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My final pre-reg flashcards > Final clinical flashcards > Flashcards

Final clinical flashcards

1
Q

Classes of antiarrhythmic drugs (5)

A
  1. Na+ blocking, membrane stabilising
  2. Beta blockers
  3. K+ channel blocking
  4. Non dihydropyridine CCBS
  5. Others
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2
Q

Class 1 antiarrhythmic drugs (3)

A
  1. Na+ blocking
  2. E.g lidocaine, propenafone, flecanide (split into further classifications)
  3. Contraindicated in asthma, copd, structural/IHD
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3
Q

Class 2 antiarrhythmic drugs (2)

A
  1. Beta blockers

2. Cardiospecific beta blockers: acebutol, atenolol, bisoprolol metoprolol, nebevilol

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4
Q

Class 3 antiarrhyhmic drugs (4)

A
  1. K+ channel blockers
  2. E.g. amiodarone, dronedarone, sotalol
  3. Amiodarone is 4 weeks before and 12 months after electrical cardioversion to increase success
  4. Dronedarone is associated with hepatotoxic and HF side effects
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5
Q

Class 4 antiarrhythmic drugs (4)

A
  1. Rate limiting CCBS (non-dihydropyridine)
  2. E.g verapamil, diltiazem
  3. Avoid verapamil in beta blocker pts (increased risk of hypotension and asystole)
  4. Diltiazem is unlicesned for arrhythmia
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6
Q

Class 5 antiarrhythmic drugs (3)

A
  1. Other
  2. E.g adenosine and digoxin
  3. Digoxin is only used if sedentary + AF+ congestive heart failure altogether
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7
Q

Maintenance treatment AF (2)

A
  1. Rate control is 1st line, rhythm control is 2nd line

2. Anticoagulation needed for stroke prophylaxis?

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8
Q

Rate control for AF (3)

A
  1. Beta blocker
  2. Rate limiting CCB
  3. Beta blocker+rate limiting CCB/ digoxin
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9
Q

Rhythm control for AF (2)

A
  1. Beta blocker

2. Sotalol/ amiodarone/ flecainide, propafenone, dronedarone

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10
Q

How to assess stroke and bleed risk in AF

A
  1. CHADsVASc and HASBLED
  2. Anticoagulate if chadvasc is 2 or more
  3. Consider further if HASBLED high risk of bleed 3 or more
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11
Q

CHADsVASc risk factors

A 
Congestive HF
HTN
Age (75+) -2 
Diabetes
Stroke - 2
Vascular disease
Age (65-74)
Sex
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12
Q

HAS BLED risk factors

A 
HTN
Liver disease (bilirubin 2x normal and ALT etc 3x normla)
Renal impairment
Stroke history
Bleeding history
Labile INR
Elderly
Drugs (inc etoh)
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13
Q

If anticoagulation indicated in AF (as per chadvasc and hasbled)

A

If new onset give parenteral

If diagnosed, warfarin or DOAC

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14
Q

Amiodarone main indication

A

Treatment of arrhythmias, particularly when other drugs are ineffective or contraindicated

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15
Q

Amiodarone mode of action

A

K+ channel blocker. Prolongs the repolarization of the heart during phase 3 of the cardiac action potential, prolonging the length of the action potential.

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16
Q

Amiodarone side effects (8)

A
  1. Optic neuropathy (may cause blindness). Stop immediately if signs of impaired vision.
  2. Corneal microdeposits. May reverse on stopping. Cause night time glares when driving.
  3. Grey slated skin on exposure to sunlight (use wide spectrum, high SPF sunscreen for months after stopping)
  4. Phototoxicity.
  5. Peripheral neuropathy
  6. Pulmonary fibrosis, pneumonitis (SOB, cough)
  7. Hepatotoxicity. Watch out for nausea, vomiting, malaise, jaundice, itching, bruising, abdo pain.
  8. Thyroid issues (if hyper stop and give carbimazole, if hypo can continue and give levo)
    Also commonly causes constpiatiom, movement disorders, sleep disorders, altered taste, vomiting
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17
Q

Amiodarone monitoring (5)

A
  1. K+ beforehand as may cause hypokalemia
  2. Chest x ray before
  3. TFTs before and then 6 monthly
  4. LFTs before and 6 monthly
  5. Annual eye tests (not in BNF)
    +HR and BP as can cause hypotension and bradycardia
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18
Q

Amiodarone interactions (4)

A

Remember has a half life of around 50 days

  1. Enzyme inhibitors can increase the concentration of amiodarone e.g. grapefruit
  2. Amiodarone itself is an enyzme INHIBITOR and so increases the concentration of digoxin, warfarin and phenytoin (must half dose)
  3. Amiodarone increases the risk of myopathy and so avoid where possible. Manufacturer advises for simvastatin max 20mg OD with amiodarone/ amlodipine/ ranolazine/ verapamil/ diltiazem. (note max 40mg max for ticagrelor+simvastatin)
  4. Beta blockers and rate limiting CCBS can cause bradycardia, AV block and myocardial depression
  5. QT prolongation. Quinolone, macrolides, TCAs, SSRIs, lithium, quinine, hydroxychloroquinie, anti-malarials, antipsychotics
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19
Q

Drugs which prolong QT and therefore interact with amiodarone (9)

A
  1. TCAs
  2. SSRIs
  3. Lithium
  4. Quinine
  5. Quinolones
  6. Macrolides
  7. Hydroxychloroquinine
  8. Antimalarials
  9. Antipsychotics
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20
Q

Amiodarone: other

A

MHRA/CHM advice: Sofosbuvir with daclatasvir; sofosbuvir and ledipasvir (May 2015); simeprevir with sofosbuvir (August 2015): risk of severe bradycardia and heart block when taken with amiodarone (avoid but if necessary, counsel on signs of bradycardia and heart block)

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21
Q

Indications for digoxin (2)

A
  1. Maintenance for AF/ flutter (125-250)

