High Risk Flashcards
What is the common indication for amiodarone?
What else could it be used for in emergency?
- Arrhythmias - esp when other drugs ineffective/contra-indicated
AF, atrial flutter, supraventricular tachycardia
- Cardiac arrest
Oral dose schedule of amiodarone?
200mg TDS for 1 week
200mg BD for 1 week then
200mg daily as maintenance dose
Why load?
Long half life (50 days) means it would take ages to reach therapeutic levels. Also means interactions can still occur months after stopping.
Contra-indications with amiodarone? (5)
Avoid in:
1. Severe conduction disturbances (unless pacemaker fitted)
- Sinus node disease
- Iodine sensitivity
- Sino-atrial heart block (except in cardiac arrest)
- Thyroid dysfunction
Warnings signs with Amiodarone? (6)
- Signs & symptoms of hypo- or hyperthyroidism - because of the iodine in amIODarone.
- Corneal microdeposits. rarely interfere with vision - drivers may be dazzled by headlights at night. IF vision impaired/optic neuritis/optic neuropathy - STOP amiodarone
- Progressive SOB or cough - Pneumonitis
- Clinical signs of liver disease e.g. jaundice, dark urine
- Neurological effect of tremor, peripheral neuropathy (numbness/tingling of hands and feet)
- Phototoxic skin reactions - GREY skin
Monitoring requirements of amiodarone?
IV use?
Thyroid function
Liver function
Serum potassium
Chest X-RAY
IV use:
ECG + resuscitation facilities
Liver transaminases
Thyroid and Liver - repeated every 6 months
Side effects of Amiodarone? (12)
What can occur with parenteral use - following rapid injection?
- Arrhythmias
- Hepatic disorders
- Hyper/hypothyroidism
- Skin reactions - GREY
- Nausea
- Resp disorders - cough, SOB
- Corneal deposits
- Constipation
- Sleep disorders
- Taste altered
- Vomiting
- Photosensitivity
- Hypotension
Due to Amiodarone
long half life (___ days) potential for drug interactions to occur weeks/months after treatment has stopped.
Amiodarone increases the plasma concentrations of which drugs: (6)
50 days
- Coumarins
- Dabigatran (Direct thrombin inhibitor)
- Digoxin (Cardiac glycoside)
- Flecainide (Antiarrhythmics)
- Phenindione (Vit K antagonist - like warfarin)
- Phenytoin (antiepileptics)
Which patients should amiodarone be AVOIDED in?
- Heart block
- Active thyroid disease
- Severe hypotension
If a person develops hyPOthyroidism can they continue with amiodarone?
Yes if it’s essential - then can be treated with replacement therapy
What are some of the RARE/Freq not known side effects of amiodarone?
Oral use:
- Alopecia
- Erectile dysfunction
- Anaemia
- Thrombocytopenia
- Pulmonary haemorrhage
- Vertigo
- Altered smell
- Decreased appetite
- Parkinsonism
- Vasculitis
Parenteral:
- Hot flushes
- Hyperhidrosis
- Neutropenia
- Libido decreased
- Agranulocytosis
Counselling points of Amiodarone? (4)
- Taken by mouth - can be crushed and dispersed in water
- Shield skin from light& use wide-spectrum sunscreen - during and several months after stopping treatment
- Avoid grapefruit juice
- Drivers may be dazzled by headlights at night
How is amiodarone given for cardiac shock? Can it be given before it is prescribed?
300mg followed by 20ml of glucose 5%
yes in this case
Amiodarone increases the plasma concentration of digoxin, diltiazem and verapamil.
What can this increase the risk of … (3)
So what should happen with the dose of these medications?
