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Pre-Reg November Exam '24 > HIGH RISK DRUGS > Flashcards

HIGH RISK DRUGS Flashcards

1
Q

What is methotrexate indicated for?

A
  • Severe Crohn’s disease
  • Severe rheumatoid arthritis
  • Neoplastic disease
  • Severe psoriasis
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2
Q

Mode of action of methotrexate

A
  • Inhibits dihydrofolate reductase enzyme
  • Folate antagonist
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3
Q

When is methotrexate contraindicated?

A
  • Active infection
  • Ascites
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4
Q

Dosing regimen of methotrexate

A

Once weekly on the SAME day each week

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5
Q

Signs of methotrexate toxicity which need reporting to GP?

A
  • Blood disorder
  • Liver toxicity
  • Respiratory
  • Bone marrow suppression (Normal WBCs = 7-11 x10^9/L
  • GI toxicity

Other S/E:

  • Acne
  • Alopecia
  • Anorexia
  • Change in nail/skin pigmentation
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6
Q

Monitoring requirements for methotrexate?

A
  • FBC, LFTs and renal function
  • Test repeatable every 1-2 weeks until stable
  • Once stable, monitor every 2-3 months
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7
Q

Which other medications or precautions must be taken during methotrexate treatment?

A
  • Folic acid taken on different day, to reduce S/E for non-malignant conditions
  • Effective contraception required during and for 3 months after treatment in men AND women
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8
Q

Which drugs interact with methotrexate and increase its toxicity?

A
  • Aspirin
  • Acetazolamide
  • Ciprofloxacin
  • Diclofenac
  • Ibuprofen
  • Indomethacin
  • Ketoprofen
  • Meloxicam
  • NSAIDs
  • Naproxen
  • Penicillins
  • Proton pump inhibitors
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9
Q

Therapeutic range and signs of toxicity of lithium?

A
  • 0.4-1 mmol/L
  • GI disturbances, visual disturbances, ployuria, tremor, bradycardia, renal impairment and seizures
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10
Q

Therapeutic range and signs of toxicity of digoxin?

A
  • 1-2 micrograms/L
  • Nausea, vomiting, dizziness, fatigue and bradycardia
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11
Q

Therapeutic range and signs of toxicity of methotrexate?

A
  • Typically 7.5-25mg weekly
  • Bone marrow suppression, GI toxicity, liver toxicit
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12
Q

Therapeutic range and signs of toxicity of warfarin?

A
  • Dose dependant on INR
  • Haemorrhage
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13
Q

Therapeutic range and signs of toxicity of theophylline?

A
  • 10-20 mg/L
  • Severe vomiting, agitation, hyperglycaemia, restlessness, dilated pupils and sinus tachycardia
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14
Q

Therapeutic range and signs of toxicity of gentamicin?

A
  • 5-10 mg/L (PEAK) 2 mg/L (TROUGH)
  • Nephrotoxicity and irreversible ototoxicity
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14
Q

Therapeutic range and signs of toxicity of ciclosporin?

A
  • Weight related dosing
  • Tremor, gingival hyperplasia, hypertrichosis
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14
Q

Therapeutic range and signs of toxicity of phenytoin?

A
  • 10-20 mg/L
  • Nystagmus (involuntary eye movement), diplopia (double vision), slurred speech, ataxia, confusion and hyperglycaemia
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14
Q

Therapeutic range and signs of toxicity of vancomycin?

A
  • 10-15 mg/L (TROUGH)
  • Ototoxicity (discontinue if tinnitus occurs), “red man” syndrome, rash, blood disorders
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15
Q

Indications for lithium?

A

Treatment/ prophylaxis if mania, bipolar, recurrent depression, aggression or self-harming behaviour

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16
Q

Contraindications for lithium?

A
  • Addison’s disease
  • Cardiac insufficiency
  • Dehydration
  • Low sodium diets
  • Intreated hypothyroidism
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17
Q

Cautions for lithium?

A
  • Avoid abrupt withdrawal
  • Cardiac disease
  • Can lower seizure threshold
  • Risk of toxicity with diuretic treatment
  • Reduce dose for elderly
  • QT prolongation
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18
Q

Long term risk factors for lithium?

A
  • Thyroid disorders
  • Mild cognitive and memory impairment
  • Rhabdomyolysis
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19
Q

Pregnancy and BF considerations?

A
  • Females of child-bearing age should use effective contraception
  • Teratogenic in first trimester
  • Present in breast milk
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20
Q

Monitoring requirements for lithium?

