Common treatments Flashcards
1
Q
Migraine treatment
A
prophylaxis-
1. Propanolol if not then try other BB
1. FROVATRIPTAN CAN BE GIVEN INSTEAD OF OR IN ADDITION TO STANDARD PROPHYLACTIC TREATMENT IN FEMALES WITH PERIMENSTRUAL MIGRAINE (Give 2 days before until 3 days after menstruation starts!)
2a. Topiramate or sodium valproate for those >55 non childbearing
2b. Amitriptyline
3. Candesartan
should be tried for at least 3 months at the maximum tolerated dose, before deciding whether or not it is effective. A good response to treatment is defined as a 50% reduction in the severity and frequency of migraine attacks. REMEMBER IN YOUR MED REVIEW YOU DIDN’T ASK ABOUT REDUCTION IN FREQUENCY. REMEMBER IN THE GIRLS REVIEW, YOU SAID THERE WAS ONLY 2 DRUGS - BUT REALLY THERE IS AMITRIPYTLLINE AND CANDESARTAN SHE COULD HAVE TRIED!
Treatment-
1a. Triptans (Sumatriptan is the first line) - restrict to 2 days per week. can take 2 doses- wait minimum of 2 hours. max doses for oral vs intranasal differ. Take at the start of a headache not the start of aura. CONTRAINDICATED IN HTN AND IN THIS CASE YOU MUST USE ONE OF THE BELOW.
1b. NSAIDS (naproxen, tolfenamic acid or diclofenac. Ibuprofen not mentioned. Mefenamic acid if menstrual migraine).
1c. Paracetamol.
1d. Single dose metoclopramide or prochlorperazine single dose.
2. COMBINATION SUMATRIPTAN + NAPROXEN.
2
Q
Cluster headache treatment
A
prophylaxis
1. calcium channel blockers- verapamil hydrochloride
1. prednisolone short term
2. combination of pred and verapamil
treatment
1. 15L 100% oxygen for 10-20 minutes to abort attack OR triptans - sumatriptan SUBCUT again is the first line.
2. If unsuitable do nasal spray. or zolmitriptan nasal spray.
3.
3
Q
Tension headache treatment
A
paracetamol
4
Q
Stroke treatment - thrombolysis dose. Antiplatelet. Statin. And PPI dose.
A
ASPIRIN: 300 mg OD FOR 14 days started 24 hours AFTER thrombolysis or as soon as possible within 24 hours of symptom onset in patients not receiving thrombolysis. For TIA give it in combination with clopidogrel in patients with a low risk of bleeding Initially 300 mg for 1 DOSE within 24 hours of onset of symptoms, THEN 75 mg OD FOR 21 DAYS.
PPI - if histroy of dyspepsia with aspirin or if using DAPT!
Alteplase or tenecteplase
Clopidogrel 75mg OD
Atorvastatin 80mg OD
5
Q
Alzheimers medication dose
A
MILD-MODERATE= Donepezil 5mg
MODERATE alternative= MEMANTINE 5mg
SEVERE drug of choice = MEMANTINE 5mg
6
Q
GCA dose (look up Corticosteroids, inflammatory disorders)
A
60mg OD 3 DAYS. IF VISUAL SYMPTOMS THEN 1g methylpred! you should know this off by heart as it doesnt come up on BNF.
Relapse is common if therapy is stopped prematurely. Many patients require treatment for at least 2 years and in some patients it may be necessary to continue long-term low-dose corticosteroid treatment.= 7.5-10mg OD and gradually reduce.
7
Q
Amarosis fugax/TIA medication duration and dose.
A
Stroke - 300mg OD Aspirin for 21 days
TIA/amarosis fugax- 1 dose of 300mg OD aspirin + clopidogrel followed up with 21 days of DAPT at 75mg not 300mg (smaller stroke less high drug needed) then 75mg aspirin after this
8
Q
Optic neuritis medication and dose
A
if severe methylprednisolone 1g IV OD 3-5 DAYS
or
Methylpred 500mg PO OD for 5 days
9
Q
Orbital cellulitis dose
A
coamoxiclav-
PO 500/125 mg QDS (every 8 hours) for 7 days then review
IV 1.2g QDS (every 8 hours)
Alternative in penicillin allergy: clarithromycin with metronidazole.
10
Q
Meningitis medications and dose
A
If meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) is suspected, benzylpenicillin sodium 1.2 g for 1 dose should be given before transfer to hospital, so long as this does not delay the transfer.
Cefotaxime 2 g for 1 dose may be an alternative in penicillin allergy BUT IF IMMEDIATE HYPERSENSITIVITY USE chloramphenicol.
IN THE HOSPITAL (i.e., not in GP!) consider adjunctive with dexamethasone (particularly if pneumococcal suspected in adults), starting before or with the first dose of antibacterial, but no later than 12 hours after starting antibacterial FOR ALL BUT LISTERIA AND MENINGOCOCCAL MENINGITIS.
In the hospital, if aetiology unknown:
Adult and child 3 months–59 years, cefotaxime (or ceftriaxone)
Adult aged 60 years and over cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)
+ add vancomycin if prolonged or multiple use of other antibacterials in the last 3 months, if travelled in the last 3 months, to areas outside the UK with highly penicillin- and cephalosporin-resistant pneumococci.
Duration of treatment is at least 10 days.
Meningitis caused by Listeria
Amoxicillin 2 g every 4 hours IV (or ampicillin) + gentamicin
Duration of treatment is 21 days.
Consider stopping gentamicin after 7 days.
If history of immediate hypersensitivity reaction to penicillin, co-trimoxazole. Duration of treatment 21 days.
11
Q
Encephalitis medications and dose
A
note there is no encephalitis BNF page.
ACICLOVIR IV 10 mg/kg every 8 hours for at least 14 days (at least 21 days if also immunocompromised)—confirm cerebrospinal fluid negative for herpes simplex virus before stopping treatment.
12
Q
Status epilepticus medication and doses
A
midaz
loraz 4mg x2
13
Q
Trigeminal neuralgia medication and doses
A
note there is no BNF page for this. NICE says
carbamezapine 100 mg OD/BD Max 1.6g
Prescribing by brand is only needed for epilepsy.
Side locked.
14
Q
Conjunctivitis medication and dose
A
chloramphenicol drops
Most cases of acute bacterial conjunctivitis are self-limiting and resolve within 5–7 days without treatment
15
Q
Sinusitis medication and dose
A
BNF - nose for rhinitis and nose infections, antibacterial therapy for sinusitis
sinusitis typically refers to the acute infective problem
Rhinitis usually refers to the allergic or non-allergic (polyp) problem.
sinusitis is usually viral
If >10 days or has symptoms of bacterial (purulent discharge, high neutrophils), is systemically unwell, immunocompromised, coinciding pneumonia then backup prescription to be taken if they worsen at any time or symptoms do not improve within 7 days- of phenoxymethypenicillin 500mg QDS for 5 days.
rhinitis
1. topical nasal corticosteroids OR oral antihistamines. MOMETASONE 100 micrograms OD.
2. topical antihistamines (good for breakthrough but not as effective as topical nasal steroids)
3. oral steroids if severe
3. Nasal ipratropium bromide may be added to allergic rhinitis treatment when watery rhinorrhoea persists despite treatment with topical nasal corticosteroids and antihistamines; it does not affect other nasal symptoms.
REMEMBER THOUGH YOU DON’T GIVE STEROIDS TO POST NASAL DRIP/RHINITIS THAT IS ASSOCIATED WITH A COLD AS THIS WILL NATURALLY REGRESS WITH THE COLD.
nasal polyps: steroids
seasonal rhinitis can be treated 2 weekly prophylactically.
16
Q
Epistaxis medication and dose
A
SCREEN FOR HNC - Recurrent epistaxis, non healing ulcer, lump, unilateral polyp, supraclavicular or cervical lymphadenopathy, headache, vision change, >3 weeks symptoms. Smoking, alcohol, poor dentition, radiation history.
SCREEN FOR CVST - complication of sinusitis.
Naseptin® QDS 10 days (chlorhexidine and neomycin (aminoglycoside-gram negative))
Mupirocin nasal oitment BD-TDS 5-7 days.
note- vancomycin is not classified as an aminoglycoside. Instead, vancomycin is a glycopeptide antibiotic used to treat Gram-positive infections, while aminoglycosides are usually used to treat Gram-negative infections.
The commonest cause of nasal vestibulitis is staph aureus infections (gram +)- hence, theoretically vancomycin would be a better choice than aminoglycosides (which do gram negative more than positive- neomycin is an aminoglycoside) but is efective for both gram positive and negative and is easily administered hence why it is chosen.