2. Worsening/ severe heart failure in sinus rhythm (62.5-125)

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22
Q

Mode of action of digoxin

A

Digoxin induces an increase in intracellular sodium that will drive an influx of calcium in the heart and cause an increase in contractility. Cardiac output increases (positive inotrope) with a subsequent decrease in ventricular filling pressures. AV Node Inhibition: Digoxin has vagomimetic effects on the AV node. By stimulating the parasympathetic nervous system, it slows electrical conduction in the atrioventricular node, therefore, decreases the heart rate (negative chronotrope)

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23
Q

Bioavailability of digoxin preparations

A

Elixir 65%
Tablet 90%
IV 100%
BNF: “when switching from IV to oral route may need to increase dose by 20-33% to maintain the same plasma digoxin concentration)

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24
Q

Causes of digoxin toxiicty (4)

A
  1. Hypokalemia
  2. Hypomagnemesia
  3. Hypercalcemia
  4. Renal impairment
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25
Q

Signs of digoxin toxiicty

A
  1. Bradycardia/ heart block
  2. N+V, diarrhoea, abdo pain
  3. Blurred/ yellow vision
  4. Confusion/ delirium
  5. Rash
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26
Q

Digoxin - interactions (4)

A
  1. Increased Cp due to presence of enzyme inhibitors
  2. Decreased Cp in response to enzyme inducers
  3. Reduced renal excretio may lead to toxicity - watch out for NSAIDs, ACEI/ ARBs
  4. Hypokalemia predisposes, so avoid diuretics, B2 agonists, steroids, K+sparing diuretics
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27
Q

Drugs which may cause hypokalemia and therefore precipitate digoixin toxicity (4)

A
  1. Diuretics (loops eg furosemide and thiazides eg bendro)
  2. B2 agonists
  3. Steroids
  4. Theophylline
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28
Q

Target K+ if patient is on digoixin

A

4.5mmol/L.

If less than this give either K+ supplements or K+ sparing diuretics (eg spironolactone, eplerenone)

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29
Q

Drugs which precipitate digoxin toxicity

A

Anything that causes hypokalemia (loop+thiazide diuretics, asthma drugs)
Enzyme inhibitors as they increase the level of digoxin (eg amiodarone)
Drugs which cause renal failure
Drugs which cause hypomagnemesia
Drugs which cause hypercalcemia

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30
Q

Types of VTE (2)

A
  1. DVT

2. PE (detached blood clot travels to lungs and blocks pulmonary artery)

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31
Q

Risk factors for VTE (8)

A 
Malignancy
History of VTE
Thrombophilic disorder
Pregnancy
COC/ HRT
Immobility
Age >60
BMI>60
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32
Q

Risk factors for bleed (5)

A 
Systolic HTN
Anticoagulants
Bleeding disorders
Acute stroke
Thrombocytopenia
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33
Q

Prophylaxis of VTE: treatment options

A 
Mechanical prophylaxis (TEDs, IVC)
LMWH+UFH preferred in renal impairment
Fondaparinux is another option in certain cases
Apixaban+ rivaroxaban+ dabigatran are for post knee/ hip replacement
Edoxaban is for recurrent VTE
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34
Q

Prophylaxis of VTE: duration of prophylaxis

A

5-7 days post surgery /sufficient mobility
extended if hip/ knee
28 day if cancer related abdo surgery/ pelvis surgery- major

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35
Q

Treatment of VTE (non pregnant)

A

Apixaban or rivaroxaban
LMWH or UFH (monitor APTT) in renal failure
Fondaparinux
LMWH for 5 days» then edoxaban/ dabigatran
LMWH+ warfarin for 5 days or until INR 2.0 or more for 2 consecutive readings

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36
Q

Treatment of VTE in pregnancy

A

LMWH preferred

Measure antixa activity routinely if extremes of body weight

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37
Q

Anticoagulants

A

Parenteral (UFH, LMWH, fondaparinux)

Oral (DOAC, warfarin)

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38
Q

The heparins

A

UFH - activates antithrombin. short acting. good if high risk of bleed or renal impairment. Must monitor APTT.
LMWH - anti xa inhibitor. longer acting. used in pregnancy. lower risk of osteoporosis and HIT.

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39
Q

Heparins - side effects (4)

A
  1. Haemorrhage (stop heparingive protamine)
  2. Hyperkalemia (as inhibits aldosterone) - monitor before treatment+ if cont for >7 d. Higher risk if DM/ CKD.
  3. Osteoporosis
  4. HIT (usually starts 5-10 d after treatment). monitor platelets before+ if >4 d
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40
Q

DOACs

A

Dabigatran - direct thrombin inhibitor (note bottles have a 4 month expiry)
Others -anti xa
Rarely cause bleeds.
Patient alert card
Take at same time of day, with full glass of water
If dose missed do NOT double next day
Avoid if antiphospholipid syndrome (not as effective as warfarin as per MHRA warning)

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41
Q

DOAC reversal agents

A

Dabigatran - praxbind (idarucizumab)

Apixaban+ rivaroxaban (ondexxya, andexanet alfa)

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42
Q

DOAC interactions (8)
https://hertsvalleysccg.nhs.uk/application
/files/1716/2340/3507/Drug_interactions_with
_NOACs_hmmc_june_2019_version_1.1.pdf

A

Strong inhibitors of p-gp or cyp3a4 increase the circulating levels of doacs
Many, so always check interactions
But the key key ones are:
1. Dronedarone
2. HIV protease inhibitors
3. Antifungals 4. Rifampicin
5. Antirejection agents (ciclosporin and tacrolimus)
6. AEDs (carbamazepine, phenytoin, phenobarbitone)
7. Antiplatelets (particulary prasugrel, ticagrelor)
8.St Johns wort
Also consider GI risk for NSAIDs, SSRIs, SNRIs

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43
Q

DOAC counselling

A

Patient alert card
Take at same time each day with a full glass of water
Do not double dose next day

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44
Q

Warfarin indications (3)

A
  1. Prophylaxis of a clot (rheumatic heart disease, AF, insertion prosthetic heart valve)
  2. Treatment of a VTE/ PE
  3. TIAs
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45
Q

Warfarin mode of action

A

Inhibits VKORC1 - which activates vit K. This menas warfarin depletes levels of FUNCTIONAL vit k and so reduces production of clotting factors.

