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High Risk Drugs Flashcards

1
Q

Amiodarone is hepatotoxic or renal toxic?

A

Hepato

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2
Q

Amiodarone can cause neurological side effects as well, symptoms?

A 
Tremor
Peripheral neuropathy (development of numbness and tingling in hands and feet)
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3
Q

Other side effects of amiodarone?

A

Arrhythmias
Nausea
Skin recations (burning sensation followed by erythema, grey skin discolouration on light exposed areas)
Neurological side effects

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4
Q

Contraindications of amiodarone?

A

Thyroid dysfunction
Iodine sensitivity
Heart block

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5
Q

What to monitor for amiodarone?

A 
Thyroid function
LFTs
Serum potassium cocn.
Chest xray
ECG
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6
Q

Advice on amiodarone to pts?

A

Skin stuff

Pt may be dazzled by headlights at night so be careful when driving

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7
Q

Main interactions of amiodarone?

A

Antiepileptcs=increased conc.
Avoid CCBs and BBs=increased risk of cardio depression, AV block
Avoid grapefruit juice
Increase Anticoagulant effects of warfarin, dabigatran,
Increased plasma conc. Of digoxin and ciclosporin
Lithium increases risk of arrhythmia
Statin increased risk of myopathy
Increased risk of arrhythmia with QT prolongation drugs

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8
Q

Vancomycin is active aginst what kind of bacteria?

A

Aerobic & Anaerobic gram positives

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9
Q

Side effects of vancomycin if administered too quickly?

A

Hypotention

Anaphylaxis

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10
Q

Therapeutic range of vancomycin?

A

Trough of 10-15mg/L

15-20mg/L if endocarditis or less sensitive strains of MRSA or complicated infections caused by S. Aureus

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11
Q

When to take vancomycin therapeutic serum cocn?

A

Immediately before the fourth dose or after 48hrs of therapy

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12
Q

Monitoring required for vancomycin?

A 
Serum potassium
FBC
Renal function
Auditory fucntion in elderly
Urinalysis

Hepatic

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13
Q

What affect does amiodarone have on potassium?

A

Hypokalaemia can be severe

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14
Q

How long does it take for warfarin to work?

A

48-72hrs to act fully

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15
Q

How frequently do you have to assess INR?

A

Every 3 months

More frequently if signs of bleeding, N&V or illness

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16
Q

INR should be within what of units of the target value?

A

0.5units

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17
Q

What condition needs a target INR of 2.5?

A 
Treatment of DVT and PE
AF
cardioversion
Mitral stenosis
Dilated cardiomyopathy
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18
Q

What condition needs an INR of 3.5?

A

Recurrent DVT and PE

Mechanical prosthetic heart valve

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19
Q

Monitoring for warfarin?

A

INR
Liver (can cause hepatic impairment and hepatically excreted) & renal (pts with renal impairment have a higher risk of haemorrhagicc and ischemic events)
FBC
BP
Thyroid function (hyper or hypo thyroidism can alter warfarin efficacy)

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20
Q

Warfarin and pregnancy?

A

Teratogenic so need contraception

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21
Q

Side effects of warfarin?

A

Bleeding
Painful skin rasg
Blue or purple tie syndrome

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22
Q

Main stuff that can increase the effects of warfarin?

A 
Cranberry and pomegranate juice
Antifungals esp miconazole which has a MHRA warning
Chloramphenicol
Metronidazole
Macrolides
Steroids
SSRIS
statins (esp fluvastatin and rosuvastatin)
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23
Q

Main stuff that can decrease effects of warfarin?

A 
Vit K (food supplements, enteral feeds, large amounts of green veg or green tea)
Major changes in diet esp salads and veg
Alcohol consumption
St John's wart must be avouded
Carbamazepine
Phenytoin
Rifampicin
Griseofulvin
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24
Q

Gender pt advice on warfarin?

