Drugs

Question 1

Lidocaine hydrochloride

1. Indications

Answer 1

1. • Cardiopulmonary resuscitation
     - Ventricular arrhythmias, especially after MI
     - IV regional anaesthesia & nerve block
     - Pain relief (in anal fissures, haemorrhoids, pruritus ani, pruritus vulvae, herpes zoster, or herpes labialis),
     - Lubricant in cystoscopy, Lubricant in proctoscopy
     - Anaesthesia before venous cannulation or venepuncture
     - Postherpetic neuralgia (vzv reactivation)
     - Bronchoscopy, Laryngoscopy, Oesophagoscopy, Endotracheal intubation

Question 2

Lidocaine hydrochloride

1. Contra-indications for regional and IV administration
2. Contra-indications for regional administration
3. Side-effects

Answer 2

1. atrioventricular block; severe myocardial depression; sino-atrial disorders
2. application to the middle ear (can cause ototoxicity);

avoid injection into infected & inflamed tissues;

3. Common for IV: dizziness, drowsiness, paraesthesia

Common for IV or RA: bradycardia (may lead to cardiac arrest); confusion; convulsions; hypotension (may lead to cardiac arrest); respiratory depression

Question 3

Intrathecal administration is?

advantage?

use?

Answer 3

injection into the spinal canal or the subarachnoid space

reaches the cerebrospinal fluid (CSF)

spinal anaesthesia, chemotherapy, or pain management applications.

Question 4

Use of bupivicaine

Answer 4

Surgical anaesthesia

a. lumbar epidural block
b. field block
c. thoracic epidural block
d. caudal epidural block

acute pain

a. major nerve block
b. labour

Question 5

Bupivicaine

1. Contra-indications
2. Cautions
3. Side-effects

Answer 5

1. Application to the middle ear (ototoxicity);

Avoid injection into infected & inflamed tissues; (Increased absorption into the blood increases the possibility of systemic side-effects, and the local anaesthetic effect may also be reduced by altered local pH)

complete heart block;

preparations containing preservatives should not be used for caudal, epidural, or spinal block, or for intravenous regional anaesthesia (Bier’s block);

2. Cardiovascular disease; cerebral atheroma; debilitated patients (consider dose reduction); elderly (consider dose reduction); epilepsy; hypertension; hypotension; hypovolaemia; impaired cardiac conduction; impaired respiratory function; myasthenia gravis; myocardial depression may be more severe and more resistant to treatment; shock
3. Common: Arrhythmias; dizziness; hypertension; hypotension; nausea; paraesthesia; urinary retention; vomiting

Uncommon: Neurotoxicity

Rare or very rare: Arachnoiditis; cardiac arrest; diplopia; nerve disorders; paraplegia; paresis; respiratory depression

Monitor as per local protocol for at least 30 minutes after administration

Question 6

Paracetomol (NSAID

1. Indications & dose
2. General side-effects
3. Specific side-effects
   a. Common
   b. Rare or very rare
4. pregnancy safe?
5. Antidote if overdose?
6. effects of overdose?
7. MOA

Answer 6

Mild to moderate pain

Adult

PO: 0.5–1 g every 4–6 hrs; max 4 g/day

IV: (<50 kg) 15 mg/kg every 4–6 hrs, dose to be administered over 15 minutes; maximum 60 mg/kg per day.

(=>50 kg) 1 g, 4–6 hrs, over 15 mins; maximum 4 g/day.

(HEPATOTOXICITY max 3 g/ day)

Rectum: 0.5–1 g every 4–6 hours; maximum 4 g/day

Prophylaxis of post-immunisation pyrexia following immunisation with meningococcal group B

GBS-EOD are septicemia without apparent location, pneumonia, and less frequently meningitis

GBS: group B streptococcal

2. Rare or very rare: Thrombocytopenia
3. With rectal use: anorectal erythema

IV: hypersensitivity; hypotension; leucopenia; malaise; neutropenia

angioedema; liver injury; skin reactions

4. yes
5. ABCDE

IV Acetylcysteine ( within 24 hours of ingesting paracetamol)

Activated charcoal

6. Within 24hrs: hepatocellular necrosis, renal tubular necrosis, n + v (settle within 24 hrs)

over 24hrs: right subcostal pain and tenderness (hepatic necrosis). Liver damage is maximal 3–4 days after paracetamol overdose and may lead to encephalopathy, haemorrhage, hypoglycaemia, cerebral oedema, and death.

7. unknown

Question 7

Codeine (opiod)

1. Indications & dose
2. Important safety information
3. Signs or symptoms of toxicity

Answer 7

1. a. Mild to moderate pain

PO (For Adult): 30–60 mg every 4 hrs if required; max 240 mg/day (6-4 tablets)

IM (For Adult): 30–60 mg every 4 hrs if required.

b. Dry or painful cough

By mouth using linctus

15–30 mg 3–4 times a day

2.codeine should not be used in breast-feeding mothers because it can pass to the baby through breast milk

life-threatening adverse reactions in children with obstructive sleep apnoea who received codeine after tonsillectomy or adenoidectomy:

12–18 years, the maximum 240 mg

Doses may be taken up to four/day, intervals of no less than 6 hours

duration of treatment should be limited to 3 days

3. constipation, RDS, pin point pupils (para)