17
Q
Oral thrush medication and dose
A
- Miconazole (24 mg/mL) oral gel 2.5 mL QDS 14 days. gel should not be swallowed immediately but kept in the mouth as long as possible. Dental prostheses should be removed at night and brushed with the gel. (CANT BE USED IN PREGNANCY) BUT BEFORE YOU PRESCRIBE IT CONSIDER IF THEY’RE ON ANY DRUGS THAT IT WILL INTERACT WITH IE WARFARIN, AND IN THIS INSTANCE USE NYSTATIN!
- Nystatin suspension oromucosal administration 1mL 100,000 units QDS 7 days or 48hr after lesions have resolved.
18
Q
Acute asthma attack medication and dose
A
This has changed. ALL WALES GUIDELINES. Reliance on SABA has reduced and patients are being put on ICS-LABA combo.
Moderate - treat at home. salbutamol or ICS-LABA combo (hopefully Symbicort Turbohaler 200/6) up to 12/day MAX. If using MDI use spacer. If dry inhalation obviously not.
Severe or life threatening- treat in hospital. Salbutamol 5mg (no max) via an oxygen driven nebuliser –> continuous if poor response. Nebulised ipratropium bromide 500 micrograms every 4-6hr (max 2mg) combined with nebulised salbutamol.
Prednisolone 40-50mg PO OD 5 days- BNF SAYS “In all cases of acute asthma, patients should be prescribed an adequate dose of oral prednisolone”
Continue inhaled corticosteroid.
If PO cant be taken given hydrocortisone.
Magnesium sulfate by intravenous infusion or aminophylline should only be used after consultation with senior medical staff. IV aminophylline is not likely to produce any additional bronchodilation unless life threatening asthma.
OXYGEN IF <94%
NOTE IF NOT GOING TO HOPSITAL ALL PATIENTS NEED A FOLLOW UP IN 48 HOURS
19
Q
Acute COPD exaccerbation medication and dose
A
BNF under respiratory infections antibacterial therapy
Non infective= prednisolone 30mg OD 5 days
Infective= PO Amoxicillin, clarithromycin, or doxycycline 5 days. If severely unwell IV amoxicillin, clarithromycin, co-amoxiclav, co-trimoxazole or tazocin.
For patients with persistent hypercapnic ventilatory failure, use non-invasive ventilation (NIV) if patients experience exacerbations despite the optimisation of medical treatment. (Disease Specific Indications: COPD: pH < 7.35 AND PaC02 ≥ 6.5. RR > 23 despite one hour of medical management)
20
Q
CAP medication and dose
A
curb score it. Low-moderate severity = Amoxicillin 500mg TDS 5 days. Increased to 1g TDS.
If atypical pathogens suspected: amoxicillin with clarithromycin or erythromycin (in pregnancy).
High severity= Co-amoxclav WITH clarithromycin OR oral erthromycin (in pregnancy).
21
Q
HAP medication and dose
A
non-severe = PO co-amox 500/125mg TDS 5 days then review.
severe or high resistance risk = IV
tazocin, ceftazidime, ceftriaxone, cefuroxime, or meropenem.
22
Q
Bronchitis medication and dose
A
most causes of bronchitis are viral and do not neeed treatment. Only use them if systemically very unwell or at higher risk of complications as acute bronchitis is usually a self-limiting illness and the cough usually lasts about 3-4 weeks. Antibiotics only shorten cough duration by 1/2 day on average even if bacterial.
> 18 years = doxy 200mg on first day then 100mg OD 4 days (5 day total course) https://www.nice.org.uk/guidance/ng120/resources/visual-summary-pdf-6664861405
12-17 years= amoxicillin (preferred in young women who are pregnant): 500 mg three times a day for 5 days.
Offer immediate antibiotic prescription or a back-up antibiotic prescription for a person at higher risk of complications, for example:
1. A pre-existing comorbid condition such as heart, lung, kidney, liver, or neuromuscular disease, immunosuppression, or cystic fibrosis.
Older than 65 years of age with 2 or more of the following, or older than 80 years with 1 or more of the following:
1. Hospital admission in the previous year.
2. diabetes
3. History of congestive heart failure.
4. Current use of oral corticosteroids.
23
Q
Otitis externa medication and dose
A
ciprofloxacin and steroids or Gentamicin 0.3% drops (Genticin®)
with steroid.
Tips: warm drops before inserting into ear, lie on unaffected ear for 3-5 minutes. This increases likelihood of it working and reduces dizziness.
24
Q
Otitis media medication and dose
A
PO amoxicillin 500 mg TDS for 5–7 days. (BNF ONLY HAS CHILDREN’S DOSE) or if allergic clarithromycin or erythromycin if pregnant.
worsening symptoms despite 2-3 days of antibacterials = PO co-amoxiclav
TIP WITH ANY ANTIBITOIC TREATMENT YOU GENERALLY CHANGE IT IF AFTER 48HR IT HAS NOT HAD EFFECT (This incl. for otitis externa, UTI etc) so it is a good idea to book a f.u if not in hospital
25
PE medication and dose
Thrombolytic treatment may be appropriate for selected patients with a symptomatic iliofemoral DVT or a PE with haemodynamic instability (massive PE (characterised by big PE with right heart strain (RBBB, raised troponin, increased right pressure) + haemodynamic instability).
Pharmacological treatment options for confirmed PE include:
Fondaparinux
LMWH
LMWH followed by an oral anticoagulant (dabigatran or edoxaban).
Oral anticoagulant treatment (warfarin, apixaban, or rivaroxaban).
UFH
DOACs (Apixaban, Rivaroxaban, Edoxaban, Dabigatran): First-line for most patients.
LMWH or Fondaparinux: Preferred in pregnancy, CAT (cancer-associated thrombosis- DOACS can be used but LMWH is still commonly used for its established efficacy), or severe renal impairment <15 eGFR.
Warfarin: Used in special cases like mechanical valves.
NOTE THERE IS NO ONE TREATMENT CHOICE FOR PE, BUT FOR DVT THERE IS. People with confirmed proximal DVT should be offered apixaban or rivaroxaban first line, and if these are not suitable: Low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran or edoxaban, or. LMWH concurrently with a vitamin K antagonists for at least 5 days.
26
STEMI medication and dose
>11.0 mmol/litre glucose should receive insulin
PCI with radial access - preferred (UFH) or femoral access (bivalirudin)
Fibrinolysis (+fonduparinex)
Aspirin and prasugrel PRIOR TO PCI
Whereas DAPT AFTER FIBRINOLYSIS (almost akin to stroke, where aspirin is given 24hr after thrombolysis once a repeat CT is done to exclude haemorrhage) except this time it is immediately after fibronylsos not 24hr later.
27
NSTEMI medication and dose
>11.0 mmol/litre glucose should receive insulin
NO FIBRINOLYSIS - Fibrinolytic therapy (e.g., with alteplase, tenecteplase) carries a significant risk of major bleeding, including intracranial hemorrhage. Since the artery is only partially blocked in NSTEMI, using fibrinolytics poses an unnecessary bleeding risk without offering substantial benefit in opening the vessel.
In NSTEMI, the goal is more focused on stabilizing the plaque and preventing further clot formation, which is better achieved with antiplatelet and anticoagulant therapies (fonduparinex) rather than fibrinolysis.
PCI if unstable immediately
PCI within 72hr if grace >3%
if not then fonduparinex + DAPT.
28
Angina medication and dose
GTN sublingual spray - 400 microgram per 1 dose
1st BB- atenolol 100mg OD or 50mg BD, bisoprolol 5mg OD, metoprolol or propranolol
2nd rate-limiting CCB= verapamil or diltiazem
can have long-acting nitrate with GTN
Statin- atorvastatin 20mg OD
Aspirin- 75mg OD
29
HTN medication and dose ≥55
stage 1 (clinic 140/90) only treat under 80s if CVD established, diabetes, end organ damage, renal disease, or an estimated 10-year risk of CVD of ≥10%. If none present consider life style, re-review in 3-6 months and if no change --> anti-hypertensives. Consider treating if >80 years old if BP is 150/90.
stage 2 (clinic 160/100) HTN always treat
severe HTN (180mmHg or diastolic 120mmHg SAME DAY SPECIALIST REFERRAL)
Any HTN with eye, wee, heart microvascular effects or new confusion need immediate referral.
1st CCB - amlodipine 5mg OD
Thiazide-like diuretic or ACEI/ARB
Thiazide-like diuretic or ACEI/ARB
Spironalactone OR alpha or beta blocker (4.5 K+)
30
HTN medication and dose <55
stage 1 (clinic 140/90) only treat under 80s if CVD established, diabetes, end organ damage, renal disease, or an estimated 10-year risk of CVD of ≥10%. If none present consider life style, re-review in 3-6 months and if no change --> anti-hypertensives.
stage 2 (clinic 160/100) HTN always treat
severe HTN (180mmHg or diastolic 120mmHg SAME DAY SPECIALIST REFERRAL)
Any HTN with eye, wee, heart microvascular effects or new confusion need immediate referral.
