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Pre-Reg Exam > High Risk Drugs > Flashcards

High Risk Drugs Flashcards

1
Q

Therapeutic Drug Monitoring: Digoxin - Target ? Level Taken ?

A

Target Level: 1-2 mcg/L

Levels Take: 6 hours post-dose

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2
Q

Digoxin Indications

A

cardiac glycoside - controls rate

  • AF: loading dose required
  • HF: no loading dose required

can control rate at REST so is good for pts with sedentary lifestyle (elderly etc)

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3
Q

Digoxin Contraindications

A

Heart Block

Ventricular arrhythmias

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4
Q

Digoxin Cautions

A

Renal Failure - potassium management + drug metabolism
Hypokalaemia
Thyroid Disease
Recent Mi

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5
Q

Digoxin Interactions

A

Drugs that cause hyPOkalaemia
- loops & thiazides, salbutamol, steroids, theophylline

Drugs that INCREASE concentrations:

  • Amiodarone, Dronedarone, Quinine (1/2 dose)
  • Rate Limiting CCBs
  • Macrolides (e.g. enzyme inhibitors)
  • Ciclosporin

Enzyme Inhibitors/Inducers

Drugs that REDUCE renal excretion/impair kidneys

  • NSAIDs
  • ACE/ARBs
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6
Q

What electrolytes can increase the risk of digoxin toxicity?

A

Hypokalaemia
Hypomagnesia
Hypercalcaemia

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7
Q

Digoxin Toxicity symptoms ?

A
  • Bradycardia/Heart Block
  • Nausea, Vomiting, Diarrhoea
  • Confusion, Delerium
  • Rash
    KEY SYMPTOM: blurred vision, YELLOW vision

Also:

  • Hypokalaemia
  • Arrythmias/ECG changes
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8
Q

Digoxin Monitoring

A

RENAL FUNCTION
Potassium Levels

levels - only when toxicity suspected/renal impairment

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9
Q

Digoxin Toxicity Management

A

withdraw treatment + correct electrolytes

severe + life-threatening: Digoxin-Specific Antibody

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10
Q

Amiodarone - Indications + Doses

A

Treatment of Arrhythmias

loading doses:

  • 200 mg TDS for 1 week
  • 200 mg BD for 1 week
  • 200 mg OD for 1 week
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11
Q

Amiodarone - Contraindications

A
  • Conduction Issues
  • Bradycardia
  • Severe Hypotension
  • Iodine Sensitivity/Hyper-Hypothyroidism
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12
Q

Amiodarone - Interactions

A

interactions can happen for MONTHS after stopping because of 50 day half-life

Amiodarone = is an enzyme INHIBITOR

  • NTI drugs - increased concs of Warfarin, Digoxin etc.
  • Grapefruit Juice
  • Statins = myopathy
  • B Blockers/Other Anti-arrhythmic = cardio depression + bradycardia
  • Drugs that prolong the QT
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13
Q

Amiodarone - what drugs do you have to reduce the dose of if given alongside?

A

Digoxin (half dose)
Diltiazem + Verapamil

due to serious bradycardia, AV block, heart failure

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14
Q

Amiodarone - Side Effects

A

BITCH x 2
B - blue man syndrome (slate-grey skin on light-exposed areas)
B - bradycardia
I - interstitial lung disease/pulmonary fibrosis
I - impaired movement, nerves, peripheral neuropathy
T - thyroid
C - corneal micro deposits/optic neuropathy
C - cutaneous photosensitivity
H - heart block
H - hepatitis

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15
Q

Amiodarone - Monitoring Requirements

A 
Chest X Ray (before + 6 months) 
LFTs (before + 6 months) 
Thyroid (before + 6 months) 
Potassium (before) 
Eye Tests (before + annual)
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16
Q

Amiodarone - Counselling Points

A

Lungs - report SOB + cough
Eyes - night time glares when driving, if impaired vision = STOP
Skin - shield from light + use high SPF (and months after stopping due to long half life)
Nerves - report any numbness/tingling in the hands and feet

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17
Q

Warfarin INR Targets

A

2.5 (2-3) - for all except:

recurrent VTE in patients receiving anticoagulation + mechanical heart valve = 3.5 (3-4)

