A

adenexat alfa

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19
Q

What is the anticoagulant of choice for mechanical heart valves

A

warfarin

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20
Q

Which antiplatelet is indicated for primary prevention and in which cases

A

Aspirin in 10 year risk over 20%
risk vs benefit

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21
Q

which antiplatelet is used as secondary prevention post MI

A

DAPT - dual antiplatelet with aspirin and ticragelor/prasugrel
IF PCI - aspirin and clopidrogel

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22
Q

which antiplatelet is used as secondary prevention post stroke

A

clopidogrel

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23
Q

which antiplatelet is used as secondary prevention post TIA

A

clopidogrel

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24
Q

which antiplatelet is used as secondary prevention in patients with angina

A

Aspirin

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25
Q

which antiplatelet is used as secondary prevention in patients with acs

A

aspirin + ticragelor/prasugrel

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26
Q

which antiplatelet is used as secondary prevention in patients with peripheral arterial disease

A

clopidogrel

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27
Q

which antiplatelet is used as secondary prevention in patients with AF where anticoagulants are unsuitable

A

DAPT

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28
Q

Discuss cv risk assessment

A

Risk assessment
– QRISK
– 40 – 74 years every five years
– Not if already classed high risk

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29
Q

How is cv risk under 10% managed

A

lifestyle

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30
Q

how is cv risk over 10% managed

A

atorvastatin 20mg, aiming for a 40% reduction in non hdl cholesterol within 3 months

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31
Q

Which statin is indicated for secondary prevention

A

atorvastatin 80mg

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32
Q

What are the symptoms of heart failure

A

breathlesness, fatigue, oedema, orthopnoea

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33
Q

What is the lifestyle advice in heart failure

A

Reduce salt, maintain fluids, smoking, alcohol, exercise

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34
Q

Which drugs are used in the tx of heart failure

A

– ACE inhibitors / BBs
– Diuretics (loop/thiazide)
– Aldosterone antagonist (spironolactone/eplerenone)
– Sacubitril and valsartan
– Hydralazine and nitrate (especially for Afro-Caribbean origin)
– Digoxin
– Ivabradine

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35
Q

What are the symptoms of angina and acs

A

chest pain on exertion (stable) or at rest (unstable)

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36
Q

What is the treatment of stable angina

A

GTN
– Beta blocker or CCB
– ISMN
– Ivabradine
– Nicorandil
– Ranolazine
– Secondary prevention

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37
Q

What is the treatment of acute coronary syndromes

A

Immediate aspirin 300mg stat, GTN and morphine for pain
– Unstable angina / NSTEMI – PCI followed by DAPT and secondary
prevention (unless low-risk of recurrence)
– STEMI – PCI followed by DAPT and secondary prevention

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38
Q

When is insulin initiated in t2dm

A

When dual therapy has not continue to control

39
Q

When are GLP 1’s indicated

A

If triple therapy with metformin and 2 other oral drug sis not effective/tolerated/contraindicated in bmi over 35 or under 35 and insulin would have occupational implications or weight loss would be of benefit

40
Q

In which patient groups is metformin first choice

A

over weight

41
Q

Which antidiabetic has a lower incidence of weight gain

A

metformin

42
Q

What are some side effects of metformin

A

lactic acidosis, b12 deficiency, gi upset

43
Q

What are the risks of SGLT2 inhibitors

A

dka, uti, thrush, lower limb amputation

44
Q

Which antidiabetic can cause weight gain

A

sulphonylureas

45
Q

What are the adverse effects of pioglitazone

A

fluid retention and hospitalisation for cardiac failure
fractures in women
cv risk
bladder cancer risk

46
Q

Discuss GLP1 mimetics

A

significant weight loss, nausea, care when combining with insulin - reduce insulin dose

47
Q

Which dpp4 is preferred in ckd

A

linagliptin

48
Q

How can the side effects of nausea and vomitting with erythromycin be managed?

A

reduced dose of 250mg qds

49
Q

What is used for acute infective exacerbations of COPD

A

Prednisolone 30mg for 5-7 days and amoxicilin 500mg tds OR doxy 200mg stat then 100mg od for 5-7 days

50
Q

What is used for acute non-infective exacerbations of copd

A

prednisolone 30mg for 5-7 days

51
Q

What is the first line tx for asthma

A

ics - saba is only for relief

52
Q

What is the age for duoresp/symbicort inhalers

A

over 12 if mart regime
duoresp/fostair = 18+

53
Q

Which inhalers are more environmentally friendly

A

dpi - less carbon emissions

54
Q

Which patients require a spacer with a mask

A

children under 5

55
Q

How often should spacer devices be washed?

A

once a month

56
Q

How should spacers be cleaned?

