Drugs 2 Flashcards
What baseline bloods are needed before starting DOAC’s?
Baseline clotting, renal, liver function and FBC
What blood tests are required for DOAC monitoring and at what interval?
FBC, renal and liver
12 monthly
If frail, over 75 - 6 monthly
If CrCl under 60 then frequency in months is CrCl/ 10 - i.e. 30mls/min then 3 monthly
What is the suggested dosing frequency for different DOACs?
Apixaban/ Dabigatran - BD
Edoxaban/ Rivoroxaban - OD
What are the renal contraindications for each of the 4 DOACs?
Contraindicated if CrCl <30:
- Dabigatran
Contraindicated if CrCl <15:
- Rivaroxaban, edoxaban, apixaban
Name 3 contraindications for statins?
Active liver disease (or ALT/ AST over 3x ULN)
Prengnacy or breastfeeding
Women planning to concieve in next 3 months
What blood tests should be performed before starting statins?
LFT’s, HbA1c, full lipid profile, TSH, renal function
CK only if high risk for muscle issues
Following initiation of a statin - what are monitoring requirements?
Repeat LFT’s within 3 months and again within 12 months
What are the blood test monitoring requirments for ACEI?
Renal function before tx
Rpt 1-2 weeks after starting treatment and again 1-2 weeks after each dose increase
Thereafter repeat renal function annually
When should blood pressure be checked following each dose titration with ACEI?
4 weeks post dose titration
You recently started an ACEI and rpt the renal function which shows creatinie has risen by 20%. How do you manage?
Do not modify ACEI dose - recheck in 1-2 weeks
(If eGFR falls by less than 25% or creatinine rises by less than 30%)
You recently started an ACEI and rpt the renal function which shows creatinie has risen by 40%. How do you manage?
Ix other causes (dehydration, consider other medications)
If decrease in eGFR by 25% or rise in creatinine by 30% persists despite these measurers then stop or reduce dose to previously tolerated level
How do you managed raised K+ with ACEI?
If 5-5.9 > Stop or reduce K sparing diuretics or nephrotoxic drugs - if persists then stop or reduce dose of ACEI
If K+ > 6 - Stop ACEI
What are the blood test monitoring requirements for spironolactone?
Only start if K+ is below 4.5
Rpt U+E’s within 4 weeks
When may a course of steroids be abruptly stopped and when does it need to be gradually weened?
Abruptly stopped if <3 weeks
Gradual ween if:
> 3 week course
> 40mg pred daily for more than 1 week
Repeated courses/ previous LT therapy
Evening doses (Should always aim morning where possible)
Name the main contraindication to oral steroids
Systemic infection not controlled by antimicrobial therapy
What is the advice from NICE on GI protection for those on LT steroids?
Gastrointestinal protection with a proton pump inhibitor should not be provided routinely for people on long-term corticosteroids but should be considered for people at high risk of gastrointestinal bleeding or dyspepsia.
A patient finished a course of oral prednisolone 3 days ago but is planned for surgery tomorrow. What should be done regarding steroid prescription?
If stress, for example caused by infection, trauma, or surgery, occurs up to 1 week after stopping the corticosteroid, additional corticosteroid cover should be prescribed to compensate for any potential adrenal suppression.
Name 3 of the most common drug causes of xerostomia?
Dry mouth:
Anticholinergic: Diphenhydramine etc
Antidepressant
Anti-epileptic
Anti-pyschotics
Metformin, what are the renal function considerations?
Below 45 - Reduce to 1g daily
Below 30 - Avoid
SGLT-2 , what are the renal function considerations?
eGFR < 45 - Have no effect on hyperglycemia when eGFR this low so need alternative agent for this
(But still good for cardio and reno protection)
A patient is on gliclazide or insulin, what are the group 1 driving guidelines? (3 points)
To drive must be aware of hypo’s and no more than 1 severe hypo in last 12 months, not in last 3 months
Check BM no more than 2 hours before start and wWhthin 2 hours of any journey
Keep fast carbs in car, wait 45mins after BM normal before continuing
Ramipril, what are the renal function considerations?