Question 8

Codeine continued

1. Contraindications For all OPIOIDS
2. For CODEINE PHOSPHATE
3. MOA
4. S/E for codeine phosphate
5. breast feeding?

Answer 8

1. Acute respiratory depression; comatose patients; head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment); raised intracranial pressure; risk of paralytic ileus)
2. Acute ulcerative colitis; antibiotic-associated colitis;
3. codeine -> morphine CYP2D6
4. Biliary spasm; hypothermia; mood altered; sexual dysfunction; ureteral spasm
5. mothers vary considerably in their capacity to metabolise codeine—risk of morphine overdose in infant

Question 9

Morphine

1. Indications

Answer 9

1. a. Acute pain

PO, SC, IM: initially 10 mg every 4 hrs (adult)

5 mg every 4 hrs (elderly)

IV: Initially 5 mg every 4 hrs

b. Chronic pain

PO, IM, SC: 5–10 mg every 4 hrs

PR: Initially 15–30 mg every 4 hrs

c. Pain (with modified-release 12-hourly preparations) PO
d. Pain (with modified-release 24-hourly preparations) PO
e. Pain management in palliative care (starting dose for opioid-naïve patients)

PO: 20–30 mg/day, divided doses, immediate-release preparation 4-hourly/ 12-hourly modified-release preparation,

f. Pain management in palliative care (starting dose for patients being switched from a regular weak opioid)

PO: 40–60 mg/day (as above)

g. Pain in palliative care (following initial titration)
h. cough in terminal illness
i. PCA
j. MI
k. Acute PO
l. Dyspnoea

Question 10

1. Contra indications for morphine
2. S/e
3. Breast feeding?
4. MOA
5. Bioavailabilty

Answer 10

1. Acute abdomen; delayed gastric emptying; heart failure secondary to chronic lung disease; phaeochromocytoma
2. arryhtmias, insomnia, constipation,
3. safe
4. mu-opioid receptors (kappa & delta agonist)

binds to and inhibits GABA inhibitory interneurons

5. 30%.

Question 11

Ibruprofen

1. Indications
   (dose: initial, max, maintainence)

Answer 11

a. Pain & inflammation in RD & other MSK disorders,

Mild to moderate pain including dysmenorrhoea (early 20s),

Postoperative analgesia,

Migraine,

Dental pain

PO immediate release med: Initially 300–400 mg 3–4/day; increased if necessary up to 600 mg 4 times a day; maintenance 200–400 mg 3/day

PO modified-release med: 1.6 g once daily, dose to be taken in the early evening, increased if necessary to 2.4 g daily in 2 divided doses, dose to be increased only in severe cases.

Question 12

Contra-indications of ibuprofen

Answer 12

IV: active bleeding (especially intracranial or gastro-intestinal) (in neonates); coagulation defects (in neonates); known or suspected necrotising enterocolitis (in neonates); life-threatening infection (in neonates); marked unconjugated hyperbilirubinaemia (in neonates); pulmonary hypertension (in neonates); thrombocytopenia (in neonates)

With systemic use: active gastro-intestinal bleeding; active gastro-intestinal ulceration; Hx of GI bleeding/perf/ recurrent haemorhage related to previous NSAID therapy; history of recurrent gastro-intestinal ulceration (two or more distinct episodes); severe heart failure

Question 13

1. TB drugs and side
2. What is tinea pedis

Answer 13

1. image
2. dermatophyte infection of the soles of the feet and the interdigital spaces

3.

Question 14

inducers and inhibitors of cyp450

Answer 14

Question 15

Naproxen

1. Indications and dose
2. Contra-indications
3. s/e
4. pregnancy
5. caution
6. Avoid if

Answer 15

1. a. Pain & inflammation in RD

PO: 0.5–1 g daily in 1–2 divided doses

b. Pain & inflammation in MSK disorders, Dysmenorrhoea

PO: initially 500 mg, then 250 mg every 6–8 hours as required, maximum dose after the first day 1.25 g daily

c. Acute gout

PO: Initially 750 mg, then 250 mg every 8 hrs until attack has passed.

2. current or Hx of GI bleeding/per/ulcer
3. everything e.g. alopecia, agranulocytosis, vertigo
4. Avoid unless benefit outweighs the risk.

Avoid during the third trimester (risk of closure of fetal ductus arteriosus in utero and possibly persistent pulmonary hypertension of the newborn); onset of labour may be delayed and duration may be increased.

5. Long-term use of some NSAIDs is associated with reduced female fertility, which is reversible on stopping treatment
6. eGFR less than 30 mL/minute/1.73 m2 (90-120)

Question 16

Senna (low dose initially then increased)/ anthraquinone

1. Indications & dose
2. Why is it usually taken at bedtime?
3. breastfeeding? pregnancy?
4. s/e

Answer 16

Constipation

TABLETS 6–17 yo: 7.5–30 mg/day

TABLETS Adult: 7.5–15 mg/day (max. per dose 30 mg daily)

SYRUP 4–17 yo: 3.75–30 mg/day

SYRUP adult: 7.5–15 mg once daily (max. per dose 30 mg daily)

2. 8-12hrs to work , greater parasympathetic drive at night = more bowel movements, gastrocolic reflex in the morning
3. breastfeeding infant > 1mth

safe in pregnancy

4. melanosis/ pseudomelanosis coli: lipofuscin in macrophages (senna causes necrosis of bowel which is taken up by machrophages)

colonoscopy no association with disease

Question 17

ISPAGHULA HUSK/ fybogel

1. Indication
2. MOA
3. Contra-indications
4. Cautions
5. Side-effects

Answer 17

1. Constipation

PO: 1 sachet twice a day

dose in water >= 150ml

taken after food

morning and evening

2. Bulk-forming laxatives relieve constipation by increasing faecal mass which stimulates peristalsis
3. Colonic atony; faecal impaction; intestinal obstruction; reduced gut motility
4. Adequate fluid intake should be maintained to avoid intestinal obstruction
5. Abdominal distension; bronchospasm; conjunctivitis; gastrointestinal disorders; hypersensitivity; rhinitis; skin reactions

