communicating info Flashcards
Allopurinol- stop
stop immediately if rash - severe cutaneous adverse reaction (SCAR), drug reaction with eosinophilia and systemic symptoms (DRESS), SJS
allopurinol initiated
delay until inflammation settled.
100mg od with titration to serum uric acid <300umol/l. lower if reduced GFR.
Colchine
allopurinol- indications
after first gout attack. especially if >= 2 attacks in 12 months. tophi, renal disease, uric acid stones, prophylaxis for cytotoxics or diuretics. Lesch-Nyhan lifelong.
allopurinol interactions
azathioprine: high levels of 6-mercaptopurine, use 25% dose if must co-prescribe.
Cyclophosphamide: reduces renal clearance therefore marrow toxicity.
Theophylline: increases plasma conc and inhibits breakdown.
aspirin potentiates
oral hypoglycaemics, warfarin, steroids.
aspirin indication
IHD
asprin contraindication
under 16 due to reyes syndrome, unless kawasaki
verapamil- indications
angina, HTN, arrhthmias.
verapamil- cautions and se
NOT WITH BETA BLOCKERS- heart block. SE: heart failure, constipation, hypotension, bradycardia, flushing
Diltiazem- indications
angina, hypertension.
Diltiazem- se and cautions
caution with hf and beta blockesr. SE: hypotension, bradycardia, hf, ankle swelling
nifedipine, amlodipine, felodipine - indications
HTN, angina, raynauds. dihydropyridines.
Peripheral smooth vascular muscle. SE: flushing, headache, ankle swelling.
Ciclosporin- how
T cell reduces clonal proliferations by reducing IL-2.
Ciclosporin- se
increased fluid, BP, K, hair, gums, glucose.
neprhotox, hepatotox, fluid retention, hypertenision, hyperk, hypertrichosis, gingical hyperplasia, tremor, impaired glucose tolerance, hyperlipid, susceptible to sev infection.
ciclosporin- indications
organ transplantation, RA, psoriasis, UC, red cell aplasia.
digoxin mechanism
increases cardiac muscle contraction force with inhibition of na/k atpase pump, and vagal stimulation. slows av node conductino slowing ventricular rate in af.
digoxin monitoring
only in suspected toxicity. measured 8-12 hours after last dose.
digoxin toxicity range
can be toxic even in thereaputic range. liklihood from 1.5-3mcg/l.
digoxin tox sx
unwell, lethargy, N&V, anorexia, confusion, yellow green vision, arrhthmias (av block, bradycardia), gynaecomastia.
digoxin tox causes
hypokalaemia (more easily bound to na/k pump. thiazides and loop), age, renal failure, MI, low mag, high ca, high na, acidosis, low abulmin, hypothermia.
Drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone( competes for secretion from distal convoluted tubule therefore reduced excretion), ciclosporin,
digoxin tox mx
digibind, correct arrhythmias, monitor K
gentamicin- indication
IE, topical for otitis externa
gentamicin adverse effects
ototoxicity- auditory or vestibular nerve damage irreversible.
nephrotoxicity- acculumates in renal filaure, acute tubular necroriss. increased risk with furosemid. lower dose and more frequent monitoring.
gentamicin CI
myasthenia gravis
gentamicin dosing
monitor plasma conc. both peak (1hr post adm, and trough (just before next dose) meausred. if trough level is high the interval between doses is increased. if peak dose high then decrease dose.
heparin indications
activate antithrombin iii. unfractionated: thrombin, xa, ixa xia xiia inhibit. LMWH incrases antithrombin ii on factor xa.
heparin adverse effects
bleeding, thrombocytopaenai, osteoporisis , high k
standard heparin
IV, short acting. for high risk of bleeding, rapid termination, and renal failure.
. bleeding and heparin induced thrombocytopaenia (HIT) and osteoporosis (lower risk in LMWH).
heparin monitoring
standard- APTT. LMWH: anti-factor Xa (not routine).