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46
Q

Warfarin dosing: basics (dose, packet colors)

A 
5mg starting dose. Test INR every 1-2 days. Maintenance 3-9mg. Same time every day.
0.5mg - white
1mg - brown
3mg - blue
5mg - pink
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47
Q

Warfarin dosing: duration of treatment (DVT, x2 VTE)

A

DVT in calf: 6 wks
VTE if provoked: 3 mths
VTE if unprovoked: 3mths + (long term considered)

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48
Q

Side effects of warfarin (2)

A
  1. Bleeding (phytomenadione)

2. Calciphylaxis (MHRA - report if painful skin rash)

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49
Q

Monitoring of warfarin

A 
Once stable, 3monthly INR
INR targets should be 
<1.1 in normal people
2.5 for most indications, except
3.5 for valve replacement or recurrent DVT/ PE
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50
Q

Warfarin toxicity

A

Bleeding

If major, stop warfarin give IV phytomenadione and dried prothrombin complex or fresh frozen plasma

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51
Q

Warfarin: food/ herbal/ drink interactions

A 
Pomegranate, cranberry juice
Alcohol (decreases w effect)
Vitamin E
Vitamin K
St Johns Wort (decreases w effect)
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52
Q

Warfarin: drug interactions (serious) (6)

A
  1. Antibiotics (trimethoprim, co-trimoxazole, sulfonamides, metronidazole, rifampicin )
  2. Antifungals (miconazole - bleeding can take 15 days to develop. raised INR within 3 days., voriconazole)
  3. Antidiabetic drugs (glucagon)
  4. Antiepileptic drugs (carbamazepine, barbituates, primidone)
  5. Heart drugs (amiodarone, fibrates)
  6. Anticancer drugs/ hormones (anabolic steroids, tamoxifen, fluorouracil and prodrugs eg capcitabine, testosterone)
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53
Q

Warfarin: other key points (3)

A
  1. Counselling - take at same time each day, yellow book, alert card
    2.MHRA warnings - calciphylaxis, RISK INCREASED IF CKD.
    Direct acting antivirals to treat chornic hepatitis C
  2. Warfarin in surgery - special requirements as per BNF (differs depending on whether elective or emergency)
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54
Q

What increases the risk of calciphylaxis in patients on warfarin?

A

CKD

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55
Q

Warfarin and elective surgery

A

If elective - stop 5 days before.
Give PO phytomenadione if INR >1.5 the day before
Restart warfarin the evening of surgery or the next day if all g
If high risk of clot, bridge with a LMWH. Stop it at least 24h before surgery. Do not restart LMWH untli at least 48 hours after surgery.

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56
Q

Warfarin and emergency surgery

A

Delay for 6-12h and give IV phytomenadione

If you can’t delay, give dried prothrombin complex+ phytomenadione. Check INR before surgery.

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57
Q

Treatment of haemorrhagic stroke longer term (2)

A

Treat HTN, avoid hypoperfusion

Avoid anticoag, aspirin, statins

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58
Q

Treatment of TIA

A

300mg aspirin for 14 days
Then onto clopidogrel 75mg OD long term (/ aspirin+ dipyridiamole/ aspirin)
+atorvastatin 80mg, HTN drug (But not a beta blocker)
HTN target <130/80

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59
Q

Treatment of ischaemic stroke

A

Alteplase within 4.5h
If no alteplase- aspirin within 48 hours
Then onto clopidogrel 75mg OD long term ( /aspirin+dipyridamole/ aspirin)
+atorvastatin 80mg, HTN drug (But not a beta blocker)
HTN target <130/80

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60
Q

What if the ischaemic stroke patient has AF?

A

Wait 2wks before anticoagulating - give aspirin before this.

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61
Q

Types of antiplatelets

A
  1. Aspirin
  2. Clopidogrel
  3. Dipyridamole (take 30-60 mins before and discard after 6 weeks)
  4. Glycoprotein IIa/IIb inhibitors
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62
Q

Stages of HTN

A

Normal: 120/80
Stage 1: 140/90 (135/85)
Stage 2: 160/100 (150/95)
Stage 3 (crisis): 180/110

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63
Q

What to do if at each stage of HTN

A

Stage 1 - only treat if meet 5 criteria
Stage 2 - always treat
Stage 3 - urgent IV (if target organ damage)/PO over 24-48h

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64
Q

5 criteria for treating stage 1 HTN (140/90 - 135/85) IF UNDER 80

A

If under 80…

  1. QRISK 20 or more
  2. Renal disease
  3. Diabetes
  4. CVD
  5. Target organ damage
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65
Q

Treatment pathway for HTN

A

If <55 - ACEI/ARB/ diabetes
If 55 or older/ afro-carribean: CCB
If failure, both together
If failure again, add in thiazide like diuretic
If failure again, more diuretic, alpha blokcer, beta blocker (but not with thiazide diuretic due to risk of hyperglycaemia)

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66
Q

BP targets

A

> 80: 150/90
Renal disease: 140/90 or 130/80 if CKD/ diabetes/ proteinuria >1g in 24h. consider ACEI or ARB if proteinuria present.
Pregnancy (chronic HTN): 150/90 or 140/90 if had birth or target organ damage
Diabetes: 140/80 or 130/80 if end target organ damage
Healthy: 140/90
Atherscleortic CVD: 130/80

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67
Q

Gestational diabetes

A

Target for chronic HTN: 150/90 or 140/90 if given birth/ target organ damage
Treatment options:
1. Labetalol is 1st line (hepatotoxic) but do NOT give in 1st trimester
2. Methyldopa (must stop 2 days after birth) - drowsiness and driving
3. M/R nifedipine (this is unlicensed)

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68
Q

Labetalol key points (3)

A
  1. 1st line
  2. Do NOT give in 1st trimester
  3. Is hepatotoxic
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69
Q