- Bradycardia
- AV block
- Heart failure
dose should be halved
There is an INCREASED risk of VENTRICULAR ARRHYTHMIAS when amiodarone is given with which medicines… (long list) (20)
- Amisulpride
- Atomoxetine
- Chloroquine
- Citalopram
- Disopyramide
- Escitalopram
- Haloperidol
- Hydroxychloroquine
- Levofloxacin
- Lithium
- Mizolastine
- Mefloquine
- Moxifloxacin
- Phenothiazines
- Pimozide
- Quinine
- Sulpiride
- Telithromycin
- Tolterodine
- Tricyclics
There is increased risk of myopathy when amiodarone is given with _____
Simvastatin
Can Amiodarone be used in:
- Pregnancy
- Breast feeding
- Possible risk of neonatal goitre - use only if no alternative
- Avoid - present in milk in significant amounts - risk of neonatal hypothyroidism from release of iodine
What is the MHRA warning for taking amiodarone with Sofosbuvir & daclatasvir OR Sofosbuvir & ledipasvir OR Sofosbuvir & simeprevir?
AVOID - Risk of severe bradycardia and heart block
If need to use - pts to be closely monitored esp during first few weeks of treatment.
What is Lithium used for? (4)
Prophylaxis and treatment of:
Mania
Bipolar disorder
Recurrent depression
Aggressive or self-harming behaviour
Can you easily switch between different Lithium preparations?
No because they vary in bioavailability - requires same precautions as initiation of treatment.
What are the serum level monitoring requirements of lithium?
-Serum concs: 0.4-1mmol/L
(lower end of the range for maintenance and the elderly)
Blood samples should be taken 12 hours.
0.8-1mmol/L: acute episodes of mania and relapse patients and sub-syndromal symptoms
Monitoring requirements / before starting treatment for Lithium? (6+1)
Before & every 6 months
- Renal eGFR
- Cardiac
- Thyroid function
- BMI
- FBC
- Electrolytes
ECG is recommended in patient with CVD or risk factors.
What are the CI of lithium? (6)
- Addison’s disease
- Cardiac insufficiency
- Dehydration
- Family/Personal history of Brugada syndrome
- Low sodium diets
- Untreated hypothyroidism
What are cautions of lithium? (10)
- Avoid abrupt withdrawal
- Cardiac disease
- QT interval prolongation
- Diuretic treatment (risk of toxicity)
- Concurrent ECT (may lower seizure threshold)
- Elderly (reduce dose)
- Epilepsy (may lower seizure threshold)
- Myasthenia gravis
- Psoriasis (risk of exacerbation)
- Review dose in diarrhoea;
intercurrent infection (especially if sweating profusely);
vomiting;
surgery
What is the association with long term use of lithium? (2)
- Thyroid disorders (monitor thyroid function every 6 months)
- Mild cognitive and memory impairment
What are the signs of overdose of lithium? (10)
Must withdraw treatment
- Increasing gastro disturbance - vomiting/diarrhoea
- Incontinence/polyuria (renal dysfunction)
- Visual disturbance - blurred vision
- CNS disturbance - drowsiness/confusion/unsteadiness
- Muscle weakness/ tremor
Severe:
- Serum conc more than 2mmol/L
- Seizure/Coma
- Renal/Circulatory failure
- Blood pressure changes
- Cardiac arrhythmias
What is the conception, contraception advice and pregnancy & breast feeding advice with lithium?
Effective contraception during treatment for women of child bearing potential.
Pregnancy - AVOID particularly in FIRST trimester - risk of teratogenicity, including cardiac abnormalities.
Dose requirements increased during 2nd and 3rd trimesters BUT on delivery return abruptly to normal.
Breastfeeding - AVOID
present in milk & risk of toxicity in infant
When should serum levels of lithium be measured & how often?
Samples should be taken 12 hours after dose
0.4-1mmol/L - lower end for maintenance/elderly
0.8-1 mmol/L for mania/relapsed
Weekly after initiation and after each dose change until levels are stable.
Every 3 months for the first year then every 6 months
What advice should be given when stopping lithium treatment?
Abrupt withdrawal - increase chance of relapse
Dose should be gradually decreased over at least 4 weeks.