HIT
Heparin induced thrombocytopaenia. immune mediated ,abs form to platelet factor 4 and heparin complexes. bind to platelet and induce activation. 5-10 days after tx. low platelets but prothrombotic. >50% reduction in platelets, thrombosis, skin allergy.
heparin od
protamine sulphate, only partially revers with LMWH
Lithium therapueitc range
0.4-1mmol/l
lithium toxicity causes
dehydration, renal failure, diuretics (thiazides), ace in, arb, nsaiods, metronidazole/
lithium tox range
> 1.5mmol/l
lithium tox sx
coarse tremor, hyperreflexia, acute confusion, polyuria, seizure, coma
liothium tox mx
volume resuscitation with normal saline, haemodialysis, sodium bicarbonate (urinary alkilinsation).
macrolides examples
erythromycin, clarithromycin, azithromycin.
macrolide adverse effects
prolonged qt, gi side effects, cholestatic jaundice, P450 inhibit, azithromycin associated with hearing loss and tinnitius.
macrolide interaction
statins stopped as inhibit p450 so increases myopathy and rhabdomyolysis.
metformin
biguanide. t2dm, polycysitc ovarian syndrome and nash
metform mechanism
activates ampk, increases insulin sens, decresases hepatic gluconeogenesis, reduce gi carb abs.
metformin adverse effects
gi upset (nausea, anorexia, diarrhoea), reduced b12 abs, lactic acidosis (sev liver disease or renal failure)
metformin contraindications
CKD (review if cr >130 or gfr <45 or stopped if cr >150 or gfr <30)
lactic acidosis- recent mi, sepsis, aki, dehydration.
idodine containing contraast media: peripheral arterial angiography, coronary angiography, IVP. discontinue on day and 48 hours after
alcohol relative.
starting metformin
titrate up to reduce gi se. modified release if se difficult.
octreotide
long acting analogue somatositatin.
d cells of pancrease inhibits growth hormone, glucagon and insulin.
octretide uses
variceal haemorrhage, acromegaly, carcinoid syndrome, pancreatic surgey complications, VIPoma, refractory diarrhoea.
octreotide adverse effects
gallstones (secondary to biliary stasis)
paracetamol od mx
activated charcoal if <1hr.
N-acetylcysteine (NAC)- if staggered od, doubt of time of ingestion OR plasma con on or above treatment line of 100mg/l at 4 hours and 15mg/l at 15 hours, regardless of RF for hepatotox.
Infused over 1 hour (reduce anaphylatoid reactions).
liver transplant- kings college hospital criteria.
Salicylate od mx
urinary alkalinisation with iv bicarb. haemodialysis
opiod od
naloxone
benzodiazepine od
fulmazenil. supportive care. risk of seizures with fulmazenil. only really used in severe and iatrogenic
TCA od
Iv bicarb (reduce seizure risk and arrythmias Quinidine antiarrhymia class 1a, 1c (flecainide) are contraindicated as prolong depolarisation. correct acidosis.
lithium od
mild-mod- fluid resus with normal saline. haemodialysis. sodium bicarb- urinary alkinisation–> promotes excretion
warfarin od
vit k, prothrombin complex
heparin od
protamine sulphate
beta blocker od
if bradycardia: atropine
if resistant glucagon
ethylene glycol od
ethanol (competitive for alcohol dehydrogenase), limits toxic metabolites. fomepizole (inhibits alcohol dehydrogenase). haemodialsysi.
methanol od
fomepizole or ethanol, haemodialysis
organophosphate/insecticide
atropine
digoxin od
digibind (digoxin specific antibody fragments)
iron
desferrioxamine (chelation)
lead
dimercaprol, calcium edetate
carbon monoxide
100% ox, hyperbaric o2
cyanide
hydroxocobalamin, amyl nitrite, sodium nitrite and sodium thiosulfate.
phosphodiesterase type V inhibitors ex
sildenafil (viagra), tadalafil, vardenafil
phosphodiesterase type V inhibitors CI
patients on nitrates and nicorandil, hypotension, recent stroke/mi (<6months)
phosphodiesterase type V inhibitors SE
visual disturbances (blue discoloration (BLUE PILLS), non-arteritic anterior ischaemic neuropathy), nasal congestion, flushing, GI, headahce.
