Drugs 1 Flashcards
What are the 4 main types of laxatives with an example of each + onset of action?
Bulk forming: Fybogel (2-3days)
Osmotic: Lactulose, movicol (2-3 days)
Stimulant: Senna, Bisacodyl (6-12hrs)
Softener: Docusate (3 days)
In the context of possible GI obstruction or perforation which antiemetic is contraindicated?
Metoclopramide
What are the 4 main classes of antiemetic with an example for each?
Antihistamine: Cyclizine
Phenothiazines (low dose anti-psychotics): Prochlorperazine
Dopamine antagonists: Metoclopramide, domperidone
5HT3 antagonists: Ondansatron
First line antiemetic (and next options) for hyperemesis?
All first line on NICE:
Cyclizine
Promethazine
Prochlorperazine (Stematil)
Second line:
Metoclopramide
Ondansatron
Domperidone
(All maximum 5 days)
Which PPI’s are safe to prescribe with clopidogrel?
Lansoprazole
Omeprazole and Esomeprazole reduce the effectiveness of clopidogrel
What is the first line antisickness for a patient with recurrent nausea due to vertigo?
Antihistamine
- Cyclizine 50mg TDS
- Betahistine 16 mg orally three times daily
First line antiemetic choices for migraine related sickness?
Metoclopramide (5days max) - 10mg TDS
Prochlorperazine - 5-10mg TDS
What are the preventative medication options for migraine?
How do you decide whether treatment has been successful?
Propranolol - 80-240mg in divided doses
Amitriptyline - 10-75mg daily ON
Tried for at least 3 months at the max tolerated dose, before deciding whether or not effective. A good response to treatment is defined as a 50% reduction in the severity and frequency of migraine attacks.
What is first line treatment for acute migraine?
Monotherapy with aspirin, ibuprofen or a triptan
(Triptan oral 50-100mg for 1 dose, nasal 10-20mg for 1 dose - followed by 2nd 2 hours later if needed)
For patients who fail to respond to monotherapy for acute migraine what is the next appropriate step?
In patients who fail to respond to monotherapy:
- Combination therapy with sumatriptan and naproxen
What is the brand name of the most common COCP?
Microgynon (30)
What is the brand name of the most common POP?
Cerazette
Amitriptyline
1) Starting dose
2) Titration speed
3) Trial length before declaring not effective
4) Max dose
1) Start 10-25mg
2) Titrate in steps 10-25mg every 3-7 days
3) Trial 6-8 weeks (at least 2 weeks at max tolerated) before deciding ineffective
4) Max 75mg OD without specialist input
Pregabalin
1) Starting dose
2) Titration speed
3) Trial length before declaring not effective
4) Max dose
1) 150mg daily (in 2/3 doses)
2) Increase by 150mg daily every 3-7 days
3) Trial for 4 weeks before deciding ineffective
4) Max dose 600mg daily (in 2/3 doses)
A patient is one pregabalin 300mg BDand is planning on coming off, how long do you reduce over?
Any pregablin gradually over minimum one week, as this is the max daily dose more likely over 12 weeks at best (see online reduction regiemes)
A young healthy male is starting gabapentin, how do you initiate his doses?
Fast titration suitable for otherwise health young adults) can start 300mg OD, D2 is 300mg BD, D3 300mg TDS - start dose 900mg daily
Slow titration:
100mg ON, increasing by 100mg daily
What is the maximum dose of gabapentin and how long should you trial max tolerated dose for?
Max dose 3600mg daily (1200mg TDS)
Trial 3-8 weeks with at least 2 weeks at max tolerated dose before declaring ineffective.
First line treatment for vaginal thrush (uncomplicated)?
Fluconazole 150mg orally STAT
OR
Clotrimazole 500mg pessary if CI/ preferred
(All available OTC)
A 32 year old patient has vaginal thrush with vulval itching, in addition to first line treatment with stat fluconazole what else may you consider?
Topical clotrimazole 1/2% cream
(Available OTC)
A 29 year old pregnant lady attends with thrush - first line tx?