What are the patient/career advice for lithium? (8)
Report any signs of:
- Toxicity
- Hypothyroidism
- Renal dysfunction - polyuria/polydipsia
- Benign intracranial hypertension (persistent headache & visual disturbance)
- Maintain adequate fluid intake (to prevent hyponatraemia)
- Avoid dietary changes which reduce or increase sodium intake
- Avoid alcohol
- Risks of driving/operating machinery - sleepy
Give pts Lithium treatment pack
e.g. Priadel, Liskonum, Camcolit
What drugs increase the toxicity of lithium? (10)
- ACE inhibitors
- Angiotensin II receptor antagonists
- Loop diuretics
- Thiazides
- NSAIDs
- Potassium sparing diuretics
- Aldosterone antagonsits
- Metronidazole
- SSRIs
- Tricyclics
What drug increases risk of ventricular arrhythmias For lithium?
Amiodarone
What drugs increase the risk of neurotoxicity of lithium? (5)
- Methyldopa
- Phenytoin
- Carbamazepine
- Diltiazem
- Verapamil
What drugs is there an increased risk of extrapyramidal side effects ( tremor, slurred speech, akathesia, dystonia, anxiety, distress, paranoia) with lithium? (7)
- Clozapine
- Haloperidol
- Sulpiride
- Phenothiazines
- Risperidone
- Flupentixol
- Zuclopenthixol
Side effects of Lithium? (14)
- Abdominal discomfort
- Angioedema
- Electrolyte imbalance
- Hypothyroidism
- Cardiomyopathy & AV block
- Arrythmias
- Weight gain
- Tremor/ movement disorders
- Leukocytosis (WBC increase)
- Polydipsia (excessive thirst), Polyuria
- Memory loss
- Skin reactions/ulcers
- Vision disorders
- Vertigo
What are the indications for Carbamazepine? (3)
Unlicensed uses? (2)
- Focal and secondary generalised tonic-clonic seizures,
Primary generalised tonic-clonic seizures - Trigeminal neuralgia
- Prophylaxis of Bipolar disease unresponsive to lithium.
- Alcohol withdrawal
- Diabetic neuropathy
Mechanism of action of Carbamazepine?
Block sodium channels
Monitoring of carbamazepine? (3)
- Blood count
- Renal function
- Liver function (metabolised by the liver)
Side effects of carbamazepine? (6)
- GI effects - nausea & vomiting (modified release to help)
- Neurological - dizziness, ataxia (drunk like symptoms)
- Hypersensitivity - skin reactions - maculopapular rash
- Hypersensitivity syndrome - Steven - Johnson’s syndrome, skin necrolysis, fever
- Oedema - due to antidiuretic hormone like activity
- Hyponatraemia - due to antidiuretic hormone like activity
Warning signs of carbamazepine? (5)
- Toxicity - blurred vision, ataxia, diplopia (double vision), nystagmus (involuntary, uncontrollable eye movements), drowsiness, diarrhoea, arrhythmias, hyponatraemia
- Blood disorders - leucopoenia, thrombocytopenia (fever, sore throat, unexplained bruising/bleeding)
- Skin disorders - toxic epidermal necrolysis (mouth ulcers, rash)
- Hepatic disorders e.g. hepatitis
- Antiepileptic hypersensitivity syndrome - skin reactions, fever, swollen lymph nodes
Serum levels of carbamazepine? When should they be measured?
4-12 mg/L or 20-50micromol/L
not routine to check but after 1- 2 weeks and after a dose change
Interactions - Carbamazepine decreases the concentration of which drugs? (7)
what increases (5) plasma concentration of carbamazepine?
