General Practice week 1 Flashcards
What is apixaban used for?
- Prophylaxis of stroke
- Used in DVT to reduce risk of recurrence of pulmonary embolism
- Can be given to those after knee or hip replacement therapy
What are the side effects of apixaban?
- Bleeding such as nosebleeds and bruising
- Coughing up blood and blood from anus
- A skin rash
What type of drug is apixaban?
A factor Xa inhibitor anticoagulant
Mechanism of action of apixaban.
Inhibits factor Xa independent of antithrombin III. Also inhibits prothrominase which both effects prevent formation of a thrombus.
When would the dose of apixaban need to be adjusted?
In end stage renal disease
What is Chiari malformation?
Cerebellum at the back of the skull bulges through a normal opening in the skull where it joins the spinal canal.
What causes chiari malformation?
Excess leaking of spinal fluid from the lumbar of thoracic areas of the spine.
Syrinx - cyst in spinal cord
What are the symptoms of chiari malformation?
- Scoliosis
- Headaches - located at back of head and neck often made worse by exertion
- Hydrocephalus (obstruction of flow of CSF that is found inside the ventricles inside the brain)
- Sleep apnea
- Hoarseness
- Difficulty swallowing
- Rapid side to side eye movements (nystagmus)
- Muscle weakness, lack of balance, abnormal reflexes
- Nerve problems, including paralysis
What antibiotics are used in chest infections?
- Amoxacillin a beta lactam
- Macrolide antibiotics: azithromycin, clarithromycin
- Tetracycline: doxycycline
- Levaquin (fluoroquinolone antibiotic)
What is Gabapentin taken for?
Epilepsy and nerve pain
What is the mechanism action of gabapentin?
Inhibits the release of excitatory neurotransmitters. Appears to inhibit the action of a2d-1 subunits and so decreases the density of presynaptic voltage gated calcium channels and subsequent release of excitatory neurotransmitters.
What can gabapentin not be used for?
Is ineffective in absence seizures - used in caution in those with mixed seizure disorders
What is tamsulosin?
Alpha adrenoreceptor blocker (with specificty for alpha-1A and alpha-1D subtypes which are more common in the prostate and submaxillary tissue.
Why would tamsulosin be prescribed?
To treat symptomatic benign hyperplasia and chronic prostasis
Mechanism of action of tamsulosin.
- By blocking the adrenoreceptors smooth muscle in the prostate is relaxed and urinary flow is improved.
- Blocking of alpha 1D adrenoceptors relaxes the detrusor muscles of the bladder which prevents storage symptoms.
Tamsulosin side effects.
Serious:
- a light-headed feeling, like you might pass out;
- penis erection that is painful or lasts 4 hours or longer; or
- severe skin reaction - fever, sore throat, swelling in your face or tongue, burning in your eyes, skin pain, followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling.
COMMON;
- low blood pressure;
- dizziness, drowsiness, weakness;
- nausea, diarrhea;
- headache, chest pain;
- abnormal ejaculation, decreased amount of semen;
- back pain;
- blurred vision;
- tooth problems;
- fever, chills, body aches, flu symptoms;
- runny or stuffy nose, sinus pain, sore throat, cough;
- sleep problems (insomnia); or
- decreased interest in sex.
What are the red flags of Cauda Equina syndrome?
- Bilateral sciatic pain
- Neurotpathic pain
- Fecal incontinence (can’t feel it come out)
- Urinary incontinence
- Weakness in lower limbs
- Urinary retention
- Saddle anaesthesia
What is Cauda Equina syndrome?
Damage to the cauda equina, the nerve roots arising from the terminal end of the spinal cord, due to trauma or compression. Without urgent surgical intervention, it can result in paralysis, loss of sensation in the legs, and bladder and bowel incontinence.
How would you perform a knee joint steroid injection?
18 gauge needle.
- Find patella, can be done medially or laterally.
- Find medial joint line - just a few cm above this inject under the patella - feel for soft area.
What are the uses of bendroflumethazide?
