High risk drugs Flashcards
Which beta blockers do not cause nightmares (4 points)
Water-soluble beta-blockers: atenolol celiprolol hydrochloride nadolol sotalol hydrochloride
True or false:
Methotrexate can be continued if the patient develops diarrhoea
FALSE
Manufacturer advises withdraw treatment if stomatitis or diarrhoea develops—may be first sign of gastro-intestinal toxicity
The dose of which drug should be reduced when given concurrently with azathioprine/mercaptopurine
Allopurinol
Xanthine oxidase inhibitor
What drug class does ciclosporin belong to
It is a calcineurin inhibitor
True or false:
Ciclosporin is not known to be nephrotoxic
FALSE
It is markedly nephrotoxic
BNF
Which calcineurin inhibitor has a a greater incidence of nephrotoxicity:
Ciclosporin or Tacrolimus
Tacrolimus
True or false:
Sirolimus is a calcineurin inhibitor
FALSE
It is a non-calcineurin inhibiting immunosuppressant
What are the six points of the cytotoxic drug handling guidelines
- Only reconstituted by trained personnel
- PPE should be worn
- Eyes should be protected
- Pregnant staff should avoid exposure to cytotoxics
- Monitor staff exposure to cytotoxics
- Can only reconstitute in designated pharmacy areas
Oral mucositis is more common with which cytotoxics ?
3 points
Fluorouracil
Methotrexate
Anthracyclines (e.g. doxorubicin)
_________, a cytotoxic drug side effect, occurs secondary to spontaneous or treatment related rapid destruction of malignant cells
Tumour lysis syndrome
Features of tumour lysis syndrome
4 points
HYPERkalaemia and HYPERuricemia
HYPOcalcaemia and HYPOphosphatemia
These may lead to renal damage
Which two cytotoxics do NOT cause bone marrow suppression
Vincristine and Bleomycin
True or false:
Cytotoxic chemotherapy increases VTE risk
True
Though it may also be a complication of the cancer itself
Mildly, moderately or highly emetogenic:
Fluorouracil and Vinca-alkaloids
Mildly
Mildly, moderately or highly emetogenic:
Doxorubicin, cyclophosphamide (low and intermediate dose), high dose methotrexate
Moderately
Mildly, moderately or highly emetogenic:
Platinum based chemo, dacarbazine, high dose cyclophosphamide
Highly
Which class of cytotoxics are known to be cardiotoxic
Anthracyclines e.g. doxorubicin
How long should chemoprevention with tamoxifen last for familial breast cancer
Maximum 5 years
Monitoring for amiodarone
5 points
TFTs LFTs K+ (causes hypokalaemia) CXR (looking for pulmonary toxicity) ECG
True or false:
Amiodarone can cause phototoxic skin reactions
TRUE
May cause a slate grey discolouration of the skin
True or false:
SOB or cough may be a sign of amiodarone toxicity
TRUE
Amiodarone causes pulmonary toxicity
Counselling points for amiodarone
Avoid direct sunlight. Use a wide spectrum sunscreen
Amiodarone May increase the concentration of which drugs
4 points
Coumarins (eg warfarin)
Digoxin
Flecainide
Phenytoin
True or false:
The effects of amiodarone stop immediately upon discontinuation
FALSE
due to its long half life (~50 days) the effects and potential for interactions can last for weeks-months after stopping treatment
What effect do ACE inhibitors and ARBs have on electrolytes
They cause hyperkalaemia
Abnormal U & Es in patients on ACE inhibitors and ARBs is a sign of _____________
Renal artery stenosis
True or false:
ACE inhibitors abs ARBs can cause jaundice
TRUE
they may also cause a marked elevation of hepatic enzymes
What are the signs of neuroleptic malignant syndrome
5 points
Hyperthermia
Fluctuating consciousness
Tachycardia
Labile BP
Muscle rigidity
Increased of EPSEs when antipsychotics are taken with:
2 points
Amantadine
Metoclopramide
True or false:
Patients taking antipsychotics should be counselled to avoid direct sunlight
TRUE
Photosensitisation can occur with high doses
What effect does the interaction between azathioprine and warfarin have
Decreased effect of warfarin = increased risk of blood clots
Azathioprine dose needs to be reduced by ______ in patients also taking allopurinol. Why?
Reduce by 1/4
Allopurinol inhibits the enzyme that metabolises AZ = increased risk of toxicity
How many categories of Antiepileptics are there?
Which category has to be prescribed by brand ?
3 categories
Category 1 prescribed by brand
What is the therapeutic range for carbamazepine
4 - 12 mg/L
What parameters need to be monitored for patients treated with carbamazepine
(3 points)
FBC
U & Es
LFTs
Which electrolyte disturbance can be caused by carbamazepine
Hyponatraemia
What are the signs of neutropenic sepsis (associated with chemotherapy)
(5 points)
Fever - 2 temp readings of greater than or equal to 37.5°C
Flu like symptoms
Unexplained bruising or bleeding
Diarrhoea and or vomiting (uncontrolled)
Mouth ulcers - prevent eating and drinking
True or false:
Ciclosporin needs to be prescribed by brand
TRUE
What kind of vaccines need to be avoided in those taking long term corticosteroids
LIVE vaccines
Because steroids cause immunosuppression
True or false:
Corticosteroids are not known to cause electrolyte disturbances
FALSE
They may cause hypokalaemia especially alongside other drugs that reduce K+
E.g diuretics
True or false:
Different medicinal forms of digoxin are bio equivalent
FALSE
See BNF for conversion
Therapeutic range for Gentamicin
A) Peak
B) Trough
A) 5-10 mg/L (or 3-5 mg/L in endocarditis)
B) < 2 mg /L (or < 1 mg/L in endocarditis)
True or false: Penicillins are not known to cause blood disorders
FALSE
This is a rare side effect that may be caused by penicillins and their derivatives (e.g. penicillamine used to treat autoimmune diseases such as RA)
For how long must effective contraception be used (both M and F) after stopping methotrexate ?
