GP Flashcards
What to do with adult with high probability asthma?
Trial of treatment
What to do with adult with intermediate probability of asthma?
FEV1/FVC <0.7 –> trial of treatment
FEV1/FVC >0.7 –> futher investigation/referral
Adult with suspected asthma
Clinical assessment including spirometry (or PEF if not available)
Zones of peak flow?
Green = 80-100% of usual - good control Yellow = 50-79% of usual - caution, additional medication Red = <50% of usual - medical emergency, immediate action needs to be taken
Adults asthma ladder?
Step 1 = SABA + ICS (200-800 mcg)
Step 2 = Add a LABA. if response, continue. Benefit but not complete –> increase ICS to 800. No response –> stop LABA, increase ICS to 800, consider other treatments)
Step 3 = Increase ICS (2000 mcg) or add a fourth drug (LTRA, theophylline, beta agonist tablet)
Step 4 = add daily steroid tablet, conisder other treatments, refer for specialist care
When should you consider moving up the adult ladder?
If using SABA 3x per week
Kids asthma ladder?
Step 1 = SABA + very low dose ICS (200-400 mcg) or LTRA if <5
Step 2 = Add a LABA. if response, continue. Benefit but not complete –> increase ICS to low dose (400). No response –> stop LABA, increase ICS to 400, consider other treatments)
OR LTRA if <5
Step 3 = Increase ICS to medium dose (800 mcg) or add a fourth drug ( theophylline)
Step 4 = add daily steroid tablet, maintain medium dose ICS, consider other treatments, refer for specialist care
How do you step down treatment in asthma?
Consider every 3 months, 25-50% each time
Side effects of SABAs?
Tremor, headache, muscle cramps, palpitations, hypokalaemia
Side effects of ICS?
Oral candidiasis
Sore mouth
Dysphonia/hoarseness
Long term = osteoporosis, adrenal suppression
Doses of ICS for children?
> 12 = 200 mcg BD
5-12 = 100 mcg BD
<5 = 100 mcg BD (lower = 40 mcg BD)
Examples of combination inhalers? (LABA and ICS)
Symbicort = budesonide + formoterol
Seretide = fluticasone + salmeterol
Fostair = beclometasone + formoterol
Examples of LTRA?
Montelukast, zafirlukast
Complications and side effects of montelukast?
Associated with liver toxicity
Well tolerated and have few class-related adverse effects
Side effects of theophylline? How often should levels be taken?
(At high plasma concentrations) Nausea/Vom Tremor Palpitations Arrhythmias
Every 6-12 months
Side effects of oral steroids?
(Long-term)
Osteoporosis Hypertension Diabetes Hypothalamic-pituitary-adrenal axis suppression Weight gain Cataracts Glaucoma Skin thinning Easy bruising Muscle weakness
Self-management in asthma?
Education
Personalised asthma action plan (PAAP) - regular review
Trigger avoidance, smoke-free environment
Secondary prevention of asthma
Stopping smoking support
Weight loss support
Breathing exercise programmes (can improve QoL and reduce symptoms)
Signs and symptoms of AF?
Palpitations, tired/breathless, angina, ankle oedema, syncope, dizziness
Irregularly irregular pulse, loss of association between cardiac apex beat and radial pulsation
Diagnosis of AF?
ECG if irreg irreg pulse felt
If paroxysmal suspected –> 24 hour tape
ECG in AF?
No P waves
Chaotic baseline
Irregular ventricular rate
Rate often 160-180 but can be lower
Classifications of AF?
Paroxysmal = >2 episodes that terminae within 7 days
Persistent = >7 days of AF >48h in which decision made to perform cardioversion
Long standing persistent = consistent SF of >12 months duration
Permanent = decision made to cease attempts to restore sinus rhythm
Causes of AF?
Cardiac = hypertension, valvular, heart disease, heart failure, IHD
Resp = chest infections, PE, lung cancer
Systemic = alcohol, thyrotoxicosis, electrolyte depletion, infections, CKD
Investigations in AF?
TFTs, FBC, U&E, calcium, magnesium, glucose
TT echo if structural or functional heart disease suspected
CXR if lung pathology suspected
Criteria for urgent referral in AF?
