Drugs Flashcards
STATINS
Works on reducing the amount of bad cholesterol in the body (controls rate of proudction)
PO
OD
Can be life long
How long does it take to start working
U&Es, LFTs cholesteorl
Muscle pain - stop if severe. Rhabdomyolysis, headache, diarroea
St John’s Wort and grapefruit (some statins, increase the effects)
Indicated in Q risk greater than 10 percent
Mention that it can be changed for something else
STEROIDS
Supresses immune system
OD
PO
Long term treatment - TAPER OFF SLOWLY, DO NOT STOP SUDDENLY
Immediate effect
Look for remission in bloods - CRP, ESR
SEs: vit D, calcium
Side effects: weight gain (increased appt.), thin skin, mood swinging, osteoperosis, peptic ulcers, cushings
Prescribe bisphosphonates (+ PPI) acal D3
Steroid card
Contraindications: anticoagulants, peptic ulcer, diabetes, osteoperosis
WARFARIN
Extrinsic clotting pathway - inhibits VKO enzyme so inhibits of action of vitamin K
OD
PO
Life long
2-3 days to take action (requires bridging therapy with aspirin)
INR - 4 times a week as dose adjusted
SEs: LFT, U&Es
Side effects: hepatic/renal impairment, bruising, bleeding
Contraindications: CYP inducers, NSAIDs (albumin)
CYP inhibitors cause increased INR (grapefruit = more bleeding)
Pts carry anticogulation card
The action of warfarin can be rapidly reversed with an antidote in situations where we need to reduce the risk of bleeding.
Take at same time each day
Different colours depending on strength
Any new medications inform Dr
Limit drinking to one or two drinks a day
Let DR know if any significatnt changes to your diet
two yellow anticoagulant booklets, an INR monitoring booklet and a patient information booklet
BLOOD TEST IN WARFARIN
In order to ensure that we keep your blood within the necessary range we will need to monitor your INR level every so often; this is done through a blood test. The blood tests will initially be frequent (every 3-4 days until two consecutive readings are within range), and then after this, you will be tested twice weekly for 1-2 weeks (again until two consecutive readings within range). Thereafter, testing can increase to longer periods (e.g. every 12 weeks). Your dose of warfarin will be adjusted based on the INR results with the aim of keeping it within the target range.
Serious bleeding and wafarin?
“Occasionally, you can have serious bleeding from taking warfarin. This can be dangerous and needs urgent medical attention.”
“Stop taking warfarin and call your doctor or anticoagulant clinic, or go to A&E if you experience:
red pee or black poo
large bruises or bruises that happen for no reason
nosebleeds that last longer than 10 minutes
blood in your vomit or you’re coughing up blood
severe headaches, fits (seizures), changes to your eyesight, numbness or tingling in your arms or legs, or feel very tired, weak or sick – these can be signs of bleeding in your brain
any bleeding from a cut or injury that will not stop or slow down”
DOAC
Inhibt Xa/IIa - thins bloods BD PO Immideate affect Life long Minimal monitoring Side effects: anaemia, haemorrhage, bleeding, skin reactions Complications/contraindications: Elederly - bleeding risk, GI bleed, poor renal function Alert card Short half life Affect on pregnancy not known Lower intracranial bleed risk
METHOTREXATE
Decreases overactivity of immune system and works to stop damage to joints
Once weekly IM/SC/PO
Treatment - up to life long
12 week steroid cover
Takes 12 weeks to work
Regular LFTs, U&Es - 1 month, 6 month, every year
Side effects: liver damage, abdominal pain, wheeze, (pulmonary fibrosis), Agranulocytosis,
Take with folic acid every day apart from day of taking methotrexate
DO NOT BECOME PREGNANT
Coming off brings back fertility
NITRATES
GTN spray - works by widening blood vessels letting more blood and oxygen reach the heart reducing strain making it easier for the heart to pump blood
PRN
Sublingal spray
Works immediately
Dose may be repeated at 5 minute intervals if required; seek urgent medical attention if symptoms have not resolved 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell and take 300mg aspirin
Do not give in obstructive HF or hypothyroidism
Side effects: Arrhythmias; weakness; cerebral ischaemia; dizziness; drowsiness; flushing; headache; hypotension; nausea; vomiting
SSRIS
Action - seritonin reuptake inhibitor - prolongs seritonin time in brain - more circulating
Once a day
PO
Take in morning or at night depending on side effects
6 months of remission before stopping
Starts to work 4-6 weeks
May feel worse for first two weeks
Side effects: headache, tiredness, insomina, suicidal ideation (young people - use flouxitine) nausea, loss libido, hyponatremia (elderly), SIADH
Contraindications: Poorly controlled epilepsy; SSRIs should not be used if the patient enters a manic phase
Seritonin syndrome: neuromuscular excitation, hyperreflexia, myoclonus, rigidity, autonomic nervous system, excitation, hyperthermia, sweating, altered mental state, confusion more likely in combination with amphetamines, ecstacy
SULPHONYLUREA (Glicazide)
Stimulates pancreatic insulin production (by blocking ATP dependent K+ channels) OD PO Usually life long immediate action Monitor HbA1C U+Es LFTs (hepatic excertion) Side effects: weight gain, ketoacidosis, hypoglycemia, GI upset Contraindications: G6PD deficiency Elderly Weight gain Give hypoglycemic attack advice commence testing 3 times a day pre-meals when Gliclazide treatment started. If no hypo problems emerge after 1-2 weeks, reduce testing to around 3 tests a week. If the dose of Gliclazide needs to be increased then test 3 times per day again until satisfied there are no hypo concerns.