Any Cl 30-60ml/min then max dose of Ramiprill is 5mg
If CrCl < 30 treat with caution
Before starting pioglitazone what steps should be taken regarding mananging complication risk?
Urine dip - Due to risk of bladder Ca
FRAX- Due to risk of atypical fractures
(So caution/ avoid if osteoporosis)
A patient is started on a GLP-1 (Semaglutide) what are the criteria to continue it?
At 6 months
- 3% weight loss
- HbA1c reduction of 11mmol/L
What are the contraindications to starting GLP-1?
Ketoacidosis
Severe GI issues
Pancreatitis (Caution)
Your 35y patient is symptomatic with thirst and polyuria and has a new HbA1c of 128, they are not known to previously be diabetic. What rescue therapy may you consider?
Gliclazide 80mg BD
- May increase rapidly to 160mg BD - will see likely weekly
Aim is to reduce osmotic symptoms and bring quick change to HbA1c which then reduces insulin resistance and makes other therapies more effective
In what circumstances may you not want to rapidly reduce a patient’s HbA1c?
Very frail
If diabetic retionopathy, rapid Hba1c reduction can worsen the retinopathy
What is the criteria to consider rescue therapy in diabetes? What medicines can be used?
Rescue therapy if HbA1c over around 86
OR
Symptomatic
Sulphonylurea or insulin
What is the criteria for orlistat treatment?
BMI over 30
BMI over 28 with risk factors
What are the indications for:
a) Tibolone
b) Clonidine
a) Tibolone is a synthetic steroidal compound with oestrogenic, progestogenic, and androgenic activity. It may be used as an alternative to combined HRT for postmenopausal women who wish to have amenorrhoea.
b) Clonidine is used for hot flushes in post menopausal women who don’t want HRT
What are the indications for:
a) Danazol
b) Clomiphene
a) Danzol suppreses gonadotrophins and can be used in endometriosis
b) Clomiphene is a selective oestrogen receptor modulator used in fertility treatments.
What should patients wishing to start a COCP be advised about a pill free interval?
No longer deemed medically neccesary
If doesn’t want withdrawal bleeds doesn’t need to have week off (but standard is once a month, once every 3 months)
What are alternative’s to Mirena with regard to IUS?
Jaydess - Licenced for 3 years only
Kyleena - Licenced for 5 years
- Less levonogestral than mirena, also smaller and narrower tube so easier to insert, rate of ammenoorhea is less
What drug option can be used to pause menstrual bleeding?
Norethisterone 5mg TDS for 10 days
When can X be started after childbirth?
a) POP
b) COCP
c) IUS
a) POP can be started immediately and effective immediately
- Ok with breast feeding
b) Can start after 21days, need condoms 7 days
- Breastfeeding < 6weeks absolute CI
- Breastfeeding 6wk-6m - UKMEC2
c) Within 48 hrs of childbirth or at 4 weeks
What are medication options in addition to tools like laser treatment for hirsuitism?
Topical eflornithine (Vaniqua®)
COCP (off-licence other than Dianette® (cyproterone acetate and ethinylestradiol))
Spironolactone can have positive effects
Name a COCP which is licenced for acne treatment?
Co-cyprindiol (Dianette) is licenced for use in acne vulgaris which hasn’t responded to first-line treatment.
- Also only one licenced in PCOS
First and second line treatment for chlamydia?
1st: doxycycline 100mg twice daily for 7 days
2nd: Azithromycin
Two complications of CKD are raised phosphate and low vitamin D - how should this be managed?
High phosphate - sevelamer
Low Vit D - Calcitriol
Low Ca is often causes by a combination of low vit D and high phosphate
What adjustmanet should be made for overweight patients when prescribing levongestrel emergency contraception?
Double dose if:
- Weight over 70kg
- BMI over 26
Name two situations where you would only prescribe levongestrol over uliciprital (EllaOne)?
Asthma + steroids
Breastfeeding (need to stop for one week with EllaOne)
49year old black patient with T2DM needs to start antihypertensive medication - what do you start?