Methyldopa key points (3)

A
  1. Must stop 2 days after birth
  2. Drowsiness and driving
  3. 2nd line
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70
Q

Antihypertensives

A
  1. ACEIs
  2. ARBs
  3. CCBs
  4. Diuretics
  5. Alpha blockers (prazosin)
  6. Beta blockers
  7. Centrally acting - methyldopa, clonidine (flushing)
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71
Q

ACEI key points (3)

A
  1. Perindopril should be taken 30-60 minutes before food
  2. Captopril is only BD
  3. Take first dose at bedtime
    +avoid in pregnancy
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72
Q

ACEI/ ARB side effects (6)

A 
Dry cough due to build up of bradykinin (give ARB)
Hyperkalemia
Angiodema (anaphylaxis)
Nephrotoxic
Hepatic effects
Hypoglycaemia
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73
Q

ACEI/ARB interactions (3)

A
  1. Hyperkalemia-k+ sparing diuretics
  2. Nephrotoxicity and reduced eGFR-nsaids
  3. Hypotension-diuretics
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74
Q

Intrinsic sympathomimetic activity beta blockers

A 
PACO
Pinodolo
Acebutol
Celiprolol
Oxprenolol
Mean that less bradycardia and less coldness of extremities
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75
Q

Water soluble beta blockers

A 
Water CANS
Celiprolol
Atenolol
Nadolol
Sotalol
Less likely to cross the BBB and so cause nightmares and sleep disturbance.
REDUCE DOSE IN RENAL IMPAIRMENT.
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76
Q

Cardioselective beta blockers

A 
Atenolol
Acebutolol
BISOPROLOL
Nebivolol
Metoprolol
Cardioselective
Less bronchospasm and so well controlled asthma under a specialist if no other choice
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77
Q

Beta blockers with an intrinsically long duration of action

A 
BACoN
Bisoprolol
Atenolol
Celiprolol
Nadolol
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78
Q

Side effects of beta blocker (4)

A
  1. Bradycardia
  2. Cold peripheries
  3. Hypotension
  4. Masks symptoms of hypoglycaemia
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79
Q

Contraindications of beta blockers (4)

A
  1. Asthma (bronchospasm)
  2. Unstable heart failure
  3. 2nd/3rd degree heart block
  4. Severe hypotension and bradycardia
    ++++++++++caution if enzyme inhibitors as these increase Cp of beta blockers
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80
Q

Beta blockers interactions (2)

A
  1. Asystole+hypotension eg verapamil injection

2. Hyperglycaemia eg thiazide diuretics

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81
Q

Side effects of CCBs (3)

A

Ankle swelling
Flushing
Headaches

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82
Q

Rate limiting CCBs- key factors

A

Verapamil causes constipation

Diltiazem must maintain same brand when doses >60mg

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83
Q

Heart failure symptoms

A

Oedema (pulmonary-SOB, peripheral - swollen ankles or legs)
Dyspnoea (during activity/ at rest)
Fatigue/ exercise intolerance

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84
Q

Treatment of HF as per NICE guidance

A
  1. ACEI/ARB + beta blocker (alternatively hydralazine+isosorbide dinitrate for specialist use only)
  2. Add in spironolactone/ epleronone (alternatively hydralazine and isosorbide dinitrate in Afro/carribean, or and ARB with an ACE if no other option)
  3. Ivabrandine/ digoxin
    +for fluid overload add on loop diuretics/ thiazide like diuretics
85
Q

Diuretics in HF

A

Give epleronone as 2nd line for HF instead of spiro if the patient has had an acute MI with LVSD or mild HF
Loop diuretics for fluid overload are preferred in patients with poor renal function (<30ml/min) whereas thiazide like diuretics are of benefit in patients with mil HF and good renal function

86
Q

Causes of hyperlipidemia

A

Drugs-antipsychotics, immunosuppressants, corticosteroids, HIV drugs
Conditions-r HYPOTHYROIDISM, renal disease, liver disease, diabetes, family hx, lifestyle

87
Q

Cholesterol targets in healthy people

A

Total - <5mmol/L
LDL - <3mmol/L
HDL ->1mmol/L

88
Q

Cholesterol targets in at risk people

A

Total- <4mmol/L
LDL - <2mmol/L
HDL ->1mmol/L

89
Q

When to give primary prevention (atorvastatin 20mg OD)

A

QRISK >10% in 84 or younger
OR
No QRISK needed (or treatment to be considered) if T1DM/ over 85/ CKD/ familial hypercholesterolemia
https://cks.nice.org.uk/topics/lipid-modification-cvd-prevention/

90
Q

Types of lipid modifying drugs (4)

A 
Statins
Fibrates 
Ezetimibe
Bile acid sequestrants
Nicotinic acid
91
Q

Statin indications

A 
Primary hypercholesterolaemia (high intensity)
Familial hypercholesterolaemia (high intensity)
Moderate hypertriglyceridemia
92
Q

Statin MOA

A

Decreases LDL cholesterol by inhibition of HMG-CoA reductase

93
Q

The 5 types of statin

A 
Atorvastatin
Fluvastatin
Pravastatin
Rosuvastatin
Simvastatin
94
Q

Statin side effects (3)

A
  1. Myopathy
  2. DM
  3. Interstitial lung disease
95
Q

Statin monitoring

A

LFTs (discontinue if transaminases 3x normal)
TFTs
Renal function
Lipid profile (baseline)
HbA1c - high risk of developing diabetes
Creatinine kinase if muscle pain (discontinue if 5x than usual)

96
Q

Statins interactions

A
  1. Antimicrobials - macrolides, fusidic acid, imidazole, triazoles
  2. Heart drugs - CCBS, amiodarone, ezetimibe/ fibrates
  3. Other- grapefruit juice, ciclosporin (atorva), clopidogrel (rosuva)
    ALL INCREASE THE CP OF STATIN, INCREASING THE RISK OF MYOPATHY
97
Q