ACEI or ARB
Thiazide-like diuretic or CCB
Thiazide-like diuretic or CCB
Spironolactone or alpha or beta blocker (4.5 K+)
31
Acute heart failure medication and dose
So first ask yourself what is acute heart failure? It isn't really a diagnosis you can treat. You are treating the consequences of it i.e., pulmonary oedema, peripheral oedema, increased after-load leading to AKI
So in most cases the treatment for this is furosemide.
Furosemide IV- works within 30 minutes maximal effect and diuresis is complete within 6 hours so that, if necessary, they can be given twice in one day without interfering with sleep. Following oral administration, the onset of the diuretic effect is about 1 and 1.5 hours 9, and the peak effect is reached within the first 2 hours. The duration of effect following oral administration is about 4-6 hours but may last up to 8 hours.
Diuresis is dose related.
Note eGFR must be greater than 30mL.
Stop beta-blockers (cause you are often combating hypotension and bradycardia. bb are CI in heart block or bradycardia (even if the heart block doesnt have bradycardia))
32
Chronic heart failure first line medication and dose
reduced ejection fracture you worry more. therefore you have drugs that reduce mortality
- ACEI (1st)= perindopril, ramipril, captopril, enalapril, lisinopril
- BB (1st)= bisoprolol, carvedilol, or nebivolol
- MRAs (spiro or eplerenone)
Persistent symptoms of heart failure, especially breathlessness without signs of significant fluid retention, are more likely to indicate the need for an MRA rather than an increase in diuretics. Whereas symptomatic acute relief of breathlessness and oedema are an indication to use furosemide.
33
H pylori medication and dose
Oral first line for 7 days:
A PPI BD- esomeprazole 20mg BD
+ amoxicillin 1g PO, and either clarithromycin 500mg BD or metronidazole 400mg BD
34
Gastric ulcer medicaiton and dose
In patients who have tested positive for H. pylori and have no history of NSAID use, Helicobacter pylori infection should be eradicated.
If the ulcer is associated with NSAID use, a proton pump inhibitor or histamine2-receptor antagonist (H2-receptor antagonist) should be used for 8 weeks, followed by Helicobacter pylori infection eradication treatment if the patient has tested positive for H. pylori.
Full dose therapy (standard dose)
35
GORD medication and dose
'Proven GORD' refers to endoscopically-determined reflux disease, which may be due to:
Oesophagitis, when oesophageal inflammation and mucosal erosions are seen.
Endoscopy-negative reflux disease (or non-erosive reflux disease), when a person has symptoms of GORD but endoscopy is normal.
--> Offering a full-dose PPI for 4 weeks for proven GORD, to aid healing.
--> Offering a full-dose PPI for 8 weeks for proven severe oesophagitis, to aid healing.
Offer one of the following strategies to manage uninvestigated dyspepsia symptoms, depending on clinical judgement:
--> Prescribe a full-dose PPI for 4 weeks or
--> Test for Helicobacter pylori infection if the person's status is not known or uncertain.
If symptoms persist or recur following initial management:
--> Switch to the alternative strategy (for example, offer a full-dose PPI for 4 weeks if the person has been tested for H. pylori infection, and vice versa).
36
Constipation medication and dose
Constipation vs IBS
Short term - bulk forming laxatives as long as adequate fluid intake. If hard- osmotic (or stool softner) i.e., laxido, macrogol, lactulose. If soft but difficult to pass or the person complains of inadequate emptying, a stimulant- sodium picosulphate or bisocodyl.
Faecal impaction- depends on consistency. If hard stools- oral macrogol (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride). If soft stools, or with hard stools after a few days treatment with a macrogol, add bisocodyl or sodium picosulphate (stimulant).
Alternatively, an enema of docusate sodium or sodium citrate may be tried.
Chronic- bulk-forming laxative. Again same as short term constipation- hard: softner/osmotic. Soft: stimulant. Lactulose is an alternative if macrogols are not effective, or not tolerated.
If at least two laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months, the use of prucalopride (in women only) TRIAL FOR 4 weeks and only continued if effective.
In IBS - a laxative excluding lactulose as it may cause bloating. If no response to 2 classes of laxatives trila linaclotide (reduces visceral sensation). Loperamide hydrochloride for diarrhoea. Patients with IBS should be advised how on to adjust their dose of laxative or anti-motility drug according to stool consistency, with the aim of achieving a soft, well-formed stool.
IN KIDS: <1 years lactulose. >1? year you can start to use laxido. can be used long term. and glycerol suppositories are CKS first line.
37
Diarrhoea non infectious medication and dose
Acute diarrhoea is that which lasts less than 14 days, but symptoms usually improve within 2–4 days.
ORS mainstay to prevent acute diarrhoea. - disodium hydrogen citrate with glucose, potassium chloride and sodium chloride; potassium chloride with sodium chloride; potassium chloride with rice powder, sodium chloride and sodium citrate.
if cant drink- IV fluids in hospital.
loperamide (initially 4mg then 2mg for UP TO 5 DAYS, max dose 16mg) is the standard treatment when rapid control of symptoms is required i.e., for mild-to-moderate travellers' diarrhoea where toilet amenities are limited or unavailable BUT should be avoided in bloody or suspected inflammatory diarrhoea (febrile patients) AND in cases of significant abdominal PAIN (which also suggests inflammatory diarrhoea).
Ciprofloxacin - occasionally used for prophylaxis against travellers' diarrhoea, but routine use is not recommended.
38
Stomach cramps medication and dose
Antispasmodics can be divided into two main classifications:
1) antimuscarinics and
2) smooth muscle relaxants.
Antimuscarinics (anticholinergics) work by reducing intestinal motility and addressing smooth muscle spasm.
Tertiary amines (like atropine sulfate and dicycloverine hydrochloride 10mg TDS) are better absorbed but have more potential for CNS side effects.
Quaternary ammonium compounds (like hyoscine butylbromide 20mg QDS and propantheline bromide) are less absorbed and have fewer CNS side effects but may also have less systemic effect.
Dicycloverine hydrochloride has less antimuscarinic action systemically than atropine and also has direct smooth muscle relaxing effects, so it may provide a balance between effectiveness and fewer CNS side effects.
Hyoscine butylbromide is a popular choice for gastrointestinal spasm despite its poor absorption because it has minimal CNS side effects and works locally within the GI tract.
Smooth muscle relaxants (like alverine citrate 60mg TDS, mebeverine hydrochloride 200mg BD, and peppermint oil) act directly on the smooth muscle and may be helpful in Irritable Bowel Syndrome (IBS) to relieve pain or spasm.
39
Diverticulitis medication and dose
Diverticulosis:
- bulk-forming laxatives
- paracetamol
- antispasmodics - mebeverine, alverine citrate, hyoscine butylbromide.
- No NSAIDs or OPIOIDS- increase perforation risk.
Diverticulitis:
Uncomplicated and complicated
Complicated include abscess, perforation or peritonitis, fistula, intestinal obstruction, haemorrhage or sepsis.
Suspected or confirmed uncomplicated acute diverticulitis
Oral first line: Co-amoxiclav
Suspected or confirmed complicated acute diverticulitis
Intravenous first line: Co-amoxiclav, or cefuroxime with metronidazole, or AGM= amoxicillin with gentamicin and metronidazole.
40
Acute crohns flare medicaiton and dose
A corticosteroid (prednisolone 20-40MG or methylprednisolone or IV hydrocortisone 100–500 mg QDS) in patients with a first presentation or a single inflammatory exacerbation in a 12-month period.
Add-on treatment if there are two or more inflammatory exacerbations in 12 months or the corticosteroid dose cannot be reduced.
Azathioprine or mercaptopurine can be added to a corticosteroid or budesonide to induce remission.
In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, methotrexate can be added to a corticosteroid.
Under specialist care, certain tumour necrosis factor alpha inhibitors may be used for the treatment of severe, active Crohn's disease, and for moderate to severely active disease, other biologics (such as certain anti-lymphocyte monoclonal antibodies or interleukin inhibitors), or certain Janus kinase inhibitors may be used.
