Low weighted topics! Flashcards
Glaucoma
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
Prostaglandin Analogues - Latanoprost, tafluprost, travoprost or bimatoprost
Dry eyes
Ocular discomfort
Change to eye colour
Hyperpigmentation of the peri-ocular skin
Darkening, thickening, and lengthening of the eyelashes
Vaccines (Active Immunity)
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
Vaccines - Different inactivated vaccines can be given at any interval to each other
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
Vaccine Schedule - Up to 1 year
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
Vaccine Schedule - 1 year +
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
Post-immunisation fevers
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
A person whose spleen was removed following a road traffic accident is seeing their general practitioner.
Which vaccine is indicated for this patient?
Pneumococcal vaccine
If they have had a splenectomy then they are at an increased risk of pneumococcal infection.
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.
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
Eczema - dry, flaky skin - small red spots
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
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
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)
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.
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
RA - Chronic systemic inflammatory disease affecting joint synovial membrane
- 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!!!
Methotrexate
- 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
Hyperuricaemia and Gout = raised uric acid conc in the blood and the deposition of urate crystals in joints and other tissues
This can be caused by:
- diet (high salt intake)
- meds => BENDROFLUMETHIAZIDE, chemo drugs
Acute treatment for hyperuricaemia and gout
- 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
Chronic treatment for hyperuricaemia and gout
- 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!!!
ALLOPURINOL
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.
Nocturnal Leg Cramps
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
Pain and inflammation (NSAIDs)
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
NSAIDs interactions
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
NSAIDs - GI SEs
HIGH = Piroxiam, Ketoprofen, Ketorolac
MEDIUM = Indometacin, diclofenac, naproxen
LOW = ibuprofen
LOWEST = COX-2i
NSAIDs - CVS SEs
HIGH = COX-2i, ibuprofen 2.4g, diclofenac
LOW = naproxen, ibuprofen 1.2g
Nasal Rhinitis and Congestion - RHINITIS
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
Nasal Rhinitis and Congestion - NASAL POLYPS
Review by ENT specialist
Use nasal corticosteroids
Nasal Rhinitis and Congestion - NASAL STAPHYLOCOCCI
NASEPTIN (contains PEANUTS)
or
Mupirocin
ACNE - Isotretinoin
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
Scalp and Hair Conditions - DANDRUFF (Seborrheic Dermatitis)
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
Scalp and Hair Conditions - HIRSUTISM (hormonal or due to drugs)
Wt loss can reduce this in women
Can treat with laser, eflornithine or CO-PYRINDIOL
Scalp and Hair Conditions - ALOPECIA
Finasteride
or
Minoxidil - usually TOPICAL
EYE chapter
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.
SKIN chapter
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
VACCINATION chapter
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)
ANAESTHESIA chapter
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