Carbamazepine is a P450 inducer so will decrease the concentration & efficacy of the following:
- Antipsychotics
- Corticosteroids
- Coumarins
- Eplerenone
- Oestrogens
- Progesterone ** (careful Levonelle/levonorgestrel after morning pill)
- Simvastatin
Plasma conc of carbamazepine will INCREASE with:
P450 enzyme inhibitors as it is metabolised by the enzyme
1. Macrolides (clarithromycin, erythromycin)
2. Cimetidine (histamine H₂ receptor antagonist)
3. Acetazolamide (for glaucoma etc)
4. Fluoxetine (SSRI)
5. Isoniazid (TB Abx)
Interactions - efficacy of antieplipetic drugs reduced by those that lower the seizure threshold …such as (4)
- SSRI
- Tricyclic antidepressants
- Antipsychotics
- Tramadol
Interactions - possible risk of increased convulsions when antiepileptics given with what drug used for those who are overweight? (1)
Orlistat
Patient advice for carbamazepine? (5)
- Maintain same formulation & brand
- Look out for any warning signs
- Discuss pregnancy with Dr - take folic acid
- Pt is aware of law and driving - seizure free for 12 months or 3 years with only night time seizures. Should not drive for 6 months after changing or stopping treatment.
- Inform potential interactions and to check with pharmacist or dr before new meds OTC herbal etc
Can carbamazepine be used in pregnancy & breastfeeding? What’s the risk?
What is advised?
Dose needs to be adjusted - associated with neural tube defects, cardiac and urinary tract abnormalities & cleft palate.
Discuss with Dr - take high dose folic acid before conception.
Breastfeeding - ok - plasma conc too small
Pre-screening with Carbamazepine? What’s there an increased risk of ?
Test for HLA-B1502 allele in individuals of Han Chinese or Thai origin (avoid unless no alternative—risk of Stevens-Johnson syndrome in presence of HLA-B1502 allele).
What is the difference between:
Agranulocytosis
Thrombocytopenia
Blood Dyscrasias
Agranulocytosis: WBC’s go down; sore throat, fever, malaise all symptoms
Thrombocytopenia: Platelets go down: blood very thin: unexplained bleeding/ bruising. Can be from Heparins
Blood Dyscrasias: Entire blood profile goes down; symptoms of both of the above, this is why we report both sets of symptoms with some drugs
Symptoms of Aspirin overdose? (5)
- Tinnitus
- Hyperventilation
- Deafness
- Vasodilation
- Sweating
Why is rifampicin considered High Risk do you think?
Rifampicin is one of the TB drugs
Many interactions- as it is an enzyme Inducer, it induces ALL of the CYP enzymes: decreases efficacy of COC’s
HEPATOTOXIC: Monitor LFTs, counsel on liver toxicity signs, stop if:
Persistent Nausea
Vomiting
Malaise
Jaundice
Also colours urine/ body fluids/ soft contact lenses red/ orange
What monitoring is needed with Rifampicin?
LFT’s before starting- continue to monitor if on prolonged therapy
Renal function before starting
FBC if on prolonged therapy
Which class of antibiotics do we need to use with caution in EPILEPTICS?
Quinolones-
Ciprofloxacin, Levofloxacin
These lower seizure threshold!
Particularly if used with theophylline
Why do we need to check albumin levels with warfarin?
Warfarin is highly protein bound to albumin- if this is low there may be issues transporting it round the body
need to monitor both renal and liver function with warfarin
People stable on warfarin- how often is INR checked?
Every 3 months
Unless changes in clinical status occur e.g. diarrhoea and vomiting
Methotrexate inhibits dihydrofolate reductase and therefore reduces folate in the body. What drug has to be given with methotrexate as supplementation to prevent its nasty side effects, and when?
For prevention of methotrexate induced horrible side effects in Chron’s/ RA:
Folic acid 5mg ONCE WEEKLY- dose to be taken on a DIFFERENT DAY to methotrexate
Methotrexate may lead to blood disorders (most significantly neutropenia and increased infection risk) through BONE MARROW SUPPRESSION. Its anti- folate propertied may explain how it suppresses bone marrow…
Bone marrow is where the body creates new cells. Cell division requires folate in order to occur.
Since folate deficiency limits cell division, erythropoiesis, production of red blood cells, WBC, neutrophils etc is suppressed in the bone marrow when methotrexate is taken as it is anti- folate. This is the same story as with Trimethoprim/ Co- trimoxazole and Phenytoin as these are also anti-folate- Avoid use together!
Production of RBC’s being hindered also leads to megaloblastic anemia, which is characterized by large immature red blood cells that cannot divide.