BISPHOSPHONATES
- Osteoporosis is a condition that involves thinning of the bones, which increases the risk of fractures. Bisphosphonates work by preventing the thinning of the bones, allowing the bones to gain strength over time and ultimately reducing the risk of future fractures. (osteoclasts inhibited)
- Once a week - AM - SAME DAY
- The tablet should be taken with a large glass of water, and the patient should not consume any food or drink, other than water, for 30- 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
- Missed tablet, take as soon as remmeber do not take two tablets in one day
- 6 months to take affect
- Baseline calcium + vitamin D - no specific regular monitoring (BMD at 18 months)
- S/E Oesophogeal irritation, abdominal pain, nausea, gastrointestinal upset and joint/muscle pain (oesophageal irritation, ulceration and in some cases strictures)
Watch out for mucosal ulceration, pain and facial swelling - osteonecrosis of the jaw - RARE SPECIFIC SIDE EFFECT - Contraindications: HYPOCALCEMIA, uncorrected vitamin D def, renal impairment, Barrets Oesophogus or other sturctual problems with the oesophagus, (hx peptic uclers),
LEVOTHYROXINE
Levothyroxine (syntehtic T4) is a medication that can be used to top up the level of thyroxine in people whose bodies are unable to make enough thyroid hormones on their own. By using this medication, we can restore normal levels of thyroid hormones and prevent you from experiencing the symptoms associated with hypothyroidism.
PO
OD
The medication should be taken at least 30 minutes before breakfast. This is because food and coffee can reduce the absorption of levothyroxine
Lifelong
If they forget to take a dose, advise them to take it as soon as they remember but to avoid double dosing.
Monitor 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 due to over dose or underdosing or headaches and GI uspet
Warn about palpitations, struggle to keep weight on, etc
If you have diabetes you may need to check your blood glucose more frequently, as levothyroxine may affect the levels of sugar in your blood.
Cautions: adrenal insufficiency, hx of thryotoxicosis, pregnancy, CVD and epilepsy, other medications, diabetes
If taking iron tablets take hours before or after
Levothyroxine should never be taken with other medication as the other medications will stop it from working. Set your alarm clock an hour ahead of you eating breakfast then take your other morning meds 30 minutes later.
Works immediatley but symptoms might not improve for a few weeks
DPP-4 inhibitors (gliptins)?
Action: Increases glucose uptake into muscles, decreasing gluconeogenisis, increases insulin secretion, decreases glucagon secertion (prevents incretin degration by inhibiting DPP-4)
Takes effect immediately
Increases satiety - weight neutral
OD
PO
Life long
Monitor HbA1c and renal function
S/Es: headache, constipations, diziness, skin reactions
Complications: ketoacidosis
Caution in preg and renal impairment
Don’t drink alcohol
Warn about severe abdominal pain - pancreatitis
Low hypo risk only works when glucose is elevated
Take after food due to appetite supression
SGLT2 inihibitors (-flozins)
Blocks SGLT2 transporter in PCT > decreased glucose reabsorption, increases urinary glucose T1DM or T2DM OD PO Immediate HbA1c Monitor renal function Monitor ketones if T1DM Do lipid profile Side effects: DKA, back pain, dizziness, dyslipidemia, urinary infection, urinary frequency, (thrush), hypos if taken alongside something else Contraindicated in elderly (hypotension, risk of volume depletion) strictures and BPH Warn patients symptoms of DKA Weight loss (modest) Low risk of hypos
Weight loss in hypoglycemic agents?