Question 18

Lactulose

1. Indications
2. pharmacokinetics
3. Contra-indications
4. Cautions
5. S/e
6. pregnancy

Answer 18

1. a. Constipation

PO Adult: Initially 15 mL twice daily, adjusted according to response

b. Hepatic encephalopathy (portal systemic encephalopathy)

PO adult: Adjusted according to response to 30–50 mL 3 times a day, subsequently adjusted to produce 2–3 soft stools per day.

2. may take up to 48 hours to act
3. Galactosaemia; intestinal obstruction
4. Lactose intolerance
5. Common: Abdominal pain; diarrhoea; flatulence; nausea; vomiting

Uncommon: Electrolyte imbalance

6. Safe

Question 19

1. Galactosaemia

Answer 19

1. • can’t metabolize the galactose properly

+ autosomal recessive mode

Question 20

Augmentin/ co-amoxicillin (amoxicillin/clavulanic acid)

1. Indications
2. Contraindications
3. what is chronic lymphocytic leukaemia
4. Describe haematopoesis
5. Cautions:
6. general S/e
7. Specific side-effects, Frequency not known, With oral use

Answer 20

1. a. beta-lactamase-producing strains (where amoxicillin alone not appropriate): RTI, bone & joint infections, GU & abdominal infections, cellulitis & animal bites

TABLETS Child 12–17 yo: 250/125 mg every 8 hrs; increased to 500/125 mg every 8 hrs, increased dose used for severe infection.

TABLETS Adult: 250/125 mg every 8 hrs; increased to 500/125 mg every 8 hrs, increased dose used for severe infection.

IV injection/IV infusion: Adult 1.2 g every 8 hours.

b. Severe dental infection with spreading cellulitis,
Dental infection not responding to first-line antibacterial

TABLETS adult: 250/125 mg every 8 hrs for 5 days

c. Surgical prophylaxis

IV injection/ IV infusion adult: 1.2 g, to be administered up to 30 minutes before the procedure, then 1.2 g every 8 hours for up to 2–3 further doses in high risk procedures.

d. _Acute sinusitis PO a_dult: 500/125 mg 3x day for 5 days.
2. hx of co amox associated jaundice or hepatic dysfunction
3. most common type of leukaemia: breathlessness(anaemia), splenomegaly, night sweats, inc no of infections, bruising
5. CLL & CMV infection inc risk of erythematous rash

Cholestatic jaundice

6. Common: inc risk of infection

Uncommon: Dizziness; dyspepsia; headache

Frequency unknown: Colitis haemorrhagic; crystalluria; hypersensitivity vasculitis; meningitis aseptic

7. akathisia (inner restlessness brought on as a s/e of meds more common in dopaminergic meds); black hairy tongue

Question 21

co amoxiclav

1. Breast feeding? pregancy?
2. What is black hairy tongue?
3. Effect on kidneys ?
4. MOA

Answer 21

1. safe
2. proliferations of squamous epithelium and micro

RF: smoking, xerostomia (dry mouth), soft diet, poor oral hygiene and certain medications

3. inc risk of crystalluria (crystals in urine/cloudy urine) -> inc risk of urolithiasis

if poor eGFR need to adjust dose

4. cluvanate:

inhibitor of β-lactamases produced by Gram-negative bacteria including Haemophilus ducreyi, H. influenzae, Neisseria gonorrhoeae, Moraxella catarrhalis, Bacteroides fragilis, and some Enterobacteriaceae. It also inhibits β-lactamases produced by S. aureus

Question 22

Teicoplanin

1. Targets what microorganisms?
2. Teicoplanin is similar to?
3. family of drug?
4. MOA

Answer 22

1. Gram positive (aerobes and anaerobes)

methicillin-resistant Staphylococcus aureus and Enterococcus faecalis

2. vancomycin, but has a significantly longer duration of action, allowing once daily administration after the loading dose.
3. glycopeptide
4. bind to the aa within the cell wall preventing the addition of new units to the peptidoglycan

Question 23

Teicoplanin

1. Indications & dose:

Answer 23

Clostridium difficile infection (bacilli gram. gram positive, blood agar, spores)

PO Adult: 100–200 mg, 2x daily for 7–14 days

Serious infections caused by Gram-positive bacteria (e.g. complicated skin & soft-tissue infections, pneumonia, complicated UTI)

IV injection/infusion/ IM injection for adult: Initially 6 mg/kg every 12 hrs for 3 doses, then 6 mg/kg/day

Streptococcal or enterococcal endocarditis (+ another antibacterial), Bone & joint infections

IV injection/ IV infusion: 12 mg/kg every 12  hrs for 3–5 doses, then 12 mg/kg/dAy.

Surgical prophylaxis

IV adult: 400 mg, to be administered up to 30 minutes before the procedure.

Surgical prophylaxis in open fractures

IV adults: 800 mg, to be administered up to 30 minutes before skeletal stabilisation and definitive soft-tissue closure.