Loperamide hydrochloride or codeine phosphate can be used to manage diarrhoea associated with Crohn's disease in those who DO NOT have colitis (REMEMBER THESE DRUGS CANNOT BE USED IN INFLAMMATION OR INFECTION). Colestyramine is licensed for the relief of diarrhoea associated with Crohn's disease
41
Acute UC medication and dose
Mild-moderate = enemas or suppositories topical aminosalicylates - It is recommended that mesalazine is prescribed by brand (with oral if extensive or if first-line therapy has failed. And then with oral steroids if that fails)
Moderate-severe- biologics
Severe- IV corticosteroids (methyl or hydrocortisone) due to life-threatening nature. If no improvement in 72hr ciclosporin or surgery.
In patients who experience an initial response to steroids followed by deterioration, stool cultures should be taken to exclude the presence of pathogens; cytomegalovirus activation should be considered.
42
Chronic crohns medication and dose
43
Chronic UC medication and dose
44
viral Hepatitis medication and dose
Treatment for viral hepatitis should be initiated by a specialist. The management of uncomplicated acute viral hepatitis usually involves symptomatic supportive care. Early treatment of acute hepatitis C may reduce the risk of chronic infection and progression of liver disease. Hepatitis B and hepatitis C viruses are major causes of chronic hepatitis.
Active or passive immunisation against hepatitis A and B infections is available.
https://bnf.nice.org.uk/treatment-summaries/hepatitis/
45
Alcoholic hepatitis medication and dose
under alcohol dependence - https://bnf.nice.org.uk/treatment-summaries/alcohol-dependence/
discriminant function of 32 or more can be given corticosteroids but only after any active infection or gastro-intestinal bleeding is treated, any renal impairment is controlled, and following discussion of the potential benefits and risks of treatment.
Corticosteroid treatment has been shown to improve survival in the short term (1 month) but not over a longer term (3 months to 1 year). It has also been shown to increase the risk of serious infections within the first 3 months of starting treatment.
46
delirium tremens treatment
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety (think alcohol wears off if u dont keep driking and hangovers in teh morning like 12 hours later)
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Tremers and delirium (agitation, confusion, paranoia, and visual and auditory hallucinations) in an alcoholic. 24-48hr = seizures peak
oral lorazepam is first line and if declined parentral lorazepam or haloperidol (unlicensed) https://bnf.nice.org.uk/treatment-summaries/alcohol-dependence/
47
Acute decompensated cirrhosis medication and dose
BNF DOESN'T HAVE A PAGE.
So treatment here is kind of similar approach to acute heart failure. You are not treating that, that is just a overarching name for an illness in these patients (which u need to diagnose and sort) that has tipped them over the edge. The illnesses are either
HE
jaundice
variceal bleeding
ascites
hepatorenal syndrome
So the cause of decompensating for liver disease is usually either
GI bleed
constipation
drug toxicity
alcohol
infections
treatment depends on the way they have decompensated...
HE- lactulose 25 mL every 12 h until at least two soft bowel motions are produced per day... don't restrict protein intake.
jaundice- treat the cause of illness to enable liver to function and metabolise bilirubin again.
variceal bleeding- cipro prophylactically, specailist terlipressin, endoscopy, propanolol afterwards
ascites- tap, prophylactic cipro or ceftriaxone treatment SBP if protein >15g/l, and drain and albumin units.
hepatorenal syndrome- terlipressin and albumin or transplant.
48
Biliary colic medication and dose
gallstones- https://bnf.nice.org.uk/treatment-summaries/gallstones/
PO or topical (rectal) paracetamol, NSAID for mild-to-moderate pain
IM diclofenac 75 mg OD MAX 2 DAYS for severe pain or, if not suitable, an IM opioid (such as morphine or pethidine hydrochloride- 25–100 mg)- This may be used alone or in combination with diclofenac if appropriate.
49
Ascending cholnangitis medication adn dose
BNF doesn't say but as ascending cholangitis is sepsis you give sepsis antibitoics.
HOWEVER FOR UNCOMPLICATED BILIARY INFECTIONS https://bnf.nice.org.uk/treatment-summaries/gastro-intestinal-system-infections-antibacterial-therapy/ .....
1. Biliary tract infection recommends
--> Ciprofloxacin or gentamicin or a cephalosporin
50
Renal colic medication and dose
https://bnf.nice.org.uk/treatment-summaries/renal-and-ureteric-stones/
NSAIDS maybe diclofenac 75mg OD ?
If NSAIDs are contraindicated or not sufficiently controlling the pain, consider intravenous paracetamol.
alpha-adrenoceptor blockers for patients with distal ureteric stones less than 10mm in diameter
potassium citrate [unlicensed] in patients with recurrent stones composed of at least 50% calcium oxalate.
Thiazides [unlicensed] may be given if patients also have hypercalciuria after restricting their sodium intake to no more than 6g a day.
51
Pyelonephritis medication and dose
Oral first line:
--> Cefalexin, or ciprofloxacin. If sensitivity known: co-amoxiclav, or trimethoprim.
IV first line (if SEVERELY unwell or unable to take oral treatment).
--> Amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin. Co-amoxiclav may be used if given in combination or sensitivity known.
52
UTI medication and dose female male and pregnant and catheter
Female - back-up prescription to be used after 48hr if no improvement.
Trimethoprim 200 mg BD 3 days or Nitrofurantoin 100 mg BD 3 days
Pregnant- Immediate prescription
Nitrofurantoin 100 mg BD 7 days except from 37 weeks onwards, in which case use amoxicillin 500mg TDS 7 days.
Asymptomatic bacteriuria:
Amoxicillin, cefalexin, or nitrofurantoin.
Male 7 days- immediate prescription
Trimethoprim 200mg BD 7 days
Nitrofurantoin 100 mg BD 7 days
Catheter- immediate prescription and removing/changing catheter if it has been in place for > 7 days.
Oral first line (if no upper UTI symptoms):
Amoxicillin (only if culture susceptible), nitrofurantoin, or trimethoprim (if low risk of resistance).
Oral first line (upper UTI symptoms):
Cefalexin, ciprofloxacin, co-amoxiclav (if culture susceptible), or trimethoprim (if culture susceptible).
Reassess patients if symptoms worsen at any time, or do not start to improve within 48 hours of starting treatment.
Culture- all pregnant, all men, catheter, women >65, recurrent UTI, hospitalised recently, recent AB, abnormal urinary system, immunocompromised
53
ectopic pregnancy medication and dose
bnf obstetrics: https://bnf.nice.org.uk/treatment-summaries/obstetrics/
1. watchful waiting
2. medical - methotrexate
3. surgical - salpingectomy or -otomy
1. normal if <1000 hcg, <3mm and no heart beat and
2. medical if between 1000-1500 <5mm, no heart beat, can do f/u, no significant pain. will still need anti-d if >10 weeks.
3. >1500 hcg and if heart beat and if haemodynamically stable or in pain, or cant do f/u.
54
Miscarriage management
bnf obstetrics: https://bnf.nice.org.uk/treatment-summaries/obstetrics/
https://www.nice.org.uk/guidance/ng126/chapter/Recommendations#management-of-miscarriage
Threatened - expectant for 7-14 days. If this is 2nd pregnancy you may consider cervical clerage (12-14 weeks) or progesterone pessaries (ideally before 12 weeks up to 16 weeks). Before 12 weeks, it may not be clear whether the pregnancy is viable or if there are fetal anomalies incompatible with life. Performing a cerclage before confirming a viable pregnancy could result in unnecessary procedures. There is not evidence for benefits of progesterone after 16 weeks.
Missed- same as miscarriage
200 mg oral mifepristone and
48 hours later, 800 micrograms misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed.
Incomplete - a single dose of misoprostol 600 micrograms (vaginal, oral or sublingual). Do not offer mifepristone as a treatment for incomplete miscarriage. [2012, amended 2023]
****FOR REASONING WHY SEE BELOW*****
Mechanisms of Action:
Misoprostol: This is a prostaglandin analogue that induces uterine contractions by softening and dilating the cervix, which leads to the expulsion of the pregnancy tissue. It is used for both medical abortions and miscarriages by stimulating uterine contractions to evacuate the uterine contents.
Mifepristone: This is an anti-progestin that blocks the hormone progesterone, which is essential for maintaining pregnancy. It works by softening the cervix and priming the uterus to respond to misoprostol. Mifepristone also destabilizes the uterine lining, making it more susceptible to the action of misoprostol.
Mifepristone is not needed in cases of incomplete miscarriage as the pregnancy is no longer viable and the goal is simply to evacuate the uterus. In missed miscarriage there is suggestion that the foetus is still attached somewhat and of course it is still attached and alive in abortion so is needed before misoprostol.
