High risk drugs Flashcards by Chinonyelum Iwobi

Which beta blockers do not cause nightmares (4 points)

Water-soluble beta-blockers:
atenolol
celiprolol hydrochloride
nadolol
sotalol hydrochloride

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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

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The dose of which drug should be reduced when given concurrently with azathioprine/mercaptopurine

Allopurinol

Xanthine oxidase inhibitor

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What drug class does ciclosporin belong to

It is a calcineurin inhibitor

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True or false:

Ciclosporin is not known to be nephrotoxic

FALSE

It is markedly nephrotoxic
BNF

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Which calcineurin inhibitor has a a greater incidence of nephrotoxicity:

Ciclosporin or Tacrolimus

Tacrolimus

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True or false:

Sirolimus is a calcineurin inhibitor

FALSE

It is a non-calcineurin inhibiting immunosuppressant

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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

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Oral mucositis is more common with which cytotoxics ?

3 points

Fluorouracil

Methotrexate

Anthracyclines (e.g. doxorubicin)

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_________, a cytotoxic drug side effect, occurs secondary to spontaneous or treatment related rapid destruction of malignant cells

Tumour lysis syndrome

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Features of tumour lysis syndrome

4 points

HYPERkalaemia and HYPERuricemia

HYPOcalcaemia and HYPOphosphatemia

These may lead to renal damage

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Which two cytotoxics do NOT cause bone marrow suppression

Vincristine and Bleomycin

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True or false:

Cytotoxic chemotherapy increases VTE risk

True

Though it may also be a complication of the cancer itself

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Mildly, moderately or highly emetogenic:

Fluorouracil and Vinca-alkaloids

Mildly

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Mildly, moderately or highly emetogenic:

Doxorubicin, cyclophosphamide (low and intermediate dose), high dose methotrexate

Moderately

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Mildly, moderately or highly emetogenic:

Platinum based chemo, dacarbazine, high dose cyclophosphamide

Highly

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Which class of cytotoxics are known to be cardiotoxic

Anthracyclines e.g. doxorubicin

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How long should chemoprevention with tamoxifen last for familial breast cancer

Maximum 5 years

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Monitoring for amiodarone

5 points

TFTs 
LFTs
K+ (causes hypokalaemia)
CXR (looking for pulmonary toxicity)
ECG

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True or false:

Amiodarone can cause phototoxic skin reactions

TRUE

May cause a slate grey discolouration of the skin

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True or false:

SOB or cough may be a sign of amiodarone toxicity

TRUE

Amiodarone causes pulmonary toxicity

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Counselling points for amiodarone

Avoid direct sunlight. Use a wide spectrum sunscreen

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Amiodarone May increase the concentration of which drugs

4 points

Coumarins (eg warfarin)

Digoxin

Flecainide

Phenytoin

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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

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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

0. 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

1. BP (especially after a dose change) 2. Renal function 3. LFTs 4. 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

1. Vomiting 2. Tachycardia 3. Arrhythmias 4. Severe hypo-K+ 5. 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