Counselling stations - OSCE Flashcards
What type of risk factors is it important to elicit when counselling for bisphosphonates
osteoporosis risk factors including smoking, alcohol, steroid use and being post-menopause.
How do bisphosphonates work
They work by slowing down the process of bone breakdown by osteoclasts, whilst allowing osteoblasts to continue enhancing bone density(Prevent thinning of bones)
How often is alendronic acid taken
Once a week(tablet) - Same day each week
How should alendronic acid be taken
Should be taken with a large glass of water, and the patient should not consume any food or drink, other than water, for 2 hours after taking it.
Advise the patient to sit upright for 30 mins after taking the tablet as alendronic acid can cause oesophageal irritation, ulceration and in some cases strictures.
Advice regarding missed tablets - alendronic acid
If the patient misses a tablet, they should take it as soon as they remember. They should not take 2 tablets in one day.
How long do bisphosphonates take for effect and how often is this reviewed
Roughly 6 months for the bisphosphonate to take effect
Annually reviewed
Side effects of bisphosphonates
Oseophageal irritation
abdominal pain, nausea, gastrointestinal upset and joint/muscle pain
Osteonecrosis of jaw(should attend annual dental checks)
Which medications should not be taken with bisphosphonates
OTC painkillers(ibuprofen) - can worsen oesophageal irritation
Lifestyle advice when on bisphosphonates
Diet and exercise
Weight-bearing exercises
High calcium foods(dairy, leafy greens)
Smoking cessation
What type of risk factors is it important to elicit when counselling for statins
CVS history/risk factors - smoking, HTN, sedentary lifestyle
Tool used to assess need for statins
QRISK - 10-year risk of CVD over the age of 40
What are statins
Statins are a group of lipid-lowering drugs used to reduce the risk of atherosclerosis and related CVD events.
How do statins work
Work by inhibiting a key enzyme in the liver, HMG-CoA reductase, causing a decrease in hepatic synthesis of cholesterol.
Increases the expression of hepatic cholesterol receptors, increasing uptake of low-density lipoprotein (LDL) from the blood to the liver, resulting in a fall in plasma cholesterol(reduces production of new cholesterol and clears bad cholesterol)
What might patients with raised triglyceride concentrations require
Fibrate in addition to a statin
How often are statins taken
OD - at night with consistent timing
Advice regarding missed tablets - statins
If the patient misses a tablet, they should take it as soon as they remember. They should not take two tablets in one day.
monitoring treatment of statins
Pre-treatment cholesterol levels
LFTs
Another blood test within 3 months of starting treatment and again at 12 months to monitor effectiveness
Side effects of statins
Myalgia/cramps/tenderness Muscle toxicity Nausea Constipation Diarrhea
Key statin interactions
Grapefruit
Antibiotics
Immunosuppressants
Fibrates
Lifestyle advice while on statins
Physical activity(moderate intensity of 30 mins at least 5 days a week)
Healthy foods
Smoking and alcohol cessation
How is clozapine taken
Clozapine comes in tablet form, a liquid option and more recently an orodispersible form.
It is not currently available in depot form.
Why is it important not to miss a dose of clozapine
Clozapine is prescribed at a low dose to start off with and this is titrated up over a period of several weeks. It is important that doses are not missed. This is because if clozapine is not taken for more than 48 hours the titration process needs to start again
Advantages of clozapine
Studies have shown that approximately six out of ten people with treatment-resistant schizophrenia will benefit from taking clozapine.
There is also research that demonstrated clozapine is superior to olanzapine when preventing suicide attempts in patients with schizophrenia and schizoaffective disorder
Common side effects of clozapine
Sedation(consider night time dosing) Constipation Tachycardia Weight gain Hypersalivation BP changes Hyperglycaemia
Rare/serious side effects of clozapine
Agranulocytosis
Lowers seizure threshold
Cardiac complications(myocarditis/cardiomyopathy)
Baseline ix for clozapine
ECG Blood pressure and pulse Calculation of body mass index (BMI) FBC, U&Es, LFTs, prolactin, HbA1c and lipids Baseline tropi
Clozapine monitoring
Weekly FBC in first 18 weeks
Fortnightly after 18 weeks and then monthly after one year
What can cause plasma clozapine levels to change
Levels of clozapine can rise significantly with the reduction and cessation of cigarette smoking
How is levothyroxine taken
at least 30 minutes before breakfast. This is because food and coffee can reduce the absorption of levothyroxine
Once a day tablet
Missed dose - levothyroxine
If they forget to take a dose, advise them to take it as soon as they remember but to avoid double dosing.