Clotrimazole 100mg pessary ON
Tx: 7 days
(Or 5g 2% clotrimazole cream BD for 7/7)
Avoid oral azoles in pregnancy
What is the mainstay treatment for scabies, how much do you prescribe and how is it applied?
Permethrin cream (Lyclear)
- Apply twice, one week apart
- Apply thin layer over whole body, when skin cool and dry
- Leave on for 12 hours then wash off
Usually 30g for one application over whole adult, 15g cream one application over whole child
A patient is struggling with the intense itching from scabies - what is the best cream to help with the itching?
Crotamiton 10% cream
(In addition to permethrin scabies treatment)
You need to step up and inhaler dose but don’t know what to prescribe - what website is the best resource?
rightbreathe.com
What is the dose range of gliclazide?
- Starting dose
- When to take
- Max dose
Start 40-80mg daily
Up to 160mg - take in the morning
Can go to 320mg (then split 160mg BD)
What is the starting/ max dose of semaglutide s/c?
Initially 0.25 mg once weekly for 4 weeks
- Can increase to 0.5 mg once weekly for at least 4 weeks
- Max 1 mg once weekly
What is the dose of dapagliflozin?
10mg OD
(Single dose option)
What is the usual dose of isosorbide mononitrate?
Standard release:
- 10 - 60mg BD
Modified release:
- 25-120mg OD
How should a patient be advised to use GTN if suspected angina?
1) Stop what they are doing and rest.
2) Use their GTN spray
3) Take a second dose after 5 minutes if the pain has not eased.
4) Call 999 if the pain has not eased 5 minutes after the second dose, or earlier if pain intensifying patient unwell.
What is first line treatment for a fungal nail infection?
Amorolfine 5% nail lacquer
- Availble OTC
- Once/ twice weekly after nail filing
- Treat 6 (hands) - 12 (feet) months
Fungal nail infection, what is second/ third line medication if topical failed?
2nd: Oral terbinafine
- Prescribe 250 mg once a day for between 6 weeks for fingernail infections, and for 3-6 months for toenail infections
3rd: If this fails oral itraconazole given as ‘pulsed therapy’ (BD for 1 week, break 3 weeks, repeat x3 for toenails)
What are 3 of the most common ADHD medications used in the UK?
Stimulants:
- Methylphenidate
- Lisdexamfetamine
- Dexamfetamine
(Aim to stimulate areas of brain which improve attention)
Atomoxetine (SNRI)
You are starting a patient on a new DOAC for AF and stroke risk. When should they be followed up?
NICE advice is to follow up in 1 month (ask about bruising, side effects etc)
Bloods to be done annually
- If impaired renal function, frequency of monitoring to be CrCl/10 (so if 60, review every 6 months)
What is the half life of apixaban?
Around 12 hours
- Anticoagulant effect diminishes at 12-24 hours
What is the usual full dose of PPI (i.e. for mx of dyspepsia)?
(Omeprazole/ esomeprazole/ lansoprazole)
Full dose/ standard dose:
Omeprazole/ Esomeprazole - 40mg OD
Lansoprazole - 30mg OD
What is the usual high/ double dose of PPI (i.e. for mx of dyspepsia)?
(Omeprazole/ esomeprazole/ lansoprazole)
Double dose/ high dose:
Omeprazole/ Esomeprazole - 40mg BD
Lansoprazole - 30mg BD
What is meloxicam and what are it’s indications?
NSAID
Used for osteo/rhematoid arthritis, JIA and anklyosing spondylitis
- May reduce chance of GI side effects
Name three emollient shower washes for patients with eczema?
E45 body wash
QV gentle wash
Aveeno dermexa wash
Give three examples of eye drops which may be used for raised intraocular pressure or glaucoma?
Prostaglandin analogues (PGAs) - eg, latanoprost
Topical beta-adrenergic antagonists - eg, timolol
Alpha-2 adrenergic agonists - eg, brimonidine
Miotics - eg, pilocarpine
Carbonic anhydrase inhibitors - eg, dorzolamide
Give three examples of drugs which you may want to hold if possible AKI?
