Low weighted topics!

Question 1

Glaucoma

Answer 1

Most common form = Open-Angle Glaucoma => due to restricted drainage of the aq humour through trabecular meshwork leading to ocular HTN

Treated with TOPICAL PROSTAGLANDIN ANALOGUES (latanoprost, tafluprost, travoprost or bimatoprost)
- If initial one doesn’t work, TRY ANOTHER
- If that doesn’t work => BB: Betaxolol, timolol, levobunolol
- If that doesn’t work => Carbonic anhydrase inhibitors => Brinzolamide, Dorzolamide
- Brimonidine and pilocarpine can also be used

Question 2

Prostaglandin Analogues - Latanoprost, tafluprost, travoprost or bimatoprost

Answer 2

Dry eyes

Ocular discomfort

Change to eye colour

Hyperpigmentation of the peri-ocular skin

Darkening, thickening, and lengthening of the eyelashes

Question 3

Vaccines (Active Immunity)

Answer 3

Live attenuated: Measles, Mumps and Rubella

Inactivated: Meningococcal

Inactivated toxins: Tetanus and Diphtheria

Viral vectors: COVID-19 (AstraZeneca)

Nucleic acid: COVID-19 (Pfizer and Moderna)

LIVE VACCINES SHOULDN’T BE GIVEN IN PREGNANCY or IMMUNOCOMPROMISED PTS

Question 4

Vaccines - Different inactivated vaccines can be given at any interval to each other

Answer 4

Small inactivated vaccines need a minimum 4 WEEK INTERVAL

Minimum 4 week interval between VARICELLA ZOSTER (live vaccine) and MMR
- CAN be given on the same day! If not given on the same day, gotta wait for the 4 weeks.

Minimum 4 week interval between YELLOW FEVER (live vaccine) and MMR
- Can’t be given on the same day

Don’t give flu jab in egg allergy

Don’t give live vaccines to immunocompromised pts

Question 5

Vaccine Schedule - Up to 1 year

Answer 5

8 wks = 6-MR
12 wks = 6-PR
16 wks = 6-M

6 (6 in 1 vaccine) = Diphtheria, Tetanus, Pertussis, Hepatitis B, Polio, Haemophilius influenza B

MR = Meningococcal B + Rotavirus
PR = Pneumococcal + Rotavirus
M = Meningococcal B

Question 6

Vaccine Schedule - 1 year +

Answer 6

1 year:
- MMR
- Haemophilius influenza B + Meningococcal C
- Meningococcal B, Pneumococcal

3 years 4 months:
- MMR
- Diphtheria, Tetanus, Pertussis, Poliomyelitis

11 - 14 years:
- Human Papillomavirus
(second dose 6 - 24 months after first dose)

13 - 15 years:
- Meningococcal A with C

13 - 18 years:
- Diphtheria, Tetanus + Poliomyelitis (DTP)

Pregnant females:
- Diphtheria, Tetanus, Pertussis + Poliomyelitis
(1st dose from the 16th week) => DTPP
- Influenza vaccine

Question 7

Post-immunisation fevers

Answer 7

Paracetamol (120mg/5mL) - Calpol - 2 months + & X > 4kg
1st dose: 60mg STAT after vaccine
2nd: 60mg 4-6h PRN
Max 2 doses in 24h (Max 4 doses in 24h in 4 months)

Ibuprofen (100mg/5mL) - Nurofen - 3 months+ & X > 5kg
1st dose: 50mg STAT after vaccine
2nd: 50mg 6h later PRN
No more than 2 doses in 24h

Question 8

A person whose spleen was removed following a road traffic accident is seeing their general practitioner.

Which vaccine is indicated for this patient?

Answer 8

Pneumococcal vaccine

If they have had a splenectomy then they are at an increased risk of pneumococcal infection.

Question 9

Anaesthesia
- Adrenal suppression = corticosteroids combined with anaesthetics cause a dangerous fall in BP.
- Anaesthesia and driving: IV benzodiazepines and short general anaesthetics risk extends to at least 24h after; avoid alcohol; a responsible person should take pt home.

