Communication Skills

Question 1

Lithium

Answer 1

Action: Mood stabiliser, prevents upswings and downswings in mood. Calms down chatter between cells.
Timing: Take once per day before breakfast
How to take?: Tablet
Length of time: Lifelong if works
Effect: 1 -2 weeks
Tests: Risk of toxicity. TFTs, FBC, bHCG, U&Es taken before, at 5 days and every 1 week until stable for 4-weeks. Then once every 3 months. (lithium levels), 6-12 month other checks.
Inconvenient effects: Lovely taste, Diabetes inspidus, fine tremor, hypothyroidism
Contraindications & complications: CIs - Addisons disease, untreated hypothyroidism, hyponatraemia. Don’t take pregnant!
Supplementary advice: Stay well hydrated, if miss dose take next one next day. Toxicity signs: diarrhoea, vomiting, drowsiness.

Question 2

Clozapine (and other atypical antipsychotics)

Answer 2

Action: Slows down rate of brain cells communicating with each other, which is the way in which schizophrenia causes symtpoms.
Timing: Can take it each day or once monthly in depot injection
How to take: Tablet form
Length of treatment: Lifelong, if treatment works
Effect time: several weeks
Tests: Before starting FBC, LFTs
Important side effects: EPSEs, weight gain, GI disturbances (H2), dry mouth (M1).
Contraindications & complications: Complications - sore throat or ill, SEE DOCTOR. Muscle rigidity, SEE DOCTOR. CI: Liver failure, phaeochromocytoma.
Supplementary advice: Mind.org

Question 3

SSRIS

Answer 3

Action: Increases amount of certain neurotransmitters in your brain which can correct mood.
Timing: Until symptoms begin to improve or no effect noted -
How to take: tablet daily
Length of time: 6-12 months, stop 3-6 months after feeling better.
Time to effect: 4-6 weeks. If want to stop taking then taper off.
Important side effects: GI disturbances, tachycardia, nause, diarrhoea, loss of weight. Can cause cardiac problems.
Complications & CIs: Serotonin syndrome, diarrhoea
Supplementary advice: if taken with St John’s Wort can get diarrhoea, flushing, tachycardia. Mind.uk

Question 4

Amiodarone

Answer 4

Dose: 200mg OD
Monitoring: Check TFTs, LFTs, U&Es @ 6 monthly
Side effects: Pulmonary toxicity, optic neuritis, thyroid toxicity
Special advice: Use sunscreen

Question 5

ACE Inhibitors

Answer 5

U&Es & Blood pressure
Drop of <30% is ok
Otherwise angiotensin receptor blocker (losartan)

Question 6

Amiodarone

Answer 6

Resets Heart Rhythmn
Permanent 
Oral TDS 
Forever
"ECGs, CXR to start
TFTs, LFTs, U&Es @ 6 monthly  "
PF, Cataracts, Hypothyroidism, liver fibrosis 
SSRIs, B blockers, Digoxin, Warfarin (all interact) 
See above
Protect skin, see leaflet

Question 7

ACE Inhibitors

Answer 7

Inhibits convertion of angiotensin 1 to angiotensin 2 by inhibiting ACE
Permanent
Oral - ON “The first dose may make you feel dizzy, so it is best taken at bedtime.”
Forever
BP and U&Es, creatine, eGFR baseline to start, recheck 2 weeks later, Recheck at 1, 3, and 6 months after achieving maintenance dose, then at least 6 monthly thereafter. discussion with a specialist if a patient’s serum creatinine concentration rises by 30% or whose estimated GFR falls by 20% as an apparent consequence of ACEI/ARB us
HARD (Hypotension, hyperkalaemia, angiooedema, renal failure, dry cough
Severe aortic stenosis, renal artery stenosis, pregnancy, history of angiooedema, base line potassium >5.5
HARD (Hypotension, hyperkalaemia, angiooedema, renal failure, dry cough
likely that your doctor will advise that you do not use salt substitutes while you are taking ramipril. These products have a high content of potassium which could be harmful for you.

