Medications Flashcards
What are some long term risks of chronic steroid use (oral)?
Osteoporosis (1)
Osteonecrosis of the hip (1)
Myopathy (1)
Diabetes / Glucose intolerance (1)
Altered fat distribution /cushingoid appearance (1)
Loss of libido (1)
Adrenal suppression (1)
Dyslipidaemia (1)
Hypertension (1)
Cardiovascular events/ischaemic heart disease (1)
Increased risk of opportunistic infections (1)
Skin changes for example atrophy/telangiectasia/easy bruising/acne/alopecia (1)
Cataracts/Glaucoma (1)
Mood disturbances for example psychosis or depression (1)
Peptic ulcer disease (1)
Symptoms or signs of mild serotonergic toxidrome? and management
Tremor
Mild tachycardia
Inducible clonus
Hyper-reflexia in the lower limbs
Mild serotenergic toxidrome, doesn’t require anything in specific.
1. obviously cease the medication/s of concern
2. supportive therapies
For someone taking these medications
Citalopram for their depression
Tramadol prescribed for their lower back pain and
OTC St Johns Wart
What is the biggest risk?
These can cause reduced serotonin uptake specifically and therefore lead to serotonergic toxidrome.
Other drugs can decrease 5HT metabolism: e.g MOAs
Some drugs increase serotonin release: All opioids including tapentadol AND tramadol, various stimulants including phentermine, amphetamines
Some drugs are 5HT receptor agonists like Lithium
Any combination of these “classes” can lead to serotonergic toxidrome.
What are contraindications to the combined oral contraceptive pill?
(13)
Any VTE (current or past)
Immobilisation due to surgery
Thrombogenic mutations
HCC or liver tumour
Liver disease or cirrhosis
CURRENT breast cancer
IHD
Stroke or TIA
HTN sBP>160 or dBP> 110
Migraine WITH Aura in the last 5 years
Smoking 15+ /day AND aged > 35
Post partum first 6 weeks IF breastfeeding
Post partum first 3 weeks with VTE risk factors
Dose of an COPC in an appropriate patient
ethinylestradiol 30 + levonorgestrel 150 orally, daily. (Levlen ED)
How do you start a COPC versus POP
COPC
effective immediately if started on days 1-5 of cycle
will take 7 days to work at other times
POP
effective immediately if started on days 1-5 of cycle
Otherwise takes 48 hours (3 consecutive pills) to work.
What to do with a missed Progesterone only pill?
<24 hours, Take pill when remembered, then take next pill at scheduled time. Advise won’t be effective until 3 pills taken
if > 24 hours ie. more than one missed pill. Take the most recent missed pill, then take the next one when normally scheduled. Discard/don’t take the other missed pill/s. Won’t be effective for 48 hours (3 consecutive pills).
Consider emergency contraception if sexual intercourse occurred after the first missed pill. i.e 24 hours after the last pill was taken.
Forms of emergency contraception with dosing?
levonorgestrel 1.5 mg orally, as a single dose taken as soon as possible and within 96 hours (4 days) of unprotected sexual intercourse
ulipristal 30 mg orally, as a single dose taken as soon as possible and within 120 hours (5 days) of unprotected sexual intercourse
Copper IUD within 5 days.
what is quickstart method to starting oral contraception?
I means when you’re starting a patient on a oral contraception not on Day 1-5.
Needs 3 (POP) or 7 (COPC) to work, so use barrier contraception in that time.
If sexually active, since early pregnancy is not excluded, does need a pregnancy test in 4 weeks time. (or 3 weeks after starting if no further episodes of unprotected sex occurred in the first week of use)
List three types of medications that can cause a chronic cough?
ACEi (can take a year to clear)
NSAIDs (increase in LKT due to COX blockade)
Beta blockers (non selective types: propranolol and sotalol)
Side effects of PDE5i?
facial flushing
headache
dyspepsia
nasal congestion
dizziness
postural hypotension if on antihyperensive
What main effects should you watch for with prescription of montelukast?
Neuropsychiatric effects.
hallucinations, insomnia, irritability, dream abnormalities
primarily suicidal ideation
General common side effects of mirtazapine?
Increased appetite
Weight gain
drowsiness/sedation in the first few weeks
What are some side effects of lithium?
hypothyroidism
HYPERparathyroidism
Weight gain
can reduce concentrating abilities of kidneys - but doesn’t lead to impairment
no risk of teratogensis, but anti-psychotics preferred in pregnancy
Symptoms of lithium toxicity, not simply side effects.
gastrointestinal effects—nausea, vomiting, diarrhoea
CNS effects—tremor, hyperreflexia, ataxia
Cardiovascular effects—QT-interval prolongation is uncommon, but can occur in severe poisoning; arrhythmias are rare.