A

warm water and detergent, air dry

57
Q

How often should spacers be replaced

A

ideally once a year

58
Q

What is the initial step up therapy in children under 5

A

LTRA as LABA not licensed

59
Q

How is acute asthma managed

A

Salbutamol - via spacer in community and via nebuliser in hospital
prednisolone

60
Q

What is the dose of prednisolone for acute asthma

A

40-50mg for 5-7 days in adults
10mg in children under 2
20-30 in children 2-5
30-40 in children over 5

61
Q

What are the common SABA inhalers

A

salbutamol and terbutaline

62
Q

What are the common LABA inhalers

A

formoterol-salmeterol

63
Q

What are the common LAMAs

A

Glycopyronium, aclidinium, tiotropium, umeclidinium

64
Q

What are the common LABA/LAMA combos

A

duakir (aclidinium/formoterol), anoro (umeclidinium/vilanterol)

65
Q

What are the common laba/ics combos

A

fostair (formoterol/beclometasone), relvar (vilanterol/fluticasone)

66
Q

What is long term use of lithium associated with

A

thyroid disorders and mild cognitive and memory impairment

67
Q

How often should thyroid function be monitored with lithium

A

every 6 months at least

68
Q

Is lithium indicated in renal impairment

A

avoid or monitor carefully - more often if evidence of deterioration or concomitant prescribing of nsaids/ace/diuretics

69
Q

How should lithium be prescribed/dispensed

A

by brand

70
Q

What is the target serum lithium level

A

0.4-1mmol/l, 0.8-1 if high risk

71
Q

When is the trough level for litium taken

A

12 hours post dose

72
Q

What can make lithium toxicity worse

A

sodium depletion, therefore concurrent use of diuretics particularly thiazides is hazardous

73
Q

What is the most important determinant of dosage for digoxin

A

renal function

74
Q

Which electrolyte disposes patients to digoxin toxicity

A

hypokalaemia

75
Q

What is a side effect of theophylline

A

hypokalaemia

76
Q

How is theophylline metabolised

A

liver

77
Q

When are theophylline levels increased

A

heart failure, cirrhosis, viral infections, elderly and by drugs that inhibit its metabolism

78
Q

When are theophylline levels decreased

A

smokers, alcohol. inducers

79
Q

Discuss the ppp with regards to valproate

A

Valproate medicines should not be used in women of childbearing potential unless the
Pregnancy Prevention Programme is in place
* Initially consider whether valproate can be changed to another AED (with specialist
input)
* Childbearing potential: RCOG recommends PPP for all females that have started their
period, otherwise once they reach the age of 13 (unless compelling reasons otherwise)
* Women prescribed valproate should be seen by their specialist annually
* They should be prescribed highly effective contraception (ie. not user dependent)
– IUDs
– Implant
– Sterilisation
* If pills, patches or the injection are used, women must be advised to use additional
barrier methods of contraception
* Pregnancy should be excluded before starting treatment
* Pharmacies need to ensure they discuss risks with patients, including providing
appropriate PILs and full boxes where possible
* Prescriptions should be limited to a 30-day supply and be dispensed within 7 days
(note. not a legal requirement)

80
Q

What is the advice for oral retinoids with regards to pregnancy and breast feeding

A

Pregnancy
* Oral retinoids (eg. Isotretinoid) can cause serious birth defeats
* Considering the indication (acne) they are absolutely contraindicated in pregnancy
* Women of childbearing potential require a PPP to be in place (similar to valproate)
* MHRA advice:
* They should be prescribed highly effective contraception (ie. not user dependent)
– IUDs, implant, sterilisation
* If pills, patches or the injection are used, women must be advised to use additional
barrier methods of contraception
* Contraception should be continued for one month after stopping treatment
* Patients must have a pregnancy test before treatment is started, at intervals
(ideally monthly) during and one month after stopping treatment
* Prescriptions should be limited to a 30-day supply and be dispensed within 7 days
(note. not a legal requirement)
* If pregnancy occurs during treatment they must be referred to a specialist for
advice
Breastfeeding
* Retinoids are highly lipophilic and readily pass into breast milk. They are therefore
contraindicated in BF
§

81
Q

What is the monitoring requirements for methotrexate

A

FBC, renal and LFTs should be carried out before therapy and
repeated weekly until therapy is stabilised, thereafter patients
should be monitored every 2-3 months

82
Q

What should patients watch out for with methotrexate

A

Blood disorders – sore throat, bruising, mouth ulcers
* Liver toxicity – nausea, vomiting, abdominal discomfort, dark
urine
* Pulmonary effects – shortness of breath
* Aspirin and other NSAIDs – if aspirin or other NSAIDs are
given concurrently the dose of methotrexate should be
carefully monitored – avoid OTC

83
Q

Which drugs can cause bone marrow suppression

A

Carbamazepine
* Carbimazole
* Chemotherapy
* Clozapine
* DMARDs
* Methotrexate
* Phenytoin
* Other anti-epileptics

84
Q

Which drugs prolong the QT interval

A

Can lead to life threatening arrhythmias
– Antidepressants – SSRIs, TCA
– Antipsychotics – risperidone, haloperidol,
quetiapine
– Antimicrobials – erythromycin, clarithromycin,
fluconazole
– Methadone
– Domperidone

85
Q

Which drugs can cause serotonin syndrome

A

Antidepressants – SSRI, TCA, lithium, SJW
* Analgesics – tramadol, fentanyl
* Antiemetics – ondansetron, metoclopramide

86
Q

What is the tripple whammy for aki

A

The triple whammy – ACEI, diuretics, NSAIDs

87
Q

Which anti-emetic is used for chemical/metabolic/drug induced vomiting

A

haloperidol

88
Q

Which anti-emetic is used for gastric stasis

A

metoclopramide, domperidone

89
Q

Which anti-emetic is used for icp

A

cyclizine, dex

90
Q

Which anti-emetic is used for motion sickness

A

cyclizine.cinnarizine

91
Q

Which anti-emetic is used for bowel obstruction

A

cyclzine

92
Q

Which anti-emetic is used for pain/palliative/agitation

A

levomeprozamine

93
Q

Which anti-emetic is used for chemo induced

A

5ht3 antatonist ondansertron

PRE REG (24 decks)

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