Data interpretation Flashcards
Cautions and contraindications of ACEis
Pregnancy and breast feeding
Renovascular disease -> renal impairment
Aortic stenosis (may cause hypotension) (CAUTION)
idiopathic angioedema
Aminophylline infusions
Loading dose:
5 mg/kg given by slow IV over at least 20 minutes
Maintenance infusion of aminophylline
Dose:
1g in 1L -> 1mg/ml
500-700mcg/kg/hour
Key regular investigation for a patient taking Aminosalicylates (sulphasalazine/mesalazine)
FBC
Adverse effects of AMIODARONE -BITCH
Bradycardia/Blue man
Interstitial Lung Disease
Thyroid (hyper and hypo)
Corneal (ocular)/Cutaneous (skin)
Hepatic/Hypotension when IV (due to solvents)
Thyroid dysfunction - both hypo and hyper thyroidism
Corneal deposits
Pulmonary fibrosis/pneumonitis
Liver fibrosis/hepatitis
slate-grey appearance
bradycardia
Lengthens QT interval
Angina management: what should ALL patients received (in the absence of any other contraindication)
Aspirin and Statin
Angina management:
Reliever:
Maintenance:
GTN
CCB or BB
If used in combination, CCB should always be a DIHYDROPYRIDINE CCB
If patient cannot tolerate addition of BB or CCB in angina which drugs should be considered:
Long-acting nitrate
Ivabradine
Nicorandil
Ranolazine
Nitrate tolerance: What should be done
if taking isosorbide mononitrate - use asymmetric dosing -> daily nitrate free time of 10-14 hours
Anti-platelets: ACS
1)
2)
1) Aspirin (lifelong) and Ticagrelor (12 months)
2) If aspirin contraindicated -> CLOPIDOGREL lifelong
Anti-platelets: TIA or ischaemic stroke
1)
2)
1) CLOPIDOGREL (lifelong)
2) Aspirin and Dipyridamole (lifelong)
Anti-platelets: Peripheral arterial disease
1) Clopidogrel (lifelong)
2) Aspirin (lifelong)
Anti-platelets: Post PCI
Aspirin (lifelong) & prasugrel or Ticagrelor
2) clopidogrel if Aspirin CI
AF: rhythm or rate control
Rate first for most
AF rate control:
If one drug does not control
BB or CCB (diltiazem)
ADD:
A betablocker
Diltiazem (CCB)
Digoxin
in combination
What test should be done prior to starting a patient on AZATHIOPRINE
TPMT test
Is azathioprine safe in pregnancy
What drug should be monitored closely for interaction with azathioprine
Yes
ALLOPURINOL
Side effects of BBs
Sleep disturbances - nightmares
Erectile dysfunction
Bronchospasm
Cold peripheries
Fatigue
Contraindications of Beta blockers
Uncontrolled heart failure
Asthma
Sick sinus syndrome
Concurrent verapamil use - severe bradycardia
Uses of Bisphosphonates
Prevention and treatment of osteoporosis
Hypercalcaemia
Paget’s disease
Pain from bone metastasis
Adverse effects of bisphosphonates
Oesophageal reactions: oesophagitis
Osteonecrosis of jaw
atypical fractures - proximal femoral shaft
Advice for taking bisphosphonates
Advice for taking bisphosphonates
Swallowed with plenty of water while sitting or standing on an empty stomach 30 mins before breakfast
Uses of CARBAMAZEPINE
First line in PARTIAL seizures
First line in Trigeminal neuralgia
Bipolar disorder?
Blood dyscrasias from carbamazepine?
Leucopaenia
Agranulocytosis
Adverse effects of carbimazole
AGRANULOCYTOSIS
crosses placenta but may be used in small doses in pregnancy
Heart failure: first line Mx
ACEi AND BB
one drug started at a time
Heart failure: second line therapy
Aldosterone antagonist: SPIRONOLACTONE
What must be monitored for a Pt. on Spironolactone and ACEi
U&Es - Hyperkalaemia may ensue
Heart failure 3rd line therapy
To be initiated by a specialist
Ivabradine
Sacubitril-Valsartan
Digoxin
Hydralazine (++ useful in afrocaribbean patients)
Aside from medications, what other interventions should be offered in CHF
ONE OFF pneumococcal vaccine
ANNUAL flu vaccine
What commonly prescribed medication for GORD is known to interact with CLOPIDOGREL
PPIs - make it less effective (lanzoprazole less so)
C.difficile risk factor medication other than antibiotics
PPIs
Current antibiotic therapy for C.difficile
Vancomycin (ORAL) 10 days
Second line: FIDAMOXICIN
Third-line: oral Vancomycin + IV Metronidazole (ALSO for life threatening C.dif)
COPD stable management
SABA or SAMA as required
ATOPY? = SABA or SAMA PLUS LABA and ICS
No ATOPY= SABA PLUS (LABA/LAMA)
3) SABA as req. LABA + LAMA + ICS
Antibiotic prophylaxis in COPD patients?