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18
Q

Warfarin pre-operative management

A

stop Warfarin 5 days before surgery

if high risk - start LMWH 3 days after stopping Warfarin (duration of action) + then omit 24 hours before surgery

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19
Q

Warfarin MHRA Alerts

A

Calciphylaxis - build up of calcium in fat + skin tissues, common in patients with renal disease

presents as a painful rash

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20
Q

Key Warfarin Interactions

A
  • Bleeding Drugs - DOACs, LMWHs, SSRIs, Anti-platelets, NSAIDs
  • Daktarin - Miconazole OTC
  • Amiodarone
  • Antibiotics - affects the Vit K of the gut
  • Green Leafy Veggies + Green Tea
  • Pink Juices = pomegranate, cranberry
  • Inducers/Inhibitors (incl. smoking)
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21
Q

What to do when INR out of range for Warfarin

A

MAJOR bleeding = stop warfarin, Phytomenadione IV + prothrombin complex

INR OVER 8:

  • no bleeding = stop Warfarin + PO Vit K
  • minor bleeding = stop Warfarin + IV Vit K

INR 5-8:

  • no bleeding = withhold 1/2 doses and reduce maintenance
  • minor bleeding = stop Warfarin + IV Vit K
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22
Q

How often should INR for Warfarin be monitored?

A
  • initiation: daily/alternate days

- stable: every 3 months

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23
Q

Warfarin - Key Counselling Points

A
  • take at tea time ideally - accurate INR testing in the morning
  • can take dose up to 5 hours after original time
  • yellow book + anticoagulation card
  • dietary changes - green veggies etc
  • sickness + diarrhoea can affect the absorption
  • alcohol - safe to consume 1-2 units per day
  • changes in smoking can affect
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24
Q

Warfarin Side Effects

A
  • BLEEDING!
  • Calciphylaxis - a painful rash
  • Abnormal Liver Function
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25
Q

Water Soluble Β Blockers

A

CANS (watering cans)

  • Celiprolol
  • Atenolol
  • Nadolol
  • Sotalol
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26
Q

Long Duration of Action B Blockers

A

CANB (can B extremely long)

  • Celiprolol
  • Atenolol
  • Nadolol
  • Bisoprolol
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27
Q

Cardio-selective B Blockers

A

MANB (MEN think they’re good at CARDIO)

  • Metoprolol
  • Atenolol
  • Nebivolol
  • Bisoprolol
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28
Q

Theophylline levels

A

10-20, but 5-15 can be effective

but side effects can still occur in this therapeutic range

take levels 4-6 hours after dose (PEAK level)

measure levels 5 days after starting treatment, 3 days after dose adjustments

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29
Q

Theophylline Toxicity

A

FAST
- tachycardia, agitation, restlessness, CONVULSIONS, dilated pupils, hyperglycaemia

SICK
- vomiting, GI, diarrhoea, gastric irritation

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30
Q

Theophylline Side Effects

A
  • Hypokalaemia
  • Anxiety, Palpitations, Arrhythmias, Sleep Disorders, Tremor
  • GI discomfort
  • Headache, Dizziness, Seizures, Nausea + Vomiting
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31
Q

Theophylline Cautions

A
  • cardiac arrythmias - can cause
  • elderly - increased concentrations
  • epilepsy - can cause convulsions
  • fever
  • peptic ulcer
  • risk of hypokalaemia
  • thyroid disorder (tachycardia etc)
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32
Q

Theophylline Interactions

A

SMOKING

  • drugs that increase risk of hypokalaemia
  • β blockers - risk of bronchospasm
  • drugs that increase the risk of convulsions e.g. quinolones
  • enzyme inducers

needs to be prescribed by BRAND

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33
Q

Carbamazepine Levels

A

4-12mg - measure after 1-2 weeks

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34
Q

Carbamazepine Toxicity

A
  • incoordination
  • hyponatraemia
  • ataxia - involuntary movement
  • nystagmus - eye rolling
  • drowsiness
  • blurred vision + diplopia (double vision)
  • arrhythmias
  • GI disturbance

think - exerting effects in the BRAIN so too much starts causing some symptoms that relate - movements + eye rolling

antidote: activated charcoal

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35
Q

Carbamazepine Contraindications/Cautions

A

C/I

  • AV conduction abnormalities
  • Hx of BONE MARROW SUPPRESSION

Cautions

  • Cardiac Disease
  • Hx of Haematological Reactions
  • Skin Reactions
  • Angle-Closure Glaucoma
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36
Q