What monitoring does Methotrexate require?
Renal function
LFT’s
FBC (due to blood disorder risk)
These should be 1-2 weekly until dose stabilised then 2-3 monthly thereafter
Exclude pregnancy- pregnancy test before starting?
Avoid in hepatic impairment and reduce dose in renal impairment unless severe- then avoid.
What is methotrexate used for?
Main use in:
Rhumatoid Arthritis
Severe Chron’s (Inflammatory Bowel Disease)
Severe Psoriasis
It is cytotoxic- stops cell division- part of chemotherapy
What are the Methotrexate warning signs
Blood disorder: Bone marrow suppression- sore throat, ulcers, fever, rash
Liver toxicity- N&V, abdominal pain, dark urine, Jaundice
Gastro-intestinal toxcitiy: stomatitis, GI upset (sore mouth first symptom)
Pulmonary Toxicity- persistent SOB, cough
PREGNANCY & Breastfeeding- its anti-folate so avoid!!- contraception needed during treatment and for 3 months after stopping
WITHDRAW TREATMENT IF ANY OF THESE OCCUR
What OTC med’s can increase the risk of Methotrexate toxicity?
NSAIDS/ ASPIRIN !!
Reduce methotrexate excretion in kidney
As do penicillins!
A patient comes in complaining of mouth sores, they think it may be cold sores. After further questioning you find out they are on Methotrexate. What do you do?
dvise they seek medical attention ASAP
Mouth sores may be a sign of stomatitis (inflammation of mouth) which is the first sign of Gastro-intestinal toxicity associated with Methotrexate!
A patient asks for some Lozenges as they are experiencing a very sore throat. You find out they are on Methotrexate. What do you do?
Seek medical attention ASAP
Sore throat is most common side of blood disorders with Methotrexate
Patients can sometimes overdose on Methotrexate as they get confused that it is Just once weekly dosing. What are the symptoms? what is methotrexate toxicity treated with?
Renal impairment
Liver impairment
Headache, seizures, coma
Treatment: FOLINIC ACID- rescues normal cells from methotrexate effects
What happens when Baclofen (used for pain of muscle spasms in palliative care/ trauma) is suddenly withdrawn? What if it is given with ACE inhibitors or Beta blockers?
Suddenly withdrawn: hyperactivity, hyperthermia, hallucinations, convulsions
Enhanced Hypotensive effects with ACEi/ Beta blockers
Which NOAC is contra-indicated in patients with a Prosthetic valve?
DABIGATRAN
What needs monitoring with Vancomycin (4)?
- Full blood count: can cause both LOW PLATELETS and LOW NEUTROPHILS (Neutropenia)
- Renal function- Nephrotoxic- Urinalysis, CrCl used for dosing
- Hearing function in the elderly
- Plasma concentration
What needs monitoring with Gentamicin? (3)
- Renal function
- Hearing function
- Plasma concentration
NB: differs to vancomycin as do not need to monitor FBC- does not cause neutropenia/ low platelets
Which antihypertensive drugs require the SAME BRAND to be maintained?
Diltiazem
Nefedipine
(Both CCB’s)
Which CCB cannot be used in both Supraventricular and Ventricular arrhythmias?
** check **
VERAPAMIL
Used for Supraventricular only
Verapamil NOT to be used in Ventricular Arrhythmias
Ciclosporin (an immunosuppressant drug) has many interactions. This is because it is toxic to many organs, so any drug effecting each of those organs will be contra-indicated with ciclosporin use. What toxicitys can it cause (5)?
Neurotoxicity (CNS- tremor, convulsions, encephalopathy)
Liver toxicity (jaundice, N&V, abdo pain, dark urine)
Nephrotoxicity (kidney)
Blood toxicity/ disorders (fever, sore throat, ulcers, bleeding)
Hypertension- BP needs monitoring regularly
Patient should report any of these signs
What type of vaccines are Ciclosporin and Tacrolimus Contra-indicated with?
Live vaccines
Live vaccines can, in some situations, cause severe or fatal infections in immunosuppressed individuals due to extensive replication of the vaccine strain that the immune system cannot fight off.