Biguanides (metformin) - weight neutral/ weight loss - debated
DPP-4 inhibitors (sitagliptin) - weight neutral but appetite supressed
SGLT2 inhibitors (dapagliflozin) - modest weight loss
Glitazones (rosiglitazone) - weight gain
Sulphonylurea (glicazide) - weight gain
Hypoglycemic agents and risk of hypo?
Biguanides (metformin) - no DPP-4 inhibitors (sitagliptin) - no SGLT2 inhibitors (dapagliflozin) - no Glitazones (rosiglitazone) - unlikely Sulphonylurea (glicazide) - YES
IRON SUPPLEMENTATION
“Iron plays a key role in lots of different processes within the body including allowing your red blood cells to transport oxygen to the relevant tissues and helping your immune system fight infections.”
EXPLAIN CAUSES OF IRON DEF: Blood loss, Lack of iron in the diet, Inability to absorb iron (e.g. coeliac disease, inflammatory bowel disease), Increased iron demand (e.g. pregnancy, childhood, adolescence)
Explain to the patient that iron is absorbed best if taken an hour before a meal, however, iron can irritate the stomach of some people, causing them to feel nauseated, in which case iron may be best taken just after a meal.
PO
OD
Typically treatment dose iron supplementation is prescribed for three to six months and iron levels are then re-assessed to decide if long term prophylaxis is required
Nausea, Constipation, Diarrhoea, Dark-coloured stools, Metallic taste
Full effect in 1-4 weeks
Vitamin C increases solubility of iron results in increased uptake of iron in the small intestine
Recheck Hb and haemotinics in first 4 weeks
Iron overdose symptoms?
dizziness
low blood pressure and a fast or weak pulse
headache
fever
shortness of breath and fluid in the lungs
a grayish or bluish color in the skin
jaundice (yellowing of the skin due to liver damage)
seizures
BIGUANIDES (metformin)
Increases peripheral utilisation of glucose and decreases gluconeogensis
OD-TDS
PO
Life long
HbA1c U+Es
Side effects: Diarrhoea/nausea/vomitting/abdopain/decreased appetite
Weight neutral
Stop if eGFR<30
Caution in combination with drugs impairing renal function
Risk of acute metabolic acidosis/lactic acidosis
Advise lactic acidosis: SOB muscle cramps abdominal pain, hypothermia
THIAZOLIDINEDIONE (GLITAZONES)
Reduces peripheral insulin resistance OD PO Life long Immediate action Monitor HbA1C Risk of weight gain, Hypoglycemia (unlikely), Bone fractures, Infection risk, bladder cancer Contraindications: Bladder cancer, HF, haematuria unexplained, elderly CAUTION with other agents (hypos) Caution in elderly Give hypo advice
HbA1c targets in T2DM?
Lifestyle 48 mmol/mol (6.5%)
Lifestyle + metformin 48 mmol/mol (6.5%)
Includes any drug which may cause hypoglycaemia (e.g. lifestyle + sulfonylurea) 53 mmol/mol (7.0%)
Patients already on treatment:
Already on one drug, but HbA1c has risen to 58 mmol/mol (7.5%) 53 mmol/mol (7.0%)
T2DM stepwise management?
Metformin is still first-line and should be offered if the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions
if the HbA1c has risen to 58 mmol/mol (7.5%) then a second drug should be added from the following list: sulfonylurea gliptin pioglitazone SGLT-2 inhibitor
if despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then triple therapy with one of the following combinations should be offered:
metformin + gliptin + sulfonylurea
metformin + pioglitazone + sulfonylurea
metformin + sulfonylurea + SGLT-2 inhibitor
metformin + pioglitazone + SGLT-2 inhibitor
OR insulin therapy should be considered
TRIPTANS
Reverses changes in the brain that lead to migraine (seritonin receptor agonist, vasoconstriction of blood vessels)
PRN/OD
Repeat dose 2 hours later if migraine recurs - max 3 times a day
IN/PO
Rapid effect - 10-15 mins
Can be long term
Side effects: dizziness, dry mouth, fatigue, heavy arms face + chest, weakness
Do not give to children
Do not take on more than two occasions per week
HEPARIN
Inhibition of intrinsic clotting pathway - inhibits antithrombin III
OD
SC
Can be life long
Immediate effect
Monitor: APTT time SEs: LFTs, U&Es
Side effects: bleeding, bruising, hepatic/renal impairment hyperkalemia
Contraindications: Elderly, severe hypertension, risk of bleeding
Anticoagulation card