Diuretics
ACEI/ ARBS/ ABx
Metformin
NSAIDS
DAMN
When can eGFR be used to base prescribing descisions off and when should CrCl be used?
eGFR for most patients
CrCl: Toxic drugs, in elderly patients and in patients at extremes of muscle mass
Initiating Ramipril for HTN:
a) Starting dose
b) Monitoring requirements
a) Start dose 5mg for most people (BNF says 2.5mg, use lower if heart failure, elderly or frail but otherwise for practical reasons start at 5mg)
b) Renal function at 2-4 weeks
What key medicines safety information should you be aware of when prescribing ciprofloxacin (or other Fluoroquinolone)?
Risk of tendon rupture
- CI if tendonitis etc
- Avoid in elderly or if also using steroids
What do you advise patients taking methotrexate regarding sun exposure?
Photosensitivity reactions are known side effects of methotrexate treatment and can be severe. Patients should be advised to take precautions to protect their skin in the sun.
How do you convert tramadol, codeine and dihydrocodeine doses to oral morphine equivalent?
Divide by 10
(So 100mg tramadol = 10mg equivalent morphine)
How do you covert the strength of fentanyl patches to oral morphine?
Fentanyl ‘12mg patch (72hrs) is equivalent to 30mg oral morphine daily
Multiply up from there:
25mg - 60mg daily morphine
50mg patch - 120mg daily morphine etc
Standard antibiotic prescription for exacerbation of COPD?
Doxycycline 200mg stat, then 100mg daily
or
Amoxicillin 500mg three times a day
Duration: 5 days
A patient newly started on atorvastatin last month reports muscle aches and pains, how do you manage?
1) Measure CK
- Don’t measure if asymptomatic
- If >5x upper limit = stop statin, if <5x upper limit, unlikely statin
2) Either reduce dose in same intensity group or same dose in lower intensity group
What advice should parents be given on how to take desmopression (for noctural enuresis)?
Take before bed
Sips of water only from 1 hour before to 8 hours afterwards (to avoid fluid overload and hyponatremia)
Which medicines are licenced for use in PTSD (alongside pyschological therapy)?
Venlafaxine
OR
SSRI (Sertraline and paroxetine only two licensed)
A 59-year-old woman with rheumatoid arthritis requires antibiotic prophylaxis for recurrent urinary tract infections. She is currently taking methotrexate on a weekly basis.
Which SINGLE option is it important to AVOID prescribing for this patient?
Trimethoprim
The most serious complication of methotrexate therapy is bone marrow suppression, hence the need for regular blood monitoring with a full blood count. The concomitant use of an anti-folate drug (e.g. trimethoprim) increases the risk of bone marrow suppression
Having an allergy to what is a CONTRAINDICATION to the use of oral glucosamine?
Shellfish
(Glucosamine is an AA produce from shells lobster, crab and shrimp - used for mild/ moderate OA of knee (limited evidence for benefit))
Name 2 contraindications to treatment with bisphosphondates?
Alendronic acid is CI in:
Upper GI conditions (oesophageal or gastric - bleed/ inflammation/ ulcers)
Atypical femoral fractures
Name 3 groups for whom vitamin D and calcium supplementation would be contraindicated?
Severe CKD stage 4 or 5).
Hyperparathyroidism.
Renal stone disease.
Hypervitaminosis D
An allergy to peanuts or soya
Any disease or condition that results in hypercalcaemia and/or hypercalciuria (for example some malignancies, such as myeloma).
What advice should be given to patients regarding how to take bisphosphonates?
Take 30 mins before any other medicine or food
The tablet must be swallowed whole and taken with a glass of plain water (at least 200mls)
Stay upright, don’t take at night or when going to be lying down
Can get GI side effects, worse for first month and then often settle down
Name a class of antibiotics that cause ototoxicity?
Aminoglycosides
(Gentamycin, neomycin)
Also chemo agents (cisplatin, carboplatin), loop diuretics (furosemide) can also cause ototoxicity
Give 3 examples of medication that can exacerbate tinnitus?