AZITHROMYCIN
LFTs and ECG should also carried out to exclude long QT syndrome/ elongation as Azithromycin can prolong the QT
STEROID SIDE EFFECTS: ‘CUSHINGOID’
Cataracts
Ulcers (peptic ulceration)
Skin: striae, thinning, bruising
Hypertension/ hirsutism/hyperglycaemia
Infections - immunocompromised
Necrosis - avascular necrosis of femoral head
Glycosuria
Osteoporosis/obesity
Immunosuppression
Diabetes
Steroid dose for pts. with intercurrent illness
Dose DOUBLED
T2DM if pts. has CV risk what should be added once established on metformin
SGLT-2 inhibitor
Diabetic neuropathy mx.
1) Amitriptyline, duloxetine, gabapentin, pregabalin
If one doesn’t work try another
TRAMADOL may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
Diabetic - GI autonomic neuropathy mx.
Gastroparesis: Prokinetic agents - metoclopramide, domperidone
Drugs which decrease serum potassium
Loop diuretics
Acetazolamide
Thiazide diuretics
Drugs which INCREASE serum potassium
ACEi/ARBs
Spironolactone
Amiloride
Potassium supplements: Sando K
Drugs which INCREASE serum potassium
ACEi/ARBs
Spironolactone
Amiloride
Potassium supplements: Sando K
Drugs causing peripheral neuropathy
Amiodarone
Isoniazid
Vincristine
Nitrofurantoin
Metronidazole
Generalised tonic clonic seizures Mx.
Males: Sodium Valproate
Females: Lamotrigine or Levetiracetam
Focal seizures Mx.
Leviteracetam or Lamotrigine
2) Carbamazepine
Absence seizures Mx.
1) Ethosuximide
2) Sodium Valproate (M)
2) Lamotrigine or Levetiracetam
Which anti-epileptic may exacerbate ABSENCE SEIZURES
CARBAMAZEPINE
Essential tremor first line tx.
PROPRANOLOL
What is EZETIMIBE
Lipid lowering drug - decreases cholesterol absorption in the small intestine by inhibiting cholesterol receptors
Main use for ezetimibe
Primary heterozygous-familial and non-familial hypercholesterolaemia
Maintenance fluids
25-30 ml/Kg day of water
1mmol/kg/day of potassium, sodium and chloride
50-100 g a day of GLUCOSE to limit starvation ketosis
Drugs to avoid in G6PD deficiency
CIPROFLOXACIN
Sulph-drugs - sulphonamides, sulphasalazine, sulfonylureas
Antimalarials - Primaquin
GORD management
Endoscopically proven oesophagitis
Endoscopically negative reflux disease: Full dose PPI one month -> if Negative, double dose
Endoscopically positive -> Full dose PPI one month ->
No response -> Prokinetics or H2 receptor antagonist
In which two groups should thyroxine therapy be started at a lower dose
ELDERLY
IHD patients
Starting dose of Thyroxine (non-IHD/elderly)
50-100 mcg OD
Pregnant women on thyroxine should have their dose ___ by ___
INCREASED
25-50 mcg
Due to increased demands of pregnancy
Side effects of THYROID therapy
Reduced bone mineral density
Worsening of angina
Atrial fibrillation
Main interaction of Levothyroxine to look out for
Iron + calcium carbonate
What is the effect of the iron/calcium interaction with Levothyroxine and how can this be mitigated
Absorption of levothyroxine REDUCED
Give at least 4 hours apart
Which common cardiac medication commonly reduces HYPOGLYCAEMIC awareness
B-Blockers
Electrolyte disturbances with LOOP diuretics
HYPONATRAEMIA
HYPOKALAEMIA
HYPOMAGNESAEMIA
HYPOCALCAEMIA
Low everything
Metabolic disturbance from LOOP diuretics
Hypochloraemic alkalosis
Can cause GOUT
Meningitis: suspected bacterial meningitis prior to hospital transfer tx.
IM Pen V
IV antibiotics for meningitis
3 months - 50 years = CEFOTAXIME
>50 years or < 3 months = CEFOTAXIME PLUS AMOXICILLIN listeria cover)
What adjunctive drug should be considered along side antibiotics in meningitis
IV dexamathasone
Meningitis prophylaxis?
