Drugs Flashcards
Bisoprolol
Beta blocker, caution in asthmatics, step 1 NICE algorithm stable angina step 4 NICE algorithm HTN K+>4.5 Prognostic benefit in HF Don't use with verapamil (low CO) OD treated with glucagon
Amlodipine
Dihidropyridine CCB
Step 2 NICE algorithm stable angina (step 1 in prinzmetal angina)
Step 1 NICE algorithm HTN (afro/caribbean or >55)
Interacts with simvastatin (increase levels)
Diltiazem
Dihidropyridine CCB
Step 2 NICE algorithm stable angina (step 1 in prinzmetal angina)
Rate control in AF
Isosorbide Mononitrate
Vasodilator, give 0800, 1400 to give nitrate free period + avoid tolerance
SE flushing headaches hypotension
Step 3 NICE algorithm stable angina (MR)
Ivabradine
Slows HR down, patient must be NSR w resting HR >70
Step 3 NICE algorithm stable angina
Stop after 3 m if not working
Used in HF if LVEF <35% and NSR + HR >75
Ranolazine
Step 3 NICE algorithm stable angina
Helps w HR, good if bradycardia
SE: long QT, avoid in cardiac, renal, liver failure
Nicorandil
Vasodilator
Step 3 NICE algorithm stable angina
C/I: low BP, LV dysfunction
Statins
Give if Qrisk2>10% or lifestyle changes ineffective
Atorvastatin for >85/CKD with no risk stratification
High dose in proven CVD
C/I : pregnancy
Amlodipine interacts w simvastatin
Ezetimibe
Monotherapy of primary hypercholesterolaemia if statins C/I
Fibrates
Lipid modification in 2 care
Better to reduce triglycerides
Increased risk of gallstones
Combo w statins-> increase risk of rhabdo
Aliro/evoloCUmab
specialist drug for primary heterozygous familial hypercholesterolaemia to lower LDL-C
Clopidogrel
Antiplatelet Omeprazole interacts (reduces effectiveness) use ticagrelor instead (or lansoprazole)
Ticagrelor
Antiplatelet, use instead of clopi in DAPT
Tirofiban
Used in ACS for high risk patients, causes anaemia and thrombocytopaenia
Ramipril
ACE inhibitor Step 1 `NICE algorithm HTN (<55 or T2DM) Control BP in systemic sclerosis Prognostic benefit in `HF (helps remodel heart by reducing after load) SE: hyperkalaemia, dry cough, angioedema
Losartan
ARB
Step 1 NICE algorithm HTN (<55/ T2DM)
Use if dry cough not tolerated
Indapamide
Thiazide like diuretic
Step 2 or 3 NICE algorithm HTN
S/E: Impotence, hypo N/K hyper Ca, precipitates gout (hyperuricaemia)
Spironolactone
Mineralocorticoid antagonist
Step 4 NICE algorithm HTN (K<=4.5)
Treat HTN in Conns syndrome
K sparing
Prognostic benefit in HF
S/E - painful gynaecomastia, impotence, hyperK
Use selective aldosterone receptor antagonist (eplerenone) if SE not tolerated
Furosemide
Loop diuretic, offloads fluids
No prognostic benefit in HF
SE: hypoK/Na, exactas hyperglycaemia + gout
0800 1400 (avoid night diuresis)
Entresto
To treat HF, indication LVEF <35% Combo valsartan (prognostic benefit) and sacubitril
Digoxin
Need loading as long half life
Used in CHF as some positive isotropy
Used for AF in sedentary patients, only reduces ventricular rate at rest
OD: N/V/D, blurred vision w xanthopsia/halos + pals/syncope + confusion. Rx = Fab fragment to digoxin (digibind)
Amiodarone
Chemical cardio version in AF, preferred for patients with LV failure. V long half life so needs loading.
SE: photosensitivity, slate grey pigmentation. hepatotoxicity, thyroid (hypo/hyper, contains IODine), pulmonary fibrosis
Interactions: warfarin, digoxin
300mg IV (20-60 mins) then 900mg (24 hrs) in unstable tachycardia, regular broad complex tachycardia, pre-excited AF w adverse features)
Flecanide
paroxysmal AF chemical cardioversion - “pill in pocket”
Cant use in patients with structural heart conditions
Atropine
500mcg for profound bradycardia, repeat up to 3mg max if risk of asystole
Adenosine
6/12/12 mg IV boluses for regular narrow complex tachycardia after vagal manouvres
Salbutamol
SABA, works acutely S/E tachycardia, tremor/anxiety, cramps, paradoxical bronchospasm Increases lactate (false +ve on blood test), hypokalaemia, hyperglycaemia.