Potential treatment for lithium toxicity?
Airway/breathing unlikely to be affected but can be if patient collapsed
Circulation: dehydration is likely. Rehydrate with standard saline
Decontamination: no need for activated charcoal ( it doesn’t bind lithium ). May need whole bowel irrigation.
Haemodialysis.
Side effects/Adverse effects of SGLT2i?
If fasting/pre surg- avoid as could cause hypos
Could cause ketoacidosis
Irreversible creatnine increase
GIT infections
UTI
When should you avoid GLP1-RA?
in cases of pancreatitis
What are severe anti-cholinergic effects?
Also known as anticholinergic toxidrome?
Classic symptoms are delirium, mumbling, picking at the bed sheets or imaginary objects, mydriasis and tachycardia.
What drugs are purely anti-cholinergic?
Oxybutynin
Hyoscine N-butylbromide
Atropine
Benzatropine
What drugs (apart from pure anti-cholinergics) can have anti-cholinergic effects?
TCAs
Anti-histamines
Anti-psychotics
Metoclopramide and prochlorperazine can worsen parkinson’s symptoms POTENTIALLY via their anticholinergic effects.
PPIs are generally safe however you can get hypo__(a)__, increased risk of __(b)__, Clostridium difficile and other __(c)__ infections, impaired nutrient absorption, risk of __(d)__. This risks are low and if there are erosive signs on endoscopy or if barrett’s esophagus is present, treating symptoms with PPIs outweighs the risks
a. hypomagnesaemia.
b. pneumonia
c. gastrointestinal
d. Fracture
What is the biggest risks with starting Allopurinol for gout prophylaxis, and how can you minimise that risk?
- Bone marrow toxicity
Allopurinol reduces the metabolism of azathioprine and mercaptopurine, increasing the risk of severe bone marrow toxicity. If possible, avoid the combination of allopurinol with either azathioprine or mercaptopurine
- Hypersensitivity syndrome. would occur in the first 3 months
Risk factors for allopurinol hypersensitivity syndrome include use of a high starting dose and rapid up-titration (so go slowly), renal impairment, older age, and the presence of human leucocyte antigen (HLA)-B*5801 allele, which is more common in people of Asian ethnicity, especially the Han Chinese
if you can’t use allopurinol or at least if you can’t achieve target urate with higher doses of allopurinol because of side effects/not tolerated then use probenacid
Beta blockers are an essential component to treat heart failure. However when used initially they can worsen heart failure. How can you prevent an exacerbation/worsening of the heart failure?
(5)
do not initiate beta-blocker therapy during a period of acute decompensation
start therapy with a very low dose
increase the dose very gradually
monitor the patient’s symptoms frequently and measure weight daily
avoid simultaneous addition of vasodilator drugs.
If treatment of a condition, such as PMR, requires long term steroids, what should be done?
When should you consider this test/what is ‘long term’?
A. Bone mineral density scan
B. any treatment with corticosteroids over 3 months
If oral steroids are started in someone with a lower BMD, at what BMD level do you consider preventative treatment and what do you use?
- Anything under -1.5
- START an oral bisphosphonate, e.g. risendronate 35mg, weekly, on an empty stomach, orally
There are numerous side effects that can be experience from starting long term steroids, what are some that a patient should be informed about?
- higher BP (take a baseline)
- dyslipidemia (take a baseline fasting lipids)
- Raised BGL (take a baseline BGL)
- adrenal insufficiency (if ceased too quickly)
- Mood disturbance; psychosis or depression. (Screen prior)
- Osteopenia/orosis - do a BMD
- Increased risk of opportunistic infection (inform pt)
- Altered fat distribution (inform and take baseline BMI, WC)
- Peptic ulcer disease (can start a PPI)
Side effects of an SSRI?
(list 8)
Temporary worsening of depression/increased suicidal thoughts
Nausea
Diarrhoea
Agitation
Anxiety
Insomnia
Drowsiness/sedation
Tremor
Dry mouth
Dizziness
Headache
Sweating
Weakness
Sexual dysfunction
Rhinitis
Myalgia
Rash
Three most common side effects of statins?
Muscle pain, tenderness or weakness is the most commonly reported side effect.
What are features that increase the likelihood of muscular pain being due to a statin?
(6)
Bilateral pain
Aching or stiffness (not a shooting or cramping)
Large muscle groups: buttocks, thighs
Onset 4-6 weeks after starting the statin
High-potency or high dose statin
Elevated CK that reduces when statin is withdrawn
What should you initially do if you suspect statin associated muscle symptoms?
Take a CK
if >5x ULN (upper limit of normal) then send to ED.
If not then stop statin, see if it resolves, and consider restarting
