Communication

Question 1

Antipsychotics: Important side effects, common side effects, Monitoring?

Answer 1

Important side effects:

Agranulocytosis (fever/flu like symptoms check WBC)
QT prolongation, arrythmias
Worsening diabetes
Worsening Parkinson’s disease
Neuroleptic malignant syndrome (also fever, muscle cramps, confusion)

Common side effects:
Drowsiness & enhanced affects of alcohol
Constipation, urinary retention, dry mouth, hypotension (anti-muscarinic effects)
Weight gain, Galactorrhoea, gynaecomastia, sexual dysfunction (high prolactin)

Monitoring:
FBCs, U+Es, LFTs, lipids, blood glucose, blood pressure
Prolactin
Physical health (and cardiovascular risk) monitoring, QTc monitoring

Not to stop medications suddenly

Question 2

Lithium:
Symptoms of potential toxicity?
Potential causes of dehydration?
How to monitor?

Answer 2

Toxicity:
visual disturbance, persistent headaches
increased urination, muscle weakness, tremors, confusion or drowsiness

Causes of dehydration:
E.g. vomiting, diarrhoea, profuse sweating with fevers
To keep well hydrated
Risk of toxicity with diuretics

Will need monitoring of blood tests:
Lithium, TFTs, U+Es, bone profile

Avoid if possible in pregnancy (but not absolute contraindication)
Should not stop treatment abruptly without medical advice

Question 3

Metformin:
What should patients be aware of?
Method of use?
Monitoring?

Answer 3

Patient should be aware that:
Dehydration (e.g. with diarrhoea, vomiting, infections) risks severe side effects (lactic acidosis)
Gastro-intestinal side-effects are common. However, a slow increase in dose may improve tolerability

Method of use:
Take with or just after food
Start with low starter dose
Likely to require higher doses in the future
(Modified release tablets not to be crushed)

Monitoring:
Renal function (as it will influence dosing / stopping)

Question 4

Sick day rules: what medications need to be stopped if patient is sick with e.g. vomiting, diarrhoea, fevers, sweats?

Answer 4

Metformin (not insulin!!)
ACEi / ARBs / diuretics
NSAIDs
(“DAMN” medications)

Restart 24-48hrs after eating & drinking normally

Question 5

Sick day rules for T1DM?

Answer 5

• Never omit insulin (may need increased – local guidance usually provided)
• Maintain adequate (sugar-free) fluid intake
• Maintain regular carbohydrate intake – if unable to take solids, in liquid carbohydrate format
• Consider anti-emetic if nauseated
• Consider oral electrolyte replacement in diarrhoea
• If prolonged inability to keep down fluids (e.g. >4hrs), then likely needs hospital admission
• Increased blood glucose monitoring (e.g. 4hr-ly, and even more frequently if >moderate ketones)
• Ketone testing 2-4 hrly
• If persistently elevated, or elevated while low blood glucose – may need hospital admission

-Diabetic specialist nurse should provide individualised plan

Question 6

Sick day rules for T2DM?

Answer 6

• Patients on oral medication only, not including sulphonylureas:
  Continue with medication as normal (except metformin if prolonged D/V)
  Encourage adequate fluid and diet intake
  Consider providing an oral electrolyte replacement
• Patients taking sulphonylureas:
  Minimum of daily self-blood glucose monitoring
  Advice should be provided regarding the increased risk of hypoglycaemia and reinforce the importance of taking some form of regular carbohydrate
  Seek advice if blood glucose persistently elevated (e.g. > 17)

-Patients taking insulin therapy:
Never omit insulin (if regular prescription)
Emphasis on the importance of regular carbohydrate intake
Minimum twice-daily self-blood glucose monitoring
Seek advice if blood glucose persistently elevated (e.g. > 17)
Diabetic specialist nurse should provide individualised plan

Question 7

Long term steroid use: sick day rules, method of use, serious SE?

Answer 7

Sick day rules
Likely need to increase dose if unwell or undergoing surgery

Method of use
Do not stop steroids abruptly
Usually taken in morning (reduce nocturnal side effects)
Taken with or just after food
Should carry steroid card 

Serious side effects
Increased risk of psychological side effects
Increased risk of infections