Peritonitis associated with peritoneal dialysis (added to dialysis fluid)

Question 24

Teicoplanin

1. S/e

Answer 24

Common: Fever; pain; skin reactions

Uncommon: Bronchospasm; diarrhoea; dizziness; eosinophilia; headache; hearing impairment; hypersensitivity; leucopenia; nausea; thrombocytopenia; vomiting

Rare: Abscess; red man syndrome(10-30min, pruritus, an erythematous rash that involves the face, neck, and upper torso)

FNK: Agranulocytosis; angioedema; chills; neutropenia; overgrowth of nonsusceptible organisms; renal impairment; seizure; severe cutaneous adverse reactions (SCARs); thrombophlebitis

Question 25

Gentamicin

1. Indications & dose

Answer 25

1. a. Bacterial eye infections (staph a, strep pneu? both GP)

For Adult: 1  drop at least every 2 hours, reduce frequency as infection is controlled and continue for 48 hours after healing, less severe infection 3–4x daily is generally sufficient.

b. Bacterial infection in otitis externa (Pseudomonas aeruginosa GN and Staphylococcus aureus GP)

Ear for Child: 2–3 drops 4–5x day, (including a dose at bedtime).

For Adult: Apply 2–3 drops 4–5 times a day, (including a dose at bedtime).

c. Gram-positive bacterial endocarditis or HACEK endocarditis (in combination with other antibacterials)

IM injection, IV injection, IV infusion Adult: 1 mg/kg every 12 hrs, IV injection to be administered over at least 3 minutes, to be given in a multiple daily dose regimen.

Septicaemia,
Meningitis and other CNS infections,
Biliary-tract infection,
Acute pyelonephritis,
Endocarditis,
Pneumonia in hospital patients,
Adjunct in listerial (bacteria 3rd commonest cause of) meningitis,
Prostatitis

IV infusion, or by slow IV injection, or by IM injection adult: 3–5 mg/kg/day in 3 divided doses, to be given in a multiple daily dose regimen, divided doses to be given every 8 hours, intravenous injection to be administered over at least 3 minutes.

By intravenous infusion

For Adult

Initially 5–7 mg/kg, subsequent doses adjusted according to serum-gentamicin concentration, to be given in a once daily dose regimen.

CNS infections (administered on expert advice)

Intrathecal injection adult: 1 mg/day, increased if necessary to 5 mg daily, seek specialist advice.

Surgical prophylaxis

Slow IV injection adult

1.5 mg/kg, intravenous injection to be administered over at least 3 minutes, administer dose up to 30 minutes before the procedure, dose may be repeated every 8 hours for high-risk procedures; up to 3 further doses may be given.

Surgical prophylaxis in joint replacement surgery

IV infusion adult: 5 mg/kg for 1 dose, administer dose up to 30 minutes before the procedure.

Question 26

Central retinal artery occlusion:

1. What time is there irreversible loss of vision?
2. Most common microorganism which causes conjunctivitis (bacterial)

Answer 26

1. Irreversible damage after 90 minutes

but even 24 hours after symptoms begin, vision can still be saved or partially restored.

2. Common: Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae.

Rare/ hyperacute: Neisseria gonorrhoeae/ meningitidis

red sclera

gritty fealing

Question 27

Aminoglycosides display concentration-dependent bactericidal activity against?

Answer 27

most gram-negative aerobic and facultative anaerobic bacilli

not against gram-negative anaerobes

most gram-positive bacteria

e.g. gram negative anaerobe Prevotella (oral, vaginal, and gut microbiota and) are often recovered from anaerobic infections of the respiratory tract. These infections include aspiration pneumonia, lung abscess, pulmonary empyema, and chronic otitis media and sinusitis.

Question 28

1. Contra indications of gentamicin
   a. For all aminoglycosides
   b. For GENTAMICIN
2. MOA
3. s/e

For all AMINOGLYCOSIDES (BY INJECTION)

Answer 28

1. a. Myasthenia gravis (aminoglycosides may impair neuromuscular transmission)
   b. When used by ear: patent grommet, perforated tympanic membrane
2. prevents bacteria from making protein
3. Common: Hearing impairment

Uncommon: Nausea; skin reactions (very common in children); vomiting

Rare: Anaemia; eosinophilia; fever; headache; hypomagnesaemia; paraesthesia; renal impairment

Frequency not known: Bronchospasm; confusion; lethargy; nephrotoxicity

Question 29

Gentamicin

1. pregnancy?
2. Renal?

Answer 29

1. aminoglycosides: risk of auditory or vestibular nerve damage(highest risk streptomycin) 2nd/3rd tri
2. aminoglycosides: Excretion via the kidney and accumulation occurs in renal impairment. Ototoxicity and nephrotoxicity occur commonly in patients with renal failure.

Question 30

Benzylpenicillin

1. Indications & dose

Answer 30

1. Mild to moderate susceptible infections,
   Throat infections,
   Otitis media,
   Cellulitis,

IM injection, slow IV injection, or by IV infusion adult: 0.6–1.2 g (can inc) every 6 hrs, single doses over 1.2 g IV only

Endocarditis (+/- antibacterial if necessary)

slow IV injection/ IV infusion adult: 1.2 g every 4 hrs, if necessary to 2.4 g every 4 hrs

Anthrax (Bacillus anthracis)

Slow IV injection/ IV infusion adult: 2.4 g every 4 hrs.