Same goes with high dose corticosteroids: these can suppress the immune system so avoid live vaccines
What should patients on corticosteroids be told with regards to chickenpox/ measels?
If they have not have these before, avoid any exposure to anyone with these as they can contract very severe forms of these if they do.
Why is an eye exam needed with corticosteroid use?
Risk of eye problems:
Glaucoma- look for intraocular pressure
Corneal thinning
What drugs can increase the risk of someone developing gout (build up of uric acid)? (5)
- Diuretics– clears excess fluid out of body but the remaining fluid is more concentrated; increases the risk of developing the crystals that cause gout
- Beta-blockers and ACE inhibitors
- low-dose aspirin – used to reduce the risk of blood clots
- niacin – used to treat high cholesterol
- ciclosporin – used to treat conditions such as psoriasis
What are the symptoms of gout?
What are the dietary risk factors of gout?
Build up of uric acid causing:
sudden attack of severe pain in one or more joints, typically big toe.
joint feeling hot and very tender, swelling in and around the affected joint
Dietary risk factors: high in meat and seafood and high in beverages sweetened with fructose promotes higher levels of uric acid, also alcohol.
Phospohorus can help cure gout: Banana is a rich source of phosphorus.
What is the main symptom of Hypokaleamia?
What drugs can cause hypokaleamia? (5)
Ventricular Arrhythmias
(Hyperkaleamia can also cause arrhythmias!)
- Thiazide, thiazide-like and Loop diuretics
- Sotalol
- Salbutamol
- Amisulpiride
- Atomoxetine (used for ADHD)
Can you inject potassium chloride 20% w/v straight?
No- must be diluted first with sodium chloride 0.9%
Must be given by slow infusion
Monitor ECG- rapid infusion would be toxic to heart and arrhythmias occur
Need to the patient is weeing enough- contraindicated in anuria (absence of urination) as potassium would build up
What could black stools or coffee ground vomit be suggestive of with NSAIDs? What about Iron deficient aneamia?
GI bleeding
What are the following indicative of with NSAID therapy?
Unexplained weight loss
difficulty swallowing
nausea or vomiting
bloating
burping or acid reflux- recent onset dyspepsia
Peptic ulcer
What could swollen ankles indicated with NSAID therapy?
Kidney failure
Which NSAID is now contra-indicated in patients with a cardiac disease history/ risk of CV disease?
Diclofenac
The new treatment advice applies to systemic formulations (ie, tablets, capsules, suppositories, and injection available both on prescription and via a pharmacy, P); it does not apply to topical (ie, gel or cream) formulations of diclofenac.
What electrolyte disturbance could NSAIDs effectively cause?
NSAIDs can damage the kidneys (AKI)
This can in turn lead to HYPERKALEAMIA
A dose increase for an opioid should be no more than __% of the last dose
No more than 50%
Due to risk of overdose
Aside from their use in pain, what else can strong Opioids be used for?
Relief of breathlessness in palliative care
Relief of breathlessness and anxiety in acute pulmonary oedema (alongside oxygen, furosemide, nitrates)- Myocardial infarction
But do not give them in respiratory failure!
Suprising when they can cause respiratory depression! This is because they reduce cardiac work and oxygen demand- hence their use in Myocardial Infarction.
What side effects do opioids have on the skin?
They cause histamine release- this can cause ITCHING and urticaria (hives/ nettle rash), also sweating
Biliary colic is a type of pain related to the gallbladder that occurs when a gallstone obstructs the cystic duct and the gallbladder contracts. Should we use opioids for this pain?
No- opioids can worsen the pain due to sphincter spasm
How is chronic pain usually managed with strong opioids?
Oral route first:
Start with an immediate release solution such as Oramorph
Then once optimal dose found- switch to modified release (MST Continus- administered BD [12 hourly])
For breakthrough pain, immediate release (Oramorph) morphine at a dose of 1/6 the usual.
Why must codeine/ dihydrocodeine never be given via the IV route?