Rapid pulse (>150) and/or low BP (<90 systolic)
LoC, severe dizziness, ongoing chest pain, increasing breathlessness
Complication of AF - stroke, TIA, acute HF
Rate control in AF?
Beta blockers/rate limiting CCB
Digoxin if sedentary
Combination often required
Target rate in AF?
<110 bpm
Chemical cardioversion drugs?
Flecainide, propafenone
Who should be referred for cardioversion?
New onset AF
Reversible cause
HF primarily causes, or worsened by AF
Atrial flutter suitable for ablation to restore SR
When to do cardioversion if haemodynamic instability?
Within 48 hours - immediate cardioversion (no anticoagulation)
> 48 hours - start rate control and therpaeutic anticoagulation for 3 weeks and then 4 weeks afterwards
Beta blockers used in AF?
Atenolol (50-100mg)
Acebutolol, metoprolol, nadolol, oxprenolol, propanolol
Side effects and contraindications of beta blockers/
Bradycardia
Cold extremities/paraesthesiae
Sleep disturbance
Can mask hypoglycaemia
Asthma
Severe bradycardia or hypotension
Uncontrolled HF
2nd/3rd degree heart block
Side effects and contraindications of digoxin?
Cardiac = SA/AV block, PR prolongation, premature ventricular contractions, ST depression Non-cardiac = nausea, vomiting, visual abnormalities, CNS effects
SV arrhythmias Heart conduction problems VT HOCM Avoid TCAs/venlafaxine (proarrhythmic) St John's Wort decreases conc.
Side effects/contraindications of rate limiting CCBs?
Diltiazem = dizziness, palpitations Verapamil = constipation
CCF, aortic stenosis, severe hypotension, AV block, LVF, pregnancy
Metabolised by P450
What is catheter ablation?
Electrical isolation of pulmonary veins –> creates electrically inexcitable scare around them which blocks PV ectopic from entering LA.
Good for paroxysmal.
Percutaneous access via femoral veins
70% success, 2-3% complications (stroke, tamponde, PV stenosis)
Componenents of CHA2DS2VASc
Congestive HF/LV dysfunction Hypertension (>140/90) Age > 75 Diabetes Stroke/TIA Vascular disease (MI, PAD, aortic plaque) Age 65-74 Sex category (female)
Interpretation of CHADSVASC?
> 2 for females
>1 for men
Components of HASBLED?
Hypertension Abnormal renal function Abnormal liver function Stroke Bleeding tendency Labile INRS Elderly (>65) Drugs or Alcohol
Examples of NOACS?
Dabigatran = thrombin Rivaroxaban = FXa Apixaban = FXa
What to prescribed in AF if anticoagulation contraindicated?
Aspirin + clopidogrel combination
NOACs v Warfarin?
NOACs are just as good and have reduced risk of intracerebral haemorrhage.
NOACs have shorter half life so adherence more important.
NOACs don’t need monitoring.
No reversal agent for NOACs yet (except dabigatran)
Follow up after starting rate control for AF?
Within 1 week
Check tolerating, review symptoms, HR and BP
If not tolerating, change drug
Follow up after starting anticoagulation treatment?
INR should be between 2 and 3
Possible factors for poor control are - impaired cognitive function, poor adherence, illness, concurent medications interactions, lifestyle factors (diet and alcohol)
Consider switching to a NOAC if poor control
What is taken into account in QRISK2?
Age, sex, ethnicity, postcode, smoking status, medical and family history
BP and BMI
Cholesterol-HDL ratio from non-fasting sample
How often to repeat Qrisk?
Every 5 years or if any significant changes occur
Who is Qrisk not used in?
Pre-existing CVD Type 1 diabetes CKD (eGFR <60 + hyperalbuminaemia) Familial hypercholesterolaemia Age > 85
Threshold for primary prevention of CVD in Qrisk?
10% - offer atorvastatin 20mg OD
Adverse effects of statins?
Myopathy and rhabdomyolysis
What can you do before starting a statin for primary prevention?
Consider delaying if committed to lifestyle changes
Counsel on risks and benefits of statin treatment
Baseline bloods - lipid profile, CK, LFTs, U+Es, HbA1c
Monitoring of statin therapy?
Monitor total cholesterol, HDL and non-HDL cholesterol after 3 months
AIM = 40%reduction in baseline non-HDL cholesterol levels
LFTs - 3 months and 12 months
Regularly monitor for adverse effects
Symptomatic relief in angina?