ARB (Losartan)
Black usually CCB (amlodipine), white dependant on age (ACEI or CCB)
However if T2DM - Ramiprill if white, ARB (Losartan) if black
Diabetes target:
a) Diet controlled
b) With metformin
c) Threshold to start 2nd drug
d) Target when on 2nd drug/ any drug with hypo risk (Gliclazide)?
a + b) 48mmol
c) 58mmol
d) 53mmol
Name 3 groups where doxycycline is contraindicated?
Children under 12
Pregnant women
Breastfeeding
What vitamin is given to prevent isoniazid neuropathy?
Vitamin B6 (Pyridoxine)
indapamide risks what biochemical abnormalities?
Electrolytres low:
Hypokalaemia/ hyponatreamia/ hypochloraemic alkalosis
Bad things high:
Hyperuricaemia, gout and hyperglycaemia
Name 3 contraindications to Bupropion?
History of:
- Seizures
- Eating disorders
- Bipolar disorder
- Pregnancy
What is disulfram used for?
Name 3 contraindications?
Disulfram is used for withdrawal from alcohol
CI:
- Cardiac failure, coronary artery disease, history of cerebrovascular accident (CVA), hypertension
- Psychosis and suicide risk
What is acamprosate used for?
Name 3 contraindications
Used for alcohol remission maintainance
CI:
- Severe hepatic impairment
- Renal impairment (avoid if creatinine is > 120 micromol/l)
- Pregnancy.
What effect does rosuvastatin have on number of new diabetic cases diagnosed?
Increases
If using nasal steroids for hayfever, which steroids should be used?
Mometasone or fluticasone nasal spray
Not beclamethasone
How do you convert a dose of oral morphine to subcut diamorphine?
Divide by three
For which ONE of the direct oral anticoagulants (DOACs) can dialysis be used to reduce the plasma levels, in cases of overdose or accidental ingestion?
Dabigatran
The symbol ‘P’ in the bnf indicates what?
Can only be supplied at a pharmacy
Which drugs do NICE recommend for supressing lactation if needed?
Dopaminergic drugs bromocriptine and cabergoline are licensed to suppress lactation
Which two antipyschotics have the worst CVS side effect profile?
Olanzapine
Clozapine
Amiodarone monitoring requirements?
a) Starting
b) Ongoing
LFT/ TFT/ U+E + CXR before starting
TFT/ LFT 6 monthly
CXR annually
Lithium monitoring
a) How often in stable?
b) Target
c) Blood requirements otherwise
a) 3 monthly
b) 0.6-1 (beware of >0.8 if elderly)
c) Renal and TFT 6 monthly
S/c dose of morphine - how do you calculate from oral?
S/c morphine is half of oral dose
S/c dose of diamorphine - how do you calculate from oral morphine?
1/3 oral morphone dose
Name 3 reasons for free NHS prescriptions?
Age over 60
Age under 16
16-18 and full time education
Listed medical condition
War pensioners
Low income/ income support
Given birth in last 12m or pregnant
Name 3 conditions for free prescriptions
Cancer
Fistula needing dressings
Diabetes
Hypothyroid
Epilepsy
Myasthenia
In the BNF what does an NHS crossed through symbol mean?
Not for prescription on the NHS
In the BNF what does a half white, half black diagonal line mean?
Less suitable drug
BM targets at the end of life?
6 to 15 mmol/l
(Relaxed from normal)
Name 5 requirements for a schedule 2 or 3 CD prescription?
- Patients name and DOB
- Signature handwritten
- Form (i.e. tablets) and strength (i.e. 50mg tablet)
- Dose in mls if liquid (NOT litres)
- Specific dose (i.e. ONE twice daily, NOT ‘as directed’)
- Total quantity (IN WORDS and FIGURES)
Which bit of a schedule 2 or 3 controlled drug prescription needs to be in words and figures?
The total quantity
What is the safest opioid to use in renal impairement?
Fentanyl
Which two BP meds in pregnancy?
labetalol or nifedipine