Salmeterol
LABA, DELAYED onset, reduces nocturnal sx S/E tachycardia, tremor/anxiety, cramps, paradoxical bronchospasm Increases lactate (false +ve on blood test), hypokalaemia, hyperglycaemia.
Steroids (asthma)
Can be inhaled (ICS) or oral/IV (acute 5-7 days, chronic if still uncontrolled by ICS
Aim for lowest dose
Need bone + GI protection, may cause thrush (rinse mouth after inhaled)
Long term use can cause adrenal suppression -> steroid card
High acute dose can cause psychosis
May cause reactive leukocytosis but pt still “immunosuppressed”
Montelukast
Leukotriene receptor antagonist
Additive effect w ICS
S/E abdo pain, thirst, headache
V rare association with drug induced Churg-Strauss syndrome -> eosinophilia, vasculitic rash, pulmonary renal syndrome
Theophylline
Aminophylline. Give note to prevent morning dipping. Not used in GP because variable metabolism in liver (smokers/liver/heart failure), affected by inducers, narrow therapeutic index
Toxicity - Nausea, tachycardia, seizures, hypokalaemia, hyperglycaemia
Sodium Cromoglicate
INH mast cell stabilisers
Good for mild and exercise induced asthma esp kids
Omalizumab
Anti-IgE May used in persistent ALLERGIC asthma in SECONDARY care
Mepolizumab
Anti-IL5 May used in REFRACTORY EOSINOPHILIC asthma in SECONDARY CARE
Ipratropium Bromide
SAMA, used in asthma exac
Common S/E - dry mouth (anti M)
Less common S/E - Nausea/headache
RARE S/E - constipation, tachycardia, retention, confusion, blurred vision as dilated pupils, angle closure glaucoma, hypersensitivity
CAUTION -> BPH and glaucoma prone patients
Tiotropium
LAMA, used in COPD
Common S/E - dry mouth (anti M)
Less common S/E - Nausea/headache
RARE S/E - constipation, tachycardia, retention, confusion, blurred vision as dilated pupils, angle closure glaucoma, hypersensitivity
CAUTION -> BPH and glaucoma prone patients
Metformin
Insulin sensitisation (needs residual islet cells to work)
No hypos, stop weight gain
Improve HbA1c 1-2%
S/E - GI upset (can try MR)
- lactic acidosis (stopped 2-3 days pre op or pre contrast, dehydration is risk factor) -> stopped if eGFR <30 or Cr >150
Gliclazide
KATP channel inhibitor => increase insulin secretion
Improve HbA1c 1-2%
Causes weight gain, hypos
2nd line for T2DM
Rarer S/E: hepatic cholestasis, blood dycrasias, skin allergic rxn
Omit morning of surgery
Gliptins
DPP-4 inhibitor (increase GLP-1 endogenously)=> insulin secretion
Slight HbA1c reduction (<1%)
Weight neutral
No hypo risk on its own
Good 2nd line if eGFR >50
S/E - headaches, N+V, HF, pancreatitis/pancreatic cancer risk, infection risk, arthralgia
Glitazones
PPAR-gamma activator => insulin secretion + increase sensitivity
Slight HbA1c improvement (<1.5%)
Weight gain
Use if insulin RESISTANT, better lipid profile and MI risk reduction, also used if NAFLD
S/E - fluid retention (so HF =CI), hepatoxicity, osteoporosis, bladder Ca,
Need LFTs every 2mon for a yr
Monitor + stop in 3-6 mon if not working
Gliflozins
Selective SGLT2 inhibitor = blocks glucose reabsorption by kidney => excess glycosuria so only effective if eGFR >60
Reduced mort in pt with cardiovascular disease/HF
Weight LOSS
S/E - NORMOGLYCAEMIC DKA, UTIs, thrush diuresis, hyperkalaemia
Exenatide Liraglutide
Glucagon-like peptide mimetic => augment insulin release and slow gastric emptying. S/c 5 mins pre meal
No hypos when used alone
Weight LOSS
HbA1c improved <1.5%, doesn’t improve CV outcomes.