What to do if macrolide+ statin

A

Stop statin until course complete

98
Q

What to do if fusidic acid+ statin

A

Restart statin 7 days after last fusidic acid dose

99
Q

What to do if fibrate+ simvastatin

A

Max 10mg simvastatin

100
Q

What to do if amiodarone+simvastatin

A

Max 20mg simvastatin

101
Q

What to do if amlodipine/ diltiazem/ verapamil+simvastatin

A

Max 20mg simvastatin

102
Q

What to do if ciclosporin+ atorvastatin

A

Max 10mg atorvastatin

103
Q

What to do if rosuvastatin + clopidogrel

A

Initially 5mg, max 20mg rosuvastatin

104
Q

Statins in pregnancy

A

Teratogenic
Effective contraception during+ 1 month after stopping
Stop taking 3 months before conceiving and restart after breastfeeding finished

105
Q

MHRA warning simvastatin

A

80mg high risk of myopthay

106
Q

People who are high risk of myopathy

A

Family hx
High etoh intake
Renal impairment
Hypothyroidism

107
Q

Things to check for before initiating statin (4)

A

Hypothyroidism
DM
Nephrotic syndrome
Liver disease

108
Q

High intensity statins >40% reduction

A

Atorva 80, 40, 20
Rosuva 40, 20, 10
Simva 80

109
Q

Medium intensity statins (31-40%)

A

Atorva 10
Fluva 80
Rosuva 5
Simva 40, 20

110
Q

Low intensity statins (20-30%)

A

Fluva 40,20
Prava 10,20,40
Simva 10

111
Q

Ezetimibe - key facts (2)

A

Alternative to statin in primary/ familial hypercholestermia

Interacts with statins - myopathy

112
Q

Fibrates - key facts (2)

A

Used for severe hypertriglyceridemia >10mmol or in those who cannot tolerate statins
Do not use with statin due to myopathy risk
Also risk of renal impairment7

113
Q

Bile acid sequestrants - key facts

A

Decrease cholesterol, specialist use. Colesevam, colestipol and colestyramine.
These impzzair the absorption of fat soluble vitamins eg ADEK
+ other drugs should be taken 1 hour before it or 4 hours after it OR 4 hours before and 4 hours after in the case of coleveselam

114
Q

Acute angina attack

A

GTN (spray/ tab) - a short acting vasodilator which improves blood supply
Works for 20-30 minutes
Give 1 dose (1 tab or 1-2 sprays), wait 5 mins and readminister if not worked. Give 3 doses (15 minutes waited). If not worked, call an ambulance.

115
Q

Angina prophylaxis

A

Beta blocker or rate limiting CCB
Beta blocker+ normal CCB
If these contraindicated use vasodilators (long acting nitrates, ivabrandine or nicorandil if an adult)
Max 2 drugs
Note that abrupt withdrawal of nitrates (vasodilators) and CCBs WORSENS angina

116
Q

GTN - key points

A

SL tabs/ spray
Effect lasts 20-30 mins
If >2 times a week, long term prophylaxis.
Tablets expire 8 week after opening.

117
Q

Vasodilators used as 2nd line in angina prophylaxis

A
  1. Long acting nitrates
  2. Ivabrandine
  3. Nicorandil in adults only (K channel activator)
118
Q

Nicorandil MHRA warning

A

Risk of ulcer complications (mouth, skin, eye, GI)

Do not drive until established perfomranc enot impaired

119
Q

Long acting nitrates - examples

A

MR isosorbite dinitrate BD
MR isosorbide mononitrate BD
Isosorbide mononitrate OD

120
Q

How to avoid tolerance with nitrates

A

If long acting/ transdermal leave patches off for 8-12 hours, take 2nd dose after 8 hours not 12 hours
NOTE THAT MR isosorbide mononitrate is once daily and so does not produce tolerance

121
Q

Side effects of nitrates

A

Headache, dizziness, flushig, postural hypotension, tachycardia, dyspepsia, heartburn
With injection you can get severe hypotensions, restlessness, palpitations
Always avoid abrupt withdrawal as can worsen angina

122
Q

NSTEMI/ STEMI initial management drugs (6)

A
  1. GTN
  2. Aspirin 300mg
  3. Morphine
  4. Metoclopramide
  5. Oxygen
  6. LMWH
123
Q

NSTEMI/ STEMI long term management drugs

A
  1. DAPT (12mths, then either aspirin or clopidogrel lifelong)
  2. Beta blocker (review after 12mth)
  3. ACEI
  4. High intensity statin
124
Q

Cardiac arrest

A

Resuscitation
IV adrenaline 1 in 1000 every 3-5 mins
IV amiodarone if Vfib present

125
Q

Types of diuretics

A
  1. Loop eg bumetanide, furosemide, torsonamide
  2. Thiazide/ thiazide like eg chortalidone, bendro, indapamide
  3. K+ sparing/ aldosterone antagonists
    +mannitol (osmotic), acetazolamide (carbonic anhydrae inhibitors
126
Q

Loop diuretics - uses, action, side effects, monitoring

A

HF (BD) + resistant HTN
1h onset + 6 h duration
Electrolyte loss+ ototoxicity (more common in renal impairment)+ urinary retention (caution in BPH)
Monitor electrolytes

127
Q

Bumetanide - key facts

A

The most potent of the loop diuretics

128
Q

Furosemide - key facts

A

Causes gout (hyperuricaemi(

129
Q

Torsonamide - key facts

A

Musculoskeletal side effects

130
Q

Thiazides+ thiazide like - uses, action, side effects, interactions, monitoring

A

HF, HTN
1-2 hour onset, 12-24 hour duration
Electrolyet loss, except for Ca which increases
Can cause diabetes (indapamide least likely to aggravate)
GI disturbance, impotence, high LDL
Not effective in poor renal function, monitor electrolytes

131
Q

Loop diuretics - interactions

A 
Amiodarone (hypo K+)
Citalopram (hypo K+, hypo Na+)
Clarithromycin (hypo K+)
Digoxin (increased risk of toxicity)
Fluconazole (hypo K+)
Lithium (toxicity)
Methadone (hypo K+)
\+ others which cause hypotension, hypo K+, toxicity, hypo Na+
132
Q

Thiazides+ thiazide like diuretics interactions

A

Things which cause hypokalemia, hyponatremia, hypotension, hyPERCalcemia

133
Q

K+ sparing diuretics+ aldosterone antagonists - onset, duration, s/es, monitoring

A

Used in hypokalemia
Spironolactone is used in ascites in liver failure and may be useful in HF and when used in resistant HTN
Eplerenone is used for HF
Cause hyperkalemia (avoid in ACEI/ ARB/ K supplement)
Aldosterone antagonists cause gynaecomastia, hypertrichiosis, change in libido, hyperuricemia, HYPOnatremia. Spiro causes breast pain.