Sublingual GTN
Beta blocker or rate limiting CCB
(if BB and CCB contraindicated, can use isosorbide mononitrate, nicorandil ivabridine or ranolazine - specialist advice)
Advice for people with chest pain and GTN?
STOP and rest, use GTN as instructed
Take second dose after 5 minutes if pain not eased
Call 999 if pain not eased in 5 minutes
Best BB for angina?
Bisoprolol - long 12 hour half life
Secondary prevention in angina?
Low dose aspirin (75mg OD) - clopidogrel if strok or PAD
ACE-i - if DM
Statin/antihypertensive
Routine review in angina?
6 months to 1 year depending on stability and comborbidities
Symptoms
Risk factors
Complications - HF and depression
Compliance - drug interactions and side effects
Secondary prevention of MI
ACE-i - titrate up to maximum tolerated dose (10mg)
Beta blocker/CCB - bisoprolol (max tolerated dose - 10mg)
Statin - atrovastatin 80mg for life
Antiplatelet - dual for 12 months (aspirin + clopidogrel/ticagrelor/prasugrel) - aspirin indefinitely after 12 months
Who to test for CKD?
Diabetes HTN AKI CVD Structural renal disease Multisystem (rheumatological) disease FHx Haematuria Long term nephrotoxic drugs
When is urea high and low?
High = catabolic state, high protein intake, GI bleed, glucocorticoids, dehydration, cardiac failure
Low = low protein intake, liver failure
In whom is creatinine high and low?
High = large muscle mass (young, muscular, male)
Low = elderly, wasting, amputees, female
How do you test for CKD?
Serum creatinine (eGFR)
Early morning urine for ACR
Urine dip (haematuria - insensitive for protein)
Diagnostic criteria for CKD?
eGFR <60
AND/OR
ACR > 3mg/mmol
for over 3 months
Categories of urinary ACR in CKD?
Normal to mildly increase = < 3
Moderately increased = 3- 30
Severely increased = >30
Stages of CKD?
Stage 1 = >90
Stage 2 = 60-89
Stage 3a = 45-59
Stage 3b = 30-44
Stage 4 = 15-29
Stage 5 (kidney failure) = <15
How to explain CKD?
Common condition (nearly 10% adults) which increases in prevalence as you get older
A lot of people don’t realise they have it and it has no effect on their lives
Kidney damage causes leakage of protein and/or blood into urine
Kidney function deteriorates resulting in worsening ability to regulate fluid/electrolyte balance and calcium metabolism
Potential complications of CKD?
Renal disease requiring RRT CV disease Renal anaemia Renal bone disease Malnutrition Neuropathy Lipid abnormalities
Causes of CKD?
Intrinsic - HTN, DM, glomerulonephritis, HF
Nephrotoxic drugs - NSAIDs, lithium, aminoglycosides, mesalazine, ciclosporin
Obstruction - bladder voiding dysfunction, urinary surgery, recurrent stones
Multi-system disease - SLE, vasculitis, myeloma, polycystic kidney disease
Management of CKD?
Refer to nephrology eGFR <30 (stage 4)
Monitor for progression and complications
Manage causes and risk factors
Manage blood pressure and/or proteinuria
Statin
Monitoring in CKD?
eGFR/ACR at least annually
FBC - exclude renal anaemia
Serum calcium, phosphate, vitamin D, PTH (stage 4/5)
Self-management in CKD?
Smoking
Avoid NSAIDs
Diet - salt intake restriction, calories, phosphate/potassium restriction if needed
Increased risk of AKI - what to do if they become ill
Functions of kidney of CKD?
Excretory - inorganic substances, organic, larger molecules
Homeostasis - fluid balance, blood pressure, acid-base
Endocrine - EPO, bone metabolism
potential complications of CKD?
Anaemia (EPO)
Bone mineral disorder (low serum Ca, high PO4, high PTH to normalise calcium)
Lack of vitamin D hydroxylation
Phosphate retention
Metabolic acidosis (low serum bicarbonate)
Hyperkalaemia
Definition of COPD?
Progressive disorder
Airway obstruction, no reversibility, chronic bronchitis and ephysema
Definition of chronic bronchitis and emphysema?