Can cause a severe reaction similar to anaphylaxis (but not allergy based)
Which opioid should be avoided in epileptics?
Tramadol: it lowers the seizure threshold
Avoid with other drugs that lower seizure threshold: SSRI’s, TCA’s, quinolones, theophylline
How should oral antiplatelets be administered?
With or just after food (to protect stomach)
Except for Dipyridamole: 30 to 60 mins before food
Why is Tacrolimus such a high risk drug? What can it cause?
Hint: Similar to Ciclosporin. Both toxic to many organs
Neurotoxicity (CNS)- tremor, headache
Nephrotoxicity
Eye disorders (ciclosporin not toxic to eyes)
Blood disorders- report fever, sore throat, ulcers etc
Skin disorders- rash
Hyperglycaemia
Liver toxicity
What dietary substances should patients on Tacrolimus / Ciclosporin avoid?
Avoid a diet high in Potassium (as these can BOTH cause Hyperkaleamia)
Avoid grapefruit juice- Increases plasma concentrations of these as its an enzyme inhibitor
What drugs can cause Hyperkaleamia?
Ace inhibitors/ ARBs
Potassium sparing diuretics (spironolactone + eplerenone)
Ciclosporin and Tacrolimus (immunosuppressants)
NSAIDs
What do we use to treat hyperkaleamia?
Calcium gluconate
The priority is to stabilise the heart: do not want it to arrest due to fatal cardiac arrhythmias
Then sort out hyperkaleamis:
IV insulin or salbutamol as temporary measures to drive K+ back into cells
If its severe- use Heamodialysis
Why not use diuretics, as these cause hypokaleamia too?- as diuretics will effect fluid balance. do not want to put any more strain on the heart.
What should a patient do if they miss a warfarin dose?
Do not double up!
If later that evening- take dose. If next day- skip dose
Why are beta blockers used with caution in diabetes?
Can mask hypoglyceamia:
beta blockers blunt the of adrenalin: if someone becomes hypoglycemia adrenalin doesnt kick in and they dont get warning symptoms. Sweating is the only symptom that still shows.
Can also prevent adrenalin from stimulating the liver to make glucose, and therefore may make the hypoglycemia more severe
Why are beta blockers cautioned in asthma and COPD?
Risk of bronchospasm
If absolutely need one: choose a cardio selective BB like Bisoprolol
Why do we get a dry cough with Ace inhibitors and not ARB’s?
ARB’s do not increase bradykinin levels, because they do not inhibit ACE
Why are NSAID’s cautioned in asthma, what can they cause?
Bronchospasm- does not happen to every asthmatic.
Which diuretics can exacerbate diabetes?
Thiazides (most likely)
Loop diuretics
Due to hyperglyceamia side effect!
What do we need to monitor with diurectic use?
Electrolytes:
Na +
K +
Mg +
Renal function
Uric acid levels (risk of gout)
Hyperglyceamia- can exacerbate diabetes
Hypotension- BP lowering effects
When do we use simvastatin at a max dose of 10mg?
With fibrate use in combo: massive risk of myopathy
+ Bezafibrate
+ Ciprfibrate
Do not use gemfibrozil at all- risk of Rhabdomylosis too great
What vitamin deficiency can Metformin cause?
Vitamin B12 (cobalamin)
Symptoms of deficiency:
neuropathy (numbness, pain, or tingling in hands or feet)
Anaemia-
extreme tiredness (fatigue)
lack of energy (lethargy)
breathlessness
pale skin
Ace inhibitors have some protective and some negative effects on the Kidneys. When are they contra- indicated?
Bilateral Renal artery stenosis - they will make it progress into renal failure
Less effect on Unilateral renal artery stenosis
Best to avoid in patients with known or suspected RENOVASCULAR disease
What is the max daily dose of Codeine?
How long must intervals between doses be?
,Max number of days OTC?
240mg daily
6 hour intervals
3 days OTC
What drug causes ‘Purple glove syndrome’ skin disease in which the extremities become swollen, discoloured and painful
Phenytoin if given IV