CIPROFLOXACIN OR RIFAMPICIN
Unless pneumococcal meningitis in which no prophylaxis is needed
Side effects of Methotrexate
Mucositis
Myelosuppression
Pneumonitis
Pulmonary fibrosis
Liver fibrosis
How long should men and women be off MTX before attempting to conceive
6 months
When is methotrexate taken
WEEKLY (common source of error in prescribing)
What is co-prescribed with methotrexate
Folic acid
Interactions of methotrexate to be aware of:
Avoid co-prescribing TRIMETHOPRIM or CO-TRIMOXAZOLE concurrently - Increased risk of marrow aplasia
High dose aspirin can cause methotrexate toxicity due to reduced excretion
Methotrexate toxicity treatment of choice
FOLINIC ACID
Metoclopramide - MoA and resultant side effects
D2 RECEPTOR ANTAGONIST - as acts on dopamine pathway -> EPSE (acute dystonia etc.) -> parkinsonism -> tardive dyskinesia
Diarrhoea
Hyperprolactinaemia
First-line Tx. ACUTE MIGRAINE
combination therapy w/ oral TRIPTAN and NSAID
Prophylaxis for MIGRAINES
When to give?
IF more than 2 attacks per month
Prophylaxis for MIGRAINES:
PROPRANOLOL OR TOPIRAMATE
Which of the migraine prophylactic drugs should be given to women of childbearing age:
PROPRANOLOL -> topiramate may be teratogenic
Myasthenia Gravis first line medication:
PYRIDOSTIGMINE
STEMI management: all patients to receive
ASPIRIN
CLOPIDOGREL
Unfractionated HEPARIN if going for PCI
Fluids given as prophylaxis in those at risk of contrast induced nephrotoxicity
0.9% sodium chloride 1 ml/kg/hour for 12 HOURS pre and post procedure
Which drugs may worsen psoriasis
B blockers
ACEi
Lithium
NSAIDs
Antimalarials (chloroquine)
Withdrawal of systemic steroids
Nicorandil contraindication
LEFT ventricular failure
Nitrate side effects
Hypotension
Tachycardia
Headaches
Flushing
Palliative care prescribing: PAIN
1) Offer pts. w/ advanced progressive disease regular oral modified release or immediate release Morphine
2) IF no comborbidities: use 20-30 mg of MR a day with 5 mg for breakthrough pain
What should always be prescribed with pts. on strong opioids:
Laxatives
Which patient group should opioids be used only with caution
CKD pts.
What is used in preference to morphine for CKD patients
OXYCODONE
What is used for pain relief in SEVERE renal impairment
Fentanyl, alfentanil, buprenorphine
When increasing the dose of opioids, what dose percentage increase should be used
30-50%
Drug treatment for Parkinson’s:
If affecting QoL
If NOT affecting QoL
Levodopa
Dopamine agonists (ropinirole, pramipexole) Levodopa or MAO-Bi
If a patient continues to have symptoms despite optimal LEVODOPA treatment
Adjunct with Dopamine agonist (ROPINIROLE), MAO-B inhibitor or COMT
What is LEVODOPA usually combined with and why:
Carbidopa -> to prevent peripheral metabolism of levodopa to dopamine outside of the brain and reduce side effects
Common side effects of LEVODOPA
Dry mouth
Anorexia
Palpitations
Postural hypotension
Psychosis
Adverse effects of PPIs
Hyponatraemia, Hypomagnesaemia
Osteoporosis -> increased risk of fractures
Microscopic colitis
Increased risk of C. Difficile infections
Enzyme inducers (PC BRAS)
Phenytoin
Carbamazepine
Barbiturates
Rifampicin
Alcohol (chronic)
Sulfonlyureas (gliclazide)
Enzyme inhibitors (AO-DEVICES)
Allopurinol
Omeprazole
Disulfiram
Erythromycin
Valproate
Isoniazid
Ciprofloxacin
Ethanol (acute)
Sulphonamides
Drugs to stop prior to surgery (ILACKOP)
Insulin
Lithium
Anti-coagulants/ antiplatelets (aspirin 7 days before)
COCP/HRT - 4 weeks before
K+ sparing diuretics (on day of surgery)
Oral hypoglyacaemics (metformin -> lactic acidosis)
Phytonadione (Vit K) one day before INR > 1.5
UTI antibiotics to avoid in reduced renal function
NITROFURANTOIN
Which drugs tend to cause anticholinergic side effects
Amitryptiline
Paroxetine
Anti-muscarinics
Anti-psychotics (CLOZAPINE)
Anti-rheumatoid drugs: which drug causes oligospermia
Sulfasalazine