55
abortion medication and dose
bnf obstetrics: https://bnf.nice.org.uk/treatment-summaries/obstetrics/
https://www.nice.org.uk/guidance/ng140/resources/patient-decision-aid-pdf-6906582255 - great decision aid
1. medical abortion up to 24 weeks
1a. early abortion (9 weeks)
anti-progesterone mifepristone 200mg PO. Followed by 800 micograms misoprostol (vaginally, PO, sublingually) 24-48 hours later.
1b. later medical abortion. Similar principle but misoprostol is given every 3-4 hours until the pregnancy is expelled.
Surgical from 14 weeks onwards.
before 10 weeks can do it at home. after this anti-d is needed.
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Vomitting medication and dose
*WHOLE BODY*
1. Granisetron, ondansetron, and palonosetron, (5HT3) post-operative, cytotoxics, or chemical nausea.
Ondansetron (chemo) = 8 mg (5 days max)
Ondansetron (post op) = 4mg IM or IV
2. Antihistamines (e.g. cinnarizine, cyclizine, promethazine hydrochloride, promethazine teoclate) for many underlying conditions including labyrinth disorders.
Cyclizine 50mg TDS (IM IV PO)
*BRAIN*
1. Haloperidol and levomepromazine = nausea and vomiting in palliative care.
PO or S/C Haloperidol 0.5–1.5 mg OD every 2hrs (MAX 10mg)
2. Dexamethasone for chemotherapy-induced and raised ICP.
*STOMACH*
1. Metaclopramide for emesis associated with gastro-intestinal and biliary disease.
PO IV IM 10mg TDS
2. Domperidone doesn't cross BBB and is less likely to cause central effects.
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Dysmenorrhea medication adn dose
Painful periods advice NOT ON BNF but you will find it under summaries- analgesics: dysmenorrhea https://bnf.nice.org.uk/treatment-summaries/analgesics/
Managed the same as pain anywhere else in the body unless the patient wants contraception at the same time. This is because there are less side effects giving them only pain relief compared to starting them on a contraceptive (of which COCP is first line).
so 1. NSAIDS or paracetamol
--> Mefenamic acid
2. 3-6 month trial of MONOPHASIC (all pills have the same amount of oestrogen and progestin).
THE FIRST LINE COCP BY BNF ARE MONOPHASIC PREPARATIONS CONTAINING 30 micrograms or less of ethinylestradiol WITH LEVONOGESTEROL or NORETHISTERONE (to minimise cardiovascular risk).
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what oestrogen do we use in combined pills classically and why?
EE over E
aka Ethinylestradiol over estradiol
synthetic over natural.
EE has an ethinyl group at C17α in its molecule, making it more resistant to metabolism and improving bioavailability when taken orally which makes it have more effect on parts of the body, like the liver and uterus. It also decreases luteinizing hormone to reduce endometrial vascularisation and decreases gonadotrophic hormone to prevent ovulation. E doesnt do this so there is more risk of bleeding disturbance and irregularity.
However, EE can increase the risk of blood clots and other rare adverse effects.
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menorrhagia medication and dose
https://bnf.nice.org.uk/treatment-summaries/heavy-menstrual-bleeding/ - heavy menstrual bleeding
fibroid <3cm, unknown cause, suspected adenomyosis - Levonogestrel IUS, TXA NSAID 2nd line.
fibroids >3cm or distorted cavity - referral and TXA, NSAID, COCP, IUS first line.
A non-hormonal treatment is recommended in patients actively trying to conceive.
note if under 20 ius/iud is ukmec2
If an LNG-IUS is declined or unsuitable, consider other pharmacological treatment options.
The non-hormonal treatment options are tranexamic acid or a nonsteroidal anti-inflammatory drug (NSAID, off-label use).
The hormonal treatment options are combined hormonal contraception (CHC, off-label use for some CHCs) or cyclical oral progestogen (norethisterone).
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Osteoarthritis medication and dose
topical NSAID (particularly for knee involvement) is first-line treatment. If the topical NSAID is ineffective or unsuitable, consider an oral NSAID.
https://bnf.nice.org.uk/treatment-summaries/non-steroidal-anti-inflammatory-drugs/
ibuprofen has topical versions
Apply up to 3 times a day, ibuprofen 5% gel to be administered. 14 day review?max?
1% diclofenic sodium gel - 3-4x day review after 14 days. (volterol?)
LOOK AT HOW THIS IS PRESCRIBED
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Gout medication and dose, when are signs of toxicity apparent and why max dose for acute management but not prophylaxis?
Acute- colchicine, high dose NSAID or oral corticosteroid (+/- PPI).
if unsuitable IM corticosteroid.
colchicine - 500 micrograms PO BD-QDS - do not repeat course w/i 3 days even if another flare occurs (this is due to toxcitiy risk!) TOTAL DOSE PER COURSE SHOULD NOT EXCEED 6MG, so if you were taking it TDS for 4 days you would reach this.
Preventative- allopurinol (levels from 100-900mg daily in doses of no more than 300mg AFTER food) or febuxostat 2-4 weeks after flare has settled with colchicine prophylaxis 500micrograms BD (for all)- there is no max dose here and that is because it reaches a lower plasma concentration consistently vs high dose used in acute phases (up to 2mg a day) which can lead to toxicity and overdose. Give as prophylactic regime with allopurinol for as long as you need to to get uric acid levels down to <300
Onset - 6-8hr to reach peak concentration, so toxicity signs make take 6-8hr to come to fruition. if breast feeding wait 6-8hr after dosing.
**Colchicine has a narrow therapeutic range and its use is limited by the development of toxicity at higher doses. However, unlike NSAIDs, it does not induce fluid retention; moreover, it can be co-administered with anticoagulants**
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Rheumatoid arthritis short-term medication and dose
Monotherapy with a conventional disease-modifying antirheumatic drug (DMARD) (oral methotrexate, leflunomide, or sulfasalazine) should be given as first-line treatment. Conventional DMARDs have a slow onset of action and can take 2–3 months to take effect.
Consider short-term bridging treatment with a corticosteroid (by oral, intramuscular, or intra-articular administration) when starting treatment with a new conventional DMARD to provide rapid symptomatic control, while waiting for the new DMARD to take effect.
Short-term use of an oral non-steroidal anti-inflammatory drug (NSAID) or a selective cyclo-oxygenase-2 inhibitor should be considered for additional control of pain and stiffness associated with rheumatoid arthritis. Patients should be offered a proton pump inhibitor to minimise associated gastrointestinal adverse effects.
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Chronic rheumatoid arthritis medication and dose
Conventional DMARD
Then 2 conventional DMARD combination
Then, it is COMBINED WITH ADDITIONAL TNF alpha inhibitors, other biologic DMARDs, or targeted synthetic DMARDs if there is an inadequate response to combination conventionals.
WHY?
When initiating a biological or targeted DMARD, patients often continue with their conventional DMARDs (especially methotrexate) unless contraindicated or poorly tolerated. Methotrexate is often used in combination with biologics to reduce the risk of antibody formation against the biologic drug, which can improve the drug’s efficacy and reduce side effects.
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Septic arthritis medication and dose and where under the BNF does it come under?
same as osteomyelitis
https://bnf.nice.org.uk/treatment-summaries/musculoskeletal-system-infections-antibacterial-therapy/ = musculoskeletal system infections
Flucloxacillin
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If penicillin-allergic, clindamycin
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If MRSA use vancomycin or teicoplanin
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If gonococcal arthritis or Gram-negative infection suspected, cefotaxime (or ceftriaxone 2g IV OD)
Suggested duration of treatment 4–6 weeks (longer if infection complicated; treat gonococcal infection for 2 weeks).
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Sepsis medication and dose and where to find on BNF
blood infections antibacterial therapy
community acquired- tazocin (piperacillin has pseudomonal cover) 4.5g IV
If MRSA ADD vancomycin or teicoplanin
If anaerobic infection suspected, add metronidazole to ceftriaxone or cefotaxime.
If hospital acquired use beta lactam antibacterial (i.e., tazobactam, clavulanic acid, cilastatin) with antipseudomonal coverage i.e.,
Tazocin
ticarcillin + clavulanic acid
ceftazidime
imipenem with cilastatin
meropenem
if MRSA add vanc or teic
if anaerobic add metro to a broad spec cephalosporin as before
Septicaemia related to vascular catheter
Vancomycin (or teicoplanin)
If Gram-negative sepsis suspected, especially in the immunocompromised, add a broad-spectrum antipseudomonal beta-lactam.
Consider removing vascular catheter, particularly if infection caused by Staphylococcus aureus, pseudomonas, or Candida species.