Intrapartum prophylaxis against group B streptococcal infection

slow IV injection/ IV infusion adult: 3 g for 1 dose, then 1.5 g every 4hrs until delivery.

Meningitis, Meningococcal disease

slow IV injection/ IV infusion adult: 2.4 g every 4 hrs

Question 31

Anthrax: Bacillus anthracis

signs and symtoms?

Answer 31

Skin: small blister with surrounding swelling that often turns into a painless ulcer with a black center.

Lungs: fever, chest pain, & SOB

GI: diarrhea which may contain blood, abdominal pains, & N+V

Injection: fever & an abscess at puncture site

Question 32

benzylpenicillin

1. s/e of penicillin

2. s/e of benzylpenicillin

3. pregnancy? breastfeeding?
4. Renal impairment

Answer 32

1. Common: Diarrhoea; hypersensitivity; nausea; skin reactions; thrombocytopenia; vomiting

Uncommon: Antibiotic associated colitis; leucopenia

Rare: Agranulocytosis; angioedema; haemolytic anaemia; hepatic disorders; nephritis tubulointerstitial; neutropenia; seizure; severe cutaneous adverse reactions (SCARs)

2. Common: Fever; Jarisch-Herxheimer reaction

Rare: Neurotoxicity

Frequency not known: Coma

3. safe
4. Accumulation of sodium from injection can occur in renal failure.

High doses may cause neurotoxicity, including cerebral irritation, convulsions, or coma.

Question 33

1. Flucloxacillin (bactericidal)

Answer 33

1. a. Infections due to beta-lactamase-producing staphylococci including otitis externa, Adjunct in pneumonia, Adjunct in impetigo, Adjunct in cellulitis

PO adult: 250–500 mg 4x/day

IM injection: 250–500 mg every 6 rs

slow IV injection, infusion adult: 0.25–2 g every 6 hrs

b. Endocarditis (+ antibacterial)

slow IV injection/ IV infusion adult:

(body-weight up to 85 kg) 8 g/day in 4 divided doses

(body-weight 85 kg and above) 12 g/day in 6 divided doses

c. Osteomyelitis

IV injection/IV infusion adult: Up to 8 g daily in 3–4 divided doses.

Surgical prophylaxis

slow IV injection/ IV infusion

Adult: 1–2 g, to be administered up to 30 mins before the procedure, then (by mouth or by intramuscular injection or by slow intravenous injection or by intravenous infusion) 500 mg every 6 hours if required for up to 4 further doses in high risk procedures.

Question 34

Metronidazole

1. Indications

Answer 34

1. Anaerobic infections adult:

PO: 400 mg every 8 hrs, alternatively 500 mg every 8 hrs usually treated for 7 days (for 10–14 days in C.difficile infection)

PR: 1 g 3 times a day for 3 days, then 1 g twice daily, for usual total treatment duration of 7 day

IV: 500 mg every 8 hrs, 7 days (10–14 days in c.difficile infection), to be given over 20 minutes

Helicobacter pylori eradication; in combination with clarithromycin and esomeprazole; or in combination with clarithromycin and lansoprazole; or in combination with amoxicillin and lansoprazole; or in combination with clarithromycin and omeprazole; or in combination with clarithromycin and pantoprazole; or in combination with clarithromycin and rabeprazole

PO: 400 mg 2xday

H.pylori eradication; in combination with amoxicillin & omeprazole

PO: 400 mg 3xday

Fistulating Crohn’s disease

PO: 10–20 mg/kg daily in divided doses, usual dose 400–500 mg 3xday usually given for 1 month but no longer than 3 months because of concerns about peripheral neuropathy.

Leg ulcers & pressure sores

PO adult: 400 mg every 8 hrs for 7 days.

Bacterial vaginosis (notably Gardnerella vaginalis infection)

PO: 400–500 mg twice daily for 5–7 days, alternatively 2 g for 1 dose.

Bacterial vaginosis

PV vaginal gel: 1 applicatorful daily for 5 days, dose to be administered at night.

PID

PO: 400 mg twice daily for 14 days.

Acute ulcerative gingivitis

400 mg every 8 hours for 3 days

Invasive intestinal amoebiasis,
Extra-intestinal amoebiasis (including liver abscess)

Urogenital trichomoniasis

Giardiasis

Established case of tetanus

rosacea

surgical prophylaxis

Question 35

Metronidazole

1. Cautions

Answer 35

1. TOP: avoid exposure to strong sunlight or UV light

PV: avoid intravaginal preparations (particularly those that require the use of an applicator) in young girls who are not sexually active, unless there is no alternative (in children); not recommended during menstruation; some systemic absorption may occur with vaginal gel

Question 36

Metronidazole s/e

Answer 36

Common

IV: dry mouth; myalgia; nausea; oral disorders; taste metallic; vomiting

PV: pelvic discomfort; vulvovaginal candidiasis; vulvovaginal disorders

Uncommon

IV: asthenia(physical weakness/lack of energy); headache; leucopenia (with long term or intensive therapy)

PV: menstrual cycle irregularities; vaginal haemorrhage

Rare

IV: agranulocytosis; angioedema; appetite decreased; ataxia; diarrhoea; dizziness; drowsiness; encephalopathy; epigastric pain; epileptiform seizure (with long term or intensive therapy); hallucination; hepatic disorders; meningitis aseptic; mucositis; neutropenia; optic neuropathy; pancreatitis; pancytopenia; peripheral neuropathy (with long term or intensive therapy); severe cutaneous adverse reactions (SCARs); skin reactions; thrombocytopenia; urine dark; vision disorders