134
Q

K+ sparing diuretics + aldosterone antagonists - interactions

A

(For spiro) = things which cause hypotension, hyPOnatremia, hyPERkalemia

135
Q

Occlusive vascular disease drugs (2)

A
  1. Aspirin 75mg OD
  2. Statin
    For 2’ prevention of CVD
136
Q

Raynauds (vasospastic)

A

Stop smoking
Avoid exposure to cold
Nifedipine can be used

137
Q

Drugs which prolong the QT interval (non-exhaustive)

A
  1. CV - amiodarone, sotalol
  2. CNS - apomorphine, methadone, lithium, SSRIs, risperidone, amisulpride (2nd gen) , chlorpromazine, levomepromazine, haloperidol, zuclopenthixol (1st gen),
  3. Infections - macrolides, moxifloxacin, antifungals
  4. Other - ondansetron, toltoredine
138
Q

What is heart block?

A

Heart beats more slowly or with an abnormal rhythm. 1st degree, 2nd degree, 3rd degree (most severe). Only treat if causing symptoms. May need a pacemaker.

139
Q

Dementia treatment for cognitive symptoms if disease mild-moderate

A

Acetylcholinesterase inhibitors eg donepezil, galantamine, rivastigmine (in PD only)

140
Q

Dementia treatment for cognitive symptoms if disease moderate-severe (only if severe in Alzheimes)

A

NMDA glutamate receptor antagonist - memantine

141
Q

Types of acetylcholinesterase inhibitors + what they are associated with

A

Donepezil- neuroleptic maligannt syndrome (increased risk with antipsychotics)
Galantamine - SJS. Stop if rash.
Rivastigmine - give if lewy bodies. Causes GI disturbance.

142
Q

Memantine - key points

A

Give if moderate-severe dementia
ONLY give if SEVERE alzheimes
Cautioned in epilepsy/ convulsions

143
Q

Side effects of anticholinesterase inhibitors eg donepezil, rivastigmine, galamantine (which are CHOLINGERGIC and so PARASYMPATHETIC)

A 
Diarrhoea
Urination
Musculoskeletal cramps
Bradycardia 
BRONCHOSPASM
Emesis
Lacrimation
Saliva
144
Q

Treatment of non-cognitive symptoms in dementia

A

Antipsychotics.
Only treat if SEVERE symptoms. MHRA warning = increased risk of stroke+ death.
If extreme violence/ aggression/ agitation give PO benzos/ antipsychotic
But if IM give haloperidol, olanzapine, lorazepam

145
Q

1st line for each type of seizure (5)

A
  1. Focal - carbamazepine, lamotrigine (can also give levetiracetam, valproate, oxcarbazepine)
  2. Tonic-clonic - valproate, carbamazepine (can also give lamotrigine)
  3. Absence - valproate, ethosuximide (can also give lamotrigine)
  4. Myoclonic - valproate (then levetiracetam, topiramate)
  5. Atonic tonic - valproate
146
Q 
Terminology seizures:
Absence
Myoclonic
Clonic
Atonic
Tonic
Tonic-clonc
Focal
A

Absence- lose awareness of surroundings (15s)
Myoclonic - arms, legs upper body twitch
Clonic - longer twitching (up to 2 mins), may get LOC
Atonic - muscles suddenly relax
Tonic - sudden stiffened muscles
Tonic - clonic - 2 stages - stiffness and then twitching
Focal - small part of the brain affected (may be simple or complex depending on whether you remain consciousness or not)

147
Q

Brand specific prescribing in CVD (2)

A
  1. Diltiazem MR>60mg

2. Nifedipine MR

148
Q

Antiepileptics - class 1 (4)

A

Carbamazepine
Phenytoin
Primodone
Phenobarbitol (once daily dosing)

149
Q

Antiepileptics - class 2 (7+ 3 unusual)

A 
Clobazam
Clonazepam
Oxcarbazepine
Lamotrigine (once daily dosing)
Valproate
Topiramate
Zonisamide
(Eslicarbazapine
Perampanel (once daily dosing)
Rufinamide)
150
Q

Antiepileptics - class 3 (5+3 unusal)

A 
Ethosuximide
Gabapentin
Pregabalin
Lacosamide
Levetiracetam
Tiagabaine
Vigabatrin
Brivaracetam
151
Q

Epilepsy and driving

A

Typical driving licence
If a seizure while awake and LOC - will take licence away. When you get it back depends on a number of facors.
If your seizures are ONLY while you have been asleep, you may get to keep your licence.
If seizures don’t affect consciousness or driving you may get to keep your licence, but this is dependent on lots of things.
Bus/ coach/ lorry
Will lose licence even if just a one off seizure
https://www.gov.uk/epilepsy-and-driving

152
Q

Teratogenic AEDs

A
  1. Valproate
  2. Carbamazepine, primidone, phenobarbitol, phenytoin
  3. Lamotrigine
    + topiramate> 1st trimester risk of cleft palate
    Must use effective contraception, note that inducers reduce efficacy of contraceptives.
153
Q

Which AEDs need dose adjustments based on plasma drug concentration during pregnancy?

A
  1. Phenytoin (albumin is decreased in pregnancy)
  2. Carbamazepine
  3. Lamotrigine
154
Q

Which AEDs require monitoring of fetal growth during preganncy?