At least 6 months
Therapeutic range for Lithium
- 4 - 1 mmol/ L
0. 8 - 1 mmol/L for acute episodes of mania
True or false:
Lithium does not need to be prescribed by brand
FALSE
Patients must be maintained on the same brand of Li as they have varying levels of bioavailability
True or false:
Li interacts with antipyschotic drugs
TRUE
It increases the risk of EPSEs
Which drug classes increase the risk of Li toxicity
4 points
NSAIDs
ACE inhibitors/ARBs
SSRIs
TCAs
What is the nature of the interaction between Li and NSAIDs
NSAIDs decreases the renal clearance of Li = increased Li levels = increased risk of toxicity
True or false:
Li is not known to cause thyroid abnormalities
FALSE
Hypothyroidism is a sign of lithium toxicity
How often should serum Li be monitored
Weekly until stable
Then 3 monthly for a year
Thereafter 6 monthly
Why should people on Lithium avoid a low salt diet
Li+ is similar to Na+ and the body cannot differentiate between the two. Low Na+ intake leads to increased absorption of Li+ which increases the risk of toxicity
How long after Lithium dose do you need to wait before taking samples
Li samples should be taken 12 hours after the dose
How often should monitoring occur for those on methotrexate
Every 1-2 weeks until stable
Then every 2 - 3 months
True or false:
If patients develop a cough or dypnoea while taking methotrexate they should seek immediate medical attention
TRUE
Methotrexate causes pulmonary toxicity. These are signs of pneumonitis.
Which drugs are known to reduce the renal excretion of methotrexate ?
(2 points)
Penicillins
NSAIDs
What is the nature of the interaction between methotrexate and phenytoin
Phenytoin is also an anti-folate drug so additive depletion of folate levels if given alongside methotrexate
What parameters need monitoring in those on long term NSAIDs
4 points
- BP (especially after a dose change)
- Renal function
- LFTs
- Hb (in those with risk factors for GI bleeds)
True or false:
NSAIDs decrease blood pressure alongside anti-HTN drugs
FALSE
NSAIDs antagonise the hypotensive effects of antihypertensives
Oral NSAIDs should be taken ______ or ________ food
With or just after
Therapeutic level for phenytoin
10 - 20 mg/L
Which parameters need monitoring with phenytoin use
5 points
1) Serum phenytoin
2) ECG and BP
3) LFTs
4) FBC
5) Folate and vitamin D
Patients with liver impairment may show early signs of phenytoin toxicity
Why ?
Phenytoin is highly protein bound. In liver impairment, less protein is produced so there is more free phenytoin = increased toxicity
What are the signs of phenytoin toxicity
5 points
Ataxia Confusion Slurred speech Hyperglycemia Vision changes
True or false:
Different formulations of phenytoin are bioequivalent
FALSE
They are not bioequivalent. Patient needs to be maintained on the same brand
Therapeutic range for theophylline
10 - 20 mg/L
Monitoring requirements for theophylline
2 points
Plasma theophylline concentration
K+
Does theophylline cause hypo or hyper -kalaemia
HYPO
Signs of theophylline toxicity
5 points
- Vomiting
- Tachycardia
- Arrhythmias
- Severe hypo-K+
- Convulsions
What is the nature of the interaction between theophylline and B2 agonists
Both cause hypokalaemia -this is potentially serious
What is the major route of elimination of theophylline
Hepatic
Does smoking increase or decrease theophylline levels
Decreases - smoking is an enzyme inducer. Patients need to tell their doctor if they are planning to stop smoking as this affects drug levels and may lead to toxicity
What is the trough therapeutic range for vancomycin
10 - 15 mg/ml
What is the major route of elimination of vancomycin
Renal
70-90% is excreted unchanged in the urine
_____ and _____ can occur if vancomycin is administered too quickly
Hypotension
Anaphylaxis
Vancomycin major interactions :
Increased Ototoxicity and Nephrotoxicity with loop diuretics, aminoglycosides and ciclosporin
How long must effective contraception be used for after stopping oral retinoids
1 month
Pregnancy must also be excluded 1 month after stopping
What is the maximum dose of isotretinoin per course ?
How long is the course ?
Maximum 150 mg/kg per course
Given for at least 16 weeks
True or false:
Retinoids can cause suicidal thoughts
TRUE
Psychiatric changes are a known side effect of retinoids
How does renal/hepatic impairment affect the use of oral retinoids
Reduce initial dose in renal impairment
Avoid in hepatic impairment
True or false:
Warfarin can be used during pregnancy
FALSE
Do not use especially in the 1st and 3rd trimesters. Can cross the placenta = increased risk of foetal malformations
True or false:
Warfarin should not be used by breastfeeding women
FALSE
It is not present in large amounts in milk so appears to be safe
What parameters should be monitored in those taking sodium valproate
(2 points)
LFTs
FBC
Note: therapeutic drug monitoring is not needed
How should treatment with sodium valproate be withdrawn
Reduce dose gradually over at least 4 weeks
True or false:
Valproate can cause SCARs
TRUE
This includes SJS
True or false:
Valproate is not known to cause weight gain
FALSE
Which tetracycline requires LFT monitoring and when would this be required?
Minocycline
Monitor every 3 months if the treatment is lasting longer than 6 months