Question 8

Prednisolone

Answer 8

Dampens down inflammation and immune system
Permanent
Morning after breakfast
For as long as prescribed
“Steroid treatment card, tell doctors and dentists
Baseline tests (Height, weight, HbA1c, fracture assessment) “
Osteoporosis, immunosupression, worrying thoughts, indigestion, hypertension
Pregnancy, current infection,
Possibly prescribed PPI & Bisphosphonates for long term use
“Do not stop taking suddenly
You will be given steroid treatment card to fill in”

Question 9

B blockers

Answer 9

Block certain nerve impulses which can cause a variety of effects, such as reducing force and rate of heart.
Permanent
Oral OD, after breakfast
For as long as prescribed
Don’t stop rapidly, can cause palpitations & rise in blood pressure
Dizzyness, may block signs of hypoglycaemia, cool hands and feet, impotence and vivid dreams
Asthma, bradycardia, hypotension, certain rhytmn problems
See above

Question 10

Carbimazole

Answer 10

Reduces level of T3 and T4 thyroid horomes
once daily
Oral
Usually 18 months (less if block and replace treatment)
Baseline: TFT, WBC, TFTs every 1-3 months until stable, repeat wbc if patient develops fever, sore throat or mouth ulcers
rash, nausea, headaches, muscle and joint pain
pregnancy
agranulocytosis, hypothyroidism
Patients should be asked to report any symptoms or signs of infection, in particular sore throat before of agranulocytosis risk

Question 11

Mesalazine

Answer 11

Acts on intestinal cells to reduce inflammation, modifying the symptoms of ulcerative colitis
Once daily
“Oral: Swallow whole
Rectal: Foam nozzle or enema
“
Lifelong
“Before: U&Es
Every 3 months for first year: U&Es
Every 6 months for first four years: U&Es
FBC if haematological side effect suspected”
“GI: Indigestion, tummy pain - avoid spice
Diarrhoea - drink water
Headache - paracetamol
WORRYING: Sore throat, purpura”
“Renal impairment <20ml/kg/1.73
NSAIDs & Azathioprine increase risk of renal problems
Make sure always using your brand

Question 12

SSRIs

Answer 12

Increase serotonin levels
once daily
Oral
At least 6 months, but for as long a prescribed, usually stop 3-6 months after patient is feeling better but reduce dose slowly to reduce withdrawal effects
No monitoring
GI disturbances (nausea, anorexia, diarhoea, constipation,) dry mouth, inc QT interval wih citralopram, increase suicide risk on initiation
bipolar
takes 4-6 weeks to take effect, may feel worse initally before feeling better

Question 13

Gliptin

Answer 13

Insulin controls level of glucose in your blood, sitagliptin increases secretion of insulin
Same time every morning
Oral tablet
Indefinite
Diabetic check-ups - eye clinic, foot clinic, renal function. Consider self-glucose monitoring
“ACUTE PANCREATITIS,
Wind, Headache”
See above
Take special care if driving as concentration may be affected

Question 14

Clopidogrel

Answer 14

In your blood sticky platelets, clopidogrel stops them binding together.
Once daily
Oral tablet
Indefinite
Bleeding, indigestion
Pregnancy, allergies, renal impairment, liver impairment
NSAIDs OTC
Check with pharmacist if over the counter drugs ok to take

Question 15

B2 agonist

Answer 15

Relaxes the smooth muscle of the small airways, opening them up and increasing ease of breathing 
As required
Inhaler
As required
None
Tremor, cardiac dysrhytmia, hypokalaemia
None
Technique needs to be good. Can use a spacer if unable to use inhaler.  If using >3 times per week talk to GP about preventer therapy.

Question 16

Azathioprine

Answer 16

An immunosupressive drug that helps reduce inflammation, and reduce risk of infection in post transplant patients
once daily (usually)
Oral tablet normally, occasionally IV
Indefinite
Baseline: FBC, LFTs, U&Es,creatinine, TPMT assay. Montoring rate depending on indication. In rheum patients: FBC and LFTs weekly for 6 weeks and continue every 2 weeks until dose stable for 6 weeks, then monthly thereafter
Bone marrow supression (patients must look out for bruising, bleeding or infection), hypersensitivity reactions, hair loss, liver impairment. rarely pancreatitis and pneumoitis
lack of enzyme: TMPT
Take the tablets after eating a meal or with a snack. This will help to stop any feelings of queasiness or nausea. Drink plenty of water as you take the tablets.

Question 17

Lithium

Answer 17

Keeps mood stable by regulating how neurotransmitters work in the brain 
Once daily
Tablet or syrup
Indefinite if works
"TFTs, U&Es, FBC, ECG required at baseline. Monitoring Lithium levels every week until stable for four weeks.
Monitor levels of drugs every 3 months, TFTs & U&Es every 6 months."
"Lithium Toxicity 
Insipidus (Diabetes)
Tremor
Hypothyrodism 
LITHIUM TOXICITY 
- GI
- Dizziness, ataxia
- Coarse tremor"

Contrainidcations: 
"1st trimester of pregnancy
Cardiac disease
Low salt
Addison's disease"

"LITHIUM TOXICITY 
Insipidus (Diabetes)
Tremor
Hypothyrodism 
LITHIUM TOXICITY 
- GI
- Dizziness, ataxia
- Coarse tremor"
Rethink.org