Answer 9

Local = lidocaine (e.g. EMLA cream, OTC, apply 60mins before the procedure - tattoos, ear piercings) or bupivacaine = longest duration of action

General (IV):
- Propofol - rapid recovery, low hangover effect
- Thiopental - rapid onset, fat-soluble so longer hangover effect
- Etomidate - rapid recovery, no hangover effect
- Ketamine - less hypotension - slow recovery, high psychoactive SEs

General (inhalation):
- volatile liquids (isoflurane, desflurane, sevoflurane) and nitrous oxide

Question 10

Eczema - dry, flaky skin - small red spots

Answer 10

Main types = irritant, allergic, contact, and atopic

Emollients = either to apply, or as bath and shower emollients => avoid AQ cream due to high risk of skin reactions

Topical corticosteroids = can be used (MILD steroids for face and genitals)

Antihistamines = not for ATOPIC dermatitis - as it’s not an allergy response to the condition.

Mild - moderate => PIMECROLIMUS

Moderate - severe => TACROLIMUS

Severe refractory eczema:
- use systemic meds = cyclosporin, azathioprine, mycophenolate mofetil, MoAbs

Question 11

Psoriasis - skin thickening and silvery white scaling, raised and larger patches / plaques. Systemic, immune-mediated inflammatory skin disease (can be in joints too) = psoriatic arthritis

Answer 11

Emollients

Topical Corticosteroids

Coal tar preps

Vit D (topical or analogues)

Where topical treatment has failed:
- phototherapy = UVA / UVB through trained professional
- systemic treatment = methotrexate, ciclosporin or acitretin (2nd line)

Question 12

STEROID POTENCY

Prolonged use leads to skin thinning

Apply thinly

Don’t apply to broken skin

FTU = Finger Tip Unit Guide. FTU (~500mcg) is the amount of med needed to squeeze a line from the tip of an adult finger to the first crease of the finger.

Answer 12

VERY POTENT
Clobetasol - Dermovate

POTENT
Bethamethasone 0.1% - Betnovate
Hydrocortisone butyrate
Mometasone

Moderate
Clobetasone - Eumovate
Betamethasone - Betnovate RD

Mild
Hydrocortisone < 2.5% - normally give 7 days OTC

Question 13

RA - Chronic systemic inflammatory disease affecting joint synovial membrane

Answer 13

• pain and stiffness worsen with rest, inactivity and heat in the joints => symptoms: nodules, swelling, tenderness, malaise, fatigue, fever and wt loss
• non-drug therapy = physio, exercise, relaxation and stress management
• drug therapy:
  1st = METHOTREXATE, leflunomide or sulfasalazine (hydroxychloroquine in mild)
  2nd = MoAbs: adalimumab, etanercept, infliximab, tocilizumab, baricitinib
  Bridge with corticosteroids when rapid suppression is needed

NSAIDS CAN BE USED IN PAIN RELIEF - WITHDRAWN WHEN RESPONSE TO DMARDS IS ENOUGH!!!

Question 14

Methotrexate

Answer 14

• take OW
• script and label should clearly show the dose and frequency
• methotrexate is commonly co-prescribed with FOLIC ACID => not to be taken on the same day as each other
• Pts should be advised to immediately report any signs of blood disorder, liver toxicity and respiratory effects

SE:
- blood disorders => sore throat, bruising, and mouth ulcers
- liver toxicity => N/V, abdo discomfort, dark urine jaundice itchy skin
- pulmonary toxicity => SoB, coughing
- GI toxicity => stomatitis, diarrhoea

Antidote = FOLINIC ACID (Ca FOLINATE)

Monitoring & screening:
- FBC, Renal, LFT => every 1-2 weeks until stable, then every 2-3 months thereafter
- Screen out PREGNANCY b4 treatment => antifolate, so it can harm foetus growth; and use effective contraception during treatment and for at lest 6 months after for both men and women

Interactions:
- NEPHROTOXIC drugs => MTX reduces renal function = NSAIDS (no OTC ibuprofen!!!)
- ANTI-FOLATES => trimethoprim, phenytoin
- HEPATOTOXIC drugs => rifampicin, antifungals etc.
- OMEPRAZOLE / ESOMEPRAZOLE => reduces CL, increases toxicity

Question 15

Hyperuricaemia and Gout = raised uric acid conc in the blood and the deposition of urate crystals in joints and other tissues

Answer 15

This can be caused by:
- diet (high salt intake)
- meds => BENDROFLUMETHIAZIDE, chemo drugs