Indications: BMI >35 + problem ass w obesity, BMI <35, insulin poses occupational implications or weight loss may benefit obesity comorbidities
S/E TDS inj, GI inc pancreatitis/panceatic Ca risk, worsens gastroparesis (CI).
CI if eGRF<30
Repaglinide Nateglinide
Secretogogues = sulphonylurea receptor binders => increase insulin release
HbA1c <1.5% reduction
Rapid onset/short duration, give 30 min pre meal
S/E - rash, N+V, GI upset, hypos, hepatotoxic
disfavoured
Acarbose
Instestinal alpha-glucosidase inhibitor = less starch breakdown = less absorption
v small HbA1c benefit
Weight neutral.
Rarely used in Type 1s to reduce post prandial hyperglycaemia and in DUMPING SYNDROME post fundoplication
S/E flatulence, abdo discomfort, diarrhoea
Orlistat
Inhibit pancreatic and gastric lipase => less fatty acids => steatorrhea and weight loss
NICE guidelines BMI>28 + RF or BMI >30
Only continue >3 months if >5% weight loss
Cyclizine
H1 antagonist anti emetic
emetogenic for GI (PONV) or vestibular causes
Metoclopromide
D2 antagonist
(also haloperidol, domperidone, prochlorperazine)
Emetogenic for GI/Vestibular/Opiates
S/E: pro kinetic (NOT USED IN BO) can cause dystonias and oculogyric crises
Ondansetron
5-HT3 antagonist antiemetic
Emetogenic for chemo / surgery
Methotrexate
DMARD Terratogenic Req folate replacement S/E - PNEUMONITIS, GI upset, myelosuppression, hepatotoxicity. Monitor FBC, LFT, CXR, Cr at baseline.
Sulfasalazine
DMARD
Similar to aspirin so don’t use if aspirin allergy
S/E - Myelosupression (FBC monitoring, Hepatotoxic (LFTs), rash, oligospermia/male infertility), Heinz body anaemia
Hydroxychloroquine
DMARD
BULLSEYE maculopathy
/retinopathy/corneal deposits
Yearly screen if >40 or prev ocular problem
Azathioprine
DMARD
S/E Fever, bruising, hepatotoxicity, myelosupression
Check LFTs, FBC at baseline
Check thiopurine methyltransferase before starting
Penicillamine
DMARD
Can give drug induced SLE
S/E rash, ulcers, taste loss, proteinuria (check protein:Cr ratio), Myelosupression, check FBC, exacerbation of myasthenia graves
Cyclophosphamide
DMARD
S/E - skin pigmentation, male infertility, HAEMORRHAGIC CYSTITIS
Ciclosporin
DMARD
S/E myelosupression, renal failure (hyperK+, Cr, HTN, oedema), gingival hyperplasia
Anti-TNFa
Mabs
DMARDs
Screen for TB first (cause disseminated TB from reactivation
Other S/E: CHF, sepsis, demyelination
Unfractionated Heparin
Inhibits Xa, IXa, XIa, XIIa
Continuous IV a infusion
Needs monitoring of APTT (1.5-2.5) tricky
FULL reversal w protamine sulphate
S/E long term osteoporosis, pain on inj site, hyperkalaemia (inhibits aldosterone secretion)
Fondaparinux
Binds ATIII Xa - lower HIT rate
NO reversal with protamine sulphate
S/E long term osteoporosis, pain on inj site, hyperkalaemia (inhibits aldosterone secretion)
LMWH
Binds ATIII Xa
Sub cut, renal excretion, easy dosing, half life 10h (long) no monitoring
S/E long term osteoporosis, pain on inj site, hyperkalaemia (inhibits aldosterone secretion)
Dabigatran
DOAC, vs THROMBIN, for non valve AF, VTE Not for metal valves, arterial clot, pregnant or breast feeding Interactions - AED, ART, anti fungal, rifampicin Coag test = thrombin time RENAL elimination Needs 5d heparin (like Edox) Can cause GI bleeds Antidote = Idarucizumab
Apixaban
DOAC, vs Xa, for non valve AF, VTE
Not for metal valves, arterial clot, pregnant or breast feeding
Interactions - AED, ART, anti fungal, rifampicin
1st line for VTE
Faecal elimination
Bleeding - no antidote, give PCC, oral charcoal
Rivaroxaban
DOAC, vs Xa, for non valve AF, VTE
Not for metal valves, arterial clot, pregnant or breast feeding
Interactions - AED, ART, anti fungal, rifampicin
LIVER excretion
Increased menorrhagia
Bleeding - no antidote give PCC, oral charcoal (if taken <4 hrs ago)
Warfarin
Reduces II, VII, IX & protein C
VTE - aim 2.5 if recurrent/PE 3.5, AF - aim 2.5, mech valves 2.5-3.5 in old, 2-3 in new
S/e haemorrhage, teratogenic (but can use if breastfeeding) skin necrosis, purple toes.