PO: agranulocytosis; ataxia; cerebellar syndrome; confusion; dizziness; drowsiness; encephalopathy; flushing; hallucination; headache; hepatic disorders; myalgia; neutropenia; pancreatitis; pancytopenia; psychotic disorder; seizure; skin reactions; thrombocytopenia; urine dark; vision disorders

PR: agranulocytosis; ataxia; cerebellar syndrome; dizziness; drowsiness; encephalopathy; flushing; hallucination; headache; hepatic disorders; myalgia; neutropenia; pancreatitis; pancytopenia; psychotic disorder; seizure; skin reactions; thrombocytopenia; urine dark; vision disorder

Question 37

Metoclopramide (hydrochloride)

1. Indications?
2. Important safety information

cant give for vomiting due to gi obstruction as it is a prokinetic

Answer 37

Symptomatic treatment of nausea and vomiting including that associated with acute migraine,
Delayed (but not acute) chemotherapy-induced nausea & vomiting,
Radiotherapy-induced nausea and vomiting,
Prevention of postoperative nausea and vomiting

PO, IM injection, slow IV injection:

Adult (body-weight <60 kg): Up to 500 micrograms/kg/day in 3 divided doses, when administered by slow IV injection, to be given over at least 3 mins

Adult (body-weight =< 60 kg ): 10 mg up to 3x day

Hiccup in palliative care

PO, IM, SC adult: 10 mg every 6–8 hrs

Nausea and vomiting in palliative care

PO: 10 mg 3xday

SC infusion: 30–100 mg/24 hrs

2. risk of neurological effects such as extrapyramidal disorders & tardive dyskinesia outweigh the benefits in long-term or high-dose treatment

Question 38

Metoclopramide

1. Contra-indications
2. Cautions
3. MOA

Answer 38

1. 3–4 days after GI surgery, GI haemorrhage, GI obstruction, GI perforation; phaeochromocytoma
2. Asthma; atopic allergy; bradycardia; cardiac conduction disturbances; children; elderly; epilepsy; may mask underlying disorders such as cerebral irritation; Parkinson’s disease; uncorrected electrolyte imbalance; young adults (15–19 yrs old)
3. ANTIEMETIC: antagonist activity at D2 receptors in the chemoreceptor trigger zone in the central nervous system

Gastroprokinetic: D2 receptor antagonist activity, and 5-HT4 receptor agonist activity

inc the tone of the LOS

inc peristalsis of the duodenum & jejunum,

increases tone and amplitude of gastric contractions

relaxes the pyloric sphincter and duodenal bulb

Question 39

Metoclopramide

1. s/e
2. pregnancy? breastfeeding?
3. hepatic or renal impairment

Answer 39

1. Common: Asthenia; depression; diarrhoea; drowsiness; hypotension; menstrual cycle irregularities; movement disorders; parkinsonism

Uncommon: Arrhythmias; hallucination; hyperprolactinaemia; level of consciousness decreased

Rare: Confusion; galactorrhoea; seizure

Frequency not known: Atrioventricular block; blood disorders; cardiac arrest; gynaecomastia; hypertension; neuroleptic malignant syndrome; QT interval prolongation; shock; syncope

2. safe, avoid
3. avoid or use low dose

Question 40

Cyclizine

1. indications
2. contra indications
3. general s/e
4. specific s/e

Answer 40

1. Nausea,
   Vomiting,
   Vertigo,
   Motion sickness,
   Labyrinthine disorders

PO adult: 50 mg up to 3 x day, for motion sickness, take 1–2 hrs before departure.

IV injection, IM injection adult: 50 mg 3 x day

Nausea & vomiting associated with palliative care (adult)

SC: 150 mg, dose to be given over 24 hours.

PO: 50 mg up to 3 times a day

2. Neonate (due to significant antimuscarinic activity) (in neonates)
3. Rare: Angle closure glaucoma; depression

4.

Question 41

Dalteparin

1. indications

Answer 41

Unstable CAD (including NSTEMI)

SC injection adult: 120 units/kg every 12 hrs (max. per dose 10 000 units twice daily) for up to 8 days.

Patients with unstable CAD (including NSTEMI) awaiting angiography or revascularisation and having already had 8 days treatment with dalteparin

SC: Adult (body-weight =>70 kg & male)

7500 units every 12 hours until the day of the procedure (max. 45 days)

Adult (body-weight 80 kg and above and female)

7500 units every 12 hours until the day of the procedure (max. 45 days).

Prophylaxis of DVT in surgical patients—moderate risk

SC adult: Initially 2500 units for 1 dose, dose to be given 1–2 hours before surgery, then 2500 units every 24 hours.

Prophylaxis of DVT in surgical patients—high risk

SC adult: Initially 2500 units for 1 dose, dose to be administered 1–2 hours before surgery, followed by 2500 units after 8–12 hours, then 5000 units every 24 hours, alternatively initially 5000 units for 1 dose, dose to be given on the evening before surgery, followed by 5000 units after 24 hours, then 5000 units every 24 hours.

Prophylaxis of DVT in medical patients

SC adult: 5000 units every 24 hrs.

Treatment of deep-vein thrombosis,
Treatment of pulmonary embolism

SC adult:

(body-weight 69–82 kg)

15 000 units once daily until adequate oral anticoagulation with vitamin K antagonist established (at least 5 days of combined treatment is usually required).