Question 16

Acute treatment for hyperuricaemia and gout

Answer 16

• start treatment ASAP!
• COLCHICINE (500mcg BD-QDS max 3 days; don’t repeat course within 3 days) or high doses of an NSAID + PPI (excluding aspirin)
• NSAIDs induces fluid retention => can interact with diuretics
• Alternatives:
  Short course of PO corticosteroid;
  IM injection of corticosteroid or Canakinumab

Question 17

Chronic treatment for hyperuricaemia and gout

Answer 17

• offered in frequent acute attacks of gout (2 or more per year)
• Uric acid may be reduced with xanthine-oxidase inhibitors

1st: ALLOPURINOL
2nd: FEBUXOSTAT

• if acute attack happens during treatment, continue chronic treatment as well as treating the acute attack separately!!!

Question 18

ALLOPURINOL

Answer 18

When starting, flare-prophylaxis with COLCHICINE / NSAID is recommended

Common SE: RASH => discontinue, if mild, restart carefully but discontinue STAT if recurrence

Interaction:
- Allopurinol + Azathioprine / Mercaptopurine = must REDUCE dose of A/M => allopurinol potentially increases the risk of haematological toxicity when given with A.

Question 19

Nocturnal Leg Cramps

Answer 19

QUININE SULFATE - may reduce the frequency of nocturnal leg cramps

This is drug has been associated with dose-dependent QT-interval-prolonging effects and should be used with caution in pts with risk factors for QT prolongation or those with atrioventricular block - MHRA

Potential toxicity = quinine isn’t routinely recommended => use if cramps regularly disrupts sleep, are very painful or other treatment hasn’t worked

Trial for 4 weeks => if there’s benefit => CONT!

Stop treatment every 3 MONTHS and assess need for further treatment

Question 20

Pain and inflammation (NSAIDs)

Answer 20

NSAIDs = analgesic + anti-inflammatory => used in pain related to inflammation, e.g. RA, back pain, and soft-tissue disorders

CI in asthmatic patients

NSAIDs + low dose aspirin => increase GI bleed risk (use only if necessary)

NSAIDs + alcohol => increase GI bleed risk

Use PPI for stomach protection

Hypersensitivity reactions => cross-sensitivity with aspirin, too

AVOID in RENAL impairment due to risk of fluid retention and further impairments

AVOID in pregnancy and CAUTION in breastfeeding

Question 21

NSAIDs interactions

Answer 21

MTX / Li = reduces CL

Ciprofloxacin = increases risk of seizures

Blood thinners, SSRIs, DOACs, corticosteroids, carbocisteine = increases risk of bleeding

drugs that cause hyperkalemia (THANKS B = trimethoprim, heparins, ACEi and ARBS, NSAIDS, K-sparing, BB) = HyperK

drugs that cause renal failure = AKI

Question 22

NSAIDs - GI SEs

Answer 22

HIGH = Piroxiam, Ketoprofen, Ketorolac

MEDIUM = Indometacin, diclofenac, naproxen

LOW = ibuprofen

LOWEST = COX-2i

Question 23

NSAIDs - CVS SEs

Answer 23

HIGH = COX-2i, ibuprofen 2.4g, diclofenac

LOW = naproxen, ibuprofen 1.2g

Question 24

Nasal Rhinitis and Congestion - RHINITIS

Answer 24

Nasal sprays or drops

NaCl, antihistamines, corticosteroids, ipratropium, xylometazoline

Not to be used for prolonged periods of time (7 days) as it can cause rebound congestion!!

Can be used in pregnancy - low systemic absorption

Question 25

Nasal Rhinitis and Congestion - NASAL POLYPS

Answer 25

Review by ENT specialist

Use nasal corticosteroids

Question 26

Nasal Rhinitis and Congestion - NASAL STAPHYLOCOCCI

Answer 26

NASEPTIN (contains PEANUTS)

or

Mupirocin

Question 27

ACNE - Isotretinoin

Answer 27

Less severe and 1st line treatments:
- adapalene
- benzoyl peroxide
- clindamycin
- lyme/doxycycline
- erythromycin

MHRA = rare erectile dysfunction and decreased libido

MHRA = PPP (teratogenic)
- contraception taken 1 MONTH before and 1 MONTH after => use 2 methods of contraception = COC + barrier method! As POC isn’t an effective form of contraception.
- each script has a 30 DAY SUPPLY limit

Risk of neuropsychiatric reactions - seek medical attention in mood change and STOP!

