Miscellaneous

Question 1

Which drugs have teratogenic effects?

Answer 1

ACEi
Acne medicine- isotretinoin 
Alcohol
Androgens
Antibiotics- tetracycline, doxycycline, streptomycin, trimethoprim
Anticonvulsants- phenytoin, valproic acid, carbamazepine
Lithium
Methotrexate
Penicillamine
Thiouracil
Carbimazole
Cocaine
Diethylstilbestrol
Thalidomide
Warfarin

Question 2

Which drugs require monitoring during renal impairment?

Answer 2

The following may require dose adjustments and discontinuation during an AKI:
Aminoglycosides- gentamicin, streptomycin
Amphotericin
Immunosuppressants- ciclosporin, tacrolimus
Cisplatin
NSAIDs- exacerbate by hypoperfusion of kidneys
Metformin- accumulate in AKI and cause lactic acidosis
ACEi/ ARB- exacerbate by hypoperfusion of kidneys

Question 3

Which drugs require therapeutic monitoring?

Answer 3

Carbamazepine- 4 to 10 mg/L
Ciclosporin
Digoxin- 1 to 2 micrograms/L
Gentamicin- Peak 5 to 12mg/L, trough <2mg/L
Lithium- 0.4 to 1 mmol/L
Phenytoin- 8 to 15 mg/L
Theophylline- 10 to 20 mg/L
Vancomycin- : trough 5 to 15mg/L, up to 20mg/L in resistant infections

Question 4

Which drugs interact with smoking?

Answer 4

COAT:
Clozapine
Olanzapine
Aminophylline
Theophylline

Question 5

What are important interactions to look out for?

Answer 5

Alcohol and Metronidazole- disulfiram like reaction
Simvastatin and Amiodarone- increased effect of simvastatin- max 20 mg daily
Sildenafil and GTN- significant hypotension
Warfarin + ketoconazole- increased bleeding risk
Simvastatin and erythromycin
Doxycycline in children- Tetracyclines should be avoided in children under 12 years of age owing to their ability to interfere with bone development
Warfarin and antibiotics
Trimethoprim and phenytoin
Ciprofloxacin and phenytoin
Spironolactone and trimethoprim- increased risk of hyperkalemia
Ciprofloxacin and elderly- increased tendon rupture risk
Trimethoprim and methotrexate
Simvastatin and miconazole
Aspirin in under 16s- reyes syndrome
SSRI and MAOI- serotonin syndrome
Erythromycin and theophylline- increased conc of theophylline
Ciprofloxacin and theophylline- increased conc of theophylline
Erythromycin and simvastatin- increased risk of myopathy

Question 6

What are the signs of sepsis?

Answer 6

Symptoms:
fever and/or chills
confusion or disorientation
difficulty breathing
fast heart rate or low blood pressure (hypotension)
extreme pain
sweaty skin

Evidence of altered mental state: confusion
Respiratory rate: 21–24 breaths per minute
Heart rate: 91–130 beats per minute
Systolic BP: less than 90 mmHg
Signs of infection
Impaired immunity
Recent trauma/ surgery
Non-blanching rash / mottled / ashen / cyanotic
Lactate ≥ 2 mmol/l
Recent chemotherapy
Not passed urine in 18 hours (<0.5ml/kg/hr if catheterised)

Question 7

Red flag symptoms

Answer 7

Unexplained weight loss
Methotrexate- blood disorders (e.g. sore throat, bruising, and mouth ulcers), liver toxicity (e.g. nausea, vomiting, abdominal discomfort and dark urine), and respiratory effects (e.g. shortness of breath).
Gripping sudden onset chest pain radiating to left arm
High fever
Dysphagia
Dysuria
Persistent vomiting

Question 8

Which drugs cause hypokalaemia?

Answer 8

BLASTT:
Beta-2 agonists
Loop diuretics
Aminophylline
Steroids
Theophylline
Thiazide diuretics

Symptoms- muscle weakness, confusion, arrhythmias, hypotonias

Question 9

Which drugs cause hyperkalemia?