Question 18

Metformin

Answer 18

increases sensitivity of cells to insulin
Once daily with breakfast, sometimes twice day
Oral tablet
Lifelong if works
U&E before starting, then annually
Nausea, diarrhoea, abdo pain, weight loss
Lactic acidosis
Renal impairment (eGFR <30 stopped, <45 reviewed), AKI, severe tissue hypoxia, ketoacidosis
Tell a doctor you are taking metaformin before having an xray or operation

Question 19

Warfarin

Answer 19

Thins the blood by blocking vitamin K which makes blood sticky
Once daily
tablet
3 months for DVT
6 months for PE
Lifelong for AF
Start 5mg for 4 days, test INR on day 5, dose adjust, retest on day 8. Started with LMWH if immediate effect. Regular INR checks determined by clinic.
“Bleeding - dark stools, vomiting blood, cuts take longer to heal.
“
Many drug interactions - CYP450 Inhibitors, pregnancy, haemorrhage
-
Avoid liver, spinach. Avoid NSAIDs. Anticoagulant book.

Question 20

Ciclosporin

Answer 20

"Immunosupressants which reduces inflammatory cell numbers. 
"
BD
Tablet, liquid
Indefinite - Transplant, rheumatoid 
"Baseline: FBC, U&E, LFTs.
Monthly until dose and trend stable for 3 months"
"Infections & high temperature
GI disturbances
Headache
Gingival hyperplasia"
Other DMARDs
- 
Do not drink with grapefruit juice.

Question 21

Digoxin

Answer 21

reduces heart rate, increases force of contraction of heart

oral/ IV
indefinite
baseline: renal function, u&es paying particuar attending to potassium, recheck 10 days after any dose change
nausea, diarhorea, headache, bradycardia, rash, dizziness, visual distrubances
digoxin toxicity - wide range of arrhythmias, may be fatal, low therapeutic index,
loop and thiazide diuretics inc risk of digoxin toxicity, by causing hypokalaemia. Amiodarone, calcium channel blocks, spirolactone, and quinine can all increase the plasma concentration of digoxin and therefore risk of toxicity
Due to large volume of distribution, a loading dose is required if a rapid dose is required

Question 22

Furosemide

Answer 22

Reduces salt reabsorption and increases fluid output. Water tablet.
For symptoms
Oral tablet, take in morning (will disturb sleep if taken late)
As long as prescribed
U&Es within 1-2 weeks of starting treatment. Once stable check U&E every 6 months.
Sick, dizzy, postural hypotension, dry mouth, blurred vision
ototoxicity
have leaflet

Question 23

Methotrexate

Answer 23

Disease modifying agent which has both reduced inflammation and supresses the immune system. Early use improves outcome and symptoms. 
Once weekly with folic acid at different time
Tablet/injection
Long term
"FBCs, U&E, LFTs
Every 2 weeks until therapy stabilised
Then every 2-3 months"
"Headaches
Alopecia
GI disturbance

Myelosupression
- infection, unexplained bruising, anaemia"
Pregnancy, hepatic impairment
-
No NSAIDs/Aspirin, Get annual flu jab

Question 24

Bisphosphonates

Answer 24

prevents bones from being broken down, reducing bone loss and improvement of bone mass
usually once weekly
alendronic acid tablets should be swallowed whole at least 30 mis before breakdast or other medications, taken with plenty of water. reman upright for 30 mins after to reduce oesophageal irritation
indefinite if tolerated
dental check up before starting, then reguary, because of osteonecrosis of jaw risk
oesophagitis, hypophosphataemia, gi disturbances, rare but important: atypical fracture of the femur
severe renal failure, hypocalcaemia, upper gi disorders, gastric ulcers, pregnancy
Good dental hygiene is particularly important while you are taking alendronic acid - brush your teeth regularly and remember to have routine dental check-ups

Question 25

Statins

Answer 25

Statin stops liver making cholesterol, cholesterol is one of the things that contributes to heart disease
Once daily in evening
Tablet
Lifelong
“Baseline: LFTs
Monitoring: 3 months, then at 12 months
Review in 4 weeks, then every 6 months. “
“Hair loss, muscle pain (myalgia!), itching
GI disturbances
RHABDOMYOLYSIS”
Pregnancy
RHABDOMYOLYSIS
Avoid grapefruit. Only one part of CVD risk reduction.