Carbamazepine Prescribing

A

HAS to be by brand

cross-allergy with phenytoin, primidone, phenobarbital = all the CP3 branded drugs

also test for allele in Han Chinese/Thai origin !!!!! due to risk of Steven Johnson’s Syndrome

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37
Q

Carbamazepine Side Effects

A

LIVER DYSFUNCTION = withdraw immediately due to hepatotoxicity

SEVERE LEUCOPENIA - blood dyscrasia withdraw immediately

HYPERSENSITIVITY + SKIN RASHES - report immediately, particularly Han Chinese/Thai patients

  • Hyponatraemia = can lead to water intoxication
  • Major Congenital Malformations
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38
Q

Carbamazepine Interactions

A

Carbamazepine = ENZYME INDUCER, reduces efficacy of drugs e.g. Warfarin, Contraceptives, DOACs

Drugs that also cause bone marrow suppression
Enzyme inhibitors that increase concentrations = toxicity
Drugs that increase the risk of seizures (quinolones, mefloquine, SSRIs, antipsychotics, TCAs)
Drugs that increase risk of HYPOnatraemia
Drugs that increase risk of HEPATOTOXICITY

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39
Q

Carbamazepine Monitoring

A
  • Therapeutic Drug Monitoring - 1-2 weeks after
  • Blood Counts
  • Hepatic Function
  • Renal Function
40
Q

Carbamazepine Counselling

A

BLOOD DYCRASIAS - report immediately fever, sore throat, mouth ulcers, unexplained bruising/bleeding

HEPATOTOXICITY - report signs of jaundice, dark urine etc.

RASHES - risk of SJS

CONTRACEPTION = reduced efficacy

41
Q

Phenytoin Contraindications/Cautions

A

Contraindications:
- Heart Block, Sinus Bradycardia when used IV - if too rapid infusion risk of death/severe harm due to bradycardia, CV collapse etc.

Cautions:

  • enteral feeds - due to protein content + binding of drug
  • EXACERBATES ABSENCE/MYOCLONIC SEIZURES
  • IV = heart issues/resp depression
42
Q

Phenytoin Prescribing

A

HAS to be by brand

have to screen Han Chinese/Thai patients prior to treatment for the allele that pre-disposes them to SJS/hypersensitivity

phenytoin liquid is NOT same as tablets

IM - not to be used (fosphenyotoin instead )because absorption is erratic

supplement Vitamin D

43
Q

Phenytoin Interactions

A

Phenytoin is an enzyme INDUCER - so will reduce efficacy of contraceptives, warfarin, DOACs, levothyroxine

  • enzyme inhibitors = risk of phenytoin toxicity
  • enzyme inducers = low phenytoin level
  • seizure-threshold lowering drugs = quinolones, tramadol, mefloquine, SSRIs, antipsychotics, TCAs
  • increased risk of blood dyscrasias = antifolates, immunosuppressants, DMARDs etc, but phenytoin is an ANTIFOLATE so particularly the folates
44
Q

Phenytoin Side Effects

A
  • RASH = discontinue !!!!!! - Han Chinese/Thai at higher risk
  • appearance changes = coarsening of facial features, acne, hirsutism, GINGIVAL hypertrophy
  • blood dycrasias - antifolaxe
  • hypersensitivity syndrome
  • LOW VITAMIN D - induces the metabolism
  • HEPATOTOXIC - discontinue immediately
  • Congenital Malformations
45
Q

Phenytoin Levels

A

10-20 - TROUGH level

kinetics are NON-LINEAR (0 order kinetics) which means doubling dose DOESN’T mean double the concentration, unpredictable concentrations

highly protein bound - so when albumin is low need to measure free-drug concentration
- proteins levels change in pregnancy, liver impairment, elderly, neonates

46
Q

Phenytoin Monitoring

A
  • Therapeutic Drug Monitoring (Trough - at 10 days)
  • ECG + Blood Pressure
  • Full Blood Counts
  • Liver Function
  • Folate
  • Vitamin D
47
Q