Answer 9

CAPTAIN HAT:
Ciclosporin
ACE inhibitors
Potassium-sparing diuretics
Trimethoprim
ARBs
NSAIDs
Heparin
Aldosterone antagonists
Tacrolimus

Symptoms- Tachycardia, sudden death

Question 10

Which drugs cause hyponatremia?

Answer 10

DANG CAT:
Diuretics
Antidepressants
NSAIDs
Gabapentin
Carbamazepine
Aldosterone antagonists
Trimethoprim

Symptoms: muscle weakness, headache, nausea, drowsiness, confusion

Question 11

Which drugs cause hypernatremia?

Answer 11

Diuretics
Sodium bicarbonate
Sodium chloride
Corticosteroids
Anabolic steroids
Adrenocorticotrophic steroids
Androgens
Oestrogens
Symptoms: muscle weakness, confusion, thirst

Question 12

Which drugs cause hypocalcaemia?

Answer 12

RIPRAPZ
rifampin 
ibandronate
phenytoin
risedronate
alendronate
phenobarbital
zoledronic acid

Symptoms: 
Twitching in your hands, face, and feet
Numbness
Tingling 
Depression 
Memory loss 
Scaly skin
Changes in the nails 
Rough hair texture
Cramps
Seizures
Abnormal heartbeats

Question 13

Which drugs cause hypercalcaemia?

Answer 13

LETTT

Lithium
Estrogens
Thiazide diuretics
Teriparatide
Tamoxifen

Symptoms: abdominal pain, vomiting, constipation, polyruria, confusion

Question 14

Which drugs cause hypophosphatemia?

Answer 14

Chronic diuretic and antacid use

Symptoms: muscle weakness, respiratory or heart failure, seizures, or comas.

Question 15

What causes hyperphosphatemia?

Answer 15

advanced renal insufficiency; hypoparathyroidism and pseudohypoparathyroidism.

Symptoms: fatigue, SOB, anorexia, N+V, sleep disturbances

Question 16

What drugs cause hypomagnesaemia?

Answer 16

Loop and thiazide diuretics
Proton pump inhibitors
Aminoglycoside antibiotics
Amphotericin B
Digitalis
Cisplatin
Cyclosporine

Causes: Diarrohea
Ketoacidosis
Alcohol

Symptoms: Fits, tetany, arrhythmias

Question 17

Which drugs cause hypermagnesemia?

Answer 17

Antacids

Symptoms: Hypotension, CNS depression

Question 18

What are high risk drugs as per the GPHC?

Answer 18

Antibiotics
Anticoagulants
Antidiabetic drugs
Antihypertensives
Chemotherapy
Insulins
Drugs with a narrow therapeutic index
Non-steroidal anti-inflammatory drugs
Methotrexate
Opiates
Parenteral drugs

Question 19

Drug and food interactions

Answer 19

Warfarin and Vitamin K- reduced effect of warfarin
Insulin and alcohol- increased effects of insulin (hypoglycaemia)
Digoxin and St. Johns Wort- decreased digoxin effect
Digoxin and ginseng- increased digoxin effect
Statins and grapefruit- increased statin effect
Calcium channel blockers and grapefruit- increased effect
Viagra and grapefruit juice- increased effect, flushing, hypotension
Paracetamol and alcohol- liver toxicity
MAOIs and Tyramine-Containing Foods- hypertensive crisis
Antibiotics and Dairy Products- delay absorption
Antithyroid Drugs and Iodine-Rich Foods- oppose effect of medicine

Question 20

Serotonin syndrome

Answer 20

Excessive central and peripheral serotonergic activity

The characteristic symptoms of serotonin syndrome fall into 3 main areas, although features from each group may not be seen in all patients—neuromuscular hyperactivity (such as tremor, hyperreflexia, clonus, myoclonus, rigidity), autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea), and altered mental state (agitation, confusion, mania).

Treatment consists of withdrawal of the serotonergic medication and supportive care; specialist advice should be sought.