CB = productive cough on most days for 3 monhts of 2 successive years
Emphysema = histologically - enlarged air spaces distal to terminal bronchioles and destruction of alveolar walls
Risk factors for COPD?
Smoker
Occupation exposure to dusts and chemicals
Exposure to fumes from burning fuel
Age
Genetics (alpha-1-antitrypsin deficiency)
Lifestyle advice in COPD?
Encourage exercise at own level
Aim to walk 20-30 minutes 3-4 times per week (if mobile)
Upper limb activities (if immobile)
Annual influenza vaccine, pneumoccocal vaccine, smoking cessation advice
Investigations in COPD?
Spirometry - FEV1:FVC ratio <0.7 = airway obstruction
CXR - rule out cancer and HF
Bloods - anaemia or polycythaemia (due to chronic hypoxia)
ECG - cor pulmonale
BMI
Signs of COPD on CXR?
Hyperinflation Flat hemidiaphragms Large central pulmonary arteries Reduced peripheral vascular markings Bullae
Differentiating COPD from asthma?
Reversibility testing
Serial peak flow measurements (asthma has diurnal variation)
Grading of COPD?
BODE Index
MRC breathlessness scale
FEV1 as percentage of predicted
What is BODE index?
BMI
Obstruction (FEV1 percentage of predicted)
Dyspnoea
Exercise capacity index
COPD stages?
1 = mild = 80% predicted 2 = moderate = 50-79% 3 = severe = 30-49% 4 = very severe = below 30%
Side effects of SAMA?
Dry mouth
GI motility disorder
Cough
Headahce
Side effects of LABA?
Headache
Dizziness
Side effects of LAMA
Dry mouth
GI motility disorder
Cough
Headache
COPD treatment ladder? (>50% predicted)
STEP 1 = SAMA or SABA
STEP 2 = add LABA or LAMA (stop SAMA in LAMA)
STEP 3 = LABA + ICS or LAMA and LABA (not SAMA)
STEP 4 = add LAMA (SABA + LABA + ICS + LAMA)
COPD treatment ladder? (<50% predicted)
STEP 1 = SABA or SAMA
STEP 2 = add LABA + ICS or LAMA + LABA
Step 3 = add LABA + ICA + LAMA
When to consider home nebs in COPD?
When not responding to maximum therapy
When to consider home oxygen?
PaO2 < 7.3 when stable
or
PaO2 = 7.3 - 7.8 with other features
Management of acute exacerbation in primary care?
Prednisolone 30mg OD for 7-14 days
Amoxicillin 500mg TDS for 5 days (or doxy 100mg OD 5 days)
Can write action plan and prescribe rescue pack. Advise on how to recognise exacerbations.
When should COPD patients have pulmonary rehab?
MRC 3 or above, or recent hospitalisation for exacerbation
Programmes 2-3 sessions/week, last 6-12 weeks
Physical training, disease, education, nutritional, psychological and behavioural interventions tailored to the patient’s needs
Diagnosis of diabetes?
Symptoms plus…
Random glucose > 11.1 mmol/L
Fasting > 7.0 mmol/L
OGTT > 11.1 mmol/L (2 hours after 75g anhydrous glucose)
HbA1c > 48 mmol/L
If asymptomatic, should have at least one additional glucose test result.
What is HbA1c not used for?
T1DM
Children
Pregnancy
Health promotion/education in diabetes?
Diet - high fibre, low glycaemic index sources of carbs. Personalised diabetes management plan.
Physical activity - 150 minutes moderate activity per week. Time spent sedentary should be minimised.
Alcohol - don’t drink on empty stomach. Can make you more hypo and mask symptoms of hypos.
Smoking - cessation support/advice
How often should HbA1c be monitored in TIIDM?
3-6 monthly intervals until on stable unchanging therapy
6 monthly intervals once HbA1c level and sugars are stable
Targets in TIIDM?
Lifestyle only/monotherapy = 48 mmol/L
Hypoglycaemia drug = 53 mmol/L
Multiple drugs and above 58 mmol/L = 53 mmol/L
When should HbA1c targets be relaxed?
Frail
Unlikely to achieve long term risk reduction benefit
High risk of hypoglycaemia (HGV, falling, low awareness of hypos)
Intensive management inappropriate
Self-monitoring in TIIDM?