A

Take at same time each day
Take missed doses as normal the next day, don’t double any missed doses
Ensure pt has an oral Anticoagulant pack with a record booklet alert card and yellow book
Ensure pts understand different warfarin strength and colours
Advise pt to inform GP if any changes in diet or medication

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25
Therapeutic range of gentamicin for multiple daily dose regimens?
1hr peak serum conc should be 5-10mg/L (3-5mg/L for endocarditis) Pre dose trough conc should be below 2mg/L (below 1mg/L for endocarditis)
26
What to monitor with gentamicin
Plasma conc Renal function Auditory and vestibular function
27
Serum aminoglycosides conc must be determined in?
Elderly Renal impairment If high doses, Obesity and in cystic fibrosis
28
Side effects of gentamicin?
``` Antibiotic associated colitis Blood disorders Deoression Neurotoxicity Vestibular damage ```
29
Pt action required for gentamicin?
Ensure pt is hydrated and drinking adequate fluid to prevent dehydration before starting treatment
30
Signs of GI bleed?
Black stool | Coffee ground vomit
31
Monitoring requirements for NSAIDs?
``` BP (esp after dose changes) Renal function Liver function HB in pts at risk of bleeding Signs of oedema like swollen ankles and feet Signs of GI bleeds Iron deficient anaemia ```
32
Signs of iron deficient anaemia?
``` Suggests chronic GI bleeding Fatifue Dizziness Pale skin SOB ```
33
Advise on NSAIDs?
Always take with food to protect stomach
34
Important interactions of NSAIDs?
Quinolones = increased risk of convulsion Possible enhanced effects of Sulfonylureas NSAIDs antagonise hypotensive effect of BBs, CCBs, ACEi, angiotensin 2 antagonists, alpha blockers and nitrates
35
Overdose signs of Opioids?
Coma Respiratory deoression Pinpoint pupils
36
What opioid increases effects of warfarin?
Tramadol
37
What happens when Opioids and alcohol are mixed?
Increased sedation and hypotensive effect
38
Ciclosporin is hepatotoxic or Nephrotoxic?
Markedly Nephrotoxic
39
Ciclosporin contra indications?
Uncontrolled BP Malignancy Uncontrolled infections
40
What electrolyte disturbances does ciclosporin cause?
Hyperkalaemia | Magnesium
41
Monitoring requirements for ciclosporin?
``` FBC Liver function Kidney Serum electrolytes Blood lipids BP (regularly) bc hypertention is a common side effect Dermatological and physical examination ```
42
Is ciclosporin Nephrotoxic or hepatotoxic?
Nephrotoxic
43
Side effects of ciclosporin?
``` Diarrhoea Decreased appetite GI discomfort Skin reactions Flushing Vomiting Encephalopathic Blood disorders ```
44
Warning signs of ciclosporin?
``` Neurotoxicity (tremor, headache, encephalopathy, confusion, convulsions) Blood disorders Liver toxicity Nephrotoxicity Hypertension Headache Gingivial hyperplasia ```
45
Important interactions of ciclosporin?
Enzyme inducers and inhibitors Increased risk of digoxin toxicity Increased risk of myopathy with statins Increased risk of Nephrotoxicity and Hyperkalaemia
46
Patient advise on ciclosporin?
Avoid sunlight Do not receive immunisation with live vaccines Avoid high potassium diet and grapefruit juice Can be taken with orange or apple juice to improve taste Stick to the same brand
47
Side effects of tacrolimus?
``` Greater neurotoxicity that ciclosporin Cardiomyopathy reported = CV disorders Hyoerglycaemia Nephrotoxicity Eye disorders Skin disorders Blood disorders Liver toxicity Hyperkalaemia ```
48
Monitoring for tacrolimus?
Mains are Liver and renal function BP ECG Fasting blood glucose cocn. Serum electrolytes esp potassium
49
Pt advise on tacrolimus?
``` Protect skin from sun Drowsiness can affect driving Prescribe by brand No live vaccine No high potassium diet and avoid grapefruit juice ```
50
Mode of action of methotrexate?
Inhibits dihydrofolate reductase
51
Side effects of methotrexate?
Blood disorder Liver toxicity Respiratory effects GI toxicity like stomatitis
52
Monitoring requirements for methotrexate?