Monitoring in levothyroxine therapy
TFTs
2-3 weeks after initiation of treatment, tweaking levothyroxine dose as required
2-3 monthly intervals after a dose change
Annually once thyroid hormone levels are within the normal range and stable
Side effects from excessive dose of levothyroxine
Heat intolerance
Weight loss
Insomnia
Fine tremor
Side effects from inadequate dose of levothyroxine
Cold intolerance Weight gain Low mood Constipation Dry skin
What are the three main types of emergency contraception
The copper intrauterine device,
EllaOne® which is a 30mg ulipristal acetate tablet, also known as “the morning after pill”
Levonelle® which is a 1500mg levonorgestrel tablet, also known as “the morning after pill”, “plan B”, or “one-step”
Aspects of sexual history that should be asked about prior to emergency contraception
Consensual sex
LMP
Safeguarding
Screening for STIs
How does levonelle work
Levonelle® works by inhibiting ovulation for around 5 days.
When can levonelle be taken
72 hours of UPSI
Longer the delay, the less effective it is
How effective is levonelle
Less effective than Ella one
Not effective after ovulation
Side effects of levonelle and risks
Nausea/vomiting
Delayed/early menses
Double dose in patients with BMI of 26 or above
Would need to taken a second dose if vomit within 3 hrs of taking tablet
Advantages of levonelle
Generally safe
Can use with ongoing contraception
How does ellaone work
Ulipristal acetate works by delaying ovulation for around 5 days
When can ellaone be taken
120 hrs or 5 days of UPSI
What can ellaone effectiveness be affected by
rendered less effective by progestogen hormones, and as such should not be taken in a 7 day period following progestogen use
Risk and side effects of Ellaone
nausea, vomiting, and a delayed or early menses
if a patient vomits within 3 hours of taking ellaOne®, they will need to repeat the dose
Not suitable in patients with severe asthma
What is the copper IUD
a small T-shaped plastic and copper device which is inserted into the womb during a small procedure
How does copper IUD work in contraception
Fertilisation inhibition occurs through direct toxicity effects of the copper on both ovum and sperm. This toxic effect prevents pregnancy
When can copper IUD be used for contraception
up to 5 days, (120 hours) after unprotected sex; or within 5 days of the earliest expected date of ovulation
How long should copper iUD be left in place for contraception
the copper IUD should remain in situ ideally for 21 days. It can be left in place for up to 10 years to provide ongoing contraceptive protection.
When should patients be advised to take pregnancy test after emergency contraception
3 weeks after UPSI
Disadvantages of copper IUD
Infection, expulsion, perforation, ectopic pregnancy
How does methotrexate work
Disease modifying agent which reduces inflammation and suppresses the immune system
How is methotrexate taken
Tablet usually
Injection also available
Once weekly with folic acid at another time. Build up dose slowly
Length of methotrexate treatment
Long term
Time it takes for methotrexate to take effect
4-6 months
Methotrexate monitoring
FBC, LFTs and U&Es
Before starting, then every 2 weeks and then every 2-3 months
side effects of methotrexate
Alopecia
Headaches
GI disturbance
Infection
Unexpected bleeding/bruising
Anaemia
Complications of methotrexate
Myelosuppression
Liver toxicity
Pulmonary toxicity(inform if SOB)
Methotrexate contraindications
Pregnancy(including male) Hepatic impairment Breast feeding Active infection Immunodeficiency
Supplementary advice for methotrexate
No NSAIDs/Aspirin
Annual flu jab
Arthritisresearch.org.uk
How do SSRIs work
Alter balance of some of chemicals in the brain.
SSRI affect a chemical called serotonin. An altered balance of serotonin and other chemicals is thought to play a part in depression
How should SSRIs be taken
Once daily
Tablet
When should SSRIs be stopped normally
3-6 months after feeling better(taper)
How long do SSRIs take to show effect
4-6 weeks
Important side effects of SSRIs
GI(diarrhoea, nausea, vomiting) Appetite and weight change Headache Drowsiness Anxiety(first 2 weeks)
Withdrawal
SSRI contraindications
Suicide risk
Past psychiatric illness
How does lithium work
Mood stabiliser
Each mechanism unknown
How is lithium taken
Once or twice daily
Tablet, capsule or syrup
Lifelong usually(if works) with regular psych review
How long does it take for lithium to take effect
1-2 weeks
Tests for lithium therapy
FBC, U&Es, TFTs, beta HCG, ECG
How often should lithium be checked
After 5 days
Then every week until stable for 4 weeks, then every 3 months
Lithium side effects
GI(Nausea)
Metallic taste
Fine tremor
Water symptoms(thirst)
Lithium toxicity symptoms
GI
Neuromuscular(dysarthria, dizziness)
Others(drowsiness, apathy)
Complications of lithium therapy
Renal toxicity
Nephrogenic diabetes insipidus
Hypothyroidism
Lithium contraindications
1st trimester preg Breast feeding Cardiac disease Significant renal disease Addison's
