EXTRA- High Risk Drugs Flashcards by Rachel Cornish

What’s amiodarone t1/2? As a result of this what may be required?

About 50days

Loading doses may be required

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Monitoring requirements for amiodarone

Thyroid function 
LFTs 
Serum potassium 
Chest X-ray 
ECG (with IV use)

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Warning signs of amiodarone

Hypo/hyperthyroidism 
Impaired vision 
Photophobia 
SoB or cough 
Liver disease (jaundice)
Tremor &amp; peripheral neuropathy 
Phototoxic skin reactions e.g slate grey skin

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Amiodarone counselling points

Shield skin from sunlight and for several months after stopping treatment
May be dazzled by headlights at night
Clinical effects can occur up to a year after stopping

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Amiodarone + simvastatin interaction

Increased risk of myopathy

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Amiodarone increases the plasma concentrations of what drugs

Coumarins 
Dabigatran 
Digoxin 
Flecainide 
Phenindione 
Phenytoin

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Why is there potential for drug interactions even when amiodarone is stopped

Cos of its long half life

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Monitoring requirements for antihypertensives

Blood pressure
Heart rate
Renal function
Serum electrolytes

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Grapefruit juice increases the plasma concentrations of what antihypertensives

Ivabradine
Aliskiren
CCB

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Therapeutic range for carbamazepine

4-12mg/L

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Monitoring for carbamazepine

FBC
Renal function
Liver function

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Toxicity signs for carbamazepine

Incoordination 
Blurred vision 
Diplopia 
Drowsiness 
Nystagmus 
Ataxia 
Arrhythmias 
N&amp;v 
Diarrhoea 
Hyponatraemia

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Signs of blood disorders with carbamazepine

E.g leukopenia, thrombocytopenia (fever, sore throat, unexplained bruising or bleeding)

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Symptoms of antiepileptic hypersensitivity syndrome that can occur with e.g carbamazepine

Fever
Rash
Swollen lymph nodes

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You get increased plasma concentrations of carbamazepine with what 6 drugs

Acetazolamide 
Cimetidine 
Clarithromycin 
Erythromycin 
Fluoxetine 
Isoniazid

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What three drugs decrease carbamazepine levels

Phenytoin
Rifabutin
St. John’s wort

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Carbamazepine decreases the plasma concentration of what 7 classes of drug

Antipsychotics 
Corticosteroids 
Coumarins 
Eplerenone 
Oestrogens 
Progestogens 
Simvastatin

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The carbamazepine anticonvulsant effect is antagonised by what

Mefloquine

Antipsychotics

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Reaction between orlistat and antiepileptics (e.g carbamazepine)

Increased risk of convulsions

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Side effects of chemotherapy

Extravasation 
N&amp;V 
Bone marrow suppression 
Oral mucositis 
Neurotoxicity (vinkaalkaloids) 
Cardiotoxicity (anthracyclines) 
Diarrhoea 
Fatigue

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Monitoring requirements for ciclosporin

FBC 
LFT 
Serum electrolytes (K, Mg) 
Blood lipids,
Renal function 
BP 
Dermatological and physical exam

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Warning signs for ciclosporin

Neurotoxicity 
Blood disorders
Liver toxicity 
Nephrotoxicity 
Hypertension 
Headache 
Gingival hyperplasia

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Actions required for ciclosporin

Hypertension is common
No live vaccines 
Brand specific 
Avoid exposure to UV light
Avoid high potassium diet and grapefruit juice

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Ciclosporin does what to plasma concentrations of digoxin

Increases it

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Ciclosporin + statin interaction

Myopathy

What drugs decrease the plasma concentration of ciclosporin

``` Carbamazepine Orlistat Phenobarbital Phenytoin Rifampicin SJW ```

Increased risk of hyperkalaemia if you have ciclosporin and what?

ACEI ARB aldosterone antagonist

Monitoring for corticosteroids

``` BP Blood lipids Serum K Body weight and height Bone mineral density Blood glucose Eye exam Adrenal suppression ```

Warning signs of corticosteroids

``` Paradoxical bronchospasm Symptoms of uncontrolled asthma Frequent courses of antibiotics Adrenal suppression Immunosuppression Psychiatric reactions ```

Signs of adrenal suppression

``` Nausea Vomiting Weight loss Fatigue Headache Muscular weakness ```

Therapeutic range of digoxin

1-2mcg/L

Monitoring for digoxin

``` Serum electrolytes (hypo K, Mg, Ca) potentiates toxicity Renal function Heart rate (maintain at greater than 60 bpm) ```

Warning signs for digoxin

Cardiac (arrhythmias/heart block) Neurological GI Visual (blurred/yellow vision)

You get increased digoxin levels with what drugs

``` Alprazolamiodarone Ciclosporin Diltiazem Itraconazole Lercanidipine Macrolides Mirabegron Nicardipine Nifedipine Quinine Spironolactone Verapamil ```

True or false: SJW increases plasma conc of digoxin

False it decreases it

Concomitant administration of what drugs with digoxin can cause hypokalaemia thus increasing toxicity?

