Medicines 14 Flashcards
What are some key Cautions and contraindications; conditions with 1st generation antipsychotics?
Elderly – start with low dose
Avoid in dementia – increased risk of death and stroke
Avoid in Parkinson’s disease – extrapyramidal side effects
Contraindicated in CNS depression, hypothyroidism
Caution in CVD – may require ECG
Caution in conditions predisposing to seizures – epilepsy
Caution in depression
Caution in history of jaundice
Caution in diabetes
Haloperidol
Caution in hypocalcaemia, hypokalaemia, metabolic disturbances
What are some key counselling points for first generation antipsychotics?
Counselling
Look out for side effects
May cause skin to become sensitive to sunlight so protect your skin
Check glucose levels regularly in diabetes
Do not stop treatment suddenly
Name some second generation atypical antipsychotics?
second generation: atypical
Clozapine, Olanzapine, Risperidone, Quetiapine
What are the main uses of second generation antipsychotics
Main uses
Urgent treatment of severe psychomotor agitation leading to dangerous behaviour
Schizophrenia – especially when extrapyramidal side effects of first generation antipsychotics or when negative symptoms are present
Bipolar disorder – in acute episodes of mania or hypomania
WHat side effects can second generation antipsychotics have ?
Side effects
Sedation
Some extrapyramidal symptoms – less common with this generation though
Metabolic disturbance:
Weight gain
Diabetes
Lipid changes
Prolong QT interval – arrhythmias
Breast changes – Risperidone
Sexual dysfunction
Clozapine – causes severe deficiency in neutrophils = agranulocytosis and rarely causes myocarditis
WHat key monitoring is required with clozapine?
Clozapine:
Agranulocytosis
Neutropenia and potentially fatal agranulocytosis reported.
Leucocyte and differential blood counts must be normal before starting;
Monitor counts every week for 18 weeks then at least every 2 weeks and if clozapine continued and blood count stable after 1 year at least every 4 weeks (and 4 weeks after discontinuation);
If leucocyte count below 3000 /mm3 or if absolute neutrophil count below 1500 /mm3 discontinue permanently and refer to haematologist. Patients who have a low white blood cell count because of benign ethnic neutropenia may be started on clozapine with the agreement of a haematologist. Avoid drugs which suppress leukopoiesis; patients should immediately report symptoms of infection, especially influenza-like illness.
Myocarditis and cardiomyopathy
Fatal myocarditis (most commonly in the first 2 months) and cardiomyopathy reported.
Perform physical examination and take full medical history before starting
Specialist examination required if cardiac abnormalities or history of heart disease found—clozapine initiated only in absence of severe heart disease and if benefit outweighs risk
Persistent tachycardia especially in first 2 months should prompt observation for other indicators for myocarditis or cardiomyopathy
If myocarditis or cardiomyopathy suspected clozapine should be stopped and patient evaluated urgently by cardiologist
Discontinue permanently in clozapine-induced myocarditis or cardiomyopathy
What vitamin is given to new born babies usually within 72 hours of birth?
Newborns are routinely given a vitamin K injection shortly after birth to prevent vitamin K deficiency bleeding (VKDB), a condition that can cause severe bleeding due to low levels of vitamin K, which is essential for blood clotting.
Oral vitamin K requires a second dose
What is domperidone and how does domperidone work?
Relief of nausea and vomiting
Gastro-intestinal pain in palliative care
What are the symptoms of diabetic ketoacidosis?
General Symptoms: Fatigue, weakness, nausea, vomiting, abdominal pain, dehydration (dry mouth, thirst, weight loss).
Respiratory Symptoms: Kussmaul breathing (deep, rapid), fruity-smelling breath.
Neurological Symptoms: Confusion, drowsiness, stupor, or coma.
Hyperglycemia Symptoms: Polyuria, polydipsia, blurred vision.
Acidosis/Ketosis Symptoms: Abdominal pain, persistent vomiting.
Signs of Triggers: Fever, chest pain, shortness of breath (e.g., infection or myocardial infarction).
What are some key counselling points regarding insulin?
Counselling
The injection site should be rotated to prevent lipodystrophy.
Injection devices (‘pens’), which hold the insulin in a cartridge and meter the required dose, are convenient to use. Insulin syringes (for use with needles) are required for insulins not available in cartridge form, but are less popular with children and carers.
For intensive insulin regimens, multiple subcutaneous injections (3 or more times daily) are usually recommended.
Look out for signs of hypoglycaemia
Must carry your insulin passport – provides record of current insulin preparations and emergency info.
What key monitoring reqirements are there with insulin?
Should maintain a blood-glucose concentration of between 4 and 9 mmol/litre for most of the time (4–7 mmol/litre before meals and less than 9 mmol/litre after meals).
The intake of energy and of simple and complex carbohydrates should be adequate to allow normal growth and development but obesity must be avoided.
Monitor HbA1C levels at least annually
When given as a continuous IV infusion – monitor K+ levels every 4 hours to avoid hypokalaemia
When should patients with type 1 diabetes be offered a statin?
Offer statin treatment with atorvastatin 20 mg for the primary prevention of CVD in type 1 diabetes if the person:
Aged over 40 years.
Has had diabetes for more than 10 years.
Has established nephropathy.
Has other CVD risk factors (such as obesity and hypertension).