Phenytoin Toxicity

A
  • slurred speech
  • nystagmus (eye rolling)
  • ataxia (lack of co-ordination)
  • confusion
  • hyperglycaemia
  • blurred vision, double vision

difference between carbamazepine + phenytoin = carbamazepine is hypoNATRAEMIA and phenytoin in hyPERglycaemia

Carbamazepine = GI effects

48
Q

Sodium Valproate Contraindications/Cautions

A

Contraindicated

  • Mitochondrial Mutations = higher risk of liver failure
  • Hx/Family Hx of Hepatic Dysfunction
  • Urea Cycle Disorders (liver)
  • PREGNANCY

Cautions

  • Systemic Lupus Erythematosus
  • Liver Toxicity - usually occurs within the first 6 months

MHRA = contraindicated in women/girls of child-bearing age unless terms of the PPP being met

  • highly effective contraception
  • annual review + re–evaluation of treatment
  • sign a risk acknowledgement form yearly
49
Q

Sodium Valproate Interactions

A

Sodium Valproate = INHIBITOR
- increased concentrations of OTHER AEDs

Lamotrigine = risk of rash due to increased exposure
Topiramate = risk of toxicity 
Olanzapine = increased risk of adverse effects

Drugs that lower seizure threshold = quinolones, TCAs, tramadol, SSRIs, Mefloquine, Antipsychotics

Drugs that can cause blood dyscrasias

Drugs that are hepatotoxic

50
Q

Sodium Valproate Side Effects

A

HEPATOTOXICITY - discontinue

BLOOD DYSCRASIAS

PANCREATITIS

MAJOR CONGENITAL MALFORMATIONS

51
Q

Sodium Valproate Monitoring

A

Monitor LFTs before + 6 months

Full Blood Counts

52
Q

Sodium Valproate - Conditions of the PPP

A

have to exclude pregnancy

be on a form of HIGHLY EFFECTIVE contraception

  • 1 user independent
  • 2 user dependent

sign the risk acknowledgement form annually

53
Q

Sodium Valproate - Counselling

A
  • signs of hepatotoxicity

- signs of bone marrow suppression

54
Q

Sodium Valproate Prescribing

A

if under the PPP:

7 day prescription validity
maximum 30 days supply
emergency supply - refer to specialist prescriber if under the PPP

Category 2 - try and maintain on the same brand

1st Line in all generalised seizures

55
Q

Lithium Contraindications/Cautions

A

C/I

  • Addison’s disease
  • Cardiac Disease
  • Dehydration
  • Low Sodium Diets
  • Untreated Hypothyroidism (can cause)

Caution:

  • Epilepsy - may lower seizure threshold
  • Diuretics (lowers sodium)
  • Myasthenia Gravis
  • Psoriasis
  • QT prolongation
  • N&V/Diarrhoea - due to dehydration
56
Q

Lithium - Interactions

A
  • drugs that lower seizure threshold
  • drugs that prolong the QT
  • drugs that cause hypokalaemia (and increase risk of arrhythmias)
  • nephrotoxic drugs
  • drugs that cause hyponatraemia/affect salt balance
  • increased risk of neurotoxicity
  • increased risk of serotonin syndrome
  • drugs that can cause EPSEs - antipsychotics, metoclopramide
57
Q

Lithium - Side Effects

A
  • Thyroid Disorders long term
  • RENAL impairment = nephrotoxic
  • BENIGN INTRACRANIAL HYPERTENSION
  • QT PROLONGATION
  • LOWERS SEIZURE THRESHOLD
  • tremor
  • metallic taste/taste disturbances
  • weight gain
  • ankle swelling
  • thirsty + pass more urine
58
Q

Lithium - Toxicity

A

REVENGE

  • Renal Disturbances
  • Extrapyramidal Symptoms (tremor, muscle weakness, nystagmus)
  • Visual Disturbances
  • Nervous System
  • GI Effects
59
Q

Lithium Levels + Monitoring

A

Target: 0.4-1 - TROUGH level taken after 12 hours (take in the evening so that a blood sample can be taken in the morning)

acute = aim for higher end of 0.8-1

take levels WEEKLY, then 3 MONTHLY when stable (and some people can go to 6 monthly)

3 monthly people:

  • all over 65
  • on drugs that interact
  • impaired renal/thyroid
  • raised calcium
  • poor symptom control/adherence
  • last level 0.8 or higher
60
Q

Lithium Monitoring

A

Thyroid - baseline + 6 months
BMI - baseline + 6 months
Electrolytes - baseline + 6 months
eGFR/Renal - baseline + 6 months

baseline = blood counts + cardiac parameters (arrhythmias etc)

61
Q

Lithium Prescribing

A

always prescribe by BRAND

full prophylactic effect not seen for 6-12 months after initiating

taper dose over MINIMUM 4 weeks, but ideally 3 months

62
Q

Lithium Counselling

A
  • thyroid disorder symptoms
  • renal impairment
  • benign intracranial hypertension = HEADACHES
  • fluid intake + dietary sodium
  • always carry alert card for lithium
  • DON’T take OTC Ibuprofen/soluble analgesics or antacids due to salt content
  • stay hydrated in hot weather/exercising
63
Q

Clozapine - MHRA Alerts

A

Risk of Intestinal Obstruction, Impaction + Paralytic Ileum which can be fatal

Blood Concentration Monitoring: carry out when

  • changes to smoking habits
  • when concomitant meds interact
  • reduced clearance of Clozapine
  • toxicity
64
Q

Clozapine Contraindications + Cautions

A

Contraindications:

  • Alcoholic/Toxic Psychoses/Drug Intoxication
  • Bone Marrow Disorders
  • Coma
  • Uncontrolled Epilepsy
  • Severe Cardiac Disorders

Cautions:

  • over 60
  • glaucoma
  • prostatic hypertrophy
65
Q

Clozapine Interactions

A

CHANGES to smoking !!!!

  • drugs that cause bone marrow suppression
  • drugs that cause hypotension
  • drugs that increase risk of constipation = antimuscarinics, opioids, loperamide etc
66
Q

Clozapine Side Effects

A

CARDIOMYOPATHY

BLOOD DYSCRASIAS

CONSTIPATION

Hypersalivation
Postural Hypotension
Weight Gain
Antimuscarinic = urinary disorders, blurred vision, dry eye, dry mouth, constipation

67
Q

Clozapine Monitoring

A

AGRANULOCYTOSIS, monitor neutrophils

  • Weekly for first 17 weeks
  • then 2-weekly for 1 year
  • then 4-weekly thereafter
  • levels get sent to the manufacturer

MYOCARDITIS - fatal reports in the first 2 months

  • stop + review
  • tachycardia in the 1st two months to report
68
Q

Clozapine Prescribing

A

good for treatment resistant schizophrenia - that is unresponsive to other drugs

patients can have when they’ve tried 1st Gen + a 2nd Gen for a sufficient period

withdraw GRADUALLY over 1-2 weeks to avoid rebound psychosis

69
Q

Clozapine Counselling

A
  • signs + symptoms of bone marrow suppression
  • signs + symptoms of cardiomyopathy = tachycardia
  • if MISSED 2 doses = will need to re-titrate
70
Q

Vancomycin Indications

A

MRSA (gram positives)

C Diff (orally)

71
Q

Vancomycin Contraindications/Cautions

A

C/I
- previous hearing loss

Cautions
- allergy to Teicoplanin

72
Q

Vancomycin Interactions

A
  • ototoxic drugs

- nephrotoxic drugs

73
Q

Vancomycin Side Effects

A
  • Nephrotoxicity
  • Ototoxicity
  • Red Man Syndrome
  • Blood Dyscrasis
  • Skin Disorders
  • Thrombophlebitis
  • Cardiac Issues - cardiac arrest, cardiac shock
74
Q

Vancomycin Monitoring

A
  • periodic auditory testing
  • blood counts
  • urinalysis
  • hepatic function
  • renal function
75
Q

Vancomycin Levels

A

10-20 mg/L

15-20mg for more severe/deep-seated infections

76
Q

Gentamicin Indications

A

BROAD SPECTRUM - gram negative aerobes

77
Q

Gentamicin MHRA Warnings

A

Ototoxicity - monitor hearing, those with mitochondrial mutations at higher risk

Nephrotoxicity - monitor renal function

Histamine-Related ADRs - some batches had higher amounts of histamine so monitor for signs of reactions

78
Q

Gentamicin Contraindications/Cautions:

A

C/I
- Myasthenia Gravis

Cautions

  • Auditory Disorders
  • Conditions of Muscular Weakness
  • Dehydration
  • Vestibular Disorder
79
Q

Gentamicin Side Effects

A
  • Skin Reactions = Stevens Johnson’s Syndrome
  • Tinnitus
  • Nausea/Vomiting
  • Nephrotoxicity
  • Impaired Neuromuscular Transmission (MG!)
  • Hypokalaemia, Hypocalcaemia, Hypomagnaesia
  • Abs associated Colitis
  • Blood Disorders
80
Q

Gentamicin Interactions

A

Nephrotoxic Drugs
Neuromuscular Blocking Effects
Ototoxic Drugs = Loops, Cisplatin, Vancomycin

81
Q

Gentamicin Monitoring

A

MULTIPLE DAILY DOSING - need a peak (1 hr after) and trough

  • peak target: 5-10
  • trough target: < 2

if PEAK is too high = reduce the dose
if TROUGH is too high = extend the interval

82
Q

Ciclosporin Indications

A

potent immunosuppressant - used for:

- RA, UC, Atopic Dermatitis, Severe Psoriasis, Transplantation

83
Q

Ciclosporin MHRA Alerts

A

HAS to be prescribed by brand

84
Q

Ciclosporin Contraindications

A
  • Malignancy
  • Uncontrolled Hypertension
  • Uncontrolled Infections
85
Q

Ciclosporin Cautions

A
  • Elderly
  • Hyperuricaemia
  • Active Herpes Simplex infections
  • Psoriasis
  • Dermatitis
86
Q

Ciclosporin Side Effects

A

NEPHROTOXIC = kidneys

  • Bone Marrow Suppression
  • hyperglycaemia
  • Hypertension (contraindication!)
  • Electrolytes - hyperkalaemia + hypomagnesia
  • Neurotoxicity - seizures, tremor, headache, encephalopathy
  • liver toxicity

Differences to Tacrolimus:

  • Gingival Hyperplasia
  • Visual Disturbances = intracranial hypertension
  • Hyperlipidaemia
87
Q

Ciclosporin Interactions

A

Nephrotoxic Drugs: NSAIDs, lithium, diuretics, ACEs/Arbs

AVOID live vaccines

Risk of hyperkalaemia

Drugs that increase risk of hypertension

Digoxin - dose adjustments (kidneys)
Colchicine - AVOID
Statins - AVOID
Grapefruit, Pomelo, Purple Grapefruit juices

88
Q

Ciclosporin Monitoring

A
  • LFTs
  • K
  • Mg
  • Lipids prior to tx + 1 month after starting
  • KIDNEYS!
  • Blood Pressure = DISCONTINUE if hypertension develops
89
Q

Ciclosporin Counselling

A
  • avoid excessive sunlight
  • increased risk of blurred vision
  • grapefruit
90
Q

Tacrolimus Indications

A
  • prevention of rejection
91
Q

Tacrolimus MHRA alert

A

PRESCRIBE BY BRAND

92
Q

Tacrolimus Contraindications

A

Topical Only - malignant skin lesions, eyes, mucous membranes, immunodeficiency, infection at treatment site

93
Q

Tacrolimus Cautions

A
  • UV Light
  • Increased risk of Infection
  • Malignancies
  • Neurotoxicity
  • QT prolongation
  • ALLERGY TO MACROLIDES !!!!!
94
Q

Tacrolimus Interactions

A
  • nephrotoxic drugs
  • tacrolimus + ciclosporin
  • drugs that increase risk of hyperkalaemia
95
Q

Tacrolimus Side Effects

A

same as Ciclosporin

  • Kidney Impairment
  • Liver Impairment
  • Bone Marrow Suppression
  • Neurotoxicity (tremor + headache)
  • Hyperglycaemia

Differences:

  • CARDIOVASCULAR - QT, arrhythmias, myopathy
  • Skin Reactions
  • Eye Disorders

report ANY signs + symptoms to the doctor

96
Q

Tacrolimus Monitoring

A
  • ECG
  • Blood Pressure
  • Hepatic Function
  • Renal Function
  • Fasting Blood Glucose
  • Electrolytes
  • Blood Counts

Pre-Reg Exam (8 decks)

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