- High BP treatment
- Used to get rid of extra fluid (oedema)
?- To suppress lactation
How do thiazides cause vasodilation?
By activating calcium activated potassium channels in vascular smooth muscles and inhibiting various carbonic anhydrases in vascular tissue.
What is the mechanism of action of bendroflumethiazide?
- inhibits active chloride resorption at the early distal tubule via Na-Cl cotransporter, resulting in an increase in excretion of sodium, chloride and water.
- Also inhibits sodium ion transport across the renal tubular epithelium through binding to thiazide sensitive sodium-chloride transporter - this results in increase in potassium excretion via sodium potassium exchange mechanism.
Antihypertensive mechanism may be mediated through action on carbonic anhydrases in smooth muscle or action on large conductance calcium-activated potassium channel. (also found in smooth muscle)
What are the side effects of Bendroflumethiazide?
- Fall in BP standing up
- Dizziness
- Lethargy
- Muscle cramps
What type of drug is Ramipril?
An ACE inhibitor
What is the use of Ramipril?
- Mild to severe hypertension management
- To reduce cardiovascular mortality following MI in haemodynamically stable individuals who develop clinical signs of congestive heart failure within a few days.
- To reduce rate of death, MI and stroke in individuals who are high risk of cardiovascular events
- To slow progression of renal disease in those with hypertension, diabetes mellitus and microalbuinuria or overt nephropathy.
What is the mechanism of action of Ramipril?
- Inhibits RAAS ACE
- There is a decrease in angiontensin II, so less activation of G-protein coupled receptors: angiotensin receptor I and angiontensin receptor II.
- Angiotensin receptor 1 mediates vasoconstriction, inflammation, fibrosis and oxidative stress. Decreased activation of the receptor by ramipril mediates the renoprotective, antihypertensive, and cardioprotective effects by reducing inflammation and vasoconstriction.
What causes the side effect of dry cough in ACE inhibitors?
ACE is responsible for breaking down bradykinin. The resulting build u of bradykinin thought to mediate characteristic dry cough of ACE inhibitors.
What are some side effects of Ramipril?
- Weakness
- Dizziness
- Loss of appetite
- Skin rashes
What type of drug is Amlodipine?
Calcium channel blocker.
What are the uses of Amlodipine?
- Useful in combination with other antihypertensive and antianginal agents
- Hypertension
- Coronary artery disease
- Chronic stable angina
- Vasospastic angina
- Angiographically documented coronary artery disease in patients without heart failure or an ejection fraction<40%
Amlodipine mechanism of action on blood pressure.
- Peripheral artery vasodilator - action directly on vascular smooth muscle to lead to reduction in peripheral vascular resistance - causing decrease in BP
- Dihydropyridine calcium antagonist - inhibits influx of calcium ions into both vascular smooth muscle and cardiac muscle.
- Stronger effect on smooth muscle cells than cardiac muscle
- Action on smooth muscle reduces BP
Amlodipine mechanism of action on angina.
- Reduces total peripheral resistance (afterload) against which cardiac muscle functions. - as HR remains stable after admission, reduced work of the heart reduces both myocardial use and oxygen requirements.
- Dilation of coronary arteries and arterioles causes an increase in myocardial oxygen delivery in patients.
Side effects of Amlodipine.
- Headache
- Dizziness
- Fatigue
- Nausea
- Fluid retention - ankle swelling
What type of drug is Bisoprolol?
Beta-1 adrenergic blocking agent.
What is Bisoprolol used for?
- Mild-moderate hypertension.
- May be used off-label to treat heart failure, AF and angina pectoris.
What is Bisoprolol mechanism of action?
- Antagonism of B1 adrenoceptors results in lower cardiac output
- Bisoprolol is cardiac-selective, competitive B1 adrenergic antagonist
- When B1 receptors are activated by adrenergic neurotransmitters such as epinephrine, both BP and HR increase > greater cardiovascular work > increased demand for oxygen
- Thought to reduce output of renin by the kidneys
What are some side effects of bisoprolol?
- Breathing difficulty
- Fatigue
- Cold extremities
- Sleep disturbances
What is Atorvastatin?