FBC renal liver every 1-2wks until stabilised then every 2-3months
53
Pt advise on methotrexate?
Avoid NSAIDs and aspirin Contraception Advise on annual flu but avoid live vaccine
54
Contraception advise on methotrexate?
Use during and for at least 6 months after treatment in both men and women
55
Important interactions with methotrexate?
Increased risk of toxicity with NSAIDs, PPIs Increased risk of toxicity with certain antibiotics Increased risk of haematological toxicity when given with Co trimoxazole
56
Which antibiotics can cause increased toxicity with methotrexate?
Penicillin Ciprofloxacin Doxycycline Tetracycline
57
Action time of thiazide diuretics?
Act within 1-2hrs after effects last for 12-24hrs
58
Risk of Hypokalaemia is greater in loop or thiazide?
Thiazide
59
Hypokalaemia can lead to what in hepatic failure esp in alcoholic cirrhosis?
Encephalopathy
60
Mode of action of digoxin?
Positive ionotropic effect (myocardial contraction) & Negative chronotropic effect (reduced HR)
61
How is digoxin dose determined?
Ventricular rate at rest and renal function | Should not fall below 60BPM persistently
62
Response time of digoxin?
Response may fake several hours so not suitable for rapid HR control
63
Digoxin has a long or short half life?
Long so maintenance dose given OD | Can divide higher doses into BD to prevent nausea
64
Digoxin toxicity signs?
Cardiac = Arrhythmias GI = Diarrhoea, Dizziness, Nausea, Vomiting Skin reactions Vision disorders blurred or yellow
65
Monitoring with digoxin?
Plasma conc. Serum electrolytes Renal function HR
66
What increases digoxin plasma cocn?
``` Ciclosporin Enzyme inhibitors Mirabegron Rate control CCBs Spironolactone ```
67
Important interactions of digoxin?
Drugs that impair renal function can affect the plasma digoxin cocn like NSAIDs and ACEi
68
Signs and symotoms of pancreatitis?
Abdominal pain Nausea Vomiting
69
What drugs cause pancreatitis?
Sodium valproate | Pioglitazone
70
Contra indications of lithium?
Dehydratiom Low sodium diet Untreated hypothyroidism Addisons disease
71
Pt advise in lithium?
Avoid abrupt withdrawal Keep on same brand Review dose in diarrhoea, elderly, vomiting, surgery and intercurrent infection Keep a constant and adequate salt and water intake (esp if they have an infection) OTC interactions Risk of driving
72
Side effects of lithium?
QT prolongation, arrhythmia Long term use has been associated with Thyroid disorder and mild cognitive and memory impairment ``` Tremort Abdominal discomfort Angiodema Electrolyte imbalance Hypothyroidism Weight gain Leucocytosis Skin reactions Vertigo ```
73
Lithium in pregnancy and BF?
BF needs to be avoided as present in milk and risk of toxicity Avoid in preg esp in first trimester bc risk of teratogenicity and cardiac abnormalities Dose may need to be increased in second and third trimesters but on delivery return abruptly to normal
74
Monitoring requirements with lithium
Serum conc. Weekly after initiation and each dose change until stable then every 3 months Before initiation, cardiac, Thyroid and renal, BMI, FBC and electrolytes
75
Therapeutic range of lithium?
0. 4 - 1.0mmol/L for maintenance therapy and elderly pts | 0. 8-1.0mmol/L for acute episodes of mania and for pts who have previously relapsed
76
When to take lithium blood sample?
12hrs after dose
77
Major route of elimination of lithium?
Renally | Freely filtered at glomerulus with 80% reabsorbed
78
How to do treatment cessation with lithium?
Reduce gradually over a period of at least 4wks to 3 months If lithium is stopped or to be discontinued abruptly, consider changing therapy to an atypical Antipsychotics or Valproate
79
What drugs increase lithium conc?
ACEi and Angion, all diuretics, NSAIDs Antiepileptcs = increased risk of neurotoxicity
80
Increase risk of neurotoxicity when taken with lithium?
Antiepileptcs Methyldopa Rate limiting CCBs
81
Increased risk of EPS when taken with lithium?
``` Clozapine Haloperidol Sulpiride Phenothiazines Risperidone Fluoentixol Zuclopenthixol ```