A

Topiramate and levetiracetam

155
Q

Folic acid with epilepsy

A

Before conception + until week 12 of pregnancy

156
Q

AEDs which are present in high amounts of breast milk

A

ZELP

Zonisamide, ethosuximide, lamotrigine, primodone

157
Q

AEDs which accumulate in BF due to slow metabolism by infant

A

Phenobarbital

Lamotrigine

158
Q

AEDs which inhibit sucking reflex in BF

A

Phenobarbital

Primodine

159
Q

AEDs which have an established risk of drowisness in babies

A

Benzos, phenobarb + primodone

Avoid abrupt withdrawal of BF in all, but especially these

160
Q

MHRA warning for all AEDs

A

Small increased risk with all AEDs

Symptoms can occur within 1 week of startings

161
Q

AED side effects (7) inc mhra warnings

A
  1. Suicidial thoughts+ depression (within 1 week, all AEDs)
  2. Respiratory depression with some - gabapentin, benzos (especoally), barbiturates, notes say AEDs
  3. Blood dyscrasias -CVET PLZ
  4. Skin rashes -lamotrigine, SJS
  5. Encepalopathy
  6. Eyes - vigabatrin, toprimate with 2’ angle closure glaucoma
    7.AED hypersensitivity (1-8wks after started) DISCONTINUE IMMEDIATELY. This means rash, fever, lymphadenopathy, systemic involvemnt. Most associated with CPPP+ lamotrigine
    +mhra warning about switching+ classification+ pregnancy
162
Q

AEDs which cause blood dyscrasias (7)

A 
CVETPLZ
Carbamazepine
Valproate
Ethosuximide
Topiramate
Phenytoin
Lamotrigine 
Zonisamide
163
Q

AED interactions (2)

A
  1. Inhibitors increase the conc of other drugs eg valproate

2. Inducers decrease the conc of other drugs eg contraception + warfarin

164
Q

Phenytoin indications

A

Seizures. Focal and generalised tonic clonic seizures

Avoid if absence/ myoclonic seizures

165
Q

Phenytoin mode of action

A

Blocks Na+ channels

166
Q

Phenytoin side effects (7) + iv specific s/es

A

TB
Change in appearance (acne, coarsening of facial features, gingivial hypertrophy)
Blood dyscrasias (FBC needed)
Liver (discontineu and report signs of liver toxicity eg n+v, dark urine, abdo pain, itching, jaundice)
Rash (discontinue and report. HLA0B 1502 allele, chinese and thai higher risk of SJS)
Hypersensitivity (watch out for fever, rash, swollen lymph nodes)
LOW VITAMIN D
Suicidal ideation
If IV - cardiac scary effects
IV fosphenytin is a phenytoin prodrg - iv less site reaction and can be given more rapidly (1.5mg-1mg)

167
Q

Phenytoin therapeutic drug monitoring

A

10-20mg/L or 40-80mmol/L
Non linear relationship between dose and Cp
Highly protein bound

168
Q

Signs of phenytoin toxicity

A 
SNACHD
Slurred speech
Nystagmus
Ataxia
Confusion
Hyperglycaemia
DOUBLE VISION/ BLURRED VISION
169
Q

Phenytoin interactions

A
  1. Enzyme inhibitors + trimethoprim increase the concentration and so risk of toxicity
  2. Enzyme inducers - st johsn wort+ rifampicin cause therapeutic failure
  3. Quinolones, tramadol, mefloquine, SSRIs, antipsychotics, TCAs, antidepressants all antagonise the anticonvulsant effect
  4. Methotrexate and trimethoprim increase the ANTIFOLATE EFFECT AND SO THE RISK OF BLOOD DYSCRASIAS
    Is an enzyme inducer -reduces the concentration of warfarin, COC, levothyroxine, liohyronine
170
Q

Phenytoin - other key points (2)

A 
100mg phenytoin sodium = 92mg phenytoin base
MHRA warnings (4)- suicidal thoughts, risk of severe harm and death with injected phenytoin, dont switch between brands, pregnancy (increased risk of adverse effects on neurodelevlopemnt+congenital malformations)
171
Q

Carbamazepine indications

A

Seizures -focal and generalised tonic clonic

Avoid in atonic, clonic and myoclonic

172
Q

Carbamazepine MOA

A

Inhibits Na+ channels

173
Q

Carbamazepine s/es

A 
Blood dyscrasias
Hepatotoxicity
Hypersensitivity syndrome
SJS (rashes)
Hyponatremia
M/R preparations reduce the risk of side effects
174
Q

Carbamazepine monitoring

A

4-12mg/ L or 20-50mmol/L
Monitor 1-2 weeks after initiation
Manufacturer also advises blood counts, renal and hepatic tests but no evidence of practical benefit
MUST ALSO PRETREATMENT SCREEN FOR ALLELE FOR INCREASED RISK OF SJS

175
Q

Carbamazepine toxicity

A 
HANDIBAG
Hyponatremia
Ataxia
Nystagmus
Drowsienss
Incoordiantion
Blurred vision and double
ARRHYTHMIAS
GI disturbance
176
Q

Carbamazepine interactions

A
  1. Enzyme inhibitors increase Cp
  2. Enzyme inducers decrease Cp
  3. Anticonvulsant effect antagonised - SSRIs, antipsychotics, TCA, related antidepressants
  4. Increased risk of hyponatremia (nsaids, diuretics, ssris, tcas, desmporessin)
  5. increased risk of hepatotxicity (tetracyclines, sulfasalazine, na valproate, mtx, isoniazid, statins, fluconazole, etoh)
177
Q

Carbamazepine - other

A

AED suicidal thoughts+ behaviour
Do not switch between brands
Suppositories not bioequivalent to tabs (125mg:100)
Preganncy (increased risk of major congenital malformations)

178
Q

Sodium valproate indications

A

Seizures (1st line for everything except focal seizures)

179
Q

Sodium valproate MOA

A

Weak Na+ channel inhibitor

180
Q

Valproate s/es (3)