What are the risks associated with insulin use?
Hypoglycaemia – may lead to coma/death
When administered SC at same site repeatedly can cause fat overgrowth – lipohypertrophy
Local reactions at injection site
what are the uses of Insulin?
For insulin replacement in people with type 1 diabetes mellitus and control glucose in type 2 diabetes mellitus where oral therapy is not good.
Given IV in treatment diabetic emergencies such as diabetic ketoacidosis and hyperglycaemic hyperosmolar syndrome and for perioperative glycaemic control in selected diabetic patients
Alongside glucose to treat hyperkalaemia
what are the key counselling points with levothyroxine treatment
The medication should be taken at least 30 minutes before breakfast. This is because food and coffee can reduce the absorption of levothyroxine.
Will take some time for you to feel back to normal (few months)
Treatment is for life so don’t stop taking
Signs of too much treatment (shakiness, anxiety, sleeplessness, diarrhoea) – see GP
If taking calcium or iron supplements leave a 4 hour gap.
What is uACR and when is it requested?
The uACR is an important test for identifying kidney damage, in addition to the eGFR test. Albuminuria (having albumin in your urine) increases your risk of kidney failure and cardiovascular disease (heart attack or stroke).
Diabetes
Hypertension (high blood pressure)
Cardiovascular disease (history of heart attack or stroke)
Heart failure
Family history of kidney disease, kidney failure, or dialysis
Increased body weight (especially if your body mass index or BMI is over 30)
Smoking or other use of tobacco products
Over the age of 60
Which other antidiabetic medication would be contraindicated with a GLP-1
the GLIPTINS
Have overlapping mechanisms of actions
(act via the incretin pathway) so no benefit.
stop the gliptin as GLP-1 stronger.
What monitoring requirements are important with Levothyroxine?
Initial dosage in patients with cardiovascular disorders
If metabolism increases too rapidly (causing diarrhoea, nervousness, rapid pulse, insomnia, tremors and sometimes angina pain where there is latent myocardial ischaemia), reduce dose or withhold for 1–2 days and start again at a lower dose.
Assess maternal thyroid function before conception and during both second and third trimesters and after delivery.
Review patient monthly and dose changes should occur based on symptoms
Thyroid function tests should be completed 3 months after starting treatment or a change in dose.
In primary hypothyroidism – TSH is main guide for dosing
WHat conditions are cautioned or contraindicated in levothyroxine treatment?
Thyroid hormones increase heart rate and metabolism and can precipitate cardiac ischaemia in people with coronary artery disease 🡪 replacement should be started cautiously at a low dose and with careful monitoring
Hypopituitarism – steroid therapy should be initiated before thyroid hormone replacement to avoid precipitating Addison’s disease
Contraindicated in thyrotoxicosis
Caution in cardiovascular disorders, myocardial infarction
Caution in diabetes – dose of anti-diabetics may need to be increased
Levothyroxine requirements may increase during pregnancy
What side effects are associated with levothyroxine?
and what side effects could be noticed if underdosing is present?
Side effects
SE due to excessive doses = similar symptoms to hyperthyroidism
GI side effects
Diarrhoea
Nausea
Weight loss
Palpitations
Arrhythmias
Angina
Tremor
Restlessness
Insomnia
An inadequate dose of levothyroxine can result in symptoms of hypothyroidism such as:
Cold intolerance
Weight gain
Low mood
Constipation
Dry skin
What is leothyronine and when is it used?
Liothyronine is a synthetic form of the triiodothyronine (T3) thyroid hormone. It is more potent and faster-acting than levothyroxine (T4)
Usually used in extreme Hypothyroidism
What are the sick day rules in diabetes?
Sick-Day Rules (Concise Notes)
General Advice
Stop certain medications during acute illness and restart after 24–48 hours of eating and drinking normally (if renal function is stable).
Medications to stop temporarily:
ACE inhibitors/AIIRAs, diuretics, NSAIDs: Risk of dehydration and AKI.
Metformin: Risk of lactic acidosis if dehydrated.
Sulfonylureas: Risk of hypoglycemia if dietary intake is reduced.
SGLT-2 inhibitors: Risk of euglycemic DKA if unwell or dehydrated; check ketones.
GLP-1 receptor agonists: Risk of dehydration and AKI.
Insulin: Do not stop. Adjust doses if needed and seek specialist advice if unsure.
What is G6PD deficiency ?
G6PD Function:
G6PD (glucose-6-phosphate dehydrogenase) is a protein found in red blood cells.
Protects red blood cells from damage caused by harmful substances.
Prevents premature destruction of red blood cells, which normally live ~3 months.
G6PD Deficiency:
Cause: Inherited X-linked enzyme deficiency.
Leads to reduced G6PD levels, making red blood cells more vulnerable to damage.
Common in populations from malaria-endemic regions:
Sub-Saharan Africa, Asia, the Mediterranean, and the Middle East.
Which medications should be avoided in GDP6 deficiency?
Nitrofurantoin
Sulphonamides (including
Co-trimoxazole, Septrin)
Quinolones (Ciprofloxacin)
Primaquine
Use gliclazide with caution, especially in severe G6PD deficiency.
What are the different indications for sildenafil?
Erectile dysfunction
Primary pulmonary hypertension