Not necessary unless…
on insulin
Evidence of hypos
On medication which would increase risk of hypos while driving, operating machinery
Pregnant
Example, mechanism of biguanide? Side effects?
Metformin
Decreases glucose production by liver and increases insulin sensitivity of body tissues.
Bowel problems
Not if eGFR < 35
Example, mechanism of sulfonylurea? Side effects?
Gliclazide, glimepiride
Depolarises pancreatic beta cells, which opens voltage gated Ca2+ channels, leading to increased secretion of insulin.
Causes weight gain. Better than metformin at reducing blood glucose quickly – good if patient experiencing symptoms.
Example, mechanism of DDP-4 inhibitor? Side effects?
Sitagliptin, alogliptin, linaliptin
Increase incretin levels, which inhibits glucagon release, which increases insulin release, decreases gastric emptying and decreases blood glucose levels
Example, mechanism of Thiazolidinedione ? Side effects?
Pioglitazone
Reduces insulin resistance in the liver and peripheral tissues, decreases gluconeogenesis in the liver –> reduces blood glucose.
Contraindicated in heart failure, hepatic impairment, DKA, history of bladder cancer, uninvestigated macroscopic haematuria.
Example, mechanism of SGLT2 inhibitor? Side effects?
Dapagliflozin, canagliflozin, empagliflozin
Inhibits reabsorption of glucose in the kidney –> lower blood sugar because peeing out glucose.
Can cause weight loss because of lost calories, but can cause UTI/thrush.
Example, mechanism of GLP-1 agonist? (Incretin mimetic)
Works on same pathway as DPP-4 inhibitors but are more potent.
Injectable - good for weight loss
Expensive. Need to have lost certain weight or reduced HbA1c over 6 months to continue.
Better than insulin for HGV drivers etc.
Treatment pathway for TIIDM?
- Healthy eating, weight control, increased physical activity and diabetes education
- Monotherapy (MTF/SU if MTF not tolerated)
- Dual therapy
- Triple therapy or insuln
Drugs with hypo risk?
Sulfonylureas
SGLT-2 inhibtors
HGV drivers and insulin?
Need to stop driving whilst established on insulin.
Need to record sugars and prove not had hypo - see consultant and reapply.
CV risk reduction in TIIDM?
BP - control with medications. Target = 140/90, or 130/80 if end organ damage
Antiplatelet - do not routinely offer
Lipids - atorvastatin 20mg if >10% risk on QRISK
normal secondary prevention
Complications of diabetes?
Gastroparesis Painful diabetic nephropathy Autonomic neuropathy Erectile dysfunction Diabetic foot problems Diabetic nephropathy Diabetic retinopathy
Components of diabetic annual review?
Retinopathy screening
Diabetic foot check
Nephropathy screening
Cardiovascular risk factors
Insulin and driving?
Inform DVLA
Check levels before driving and 2 hourly intervals
<5 DON’T DRIVE
Investigations and diagnosis of HF>
Transthoracic Echo! within 2 weeks, and assessment by specialist MDT
BNP ECG CXR Bloods - U+E, eGFR, TFTs, LFTs, lipids, glucose, FBC Urinalysis EPFR/spirometry
Scores for HF?
Frammingham
NYHA classification (I = mild, II = mild, III = moderate, IV = severe)
First line treatment for HF?
ACEi
Beta blocker
Furosemide (symptomatic relief)
Second line for HF?
Spironolactone
ARB
Hydralazine with nitrate
Sacubitril valsartan
Implantable devices in HF?
Recommended in previous serious ventricular arrhytmia
Cardiac arrest (VT/VF) Spontaneous sustained VT --> syncope/haemodynamic compromise
CRT with defib (CRT-D) or pacing (CRT-P)
Self-management plan in HF?
Monitor own symptoms
Monitor weight at home at same time every day (2kg in 3 days is substantial)
Avoid excessive salt intake
Restrict fluid intake (30 ml/Kg/day) - if D+V, maintain fluid intake and stop treatments until recover and eating and drinking normally.
Regular low intesity physical activity
Smoking cessation/alcohol/nutritional advice
Annual review in HF?
