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