Acetazolamide Amphotericin Loop diuretic Thiazides & related

Drugs that impair renal function can affect the plasma digoxin concentration - give two examples of drugs that impair renal function

NSAIDs | ACEI

Monitoring for diuretics

BP Serum electrolytes Weight (as a measure of fluid loss)

Warning signs for diuretics

Heaviness in centre of chest Water retention Depression Extreme tiredness, thirst or excessive urination Irregular heartbeat, muscle weakness, nausea Gout

Increased risk of hyperkalaemia when potassium sparing diuretics or aldosterone antagonists given with what meds?

``` ACEI ARB Ciclosporin Potassium salts Tacrolimus ```

Hypokalaemia cause by acetazolamide, loop, thiazides increases the risk of ventricular arrhythmias when given with what

Amisulpride Atomoxetine Pimozide Sotalol

Hypokalaemia caused by diuretics increases the risk of cardiac toxicity with what specific class of drug

Cardiac glycosides

Clarithromycin and itraconazole increases the plasma concentration of what diuretic

Eplerenone

Plasma concentration eplerenone is reduced by what drugs

``` Carbamazepine Phenobarbital Phenytoin Rifampicin SJT ```

Increased risk of ototoxicity when you give loop diuretics with what 3 drugs

Aminoglycosides Polymixins Vancomycin

Therapeutic range for gentamicin and target trough conc

5-10mg/L (3-5mg/L for endocarditis) | Trough: <2mg/L (<1mg/L in endocarditis)

Monitoring requirements for gentamicin

Renal function | Auditory and vestibular function

True or false: pt must be fluid restricted when starting an aminoglycoside

False! Must ensure adequate hydration

Increased risk of nephrotoxicity when aminoglycosides are given with what

Ciclosporin Tacrolimus Vancomycin

Increased risk of ototoxicity when aminoglycosides given with what

Loop diuretics | Vancomycin

Monitoring for insulin

Blood glucose | HBA1C

Warning signs for insulin

Recurring hypos Signs of DKA Symptoms of liver toxicity, heart failure, pancreatitis Ulceration of foot tissue

List some drugs that may lower insulin requirements

``` Oral antidiabetic meds ACEI MAOIs Salicylates Sulphonamide abx ```

Substances that may increase insulin requirements

``` Corticosteroids Diuretics Sympathomimetics (ephedrine, salbutamol, terbutaline) Thyroid hormones Oral contraceptives ```

Two things that can potentiation and/or weaken insulin activity

Beta blockers | Alcohol

Max concentration of IV K+ ?

40mmol/litre

How is IV potassium given and what is required

SLOW IV infusion | Needs ECG and electrolyte monitoring

Recommended maximum rate of K+ IV infusion

20mmol / hour

Therapeutic range for lithium

0.4-1 mmol/L

Monitoring requirements for lithium

Lithium conc Renal function Cardiac function Thyroid function

Interaction between lithium + amiodarone

Increased risk of ventricular arrhythmias

Lithium + what drugs increases toxicity

``` ACEI/ARBs Diuretics NSAIDs Metronidazole SSRIs TCAs ```

Lithium + what drugs results in increased risk of neurotoxicity

``` Methyldopa Phenytoin Carbamazepine Diltiazem Verapamil ```

Lithium plus what drugs can increase risk of extrapyramidal side effects

``` Clozapine Haloperidol Sulpiride Phenothiazines Risperidone Flupentixol Zuclopenthixol ```

Methotrexate monitoring

FBC Renal function Liver function

Methotrexate warning signs

``` GI toxicity e.g stomatitis Liver toxicity Blood disorders Pulmonary toxicity Preganancy and breast feeding ```

What increases the plasma concentration and risk of hepatotoxicity when given with MTX

Acitretin

Excretion of MTX is reduced by what drugs

``` NSAIDs Penicillins Ciprofloxacin Doxycycline Tetracycline Sulfonamides Ciclosporin PPI Leflunomide ```

MTX plus what increases risk of haematological toxicity

Sulfamethoxazole (co-trimox) or trimethoprim

NSAIDs + quinolones

Increased risk of convulsions

NSAIDs + coumarins and phenindione

Possible enhanced anticoagulant effect

NSAIDs increase the effects of what oral antidiabetic class

Sulfonylureas

NSAIDs may reduce the excretion of what two drugs

Lithium | Methotrexate

NSAIDs increased risk of nephrotoxicity when given with what drugs?

Ciclosporin Tacrolimus Diuretics

Monitoring for NSAIDs

BP Renal function Liver function Haemoglobin

Monitoring for opiates

Pain | Sedation

Warning signs for opiates

``` Respiratory depression Bradycardia, hypotension Extreme sleepiness Reduce concentration Cyanosis Vivid dreams Convulsions Pinpoint pupils ```

Opiates + alcohol

Enhanced hypotensive and sedative effects

Tramadol enhances the anticoagulant effects of what

Coumarins

Rifampicin can decrease the effects of what opiates

``` Fentanyl Morphine Codeine Methadone Alfentanyl ```

Opiates + MAOIs

CNS excitation or depression

Warning signs for oral antiplatelets

``` Chronic GI bleeding Heaviness in centre of chest Severe itching or rash Unusual bruising or bleeding Pregnancy or breastfeeding ```

Clopidogrel antiplatelet effects are reduced by which PPIs?

Omeprazole | Esomeprazole

What's the therapeutic range of phenytoin

10-20mg/L

True or false: small changes in dose/missed dose / change in drug absorption can result in marked change in plasma drug concentration of phenytoin

True- non linear relationship

Monitoring requirements for phenytoin

``` Serum conc ECG + BP with IV LFT FBC Serum folate Vitamin D ```

How is phenytoin metabolised

Hepatic metabolism

Warning signs for phenytoin

``` Toxicity Skin disorders Blood disorders Suicidal thoughts Low vitamin D ```

Toxicity signs of phenytoin

``` Nystagmus Ataxia Slurred speech Hyperglycaemia Diplopia Blurred vision ```

Equivalents of phenytoin sodium and phenytoin base

Phenytoin sodium 100mg | Phenytoin base 92mg

What drugs reduce the plasma concentrations of phenytoin

``` Rifampicin SJW theophylline Itraconazole Ciclosporin ```