(body-weight 83 kg and above)

18 000 units

Extended treatment of DVT and prevention of recurrence in patients with solid tumours

Treatment of venous thromboembolism in pregnancy -> not licensed

Question 42

Dalteparin sodium

1. Contra-indications, For all HEPARINS
2. breastfeeding and preganncy
3. cleared by?

Answer 42

1. Acute bacterial endocarditis; after major trauma; epidural anaesthesia with treatment doses; haemophilia and other haemorrhagic disorders; peptic ulcer; recent cerebral haemorrhage; recent surgery to eye; recent surgery to nervous system; severe hypertension; spinal anaesthesia with treatment doses; thrombocytopenia (including history of heparin-induced thrombocytopenia)
2. not know to be harmful but best to avoid
3. kidneys - unfractionated heparin may be preferable.

Question 43

Normal and diabetic blood sugar ranges before and after eating

Ketone ranges

Answer 43

• Healthy individuals
◦ Between 4.0 - 5.4 mmol/L when fasting
◦ Up to 7.8 mmol/L 2 hours after eating
• People with diabetes
◦ Before meals: 4 - 7 mmol/L (T1DM/T2DM)
◦ After meals: <9 mmol/L (T1DM) / <8.5 mmol/L (T2DM)
• Blood ketones
◦ <0.6 = normal
◦ 0.6 -1.5 = extra insulin
◦ >1.5 = DKA

Question 44

Metformin

1. First line for?
2. Benefits?
3. How to take?
4. Types and administration
5. Mechanism
6. S/e
7. Monitoring?

Answer 44

1. T2DM
2. ◦ Effective, safe, inexpensive and may reduce the risk of CVS events and death

◦ Has beneficial effects on HbA1C, weight and CVS mortality

3. ◦ With food usually breakfast and evening meal
4. • Only biguanide on the market

◦ Metform IR (immediate release) - taken up to TDS

◦ Metformin SR (slow release) - taken OD

5. ◦ Prevents the production of glucose in the liver

◦ Improves body’s sensitivity towards insulin- benefits for weight management and not hypoglycaemia

◦ Reduces amount of sugar absorbed into the intestine

6. ◦ GI upset - main reason it may not be tolerated
   ◦ Lactic acidosis
   ◦ Distortion of sense of taste
   ◦ Reports of altered LFTs
   ◦ Hepatitis
   ◦ Skin reactions
   ◦ Reduced vitamin B12 absorption
7. Need to monitor renal function before and at least annually during treatment

Question 45

Sulphonylureas

1. Examples
2. Mechanism
3. How is it taken?
4. S/e
5. Warning -

Answer 45

1. gliclazide, glipizide, glimepiride, tolbutamide
2. ◦ Stimulates insulin release from ß cells of the pancreas by closing ATP-sensitive K+ channels and opening of voltage dependent Ca2+ channels:

‣ Require functioning ß cells to work

‣ Need to be taken with meals to prevent hypo

‣ Risk of accumulation and hypo in renal impairment (ELDERLY)

3. Just before food with breakfast and evening meal
4. ◦ Hypoglycaemia
   ◦ GI upset
   ◦ Skin reactions
   ◦ Reports of decreased hepatic function
   ◦ Abnormalities
   ◦ Hepatic failure
   ◦ Hepatitis
   ◦ Jaundice
   ◦ Blood abnormalities

Obesity as a result of increased plasma insulin concentration

5. Metabolised by liver with urinary excretion of metabolites, so should be used cautiously in the presence of renal or hepatic dysfunction

Question 46

• *Thiazolidinediones - pioglitazone**
  1. Mechanism

2. Adverse effects
3. Warning -
4. May benefit

Answer 46

1. Takes 6 wks to work

◦ Improves metabolic control in patients through improvement of insulin sensitivity

◦ Reduces insulin resistance in adipose tissues/fat, muscle and liver

2. ◦ Water retention
   ◦ Weight gain
   ◦ Eyesight problems
   ◦ Reduced sense of touch
   ◦ Chest pain and infections
   ◦ Allergic skin reactions
3. including HF, macular oedema, bone fractures and bladder cancer
4. CVS parameters, such as lipids, BP, inflammatory biomarkers, endothelial function and fibrinolytic status but oedema can occur therefore not recommended for patients who have any degree of heart disease

Question 47

DPP4 -

1. Examples
2. Mechanism
3. Adverse effects
4. Warning

Answer 47

1. sitagliptin, saxagliptin, linagliptin, alogliptin
2. Blocks the action of enzyme DPP4 which destroys hormone incretin (a natural hormone that tells the body to release insulin when needed such as after eating and reduces the amount of glucose being produced by the liver when it is not needed)

More incretin
‣ Which inhibits glucagon release
‣ Which increases insulin secretion
‣ Decreases gastric emptying
3.
◦ Potential risk of acute pancreatitis
◦ GI problems - nausea, diarrhoea and abdo pain
◦ Flu-like symptoms, signs of URTI, joint pain
◦ Skin reactions/hives
◦ Signs of UTIs/blood in urine

4. ◦ Renal dose adjustment required but can be used in renal impairment (eGFR < 30) - no dose adjustment for linagliptin but adjustment is required for the others

Question 48

SGLT2 (sodium glucose co-transporter-2 inhibitors)

1. E.g.
2. Mechanism
3. Recommended for?
4. Adverse effects
5. Warnings

Answer 48

1. dapagliflozin, canagliflozin, empagliflozin
2. Blocks SGLT2 which reduces the reabsorption of glucose by kidneys and increases glucose excretion in the urine
3. T2DM not for T1DM