6 monthly
Signs/symptoms - examine the heart - ECG
Assess fluid status
Functional capacity
Cognitive status and psychosocial needs (MOOD)
Assess nutriitonal status
Review of medication/side effects
Bloods (urea, electrolytes, creatinine, eGFR)
Diagnosis of hypertension?
If BP persistently above 140/90 –> ambulatory BP monitoring or home BP monitoring
Ambulatory BP monitoring?
Two measurements per hour during normal waking hours - average of at least 14 measurments
Home BP monitoring?
Two measurements at least `1 minute apart, with person seated.
Record twice daily for at least 4 days, ideally 7. Discard the first day, average the rest.
What is stage 1 hypertension?
Clinic BP above or equal to 140/90
ABPM average above or equal to 135/85
What is stage 2 hypertension?
Clinic BP above or equal to 160/100
ABPM average above or equal to 150/95 OR there is isolated systolic hypertension with systolic BP of 160 or higher.
Causes of secondary hypertension?
Renal - chronic pyelo, dabetic nephropathy, glomerulonephritis, polycystic kidney, obstructive nephropathy, renal cell ca
Vascular - coarctation, renal artery stenosis
Endocrine - primary hyperaldosteronism, phaeochomocytoma, Cushing’s, acromegaly, hypothyroid/hyperthyroid
Drugs - alcohol misuse (most common cause of secondary)
how to assess target organ damage in hypertension?
PCR/haematuria Bloods Fundoscopy ECG Cardio exam
Lifestyle factors in HTN?
Weight Diet Exercise Cut out caffeine Reduce sodium intake Smoking cessation Group therapies
Adverse effects/contraindications of ACEi?
Renal function, hyperkalaemia, cough, angioedema, dizziness and headaches.
Angioedema, bilateral RA stenosis, pregnancy, breastfeeding.
Adverse effects/contraindications of ARB?
Renal function, hyperkalaemia, dizziness and headache
Angioedema, bilateral RA stenosis, pregnancy, breastfeeding
Adverse effects/contraindications of thiazides?
Excessive diuresis, hypokalaemia, other electrolyte imbalances (hyponatraemia –> confusion), gout, DM
Gout (hyperuricaemia), electrolyte imbalance, low eGFR, pregnancy.
Adverse effects/contraindications of CCB?
Vasodilatory (flushing, headaches, ankle swelling), gingival hyperplasia.
Heart failure, cardiac outflow obstruction. Antidepressants (post hypoT), CYP450 metabolised, beta blockers.
Adverse effects/contraindications of aldosterone antagonist?
Gynaecomastia, GI, renal/ electrolyte disturbances.
AKI, hyperkalaemia, Addison’s.
ACEi/ARB, heparins, potassium containing things, aspirin/NSAIDs.
Adverse effects/contraindications of alpha blocker?
Uncommon – dizziness, drowsiness, headache, post hypotension.
Postural hypotension.
Phosphodiesterase-5 inhibitors, antidepressants.
Blood pressure targets?
Clinic BP
Under 80 yrs – 140/90
Over 80 yrs – 150/90
ABPM/HBPM
Under 80yrs – 135/85
Over 80 yrs – 145/85
Monitoring of HTN?
Lifestyle only
Every 3-4 months until BP well controlled.
Annually thereafter.
On treatment
Recheck BP at after 4 weeks.
ACEi/ARB – U&E and eGFR at baseline and 1-2 weeks after treatment and every time you increase dose.
Thiazide – U&E and eGFR at baseline and 4-6 weeks after treatment.
CCB – no specific monitoring required.
Crietria for starting antihypertensive treatment
People under 80 with stage 1 hypertension who have one or more of: Target organ damage Established CV disease Renal disease Diabetes 10-year CV risk of 20% or greater
Anyone of any age with stage 2 hypertension.
What is stage 3 hypertension? What is criteria for admission?
Systolic 180mmHg or higher or diastolic 110mmHg or higher – diagnose hypertension and start antihypertensive treatment immediately.
180/110 + signs of papilloedema and/or retinal haemorrhage – arrange same day admission.
Types of stroke?
Ischaemic - Thrombotic/Embolic
Haemorrhagic - Intracerebral/subarachnoid
FAST Test?
Facial weakness
Arm weakness
Speech problems
Score for risk of stroke after TIA?