Avoid UV light, laser skin treatment, dermabrasion and epilation

Other SE: pancreatitis, hepatotoxicity sin peeling, severe dryness of the skin.

Management of SEs:
- Risk of pancreatitis if triglycerides above 9mmol/L
- Discont. if uncontrolled hypertriglyceridaemia or pancreatitis
- Discont. treatment if severe skin peeling or haemorrhagic diarhoa
- visual disturbances require expert referral and possible withdrawal

Question 28

Scalp and Hair Conditions - DANDRUFF (Seborrheic Dermatitis)

Answer 28

Treat with antimicrobials:
- pyrithione zinc
- selenium
- tar extracts

More persistent or severe dandruff:
- ketoconazole shampoo — PO used in Cushing’s syndrome (specialist use only)

Psoriasis of the scalp:
- coal tar and salicylic acid

Question 29

Scalp and Hair Conditions - HIRSUTISM (hormonal or due to drugs)

Answer 29

Wt loss can reduce this in women

Can treat with laser, eflornithine or CO-PYRINDIOL

Question 30

Scalp and Hair Conditions - ALOPECIA

Answer 30

Finasteride

or

Minoxidil - usually TOPICAL

Question 31

EYE chapter

Answer 31

Application = if using 2 different eye drops, space out with a 5 MIN INTERVAL and longer if gel.

Preservatives = BENZALKONIUM CHLORIDE is commonly used that can cause stinging and irritation.

Closed-angle glaucoma = medical emergency => cloudy eye, N/V, headache, intense eye pain, blurred hazy vision, sight loss, rainbow-coloured rings around lights.

Question 32

SKIN chapter

Answer 32

Excipients and sensitisation:
- Patch test
- Preps containing salicylate = salicylate toxicity in neonates and if applied in large areas
- Avoid benzyl alcohol in neonates = fatal toxicity syndrome

Emollients used in eczema:
- Apply the emollient in the direction of hair growth; reduce the risk of folliculitis

ROSACEA: Treatment is a 6-12 week course; repeated intermittently
- Facial erythema (face redness) => BRIMONIDINE = MHRA: Rise of systemic CVS effects, to minimise systemic absorption, avoid application to irritated or damaged skin, including after laser therapy. Risk of exacerbation of rosacea, increase gradually and to stop and report if symptoms worsen.
PUSTULES and PAPULES:
- topical: metronidazole, azelaic acid, invermectin OR
- oral: oxytetracycline, tetracycline, erythromycin

Question 33

VACCINATION chapter

Answer 33

Routine immunisation during adult life:
- Under 25s; those entering uni who are at risk of meningococcal disease => Men A with C, and W135 and Y vaccine
- during adult life, if not previously immunised or 5 dose course is incomplete => DTP vaccine
- 65 years => pneumococcal polysaccharide vaccine
- from 50 years => influenza vaccine (inactivated) - each year from September
- 70 - 79 years => Herpes-zoster vaccine (LIVE). If CI, then use herpes-zoster vaccine (RECOMBINANT, ADJUVANTED)

Question 34

ANAESTHESIA chapter

Answer 34

Stop meds before surgery:
- COC => stop 4 weeks before major surgery and all surgery to legs or surgery that involves prolonged immobilisation due to risk of VTE
- HRT => stop 4 - 6 weeks b4 surgery and restart after full immobilisation
- AEDs => MAOIs (gradually withdraw 2 weeks b4 surgery; TCA (inform anaesthetist if continued; risk of arrhythmias ad hypotension)
- Li => Stop 24h before major surgery (constant fluid and electrolyte balance to avoid toxicity)
- K+sparing drugs => ACEi, ARBS (cause severe hypotension), K+ sparing diuretics as risk of HyperK if renal perfusion is impaired or if there is tissue damage
- Antiplatelet/DOAC/warfarin => consider stopping if increased risk of bleeding and convert to heparin for during surgery
- DM => switch pt to INSULIN during surgery. Give infusion of GLUCOSE with K+ and INSULIN on a sliding scale. Once pt begins to eat, start S/C insulin b4 breakfast and STOP IV insulin 30mins after.

May continue meds during surgery:
- AEDs
- antiparkinson
- antipsychotics
- anxiolytics
- bronchodilators
- CVS drugs, except K+ sparing diuretics
- glaucoma drugs
- immunosuppressants
- Progestogen only contraceptives
- thyroid and antithyroid meds