Loop diuretics (furosemide)
Antibiotics (Erythromycin, vancomycin)
Aspirin
Methotrexate
Chemotherapy agents
First line antibiotic in a patient with sinusitis for 10 days who is systemically unwell?
Co-amoxiclav
If not systemically unwellthen PenV QDS for 5 days
Sinusitis first line antibiotic if systemically well?
Phenoxymethylpenicillin 500 mg QDS for 5 days
Sinusitis first line antibiotic if systemically well and penicillin allergic?
Doxycycline 200 mg on the first day, then 100 mg once daily for 4 days (a 5-day course in total),
or
Clarithromycin 500 mg twice a day for 5 days.
An 85-year-old man has metastatic prostate cancer. He is currently being treated with oral cyproterone acetate 200 mg daily. What monitoring blood tests should be done?
Liver function tests should be done before treatment, at regular intervals during treatment and whenever any symptoms or signs suggestive of hepatotoxicity occur.
A 79-year-old man is treated with androgen deprivation therapy for prostate cancer but develops severe hot flushes. What is the most appropriate therapy to treat his hot flushes?
Medroxyprogesterone
(First-line for hot flushes secondary to androgen deprivation therapy)
Initially for a period of 10 weeks
What should patients be advised is the most effective ear drop or spray for the removal of ear wax in adults and children?
None superior
Cerumol - arachnis oil
Dioctyl - doccusate
Saline
Sodium bicarb
All similar efficacy
In palliative care, what anti-emetics are most useful for opioid induced nausea? (3)
Halloperidol (start 1.5mg PO PRN)
Can be PO or s/c or infusion
Metoclopromide (10mg PO QDS) - can also be syringe driver
Levomepromazine - subcut/ syringe driver only
What is first line antiemetic therapy for intercranial disease?
Cyclizine
(Consider adding dexamethasone)
What is the most appropriate prokinetic antiemetic medication for nausea caused by peristaltic failure or gastric stasis?
Metoclopromide
2nd line domperidone
(Domperidone is less effective but has less side effect (sedation, dystonic reactions as doesn’t as easily cross blood brain barrier)
What is the most appropriate antiemetic to use if mechanical bowel obstruction?
b) What about if past is in the past days of life?
Cyclizine
2nd line: Haloperidol or levomepromazine
b) Hyoscine (buscapan) best in last days of life, reduces peristalsis
(Avoid prokinetics like metoclopramide or domperidone)
Name three examples of drugs which decrease peristalsis?
Opioids
Tricyclic antidepressants
Cyclizine
First line antiemetic in palliative care if nausea is made worse by movement?
Cyclizine
(Common if abdominal or pelvic tumours)
Prokinetics (metoclopramide and domperidone) should not be used with which other antiemetics?
Antimuscarincs
(Cyclzine and hyoscine > stops them working)
Name 4 antiemetics that can be used for N+V in palliative care where no clear cause of nausea has been found?
Levomepromazine
Haloperidol
Metcloramide
Cyclizine
When starting opiods in palliative care, what should be prescribed concurrently to prevent constipation?
Senna (Stimulant) - start at time of 1st prescription rather than waiting for constipation to occur
Add osmotic (lactulose/ macrogol) or softner (doccusate) as needed
What types of medicine are used to manage cough in palliative care (Dry vs. wet)?
Wet cough - Nebulised saline, mucolytic can help
Dry cough - Codeine linctus, morphine
What are management options for dyspneoa in the context of palliative care symptom control?
Strong opioid
Benzodiazapine (especiially if anxiety, near end of life)
Bronchodilator if wheeze, oxygen if hypoxia
A patient is currently on morphine for pain relief at the end of life. If pain is not adequately controlled - what is the NICE guidance on how to increase morphine dose?
Total up 24 hour morphine requirement
- Increase by no more than 30% every 2- 3days until pain well controlled
What medication is used to treat respiratory secretions at the end of life (assuming positing, suction etc. not achieved desired effect)?
What dose is used?