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Warfarin reversal medication and dose
inr <5 not bleeding - hold dose 48hr then recheck restart at a dose 1mg lower
inr 5-8 not bleeding - nothing - hold dose 48hr then recheck, restart at a dose 1mg lower when inr <5
inr 5-8 bleeding - iv vit k 1-3mg
inr ≥8 bleeding - iv vit k 1-3mg, repeat if needed after 24hr, restart when inr <5
inr ≥8 not bleeding - oral vit k 1-5mg, repeat if needed after 24hr, restart warfarin when inr <5
major bleeding - PCC, 5mg vit k,
vit k takes 6hr to work. pcc works immediately
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Pre-eclampsia medicationS and doseS and where to find this. What is pre-eclampsia.
*****So pre-eclampsia is hypertension with multiple organ involvement and damage. Essentially the symptoms you'd see in a non pregnant person with ragingly high BP not just your classic hypertension (which is what SEEM to have in pregnancy). The reason for this is are more susceptible is because they have increased blood volume and stroke volume (hence cardiac output). Since we know that Blood Pressure (BP) = Cardiac Output (CO) x Systemic Vascular Resistance (SVR) and in pregnancy patients are in maximum state of vasodilation there is huge potential for BP to rise. And also the reason their vessels are dilated is because so much blood is diverted to the placenta, so their other organs are only just about surviving in normal pregnancy, therefore when the body does go into a state of vasoconstriction the mothers organs are disproportionally affected. Leading to BRAIN, LIVER and KIDNEY damage.****
***risk factor why?= 1 of the following: CKD, DM, autoimmune conditions, HTN, HTN in previous pregnancy. All these conditions blood vessels are already damaged or not delivering as much to the organs as a normal persons. 2 of the following= first pregnancy, >40 years, BMI >35, multiple pregnancies, family history. All these are risk factors not 100%s for the blood vessels not to work as well due to inflammation/fibrosis/genetic predisposition/new change for the body, OR due to more inflammatory markers being produced by the babies****
bnf htn summary https://bnf.nice.org.uk/treatment-summaries/hypertension/#hypertension-in-pregnancy
Treatment =
1. Aspirin 75–150 mg OD prophylactically from 12 weeks
2. Labetalol 100 mg BD --> nifedipine --> methyldopa 250 mg BD/TDS
If on methyldopa change within 2 days of birth. Breastfeeding enalapril maleate is first line. In females of black African or African-Caribbean family origin consider nifedipine or amlodipine first line.
3. Seizure prophylaxis for severe HTN, pre-eclampsia or expected to deliver within 24hr (high risk period not because you have to deliver within 24hr of giving it, although delivery is the only treatment for eclampsia. Maternal administration of magnesium sulfate for longer than 5–7 days in pregnancy has been associated with hypocalcaemia, hypermagnesaemia, and skeletal side-effects in neonates)= IV magnesium sulfate. 4 g for 1 dose, to be given over 5–15 minutes, followed by (by continuous intravenous infusion) 1 gram/hour for 24 hours.
4. corticosteroids if early birth expected in 7 days and less than 35 weeks?
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Bone protection medication adn dose
1st= PO Alendronic acid 10mg OD, risedronate sodium or Ibandronic acid (reduce the occurrence of vertebral, non-vertebral and hip fractures).
2nd= IV zoledronic acid 5 mg once yearly as a single dose or s/c denosumab (RANKL inhibitor that also inhibits osteoclasts) zolendronic acid is 2nd line becasue among the bisphosphonates it has a higher incidence of ONJ. denosumab is 2nd line becasue its effects are quickly reversed after discontinuation, which increases the risk of fractures especially multiple vertebral fractures.
Zolendronic acid- 60 mg every 6 months.
strontium, or (raloxifene for women only= SERM- 2nd line because it's less effective in reducing fractures at non-vertebral sites esp hip and both ralox and strontium have side effects: CVD, VTE and MI. Strontium can also aggravate menopausal symptoms) (teriparatide for men only) are alternative option for women and men who are intolerant of ORAL bisphosphonates.
In postmenopausal women with at least one severe or two moderate low-trauma vertebral fractures, teriparatide (s/c 20 micrograms daily for maximum duration of treatment 24 months) or romosozumab (s/c 210 mg once a month for 12 months, administered as two consecutive 105 mg injections at different injection sites) are recommended over oral bisphosphonates.
Younger postmenopausal women with menopausal symptoms who are at high risk of fractures= HRT or tibolone.
*******Teriparatide MOA: parathyroid hormone analogue that stimulates new bone formation by acting on osteoblasts (bone-building cells). It’s typically reserved for severe osteoporosis because it builds new bone, making it highly effective in patients at very high risk of fractures. Again not first line for everyone even though they work because they're such faff (S/C for 2 years! and not well adhered to) *******
******Romosozumab MOA: a sclerostin inhibitor that both increases bone formation and decreases bone resorption used in patients at high risk of fractures, particularly those who’ve already had a fragility fracture and need urgent treatment to prevent more fractures. Again not first line for everyone even though they work because they're such faff (S/C for 2 years! and not well adhered to) ********
NOTE DOSES ARE DIFFERENT FOR MEN VS WOMEN!
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Irregular broad rhythm tachycardia medication adn dose
70
regular broad tachycardia medication adn dose
71
regular narrow tachycardia medication and dose
72
irregular narrow tachycardia medication adn dose
73
non shockable rhythm medication and dose
74
shockable rhythmn medication and dose
75
paracemtaol reversal medication and dose
nac 12 or 21hr regime
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opioid reversal medication and dose
naloxone
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depression medication and dose
new episode depression: SSRIs
citalopram 20 mg OD (MAX 40MG)
escitalopram 10mg OD (MAX 20MG)
sertraline 50mg OD (MAX 200MG)
fluoxetine 20mg (MAX 60MG)
paroxetine 20mg (MAX 50MG)
Other antidepressant options include serotonin and noradrenaline reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine, or an antidepressant based on the patient's previous treatment history such as a tricyclic antidepressant (TCA). Note that TCAs are associated with the greatest risk in overdose, although lofepramine has the best safety profile.
Chronic depressive symptoms who havent sought treatment SSRI, SNRI or TCA.
Safety: SSRIs are safer, especially for initial treatment, because they have fewer serious side effects and are safer in overdose.
Side Effects: SNRIs and TCAs often have more intense side effects, like increased blood pressure (SNRIs) or anticholinergic effects (TCAs), making SSRIs a better first option for most patients.
Efficacy in Chronic Depression: SNRIs and TCAs may be more effective when depression is chronic, severe, or resistant to SSRIs, as they target multiple neurotransmitters (serotonin and norepinephrine), which may be more helpful in long-standing or complex cases.
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bradycardia medication and dose
79
hyperkalaemia medication and dose
CALCIUM GLUCONATE 100MG/ML - 30ml injection IV once only.
BNF says calcium glucomnate is the preferred salt except in cardiac arrest or peri-arrest where calcium chloride is preferred.
Insulin 2nd line.
Beta agonists 3rd line because theyre unreliable and offset by other adverse affects like tachycardia.
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hypercholestremia
81
T2DM
82
eczema management infected.
be specific type of eczema as there are lots
atopic dermatits......
non systemic symptoms dont treat with antibiotics just give steroids and emollients. cream (inflammed red skin, daytime) = epimax cream, oitment (really dry areas, night time)= epimax ointment. Steroid= hydrocortisone 1% (mild), eumovate aka Clobetasone butyrate (moderate), betnovate 0.1% (strong) or Clobetasol propionate (very strong).
systemic symptoms give oral steroids and emollients if moderate-severe infection.
if you decide to treat for non systemic symptoms give fucidic acid 2% cream 3 to 4 times a day or fucidin H (comes with hydrocortisone) - A topical antibiotic that can be used to treat infected eczema. It's usually applied to a small area of infected eczema (less than 5 cm2) that isn't responding to other treatments. rule out eczema herpatiform (commonly found on the face).
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smoking cessation first line drugs and which is contrainidcated in depression/epilepsy/psychiatric illness . Which is contraindicated in
Varenicline (side effect nightmares), or a combination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray and oral spray), are the most effective treatment options and thus the preferred choices. If these options are not appropriate, bupropion hydrochloride or single therapy NRT should be considered instead. Note: varenicline is currently unavailable in the UK—for further guidance, see MHRA alert: Champix (varenicline) 0.5mg and 1mg tablets - Supply Disruption (available at: https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103160).