Causes of high INR: diet, liver disease, Omeprazole, Disulfiram, Erythromycin, Valproate, Isoniazid, Cipro/Cimetidine, acute Ethanol, Sulphonamide, Cranberry juice, NSAIDs
Avoid foods high in vitamin K (brocoli spinach, kale sprouts)
Reverse w VIT K
Use if CrCl <30
Levodopa
PD, combined with decarboxylase inhibitor (carbidopa) to prevent peripheral metabolism to dopamine
Reduced effectiveness with time
S/E: dyskinesia, on off effect, dry mouth, anorexia, palps, postural hypotension, psychosis, drowsiness.
Don’t use in neuroleptic induced Parkinsonism
Don’t acutely stop it! (patches if can’t take orally)
Bromocriptine, cabergoline
PD, Ergot derived dopamine agonists
Ass with pulmonary, retriperitoneal and cardiac fibrosis. Need echo, ESR, Cr and CXR before Rx and closely monitor
Can cause impulse control disorders and daytime somnolence
More likely to cause hallucinations in elderly than levodopa
S/E nasal congestion, postural hypotension.
Ropinirole, Apomorphine
PD: Newer, non ergot derived dopamine agonists
Can cause impulse control disorders and daytime somnolence
More likely to cause hallucinations in elderly than levodopa
S/E nasal congestion, postural hypotension.
Selegiline
MAO-B inhibitor, PD
Inhibits breakdown of dopamine secreted by dopaminergic neurons
Amantadine
PD, mech not fully understood
S/E: ataxia, slurred speech, confusion, dizziness, livedo reticularis
Entacapone, Tolcapone
COMT inhibitor, adjunct to levodopa in patients with established PD
Procyclidine, Benzotropine
Antimuscarinics, used more for drug induced Parkinson’s disease, help tremor and rigidity
Carbemazepine
Used for partial seizures (1st line), trigeminal neuralgia.
P450 enzyme INDUCER
S/E dizziness and ataxia, drowsiness, headache, Diplopia, Steven-Johnson syndrome, leucopenia, agranulocytosis, hyponatraemia 2 to SIADH
Lamotrigine
Antiepileptic 2nd line for generalised and partial seizures
Adverse effect: Steven Johnson syndrome
Phenytoin
Antiepileptic
P450 INDUCER
Lots of adverse effects.
Acute: dizziness, diplopia, nystagmus, slurred speech, ataxia, then confusion, seizures
Chronic: gingival hyperplasia, hirsuitism, coarsening of facial features, drowsiness, megaloblastic anaemia, peripheral neuropathy, osteomalacia, lymphadenopathy, dyskinesia
Idiosyncratic: fever, rashes, hepatitis, dupuytrens, aplastic anaemia, drug induced lupus.
Teratogenic - cleft palates, heart disease
Sodium Valproate
1st line generalised seizures
P450 enzyme INHIBITOR
Adverse effects:
Terratogenic (not used in women of childbearing age), nausea, weight gain, alopecia, ataxia, tremor, hepatotoxicity, pancreatitis, thrombocytopenia, hyponatraemia, hyperammonemic encephalopathy
Triptans
5-HT1B and 5-HT1D agonists for migraine
1st line combo with NSAID or paracetamol
Take asap after onset headache (not aura)
Adverse effects: tingling, heat, tightness, heaviness, pressure
CONTRAINDICATED in IHD or CVD