Glycopyrronium bromide
- 200 micrograms s/c every 4 hours
- 0.6-1.2mg 24 hour infusion s/c
Hyoscine butylbromide
- 20mg s/c every 4 hours
- 20–120 mg/24 hour infusion s/c
A patient is using modified release oral morphine for pain in a palliative setting. What is the NICE guidance on dosing of medication for breakthrough pain for patients already on morphine?
Use immediate release morphine (oromorph or subcut)
- Breakthrough dose should be 1/6 to 1/10 of total 24 hour regular dose
You are switching a palliative patient from immediate release to modified release morphine - what should you do with regards to the timings of the switchover?
If switching from regular immediate-release to modified-release morphine, give the first dose of modified-release morphine within 4 hours after the last dose of immediate-release morphine (and discontinue the immediate-release preparation).
A pallative patient is currently using an NSAID, paracetmol and codeine for pain. You plan to start morphine, what dose do you initiate the patient on if they are:
a) 40yrs
b) 84yrs
a) Morphine 5 mg every 4 hours plus as required (up to 2-hourly) for breakthrough pain (total daily 30mg + breakthrough)
- If starting modified release this would be 10-15mg BD
b) Morphine 2 mg every 4 hours plus as required (up to 2-hourly) for breakthrough pain (total daily 12mg plus breakthrough)
A patient has CHD, what statin should they take?
Atorvastatin 80mg (Secondary prevention dose for all those with CVD)
A patient has CKD, what statin should they take?
Atorvastatin 20mg
(Primary prevention for all patients with CKD - note this is not treated as secondary prevention as it would be with patients with CHD)
What monitoring should be done for a patient newly started on a statin?
At 3 months:
- Total cholesterol, HDL, LDL
(Aiming >40% reduction in non-HDL cholesterol)
- LFT’s
A patient has their 3 month bloods after startin a statin. ALT (7-55) has risen from 45 to 68. What should you do with the statin?
Do not stop statin if ALT/AST <3x upper limit normal
When starting a statin what is the target you are aiming for?
> 40% decrease in non HDL
(If patient high risk and not achieved this reduction then can consider increasing dose)
What time a day should patients take statins?
At night (liver produces most cholesterol overnight)
What is the nocebo effect?
When I expect to have a side effect I’m more likely to get it
What should you do with a patient reporting muscle symptoms after starting a statin?
Do CK and renal function
If tolerable syx and CK <4x ULN (upper limit normal) then continue
If CK4-10x ULN then follow de-challenge, re-challenge pathway if needed (stop 4-6 weeks then start new lower dose/ alternative statin).
- Can also consider alternative daily or twice weekly dosing
A patient is not achieving >40% reduction in non-HDL cholesterol on high dose statin, what should you do?
Refer to lipid clinic
- Add ezetimibe
Give an example of a nasal steroid prescription you may use if a patient presents with an 11 day history of acute sinusitis?
Mometasone 200 micrograms
Twice a day
How do you calculate initial dose for a syringe driver in palliative care settings?
Take total previous 24 hour dose that was required
(Maybe more if symptom wasn’t controlled in that 24 hours)
Your end of life patient is struggling with pain but has significant renal impairment - what would be the alternative to morphine to treat pain? What may indicate the need for this instead of morphine in the context of renal impairment?
Oxycodone
(Can be subcut, syringe driver)
Consider if eGFR <30 (or low urine output etc.
A patient with lung cancer and cerebral metastases is receiving his drugs by syringe driver. The infusion discolours very rapidly. Which drug is likely responsible?
Under some conditions, infusions containing metoclopramide become discoloured; such solutions should be discarded.
What is the conversion ratio of oral morphine to oxycodone?
What would be 30mg of oral morphine equivalent as oxycodone?
1.5 to 1 (So 10mg morphine is 6.6mg oxycodone)
So 30mg morphine is approximately 20mg oxycodone
What is the emergency dose of dexamethasone is suspected metastatic spinal cord compression?
16mg
According to current BNF guidance - at what eGFR should thiazide diuretics be avoided?
eGFR <30mls/min
Name 3 medications used for restleness or confusion at the end of life?
Haloperidol, levomepromazine and midazolam