A HMG-CoA reductase inhibitor (drug)
What is Atorvastatin used in?
- Dyslipidaemias
- To prevent cardiovascular events in patients with cardiac risk factors and/or abnormal lipid profiles.
- Preventative agent for MI, stroke, revascularisation and angina.
- Prescribing statins is standard practive following any cardiovascular events and people with moderate - high risk of CVD development.
- Statin indicated conditions (diabetes mellitus, clinical atherosclerosis, Abdomical aortic aneurysm, CKD, severely elevated LDL-c levels
Atorvastatin mechanism of action.
- HMG-CoA reductase catalyses conversion of HMG-CoA to mevalonate an early rate limiting step in cholesterol synthesis
- Decreased hepatic cholesterol concentrations stimulate upregulation of hepatic LDL receptors - statins stop this/
Side effects of Atorvastatin.
- Insomnia
- Abdominal pain
- Flatulence
- Diarrhoea
- Nausea
What comorbidities can increase the risk of developing CVD?
Hypertension, diabetes mellitus, chronic kidney disease, dyslipidaemia, rheumatoid arthritis, influenza, serious mental health problems and periodontitis
What is the current health check programme for CVD in England?
o Everyone 40-74 years not already diagnosed with CVD, diabetes or CKD is invited every 5 years for health check.
o Health check involves CVD risk assessment, assessment of alcohol consumption, physical activity, cholesterol level, BMI, assessment for dementia in ages 65-74 years, & screening for diabetes mellitus and CKD in those at increased risk of developing these conditions.
Who are considered high risk for CVD?
Those with type I diabetes, or CKD stages 3,4,5.
How can 10 year CVD risk be assessed in patients every 5 years?
Using QRISK score.
Why may we not need to use the QRISK score on some people?
They already have CVD, a high risk of developing CVD or are over 85.
How can most people reduce their risk of CVD?
By lifestyle changes and drug treatment if appropriate.
When given CVD assessment what lifestyle advice should you provide a patient with?
Smoking, weight loss, eating healthy diet, Keeping alcohol consumption within recommended limits, being physically active.
When should statin treatment be offered to a patient?
Should be offered as primary prevention of CVD to people with estimated 10 year risk of 10% or more if lifestyle interventions have not been effective.
What is the recommended statin for primary prevention of CVD?
Atorvastatin 20mg/ day if patient decides to take it after discussion of benefits and harms and also lifestyle advice. There must also be no contraindications.
What must be considered before offering statin treatment for primary prevention of CVD?
o Use clinical findings, lipid profile and family history to judge likelihood of familial lipid disorder.
o Exclude possible secondary causes of dyslipidaemia ( excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome)
o Discuss the benefit of lifestyle modifications and optimise management of all other modifiable CVD risk factors, including relevant comorbidities that may not be optimally treated.
Offer opportunity to reassess CVD risk again after they have tried to change lifestyle
Recognise people may need support to change their lifestyle – referaly to programmes for exercise or smoking cessation.
When should statin treatment be offered for primary prevention of CVD?
If lifestyle modification is ineffective or inappropriate.
What lifestyle factors increase the risk of stroke?
- Smoking
- Excessive alcohol intake
- Diet high in salt and saturated fats
- Obesity
- Lack of exercise
- Previous stroke or TIA
- High blood pressure
- Diabetes
- High cholesterol
- Heart disease (Atrial fibrillation) Warfarin can be used to treat AF
What is atrial fibrillation?
AF is the most common sustained cardiac arrhythmia, characterized by irregularly irregular ventricular pulse and loss of association between the cardiac apex beat and radial pulsation
How does AF come about?
Chaotic electrical activity of the atria is conducted to the ventricles in a random manner resulting in a rapid and irregular pulse rate.
What is loss of active ventricular filling associated with? (this occurs in AF)
o Stagnation of blood in the atria leading to thrombus formation and risk of embolism, increasing the risk of CVA
o Reduction in cardiac output (especially during exercise) which may lead to heart failure