TRICK QUESTION KIND OF BOTH
1. vareniciline is CI/caution with neuropsychiatric disorders (depression pscyhosis and sseizures)
2. Bupropion also has increased risk of seizures hence why it is CONTRAINDICATED in Acute alcohol withdrawal; CNS tumour; history of seizures; acute benzodiazepine withdrawal; bipolar disorder (due to causing mania, its like a serotonin drug); eating disorders (appetite reduction); severe hepatic cirrhosis
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psoriasis management
EMOLLIENTS! - Use ointments in dry skin and creams for moist or weepy lesions (Epimax).
face and flexors- weak steroid 2 weeks, avoid vit D on face and flexors as it can cause erythema and irritation
trunk and limbs- vit d and steroid od (one in morning one at night), vit d BD, vit d and steroid BD. enstillar foam 2nd line is effective. 4 weeks on 4 week break (from steroid, Vit D can be continued).
scalp- steroid potent 4 weeks
Narrowband ultraviolet B (UVB) phototherapy can be offered to patients with plaque or guttate psoriasis in whom topical treatment has failed to achieve control.
Aim for a break of 4 weeks between courses of treatment with potent or very potent corticosteroids. (elocon, betnovate (strong) and dermovate (v strong))
can use steroids twice weekly for maintenance.
IF >10% BODY INVOLVED - TOPICAL TREATMENT ARE NOT ENOUGH- REFER TO DERM FOR ORAL OR NBUVB.
Give advice on how to minimize the risk of corticosteroid adverse effects, such as stopping the topical corticosteroid once the skin is clear or nearly clear.
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galactorrhea
cabergoline over bromocriptine
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DVT treatment
NOTE THERE IS NO ONE TREATMENT CHOICE FOR PE, BUT FOR DVT THERE IS. People with confirmed proximal DVT should be offered apixaban or rivaroxaban first line, and if these are not suitable: Low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran or edoxaban, or. LMWH concurrently with a vitamin K antagonists for at least 5 days.
87
vancomycin and neomycin or gentamicin uses and why.
vancomycin is not classified as an aminoglycoside. Instead, vancomycin is a glycopeptide antibiotic used to treat Gram-positive infections, while aminoglycosides are usually used to treat Gram-negative infections.
vanco - c diff (gram positive),
neomycin - otitis externa (pseudomonas),
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allergic conjuncitivits
1st rule out red flags for acute situations that need ophthalmology review (Serious conditions such as:
Acute glaucoma.
Episcleritis and scleritis.
Keratitis.
Iritis/uveitis.
Corneal ulcer, abrasion, or foreign body.
Preseptal or preorbital cellulitis.)
then distinguish from dry eye. KEY DIFFERENCE - THERE WILL ALWAYS BE INTENSE ITCHING WITH ALLERGIC CONJUNCITIVITS. DRY EYE WILL NOT BE ITCHY. Why you need to know this is because one of the treatments for allergic conjuncitivitis- anti-histamines cause antimuscarinic side effects includign dry eyes.
NUMBER 1 TREATMENT - NON PHARMACOLOGICAL.
*Wash hair before bed to reduce allergen exposure.
*Avoidance of eye rubbing.
*Apply cold compresses to the eyes (for 5–10 minutes once or twice daily)
*Apply ocular surface lubricants such as saline solution or artificial tears
NUMBER 2 PHARMACOLOGICAL
Preparations that have mast cell stabilizing properties include:
Sodium cromoglicate — licenced for use in allergic conjunctivitis and seasonal keratoconjunctivitis in adults and children, apply eye drops 4 times daily.
Lodoxamide — licenced for use in allergic conjunctivitis in adults and children over 4 years, apply eye drops 4 times daily.
Preparations that have antihistaminergic properties (contraindicated in acute glaucoma as it causes pupil dilation) include:
Antazoline — note: the only available preparation also contains xylometazoline. Licenced for use in seasonal allergic conjunctivitis in adults and children over 12 years, apply twice to three times daily; maximum duration of treatment 7 days.
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hameorrhaoid treatment
https://bnf.nice.org.uk/treatment-summaries/haemorrhoids/
external - visible painful and cause itching
internal - not visible not painful and cause bleeding
hygeine - Warm sitz baths
drugs - none more effective than the other - don't actually reduce swelling protrusion or bleeding.. corticosteroids + LA. LA shouldn't be used for more than 3 days as causes sensitisation of the skin and in rare cases - increased itching. steroids no longer than 7 days - thinning skin, and don't use if fungal infection, ulcers, etc. as increase risk of infection.
preparation examples -
1. lidocaine hydrochloride,
2. benzyl benzoate with bismuth oxide, bismuth subgallate, hydrocortisone acetate, peru balsam and zinc oxide ,
3. cinchocaine with hydrocortisone,
4. cinchocaine with prednisolone.
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rubella in a child treatmnet
1. notifiable
2. avoid pregnant people
3. dont go to school for 5 days
4. symptomatic
5. safety net
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Recurrent UTI treatment?
Ensure you first rule out all reversible causes - take a comprehensive history.
Then if no obvious cause - if >40 - non-urgent referral to urology.
Otherwise a self limiting prescription of trimethoprim 3-6 months only. Don't keep them on forever!
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Recurrent DVT medication
For the prophylaxis of recurrent DVT and PE in adults (following completion of 6 months of anticoagulation treatment):
The recommended dose is 2.5 mg twice daily.
The duration of treatment is based on an assessment of benefit against the risk of bleeding.
93
Why this? and what is terbutaline?
terbutaline = laba
94
opioid induced constipation treatment ?
never bulk forming laxatives
95
How long can you leave a lidocaine patch on for?
12hr with a 12 hour gap every 24hr
96
upsi rules. How long until a pill is counted as 'missed'?Why is this option correct ?
24hr late and must be 2X (not just 1 missed pill)
97
UPSI rules depending on the cycle
2 pills missed and you've had sex in the last 7 days (sperm live for 5 days).
called missed pill if >24hr
first week highest risk - emergency contrapcetion needed
ulipristol acetate 5 days
levonelle 3 days
copper coil
if taking ulipristol acetate - dont restart contraception until *5 days later*
if taking levonelle can take contraception immediately after
second week - no contraception needed, continue as normal.
third week- skip pill free interval or use condoms during it (it takes 7 days for hormone levels to stabilise again), no emergency contraception is needed.
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Contraception advice after taking emergency contrapcetion?
Specific Guidelines by EC Type:
Levonorgestrel (Levonelle):
If you've missed any pills or are using COCP/POP, continue with your usual contraception and use backup for 7 days.
Levonorgestrel is effective for up to 72 hours after unprotected sex but works best the sooner it is taken.
Ulipristal Acetate (ellaOne):
It’s effective for up to 5 days (120 hours) after unprotected sex, but it may interfere with the efficacy of hormonal contraception (like COCP and POP).
If you take Ulipristal acetate, you should avoid using hormonal contraception for 5 days after taking the pill (since it may reduce the effectiveness of the hormones).
During this period, use non-hormonal contraception (e.g., condoms), and after 5 days, resume your regular contraception method.
99
what needs to be present to give drug treatment for HTN in those <80 years?
TARGET ORGAN DAMAGE, CVD, KIDNEY, DIABETES or QRISK 10% +
100
How to find HRT on BNF?
If you type up oestrogen it will come up with conjugated oestrogens with medroxyprogesterone. Using this you then select 'other drugs in class' on the 'navigate to section' bit.
Once you click here it will come up with a whole list. The 2 most common prescribed ones that you want to look at are
1. Estradiol 1mg (or 2mg) +
norethisterone sequential or continuous
2. Estradiol + dydrogesterone
1/10mg (or 2/10mg) sequential
Brand names- elleste duet or evorel.
in sequential treatment progesterone should be given for 10 / 28 days.
remember hrt oestrogen is natural (estradiol), whereas contraceptive oestrogen is synthetic.
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Inflammed skin treatment.
Sensitive areas- hydrocortisone 1%
less sensitive areas- betamethasone valerate 0.025%- BETNOVATE RD (moderately potent topical corticosteroid) or clobetasone butyrate 0.05% - EUMOVATE
Aim for maximum of 5 days' use.
Then for maintennce u tend to use a 2x weekly 1x less strength steroid to keep symptoms at bay
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How long to continue steroids after flare has resolved ?
48hr
and for maintenance they can be continued 2x weekly.
Usually tell the patient to trial 3-7 days worth and then come back.
Psoariasis tends to need 4. weeks whereas eczema 2 weeks.
103
itch symptomatic treamtnet
non sedating antihistamine
- cetirizine, loratadine, or fexofenadine
fexofenadine 120mg is really good
104
CKD treatments?
Statin and aspirin 1st line (low protein --> more likely to clot and also high triglycerides as a result)
+/- SGLT2 - almost everyone
+/- ACEI if HTN 30mg/mmol albumin or T2DM with 3mg/mmol albumin. or 70mg/mmol if no condition.