Question 26

NSAIDs

Answer 26

Anti inflammatory drugs which reduce pain and level of inflammation
pain: usually 6 hourly max TDS, usually 12 hourly for RA BD. oral nsaids should be taken with food to minimiise gi upset
Usually orally, but also topical gels and suppositries
pain: as needed, artheritis pain may be longer term
Renal function should be monitored in patients with renal, cardiac or hepatic impairment
most people have no side effects
Severe renal impairment, heart failure, liver failure, known NSAID hypersensitivity, peptic ulcer diease, gi bleedind
GI toxicity, renal impairment, inc risk of cardiovascular events, hypersensitiviy reactions, fluid retention
long term use: ppi cover, The risk of bleeding into the stomach is increased if you are taking an anti-inflammatory plus warfarin, steroids, or low-dose aspirin

Question 27

Anti-psychotics

Answer 27

Brain gets too talkaltive, antipsychotics reduce chatter between cells
Daily or monthly
Tablet or depot injections
1-2 years from symptom onset
Baseline: U&E, FBC, LFTs, BM
FBC every week for 18 weeks -> every 2 weeks -> After one year every 4 weeks 
"EPSEs
Constipation
Weight gain
Dry mouth 
Tachycardia, drowsiness"
Severe cardiac disorders, CNS depression
- 
DO NOT STOP SUDDENLY - rebound psychosis, 80% improvement in symptoms

Question 28

Levothyroxine

Answer 28

Synthetic version of thyroid hormone, brings levels back to normal
Once daily before breakfast
Tablet
Lifelong
“Start test dose and review in 2-3 weeks
TSH test every 2-3 months
When TSH stable, annually”
Rare when replacing but could have hyper/hypothyroid symptoms
-
-
Free prescriptions for levothyroxine users

Question 29

Insulin

Answer 29

Replacement of insulin in the body that helps with glucose regulation. ‘Lock and Key’ explanation; lock = insulin receptors and key = insulin; T1DM results in less ‘keys’, and T2DM results in less ‘locks’.
Depending on types of insulin. Biphasic regime (e.g. NovoMix 30) and basal bolus regime (short-acting e.g. Actrapid with long acting e.g. Levemir).
Subcutaneous injections; short acting insulin 15-30 minutes before meals. [OD regiment long/intermediate acting given at bedtime, only suitable for T2DM +/- in combination with oral hypoglycaemic. BD regimen, injected pre-breakfast and pre-evening meal; assumes patient eats three meals a day. RISK OF NOCTURNAL HYPOGLYCAEMIA + Fasting hyperglycaemia in the morning; Basal bolus regimen - provides optimal glycaemic control.]
Lifelong
Regular BM testing, several times every day; tends to be first thing in the morning, before meals and after meals????? Depends on HCP recommendation.
Hypoglycaemia; Lipodystrophy - must switch injection sites every time you inject. Common sites include lower abdomen and upper thighs.
Alcohol
HYPOGLYCAEMIA - early signs include feeling shaky, anxious, sweating, looking pale, feeling hungry, palitations and dizziness. If this takes place eat/drink something containing sugar immediately. DRIVERS must inform DVLA that they are on insulin; check blood sugar level just before journey commencement and every two hours during the journey. If BM is low you must stop and have something sugary to eat/drink and only drive 45 minutes after BM returns to normal before resuming driving.
Insulin must be stored in a fridge when unopened; do not freeze! When in use you can keep it for a few weeks at room temperature <25 degrees and away from direct heat and sunlight.
Safeguarding - when developing an INFECTION, insulin dose needs to be adjusted. If patient gets unusually thirst/pass more urine/feeling very tired, patient needs to inform a doctor/diabetic nurse ASAP
Pregnant women - important to reinforce concordance due to risk of gestational diabetes and foetal macrosomia.

Question 30

GTN

Answer 30

Used for chest pain associated with angina; a nitrate; facilitates venodilation & vasodilation; venodilation to reduce strain on heart, vasodilates coronary arteries to improve supply of blood to cardiac tissue. Comment on atheromatous disease and target lifestyle factors e.g. Diet exercise HTN DM high cholesterol/triglycerides etc.
PRN / OD
Spray/Tablet - short acting preparations; 1 or 2 sprays under tongue when pain develops and pain should ease within the minute; 1 tablet under tongue when pain develops and allow it to dissolve and pain should ease within a minute (effects last about 20-30mins); longer acting nitrates also available - transdermal preparations, apply 1 every 24 hours; prescribed to prevent pain from developing as opposed to symptomatic alleviation.
Indefinite?

Throbbing headache (take painkillers), feeling dizzy (do not drive!), fast heartbeat (if troublesome speak to HCP); less common SE: feeling sick and flushing/skin reactions.

GTN tablets are very perishable so they need to be replaced every 8 weeks. Store in cool dry place, away from direct heat and light. GTN spray has a longer shelf life. CONTAINS FLAMMABLE INGREDIENTS! Warn surgeons/dentists that you’re on GTN.