A
  • Weight or BMI
  • U&Es
  • eGFR
  • Thyroid function every 6 months
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21
Q

How should dose reduction be carried out with lithium?

A

Gradually over the course of at least 4 weeks (preferably over the course of 3 months)

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22
Q

Patient advice for lithium administration?

A
  • Maintain adequate fluid intake
  • Avoid dietary changes reducing or increasing sodium
  • Learn to recognise toxicity symptoms
  • Report episodes of diarrhoea, vomiting or forms of dehydration (sodium depletion)
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23
Q

Indications for digoxin?

A
  • AF
  • Flutter
  • Heart failure
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24
Q

Where do dose changes need to be made with digoxin?

A
  • Reduce by half with amiodarone, dronedarone or quinine
  • Increase by 20-30% when switching from IV to oral
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25
Q

Contraindications for digoxin?

A
  • Intermittent complete heart block
  • Myocarditis
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26
Q

Cautions of use with digoxin?

A
  • Risk of digitalis toxicity with hyperglycaemia
  • Hypomagnesaemia
  • Hypoxia
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27
Q

Pregnancy and BF considerations with digoxin?

A
  • Dose may need adjusting
  • Amount too small in BF to be harmful
28
Q

Monitoring requirements with digoxin?

A
  • Renal function
  • U&Es (toxicity increased by electrolyte imbalance)
29
Q

Indications for methotrexate?

A
  • Crohn’s
  • RA
  • Neoplastic disease
  • Psoriasis
30
Q

Contraindications for methotrexate?

A
  • Active infection
  • Immunodeficiency syndromes
  • Significant plural effusion
31
Q

Cautions in methotrexate?

A
  • Blood disorders
  • Liver toxicity
  • Respiratory effects
  • Photosensitivity
  • Stomatitis
32
Q

Where is immediate withdrawal required during methotrexate therapy?

A

Drop in WBC or platelet count

33
Q

Pregnancy and BF considerations for methotrexate?

A
  • Effective contraception needed for duration of treatment and 3 months (male and female)
  • Avoid in pregnancy as teratogenic
  • Present in BF
34
Q

Monitoring requirements for methotrexate?

A
  • FBC
  • Renal function
  • Liver function

Repeated every 1-2 weeks until stable, and 2-3 months thereafter

Patients advised to report signs of infection, esp sore throats

35
Q

What should be co-prescribed with methotrexate, and why?

A

*Folic acid- 5 mg weekly (on different day to methotrexate
* Decrease mucosal and GI SEs. May also prevent hepatotoxicity

36
Q

Indications for warfarin?

A
  • Prophylaxis of embolism in rheumatic heart disease and AF
  • After insertion of prosthetic heart valve
  • Venous thrombosis and pulmonary embolism (treatment and prophylaxis)
  • Treatment of transient ischaemic attacks
37
Q

Contraindications of warfarin?

A
  • Within 48 hours post partum
  • Haemorrhagic stroke
  • Significant bleeding
38
Q

Cautions with use of warfarin?

A
  • History of GI bleed
  • Hyper-hypothyroidism
  • Uncontrolled HTN
  • Recent ischaemic stroke
  • Changes in diet (Vit K intake)
39
Q

Pregnancy and BF considerations with warfarin?

A
  • Danger of teratogenicity, avoid in 1st trimester (crosses the placenta)
  • Safe in breastfeeding
40
Q

Monitoring requirements for warfarin?

A

INR up to every 12 weeks

Depending on changes in patient’s clinical condition

41
Q

Indications for theophylline

A
  • Chronic asthma
  • Reversible airyway obsstruction
  • Severe acute asthma
42
Q

Cautions to consider when prescribing theophylline

A
  • Cardiac arrhythmias
  • Elderly
  • Epilepsy
  • HTN
  • Peptic ulcer
  • Thyroid disorder
43
Q

How does smoking affect theophylline therapy?

A

Increases clearance of theophylline

Requires greater dose

Patients stopping/starting smoking need monitoring

44
Q

Signs of theophylline overdose?