A
  1. Hepatotoxicity
  2. Blood dyscrasias
  3. Pancreatitis
181
Q

Valproate monitoring

A 
No therapeutic (not an indicator of efficacy)
Monitor liver function before treament+ during 1st 6 months
Measure FBC
182
Q

Valproate interactions

A
  1. Hepatotoxicity - tetracycylines, sulfazalaisne, metx, isoniazid, statins, fluconazole
  2. Is an inhibitor (increases cp of lamotrigine and phenobarb)
  3. Antagonised by tramadol, quinolones, tcas, mefloquine
183
Q

Valproate other

A

Suicidal thoughts and behaviorus, PPP, contraindicated in acute porphyrias, consider vit D supplementation, liver dysfucntion - usually in first 6mth - disocntinue if abnormally prolonged prothrombin. withdraw tretament immediatley if persistent vomiting+ abdomonal pain, anorexia, jaudnidce. discontinue if symptoms of pancretatis.
Unlicensed in women of child bearing age for bipolar and migraine prophylaxis.
If needst o be given for epilepsy, divided dose/ MR. >1g associated iwth more tetarogenicity.
May give a false urine test for ketones
PAYIENTS MUST HAVE A PATIENT CARD

184
Q

Status epilepticus -how to manage in hospital and community

A

Hospital: IV lorazepam (diaz would cause thrombophlebitis)
Community: >5 mins diaz rectal/ buccal midazolam. Can readminister after 10-15 mins.

185
Q

Anxiety - drugs used

A 
Long acting benzo
Short acting benzo (only lorazepam+ oxazepam)
Benzos - only for 2-4 wk release
Buspirone (takes 2 weeks to work)
Beta blocker
Antidepressants
Antipsychotics
Gabapentin
186
Q

When to use short acting benzos (lorazepam and oxazepam)

A
  1. Elderly

2. Liver impairment

187
Q

When does benzo withdrawal happen?

A

1 day after a short acting

3 weeks after a long acting

188
Q

How to help w benzo w/drawal

A

Convert over 1 wk to equivalent diazepam ON dose

Reduce by 1-2mg dose every 2-4 wk

189
Q

Interactions of benzos

A
  1. Respiratory depression (antihistamines, antidepressants, barbituates, antipsychotics, z drugs)
  2. Increased Cp due to enzyme inhibitors
190
Q

ADHD treatment if <5

A
  1. Methylphenidate
  2. Lisdexamphetamine
    or atomoxetine or guanfacine
191
Q

ADHD treatment if adult

A 
1. Methylphenidate or lisdexamphetamine
or atomoxetine (noradrenaline reuptake inhibitor)
Both methyphenidate and lisdexamphetamine work by increasing noradrenaline and dopamine in the brain
192
Q

Methylphenidate key points

A

Prescribe modified release preps by brands
Side effects - skinny (ie you would lose weight, appetite reduced, insomnia, increased HR+ BP, tics and tourettes, growth restriction in chdilren)
Monitor- HR, BP, appetite, weight, height, psychiatric symptoms
Contraidnicated if CVD, hyperthyroidism, hypertension, bipolar, severe drpession

193
Q

Atomoxetine key points

A

For ADHD but not first line

Can cause suicidal ideation, hepatotoixicty and QT prolongation

194
Q

Bipolar disorder treatment - episodes of mania and hypomania

A

For acute episodes give benzos short term or antipsychotics
For long term prophylaxis (>2y) give lithium, valproate, carbamazepine, olanzapine
Do not give antidepressants

195
Q

Antipsychotics used in bipolar disorder

A 
Quetiapine
Olanzapine
Risperidone
Lithium/ valproic acid if unpresponsive
Asenapine
196
Q

Lithium indications

A

Treatment and prophylaxis of mania, bipolar disorder, recurrent depression and aggressive/ self harming behaviour

197
Q

Lithium moa

A

Stimulates nmda receptor

198
Q

Lithium side effects (5)

A 
Thyroid disorders
Renal impairment
QT interval prolongation
Benign intracranial HTN
Lowers seizure threshold
199
Q

Lithium monitoring

A

Before treatment: renal, cardiac (ECG), thyroid, BMI, serum electrolytes, FBC
Duirng treatmnet: BMI, serum electroyltes, egfr, renal every 6 months (more often if increased Ca++)

200
Q

Lithium therapeutic monitoring

A

12 hours post dose, every 3 months

0.4-1 or 0.8-1 in acute

201
Q

Lithium toxicity

A 
Renal disturbance
Extrapyramidal
Visual disturbance
Nervous system - confusion
GI symptoms
202
Q

Lithium interactions

A

Body systems
QT prolongation (antipsychotics, amiodarone, ssris, macrolides, tcas, things which cause hypokalemia)
Seizure threshold lowered (quinolones, ssris)
Renal impairment - ACEIs, ARBs, NSAIDs (increased risk of toxicity)
Neurotoxicity - with aeds, antipsychotics, amitryptylline
Electrolytes
Hyponatremia causes toxicity (diuretics, antidepressants)
Alginates and soluble analgesics affect salt balance
Enzyme inhibitors
Others
EPSE - antipsychotics, PD, metoclopramide
serotonin syndrome

203
Q

Lithium - other

A 
teratogenic
counselling on salt and water
purple book
otc nsaids, soluble analgesia, 
same brand 
hyponatremia-toxicity
avoid etoh
drowsiness
204
Q

Antidepressants - types

A

TCAs, SSRIs, MOAIs

205
Q

SSRIs side effects

A

GI
A
Suicidal
Hyponatremia

206
Q

SSRIs- key points

A

Washout of 1 wk
Sertraline if MI
Fluoxetine if child
Paroxetine if risk of overdose

207
Q

TCAs - key points

A

Washout of 1-2 wks
Drowsy vs non drowsy depending on anxiety
Trazadone is a tetracycline

208
Q

MOAIs - key points

A

Washout of 2 wks unless moclobenamide (short acting and reversibel)
eg phenelzine, isoxicarbozi
Tyramine reaction - hypertensive crisis -

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