Potassium sparing diuretics- classification and examples
sodium channel blockers- amiloride, triamterene aldosterone antagonists (spironolactone, eplerenone)
amiloride- type, where works, used?
type- sodium channel blocker at distal convoluted tubule. weak. with thiazide/loop to maintatain potassium levels.
spironolactone type where use
aldosterone antagonist, at cortical collecting duct. used in ascites (secondary hyperaldosteronism)- large dose 100-200mg. HF, nephortic syndrome, conns.
asthma cautions
nsaids, beta blockers, adenosine.
epilepsy cautions
alcohol, cocaine, amphetamines,
ciprofloxacin, levofloxacin,
theophylline and aminotheophylline,
bupropion, methylphenidate, mefanamic acid.
withdrawl of benzos, baclofen, hydroxyzine.
and p450 inhib or enhancers
HF cautions
thaizolidinediones, verampil, nsaids/glucocorticoids (fluid retention), low dose aspirin allowed on risk benefit, class i antiarrythmics (flecainide)
negative ionotropic effects for above.
IHD cautions
nsaids, oestrogens (cocp, hrt), varenicline
renal failure cuations
tetracycline, nitrofurantoin, nsaids, lithium, metformin,
dose adjustment for antibiotics, digoxin, atenolol, methotrexate, sulphonylureas, fureosemide, opioids.
safe: erthromycin, rifampicin, diazepam, warfarin
pregancy cautions
tetracycline, aminoglycosides, sulphonamides, trimethoprim. quinolones.
ACE in, ARB, statins, warfarin, sulfonylureas, retinoids (including topical), cytotoxic.
antiepileptics: sodium valproate, carbaemaqpine, phytoin.
quinolones ex
ciprofloxacin, levofloxacin. inhibit dna synthesis.
quinolones adverse effects
lower seizure threshold, tendon damage, cartilage damage (thus not used in children), long QT interval
quinolones ci
pregnant and breastfeeding, G6PD
tamoxifen what and how long
serm: selective eostrogen receptor modulator. ER pos cancer 5 years.
tamoxifen adverse effects. lower risk?
menstrual disturbance, bleeding, amenorrhea, hot flushes, VTE, endometrial cancer. raloxifene pure oestrogen receptor antagonist therefore lower endometrial cancer risk
breast feeding allowed abx
penicillins, cephalosporins, trimethoprim
breast feeding allowed endocrine
glucocorticoids, levothyroxine
breast feeding allowed epilepsy
sodium valporate, carbamazepine
breast feeding allowed asthma
salbutamol, theophyllines
breast feeding allowed psych
TCA, antipsych
breast feeding allowed HTN
beta blockers, hydralazine
breast feeding allowed coag
warfarin and heparin
breast feeding allowed cardio
digoxin
breast feeding avoid abx
ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
breast feeding avoid psych
lithium benzodiazepine, clozapine.
breast feeding avoid cardip
aspirin, amiodarone
breast feeding avoid others
carbimazole, methotrexate, sulfonylureas, cytotoxic.
antipyschotics monitoring
FBC, U&E, LFT- prior, annual.
lipids, weight- prior, 3 months, annual
fasting glucose, prolactin- begin, 6 months, annual.
BP- baseline, frequently with dose titration
ECG: baseline
cardio risk assessment.
Clozapine: FBC initially weekly
VTE prophylaxis assessment
medical reduced mobility for 3 + days.
Surgical: hip/knee replacement, hip frac, general with >90mins surgery, pelvic, lower limb with general and >60mins, acute surgical with inflamm or intraabdo, any significant mobility reduction.
RFs: cancer/chemo, >60yrs, clotting disorder, >35 BMI, dehyration, comorb, critical care, HRT, COCP, varicose veins, pregnant/<6wks post partum.
types of VTE prophylaxis
mechanical and pharm
Mechanical VTE prophylaxis
anti-embolism compression stockings, intermittent pneumatic compression device.
Pharm VTE prophylaxis
fondapariunux sodium SC inj
LMWH- enoxaparin reduced dose in renal impairment
UFH- ckd instead of LMWH
pre and post surgical vte advise
stop cocp/hrt 4 weeks before
mobilisation, hydration
hip prophylaxis
LMWH 10 days then aspirin (75or150mcg) for 28 days or LMWH for 28 days with stockings until dx or Rivaroxaban
elective knee prophylaxis
aspirin (75 or 150mcg) for 14 days. or LMWH for 14 days with stockings until dx or rivaroxaban
fragility frac of pelvis hip, prox femur prophylaxis
1 month VTE if risk
LMWH- 6-12 hours post surgery
or
fondaparinux sodium at 6 hours post providing low bleeding risk .