Anti-rheumatoid drugs: Which drug causes HEINZ BODY ANAEMIA
Sulfasalazine
Anti-rheumatoid drugs: Which drug causes retinopathy and corneal deposits
Hydroxychloroquine
Anti-rheumatoid drugs: drugs causing proteinuria
Gold
Penicillamine
As well as BBs, which drugs can commonly cause bronchospasm in asthmatics
NSAIDs
NSAIDS adverse effects mnemonic
Nausea, dyspepsia
Swelling
Allergy
Impaired renal function
Damaged stomach wall
Stroke/heart attack
SIADH: Malignancy causes
Small cell lung cancer
Pancreas/prostate cancer
Drug caused of SIADH (water retention)
Sulfonylurea
SSRIs, Tricyclics
Carbamazepine
Vincristine
Cyclophosphamide
MoA Sodium valproate
Increases GABA activity
Adverse effects of sodium valproate (VALPROATE)
Vomiting
Alopecia
Liver toxicity
Pancreatitis
Retention of fat (weight gain)
Oedema
Appetite increase
Tremor - TERATOGENIC
Enzyme inducer
Spironolactone adverse effects:
GYNAECOMASTIA: less common with Eplerenone
HyperKALAEMIA
Statins adverse effects (HMG CoA RI)
Hepatotoxicity
Myopathy (myalgia, myositis)
GI upset (nausea, vomiting, diarrhoea)
Cataracts
Rhabdomyolysis
Increased risk of diabetes
*RI = Reductase inhibitors in mnemonic
Statins adverse effects (HMG CoA RI)
Hepatotoxicity
Myopathy (myalgia, myositis)
GI upset (nausea, vomiting, diarrhoea)
Cataracts
Rhabdomyolysis
Increased risk of diabetes
*RI = Reductase inhibitors in mnemonic
What are SULPHONAMIDES
Class of drug which work by inhibiting dihydropteroate synthetase (antibiotic and non-antibiotic forms
In form of antibiotics: SULFAMETHOXAZOLE
Co-tromoxazole = combination with trimethroprim which is used in treatment of Pneumocystitis Jiroveci pneumonia
Non-antibiotics sulphonamides
Sulfasalazine
Sulfonylureas
Common side effects of Sulfonylurea
Hypoglycaemia
Weight gain
Rarer adverse effects of sulfonylureas
Hyponatraemia -> secondary to SIADH
Bone marrow suppression
Hepatotoxicity
Peripheral neuropathy
Are sulphonylureas given in breastfeeding and pregnancy
No, should be avoided
Thiazide diuretics common adverse effects
Dehydration
Postural hypotension
Hyponatraemia, hypokalaemia
Gout
Impaired glucose tolerance
Impotence
Thiazide diuretics effect on calcium
HYPERCALCAEMIA -> which translates to hypocalciuria (may be useful in reducing the incidence of renal stones)
Thiazolidinediones main concerns
Fluid retention -> contraindicated in heart failure
Bladder cancer (pioglitazone)
Weight gain
MoA of thrombolytic drugs
Activate plasminogen to form plasmin which degrades FIBRIN and helps break up thrombi
Contraindications to THROMBOLYSIS (ALTEPLASE, STREPTOKINASE, TENECTEPLASE)
Active internal bleeding
Recent haemorrhage, trauma or surgery
Coagulation or bleeding disorders
Intracranial neoplasms
Stroke < 3 months
Aortic dissection
Recent head injury
severe hypertension
Triptans - prescribing points:
When should they be taken
Should be taken as soon as possible after the onset of headache rather than at onset of aura
Adverse effects of triptans:
‘Triptan sensations’ tingling, heat, tightness (Throat and chest), heaviness, pressure
Contraindications of TRIPTANS
Pts. w/ history or risk factors for IHD or CVD
Variceal haemorrhage management
ABC
Correct clotting: FFP, VitK, Platelets
Vasoactive agents: TERLIPRESSIN
What should be used prophylactically following an acute variceal bleed
Antibiotics -> IV QUINOLONE
Following resus, clotting correction and terlipressin, what should be done to correct variceal bleed
Endoscopic band LIGATION
If uncontrolled haemorrhage: Sengstaken-blakemore tube
TIPSS if all above measures fail
Prophylaxis of variceal haemorrhage
Propranolol (reduced rebleeding and mortality)
Warfarin indications
Mechanical heart valves: target INR depends on type of valve
Second line after DOACs
Juice which potentiates warfarin
CRANBERRY
Side effects of WARFARIN
Haemorrhage
Teratogenic (although safe in breastfeeding)
Skin NECROSIS
Purple toes