◦ Low risk of hypoglycaemia

◦ Reduction in CVS disease and HF risk

◦ Not recommended for people with kidney disease (not in eGFR < 60)

4. ◦ Amputations - stop in diabetic foot
   ◦ Kidney injury (eGFR >45-60)
   ◦ Genital and UTI (W>M) can lead to blood infections
   ◦ Lactic acidosis
   ◦ Bone fractures
   ◦ Bladder cancer risk
5. ◦ SGLT2 in rare cases lead to DKA, this may occur whether the glucose levels are high or healthy (euglycaemic DKA as SGLT2 normalises glucose level in DKA)
   ◦ Caution with loop diuretics

Question 49

GLP-1 (glucagon-like peptide 1)

1. E.g.
2. for?
3. MOA
4. Advantages
5. Adverse effects
6. Warnings

Answer 49

1.

• Exenatide (byetta & bydureon)
• liraglutide (victoza)
• lixisenatide
• dulaglutide (IV)

2. GLP-1 receptor agonists, are normally prescribed for pt who have not been able to control their condition with tablet medication (last resort?)

3.

• Stimulates release of insulin by pancreas,
• inhibits release of gulcagon,
• stomach emptying slows (more satisfied after eating)

4. ◦ Relatively low risk of hypo

◦ Strong efficacy/HbA1c reduction

◦ Weight loss

◦ Other possible benefits (ß cell preservation, CVS benefit) being investigated

5. ◦ Diarrhoea
   ◦ N + V
   ◦ Headaches
   ◦ Dizziness
   ◦ Increased sweating
   ◦ Indigestion
   ◦ Constipation
   ◦ Loss of appetite
6. ◦ Delivered by injection
   ◦ Nausea/GI s/e (~ decreasing over time)
   ◦ More expensive than sulphonylureas/metformin
   ◦ Possibility of slight association with pancreatitis

Question 50

Insulin

1. Rapid acting analogue - e.g.
2. Medium acting insulins - e.g.
3. Long acting insulins -
4. Analogue mixtures - contains rapid acting and slow acting insulin (taken with food)
5. Mixed insulins - fast acting and slow acting insulin (taken 20-30 mins before food)

Answer 50

1. Within 5 mins of a meal
   ◦ Novorapid/Aspart
   ◦ Humalog/Lispro
   ◦ Apidra/Glulisine
   ◦ Fiasp/Aspart
2. 30 mins before food or bed
   ◦ Insulatard
   ◦ Humulin I
   ◦ Insuman Basal
3. Unusual to have no fast acting insulins with a BG insulin
   ◦ Lantus/Abasaglar
   ◦ Levemir//Detemir
   ◦ Toujeo 300 units/ml
   ◦ Degludec/Tresiba
4. ‣ Humalog mix 25
   ‣ Humalog mix 50
   ‣ Novomix 30 - 30% FA and 70% LA
5. Peaks at 1-8 hrs - may stay in system for up to 24 hours (shake thoroughly)
   ‣ Humulin M3 - given on feeds
   ‣ Insuman comb 15/25/50

Question 51

Arrythmia medications

Answer 51

Question 52

Lipid lowering drugs

Examples, MOA, s/e & dose

Answer 52

Statins

E.g. atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altocor), pravastatin (Pravachol), simvastatin (Zocor),

Mechanism = inhibits cholesterol synthesis in hepatocytes by acting on HMG-CoA reductase which also leads to increased clearance of LDLs

S/e = inc transaminase levels, myopathy, GI complaints, arthralgies, headaches

Atorvastatin - 10mg (can be increased to 80mg) if QRISK >20%

20mg given in ACS primary prevention,

80mg in secondary prevention

◦ Uses = IHD, angina, ACS, TIA, stroke
◦ Simvastatin (take at night), rosuvastatin

Nicotonic acid
• Mechanism = inhibits lipoprotein synthesis and raises HDLs, reduces coronary events
• Side effects = flushing, itching, headache, N+V, hepatotoxicity, GI or peptic ulcer, hyperglycaemia, decreased insulin sensitivity

Ezetimibe
• Mechanism = cholesterol lipase inhibitor which selectively inhibits intestinal cholesterol absorption
• Side effects = headache, abdominal pain, diarrhoea
• Dose = 10mg

PCSK9 inhibitors
• Mechanism = reduces LDL receptors - more cholesterol removed
• Side effects = nasal complaints, oropharyngeal pain, pulmonary reactions, skin reactions
• E.g. alirocumab, evolocumab

Question 54

What is diltiazem?

Indication?

s/e?

Answer 54

Calcium channel blocker -> relaxing the blood vessels

HTN, angina

Dizziness; flushing; headache; nausea; palpitations; peripheral oedema; rash; tachycardia; vomiting

Question 55

Some DOAC medications include:

Answer 55

• Apixaban (Eliquis®)
• Dabigatran (Pradaxa®)
• Rivaroxaban (Xarelto®)
• Edoxaban (SavaysaTM)

Question 56

What is the MOA for DOACs?

Answer 56

Question 57

What is Enoxaparin? MOA?

Answer 57

LMWH

Enoxaparin binds to and potentiates antithrombin (a circulating anticoagulant) to form a complex that irreversibly inactivates clotting factor Xa. It has less activity against factor IIa (thrombin) compared to unfractionated heparin (UFH) due to its low molecular weight.