105
Behavioural symptoms of dementia licensed drugs.
antipsychotics once non pharm trialled first. You must complete the NPI to assess BPSD in dementia.
only 2 licensed are risperidone and haloperdiol
(rule out PD and dementia with Lewy Bodies before giving and safety net for these side effects)
If you are trialling anti-psychotics in lewy body the best choice is olanzapine or clozapine
BUT FOR ALL THERE IS INCREASED RISK OF STROKE = REVIEW EVERY 6 WEEKS!
106
How is depression treated in dementia patients?
SSRI are avoided unless severe depression. Dont give for mild to moderate.
107
Lung cancer referral guidelines
>40 with a smoking history and any generic signs of cancer (unexplained SOB, appetite loss, weight loss, fatigue).
>40 with a smoking history and lung cancer specific signs of cancer (chest pain, ongoing cough)
>40 and NO SMOKING HISTORY IS NEEDED IF
1. Finger clubbing
2. Haemoptysis
3. Recurrent/ongoing infection
4. Supraclavicular lymph nodes
5. Exam findings consistent with cancer
108
infective endocarditis treatment
native blind therapy - amoxicillin
109
VTE prophylaxis in surgical patients
Mechanical prophylaxis (stockings or intermittent compression) should continue until the patient is sufficiently mobile or discharged from the hospital (or for 30 days in spinal injury, elective spinal surgery or cranial surgery).
Pharmacological/LMWH prophylaxis should be started within 6-12 hours of surgery and how long you continue this depends on the surgery and risk factors, but again is until the patient is sufficiently mobile OR if it is orthopoedic it tends to be longer.
Hip- 28 days
Knee- 14 days
Spinal- 30 days
Cranial-28 days
Fragility fractures of the pelvis, hip and proximal femur- 30 days
110
VTE prophylaxis in medical patients
if acutely unwell pharmacological treatment for all for at least 7 days
if pharmacological treatment is contraindicated ie. acute stroke (and also stockings are contraindicated), then you give IPC starting within 3 days and then again continue until the patient is sufficiently mobile or for 30 days.
111
which anticoagulants can you have if you have active bleeding?
NONE! - So if they have a PE but they also have a gastric ulcer, they need a SVC filter! Gastric ulcers that are current are SIGNIFICANT RISKS FOR BLEEDING
112
which HTN treatment do you give a black 40 year old?
CCB - race always trumps age
The only thing that slightly trumps race is diabetes- where you give an ARB
113
Massive PE treatment
Alteplase BUT REMEMBER THE KEY CONTRAINDICATIONS -
1. Active bleeding incl. GI ulcer, haemorrhagic stroke,
2. Stroke in the last 3 MONTHS !
3. Aneurysm or AVM
4. Acute pancreatitis
5. Aortic dissection
6. Bacterial endocarditis
7. Coagulation defects on blood test
8. Coma
9. Heavy vaginal bleeding except menses.
10. Neoplasm with risk of haemorrhage
11. Oesophageal varices
12. Pericarditis
13. Recent surgery (including dental extraction) 3 WEEKS!
14. Severe hypertension (>180)
They all roughly make sense except aneurysm, AVM, pericarditis and bacterial endocarditis to me.
WELL PERICARDITIS - RISK OF TRANSFORMING INTO CARDIAC TAMPONADE.
ENDOCARDITIS- RISK OF DISLODGING A SEPTIC VEGETATION - CLOT.
And aneurysms and AVM are fragile and thrombolysing them may dislodge any clot that may have formed secondary to injury in the area.
114
hypoglycaemia management BNF
if diabetic hypoglycaemia is classed as <4mmol
in non diabetics, hypoglycaemia is rare unless liver disease or prolonged starvation, alcohol, addisons.
TREATMENT
if oral route is tolerated start with glucogel, oral glucose tablets- aiming for 20g repeated after 15 minutes up to 3X
Give by buccal administration [in conscious but uncooperative patients]- 1.5–2 tubes of glucose 40% oral gel
if oral route not tolerated or unconscious 1st line is IM glucagon 1mg
if not responsive after 10 minutes to this give Glucose 10% 150-200mL or 20% 75-100mL over <15 minutes
NOTE - Glucagon will not be effective in addisons, steroid use prolonged, liver disease, alcoholic and those on sulphonlyureas.
115
perioperative diabetes control T1DM
if T1DM and minor surgery VRII is not needed unless 1. poor control (≥69mmol/mol / 8.5%), 2. risk of AKI or deranged electrolytes, or 3. more than one meal missed. Instead adjust to 80% basal regime on day before and day of surgery. If mixed insulin adjust to 50% on the day of surgery (not needed on day before).
if major surgery ---> VRII needed
116
perioperative diabetes control T2DM
if minor surgery just like T1DM VRII is not needed unless 1. poor control (≥69mmol/mol / 8.5%), 2. risk of AKI or deranged electrolytes, or 3. more than one meal missed. Instead adjust their medications
The same goes for major surgery.
Specific rules apply then after this. see diabetes notes.
117
HRT is generally prescribed for how many years? And what risk is there if it is prescribed for the first time in someone 65 years and older?
CVD stroke
5 years
118
For maintenance in eczema and psoriasis how often can you apply steroid?
tend to use a steroid that is one down from the strength you needed to control it
so if you were using strong steroid to control varicose eczema as is advised (clobetasone/eumovate) then use betametasone to maintain it and use it 2x a week no more than 2x a day.
Same goes for eczema and psoriasis
119
do you need to do a dipstick to treat UTI in those under 65?
"urine dipstick testing is not needed in a woman under 65 with two or three key symptoms of UTI and no risk factors for complicated UTI"
- clinical presentation is suggestive enough of a UTI that you can treat the patient empirically without needing to confirm the diagnosis with a dipstick test or urine culture.
120
who do you need to do a urinary culture on to diagnose UTI?
1. men
2. catheters or who have been catheterized within the previous 48 hours
3. risk factors for complicated utis - diabetes, immunocompromised, recurrent UTI, recent hospitalisation or AB use, structural abnormalities of the urinary tract
4. pregnant women
5. women over 65
6. Women with visible or non-visible hematuria
121
what type of laxative is bisacodyl and sodium picosulfate,
stimulants
under the brand name Dulcolax and Dulcolax pico (aka dynamite)
122
docusate is what type of laxative?
stimulant and softener
123
examples of stool softners
glycerol suppositories have softening properties. Enemas containing arachis oil. +/- osmotic laxatives like lactulose
124
what laxatives are contraindicated in opioid induced constipation and what is recommended instead?
bulk forming i.e. bran, isaphaga hulk.
In patients with opioid-induced constipation, an osmotic laxative (or docusate sodium to soften the stools) AND a stimulant laxative is recommended
125
shingles treatment?
Oral antiviral treatment should be offered to patients with shingles who are immunocompromised, have non-truncal involvement (e.g. neck, limbs, perineum), or to those with moderate to severe pain or rash. Consider oral antiviral treatment for patients aged over 50 years to reduce the risk of post-herpetic neuralgia. Treatment with the antiviral should be started within 72 hours of the onset of rash. Immunocompromised patients with severe or widespread infection, or severely immunocompromised patients, or patients with shingles in the ophthalmic distribution of the trigeminal nerve, should be admitted to hospital or specialist advice should be sought.
126
hyperlipidemia first line medication
20mg high intensity statin like atorvastatin (aiming for 40% reduction in LDL in 3 months. CK can be elevated up to 5x, LFT can be elevated up to 3x. NOTE do not get this confused with ACE-I where creatinine can only be raised up to less than 30% and eGFR less than 25%).
127
vaginal fungal infection pregnancy tx.
clotrimazole pessary but like uti u have to treat it for longer (7 days as opposed to 1 singular pessary!)
128
what symptoms would be an indication to start systemic HRT. and if a patient is getting vaginal/genitourinary issues is systemic or vaginal oestrogen preferred?
Indications
vasomotor symptoms such as flushing, insomnia and headaches are considered the most important factor in choosing whether to start HRT.
other indications such as reversal of vaginal atrophy should be treated with other agents as first-line therapies.
129
What are the 2 time periods LMWH should be started in pregnancy and what are the 2 time periods it is usually continued for post partum
straight away (history of VTE non-provoked, history of VTE + thrombotic condition, low levels of antithrombin, protein C or S (even if asymptomatic), or if there are 4 risk factors) OR at 28 weeks (if there are 3 risk factors).
10 days post delivery or 6 weeks.
130
after MI how long do you keep the second antiplatelet going for? and how might this present in a question
12 months- and it may be in a question like this- "which drug is inappropriate!"- remember inappropriate is not safe (wrong dose, drug CI in their age, renal, pregnancy, etc, OR WITH THEIR CONDITION), not fit for use (i.e doesn't match their conditions, no longer needed i.e,. HTN drugs and patient has hypotension), or