SSRI adverse effects
GI, GI bleeding (give PPI if on NSAID also), counselled for increased agitation and anxiety after.
fluoxetine and paroxetine increased drug interactions
citolopram cardio
prolonged qt interval. dose dependent. CI with congenital qt syndrome, or preexisting, or with meds that prlong.
Max dose 40mg adults, 20mg for >65yrs, 20mg for hepatic impairment.
SSRI interactions
NSAIDs- give PPI
warfarin/heparin- consider mirtazapine
triptans/MAOIs- increase serotonin syndrome risk
SSRI initiation
reviewed at 2 weeks. review at 1 week if <30 or high suicide risk. continue at least 6 months after remission as reduces relapse
SSRI discontinuations
mood change, restlessness, sleeping diff, unsteady, sweating, GI sx, paraesthesia.
SSRI preganancy
risk benefit. first trimester- cardiac deformities
3rd trimester peristent pulmonary hypertension.
Paroxetine: increased congenital malform esp first trimester
TCA SE:
drowsy, dry mouth, blurred vision, constipation, urinary retention, QT lenghten
Retinoids adverse effects
teratogenicity- 2 forms of contraception.
dry skin, eyes lips and mouth
low mood
raised triglycerides, hair thinning, nose bleeds, intracranial hypertension, photosens
psoriasis triggers
trauma, alcohol, beta blockers, liithiym, antimalarias (quinine), NSAIDs, ACE in, infliximab
withdrawl of steroids.
POP counselling- starting when, se
up to and including day 5- immediate protection. otherwise first 2 days condoms.
same time every day wihtout break
irregular bleeding
missed pills pop
<3hrs: continue
>3hrs: take missed pill asap, continue with pack and use condoms until pill taking reestablished for 48 hours.
diarrhoea- assume missed but continue taking,
inducers reduce efficaccy.
lithium adverse effects
n and v, diarrhoea, fine tremor, nephrotox (polyuria, nephorgenic DI, thyroid hypo.
ECG: t wave inversion or flattening.
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroid, resultant hypercalcaemia
lithium monitoring
12 hours post dose
at start- weekly and after each change until stable
once established- 3 months lithium level
after dose change- one week later and weekly until stable
TFT, U&E 6 months
info book, alert card, record book
GAD mx
educatino, active monitoring.
low intensity psych intervention (non-facilitated self-help or induvidual guided self help, or psychoeducational groups.
high intensity psychological intervention (CBT, applied relax), drug treatment.
Specialist input.
DRUGS: sertraline.
SSRI/SNRI (duloxetine, venlafaxine.
pregabalin if not tolerated.
paracetmol dose
1g QDS
ibuprofen dose
200-400mcg tds
codeine dose
30-60mg qds
cocodamol 8/500 or 30/500
2 tabs qds
cyclizine dose
50mg tds
metoclopramide dose
10mg tds
amoxicillin dose
500mg tds
clarithromycin dose
500mg bd
lansoprozole dose
15-30mg od
omeprazole dose
20-40mg od
aspirin dose
75-300mg od
clopidogrel dose
75-300mg od
simvastatin dose
10-80mg on
atenolol dose
25-100mg od
ramipril dose
1.25-10mg od
bendroflumethiazide dose
2.5mg od
furosemide dose
20mg od- 80mg bd
amlodipine dose
5-10mg od
levothyroxine dose
25-200mcg od
metforim dose
500mg od - 1g bd
COCP CI
UKMEC 1: no restriction
2: advantages
3: disadvantages outweigh
4: unacceptable health risk
UKMEC 3
> 35 yrs, smoking >15 cigareets/day, BMI >35
first degree relative thrombus <45 years, HTN, immbility, BRCA1/2, gallbladder disease, DM diagonsis >20 year
UKMEC 4
> 35 with >15 cigareets/day, migraine with aura, thromboembolic disease hx, thombogenic mutation, history stroke or IHD, breast feeding <6 weeks pp, uncontrolled HTN, current breast cancer, major surgery prolonged immobilisation. DM diagnosis >20 years.
penicillin containing
phenoxymethylpenicillin, benzylpenicillin, flucloxacillin, amoxicillin, ampicillin, co-amoxiclav (augmentin), co-fluampici l(magnapen), piperacillin with tazobactam (tazocin), ticarcillin with claculanic acid (timentin)
bisphosphonates
oral or iv.
daily weekly or monthly.
methotrexate
weekly