A
  • Vomiting
  • Agitation
  • Restlessness
  • Tachycardia
  • Hyperglycaemia
45
Q

Ideal serum conc. of theophylline

A

10-20 mg/litre

Adverse effects increase over 20 mg/litre

46
Q

Monitoring requirements for theophylline

A

Plasma conc taken 5 days after starting oral treatment
AND
At least 3 days after any dose adjustment

47
Q

Extra considerations for prescribing theophylline

A

Maintain patients on specific brands- MR preps differ

48
Q

Indications for phenytoin

A

Treatment of:
* Tonic clonic seizures
* Focal seizures

Prevention and treatment of seizures during or following:
* Neurosurgery or severe head injury
* Status epilepticus

49
Q

Contraindications for phenytoin

A
  • Second/third degree heart block
  • Sinus bradycardia
  • Stokes-Adams syndrome (sudden, brief loss of consciousness from large drop in cardiac activity)
50
Q

Cautions for phenytoin use

A
  • Heart failure
  • Hypotension
  • Respiratory depression
51
Q

Signs and symptoms of phenytoin overdose

A
  • Nystagmus
  • Slurred speech
  • Confusion
  • Hyperglycaemia
52
Q

Pregnancy and BF considerations for phenytoin

A

Increased risk of congenital malformations in pregnancy- dose adjusted depending on plasma conc.
(IF benefits outweigh the risks)

Found in breast milk but not known to be harmful

53
Q

Monitoring requirements for phenytoin

A
  • Patients of Thai or Han Chinese origins are pre-screened for HLAB*1502 allele. Increased risk of Stevens-Johnson syndrome
  • Blood counts
  • In IV use, ECG + BP
54
Q

Indications for ciclosporin

A
  • Keratitis
  • Ulcerative colitis
  • Rheumatoid arthritis
  • Atopic dermatitis
  • Organ/bone marrow transplant
55
Q

Contraindications in ciclosporin use

A
  • Peri-ocular infection (if used in eye)

Systemic use:
* Abnormal renal function
* Uncontrolled hypertension

56
Q

Cautions in ciclosporin use

A
  • Glaucoma (if used in eye)

Systemic use:
* Hyperuricaemia
* Malignancy
* In the elderly, monitor renal function

57
Q

Pregnancy and BF considerations for ciclosporin

A

Avoid in both- crosses placenta and present in milk

Can be harmful

58
Q

Monitoring requirements for ciclosporin

A
  • Blood conc.
  • LFTs
  • Potassium
  • Magnesium
  • Blood lipids
  • Kidney function
  • BP

Reduce dose if eGFR decreases by more than 25%, dose reduction of 25-50%

59
Q

Other considerations for ciclosporin use

A

Patients on oral ciclosporin should be maintained on the same brand due to changes in blood conc.

60
Q

Indications for gentamicin

A
  • Septicaemia
  • Meningitis and other CNS infections
  • Biliary-tract infections
  • Acute pyelonephritis
  • Endocarditis
  • Pneumonia (in hospital)
  • Adjunct in listerial meningitis
  • Prostatitis
61
Q

How is dose calculated in gentamicin use in obese patients?

A

Ideal body weight used for obese patients

62
Q

Contraindications for gentamicin use

A

IV use:
* Myasthenia gravis

Use in ear:
* Patent grommet (tubes to allow airflow through eardrum)
* Perforated tympanic membrane

63
Q

Cautions for gentamicin use

A
  • Dose related SE
  • Conditions with muscular weakness
  • Dehydration must be corrected before treatment
64
Q

Pregnancy and BF considerations for gentamicin use

A

Avoid due to risk of auditory and vestibular nerve damage in infant when used in 2nd and 3rd trimester

65
Q

Monitoring requirements for gentamicin

A
  • Serum conc. in renal impairment as drug is excreted renally
  • Auditory and vestibular function
66
Q

Indications for vancomycin use

A
  • Complicated skin and soft tissue infections
  • Bone infections
  • Joint infections
  • CAP + HAP
  • Infective endocarditis
  • Acute bacterial meningitis
  • Bacteraemia
  • C. diff infection
67
Q

Routes of administration for vancomycin

A

NOT to be given orally due to lack of absorption

Only given IV and to the ear and eye

68
Q

Contraindications for vancomycin use

A

Previous hearing loss with IV use

69
Q

Cautions for vancomycin use

A
  • Systemic absorption may be enhanced in inflammatory bowel disorders of the intestinal mucosa
70
Q

Pregnancy and BF considerations for vancomycin use

A
  • Advises only use in pregnancy if benefits outweigh the risk. Monitor blood conc.- essential to reduce risk of fetal toxicity
  • Present in breast milk- significant absorption following oral admin. unlikely
71
Q

Monitoring requirements for vancomycin

A
  • Auditory function
  • Blood count
  • Hepatic and renal function
  • Leucocyte count (risk of neutropenia or agranulocytosis with long term use)

Pre-Reg November Exam '24 (10 decks)

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