82
What type of epilepsy do you have to avoid carbamazepine?
Absence Tonic and clonic Myoclonic As may exacerbate
83
Therapeutic range of carbamazepine?
4-12 mg/L | 20-50micromol/L
84
Side effects of carbamazepine?
Common = headache, ataxia, drowsiness, N&V, blurred vision, allergic skin reactions (more common at the start of treatment, can be reduced by using MR preps) Blood disorders = leucopenua and thrombocytopenia Skin disorders Hepatic disorders Anti epileptic hypersensitivity syndrome
85
Symptoms of antiepileptc hypersensitivity syndrome?
Fever Rash Swollen lymph nodes
86
Monitoring requirements of carbamazepine?
FBC Liver Renal
87
What's the relationship between dose and plasma drug conc of Phenytoin?
Non linear relationships | Small changes in dose or missed dose and Chnage in absorption can result in marked change in plasma drug conc.
88
Therapeutic range of phenytoin?
10-29mg/L
89
Side effects of phenytoin?
Blood disorders Skin disorders like rash = discontinue Suicidal thoughts Low vit D levels which can lead to rickets and osteomalacia
90
What is rickets?
Affects bone development in children | It causes bone pain, poor growth and soft, weak bones which can lead to bone deformities
91
What is osteomalacia?
Soft bones
92
Toxicity signs of phenytoin?
``` Nystagmus Ataxia Slurred speecg Hyperglycaemua Diplooia Blurred vision Confusion ```
93
What to monitor with phenytoin?
``` FBC Liver function = phenytoin is highly protein bound so liver impairment and elderly can show early signs of toxicity BP & ECG Serum cocn. Vit D levels Serum folate ``` Serum conc, ECG and BP esp with IV use
94
Interaction between ohenytoj. And trimethoprim?
Increased antifolate effect so be ware
95
What is theophylline?
A xanthine used as bronchodilator in asthma and stable COPD
96
How is theophylline metabised?
Liver
97
Therapeutic range of theophylline?
10-20mg/L
98
What condition can lead to increased theophylline conc?
HF Hepatic impairment Viral infection
99
What condition can decrease theophylline cocn?
Smokers | Alcohol
100
Monitoring requirements for theophylline?
Serum potassium | Plsma cocnc.
101
Caution in theophylline?
``` CV disease Elderly can increase plasma theophylline cocnc. Fever Hypertention Peptic ulcer Risk of Hypokalaemia ```
102
Side effects of theophylline?
``` Serious Hypokalaemia with B2 agonist Anxiety Tremor Vomiting and diarrhoea Nausea Arrhythmia GI probs Skin recations Sleep disorder ```
103
Important interactions of theophylline?
Serious Hypokalaemia with beta 2 agonists Increased risk of convulsions with quinolonrs Smoking Theophylline decreases lithium conc.
104
Toxicity signs of theophylline?
``` Vomiting Agitation Restkessness Dilated oupils Tachycardia Hyperglycaemia Severe hypokalaemia Convulsions Arrhythmia ```
105
Monitoring requirements for Antiplatelets?
Renal Liver Signs of bleeding GI ulcers
106
Dipyridamole pt advise?
Discard MR caps 6wks after opening OP Take 30-60mins before food
107
What can decrease the efficacy of clopidogrel?
Antifungals SSRIs PPIs like omeprazole and esomeprazole
108
Warning signs of ACEi and Angio?
Dizziness, Light-headedness, blurred vision = postural hyootention Jaundice Abnormal renal function Anuria, confusion, N&V and dehydration = AKI
109
How long can a ACE cough last after stopping the drug?
8-12wks
110
Sick days rule in hypertensive?
Stop Esp when experiencing diarrhoea or vomiting unless minor Or fever, swears and shaking to prevent dehydration which can lead to AKI
111
What can masks sings of Hypoglycaemia?
BBs | Alcohol
112
Signs of Hypoglycaemia?
``` Shaking and trembling Sweating Pins and needles in lips and tongue Hunger Palpitations Headache Double vision ``` More serious are: Difficulty concentrating Confusion, unconsciousness, change of behaviour Slurring of speech and convulsions
113
What increase the risk of Hypoglycaemia?
Fibrates Oral antidiabetics ACEi MAOIS

Inori Pre Reg (22 decks)

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