ABCD2 score
A - age - 60+
B - blood pressure (>140/90 = 1 point)
C - clinical features (uni weakness = 2, speech without weakness = 1)
D = duration (60 minutes = 2, 10-59 = 1)
D = diabetes (1 point)
Management of high/low risk post-TIA?
HIGH Specialist assessment in 24 hours Atorvastatin 20mg Clopidogrel/aspirin 300mg (unless on anticoagulation) No driving until seen by specialist
LOW
Specialist assessment ASAP, within 1 week
Clopidogrel/aspirin 300mg loading and 75mg after
Review CV risk factors
No driving until seen by specialist
Driving after a stroke?
Not for 4 weeks
No need to notify DVLA unless residual neuro deficit 1 month after episode
HGV/coaches - 12 months no driving
Need to be assessed for factors that preclude safe driving
Need to inform insurance company
Secondary prevention of stroke?
Aspirin 300mg OD 2 weeks
Clopidogrel 75mg OD indefinitely
If no clopidogrel –> dipyridamole 200 BD + aspirin 75
If not, aspirin alone 75mg OD
STATIN - atorv 80mg
Follow up after TIA?
Within 1 month, then annually in primary care
Annual lipid/BP check
Flu vaccinations
Secondary prevention of TIA?
Manage AF, diabetes, hypertension
Antiplatelet - clopidogrel 75mg OD
Statin - atorv 80mg
DVLA rules for epilepsy? (Cars)
Multiple seziures while awake + LoC - need to be free for 1 year to reapply
One-off seizure while awake + LoC - need to be seizure free for 6 months and doctor deems low risk of another seizure to reapply
Attacks whilst asleep and awake - DVLA discretion
Attacks whilst asleep - DVLA discretion
Attacks that don’t affect consciousness or driving - DVLA discretion
DVLA rules for epilepsy? (Bus, coach or lorry)
Multiple seizures - No attacks for 10 years and no anti-epileptic medication for 10 years, 2% or lower risk of seziure
One-off seziure - no attacks for 5 years, no AEDs for 5 years. Must have been assessed by neurologist in last 12 monhts.
1st/2nd line for idopathic generalised epilepsy, absence seizures, generalised tonic clonic seizures, myoclonic seizures, tonic/atonic seizures?
Sodium valproate
Lamotrigine
First line in focal seizures?
Carbamezapine or lamotrigine
Problems with sodium valproate?
Teratogenic – should be avoided in pregnancy.
CYP450 inhibitor – can increase concentration of warfarin etc.
Inhibits glucuronyl transferase and epoxide hydrolase – may interact with drugs that are substrates for these enzymes or are highly protein bound.
Carbapenem antibiotics, OCP decreases valproate plasma concentrations.
Problems with carbamezapine?
Teratogenic – avoid in pregnancy.
CYP450 inducer – increases concentration of drugs metabolised by this pathway.
Other interventions in epilepsy?
Surgical resection
Ketogenic diet in children and young people – referral to tertiary pediatric epilepsy specialist.
Vagus nerve stimulation – in children and young people who are refractory to AEDs but who are not suitable for resective surgery.
Deep brain stimulation – patients with medically refractory epilepsy for whom surgical resection is considered unsuitable. .
Advice in epilepsy?
Avoid swimming alone
Bathing alone with door locked
Climbing
Advice for women in epilpesy?
Take folic acid
Contraception
Pre-conception counselling
Drugs present in breast milk
Some drugs can affect contraceptive pill - double dose
Advice on managing seizures?
Protect them from injury by:
Cushioning their head with your hands or soft material.
Removing harmful objects from nearby, or if this is not possible, moving the person away from immediate danger.
Do not restrain them or put anything in their mouth.
When the seizure stops, check their airway and place them in the recovery position.
Observe them until they have recovered.
Examine for, and manage, any injuries.
Arrange emergency admission if it is their first seizure.
Side effects of valproate?
Weight gain Nausea Vomiting Hair loss/curly regrowth Tremor
Side effects of lamotrigine?
Drowsiness
Nausea
Dizziness
Diplopia
Side effects of carbamezapine?
Nausea Vomiting Diarrhoea Hyponatraemia Rash Itching Urinary retetnion Drowsiness Headache Blurred vision Diplopia Dizziness