Question 21

Sildenafil

Answer 21

Viagra connect is only intended for men aged 18 years and older who are experiencing erectile
dysfunction (ED)
If patient presents with CVD e.g. hypertension, angina, then cannot supply

Cannot supply if taking:
Nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate) for chest pain?
Poppers for recreational purposes (e.g. amyl nitrite)?
Riociguat or other guanylate cyclase stimulators for lung problems?
Ritonavir (for HIV infection)?
CYP3A4 inhibitors, e.g. saquinavir (to treat HIV infection), cimetidine (a heartburn treatment), itraconazole or ketoconazole (to treat fungal infections), erythromycin (antibiotic) or diltiazem (for high blood pressure)?
Alpha-blockers, such as alfuzosin, doxazosin or tamsulosin, which are medicines to treat urinary problems due to enlarged prostate (benign prostatic hyperplasia) or occasionally to treat high blood pressure?

Cannot supply if:
Do you have previously diagnosed hepatic (liver) disease (including cirrhosis of the liver) or severe renal (kidney) impairment?
Do you have any of the following: sickle cell anaemia, multiple myeloma or leukaemia?
Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers?

Counselling:
Men should be advised:
• Viagra connect is only intended for men aged 18 years and older who have erectile dysfunction (ED). Men who do not have ED will not
benefit from using this product
• Take one tablet approximately 1 hour before planning to have sexual intercourse. Viagra connect can start to work within 30 minutes
• Take with or without food, but Viagra connect may take longer to work after a high-fat meal
• Do not take with grapefruit or grapefruit juice, as it may modestly increase plasma levels of sildenafil
• The maximum recommended dosing frequency is one 50 mg tablet per day
• They may need to take Viagra connect a number of times on different occasions (a maximum of one 50 mg tablet per day), before they can achieve a penile erection satisfactory for sexual activity. If, after several attempts (up to a maximum of 8 times) on different dosing occasions, patients are still not able to achieve a penile erection sufficient for satisfactory sexual activity, they should be advised to
consult a doctor
• Medicines containing any nitrates (e.g. glyceryl trinitrate, isosorbide mononitrate, isosorbide dinitrate, amyl nitrite also known as
‘poppers’), or nitric oxide donors (e.g. sodium nitroprusside or nicorandil), must NOT be used at the same time as Viagra connect as this
combination may lead to a dangerous fall in blood pressure
• Men should tell their doctor that they have started taking Viagra connect, especially if they are started on any new medicines
• Remind patients about common side effects. These include: headache, flushing, dyspepsia, nasal congestion, dizziness, nausea, visual
disturbance, cyanopsia (blue-tinted vision) and blurred vision

Stop taking if:
Chest pains: If this occurs before, during or after intercourse, they should get into a semi-sitting position and try to relax. Nitrates must NOT be used to treat chest pains
• A persistent and sometimes painful erection lasting longer than 4 hours
• A sudden decrease or loss of vision
• An allergic reaction. Symptoms include sudden wheeziness, difficulty breathing or dizziness, swelling of the eyelids, face, lips or throat
• Serious skin reactions such as Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Syndrome (TEN). Symptoms may include severe
peeling and swelling of the skin, blistering of the mouth, genitals and around the eyes, fever
• Seizures or fits

Advice:
• ED can be associated with a number of contributing conditions, e.g. hypertension, diabetes mellitus, hypercholesterolaemia,
cardiovascular disease, depression and lower urinary tract symptoms (LUTS). As a result, all men with ED should be advised to consult their doctor within 6 months for a clinical review of potential underlying conditions and risk factors associated with ED
• Provide appropriate advice on lifestyle factors and general healthy living, including:
– Losing weight
– Giving up smoking
– Cutting back on alcohol/ recreational drugs
– Exercising regularly
– Reducing stress

Question 22

Tripple whammy?

Answer 22

ACEi/ARB
Diuretic
NSAID

Question 23

Antihistamines

Answer 23

Examples of sedating antihistamines:

Alimemazine
Chlorphenamine
Clemastine
Cyproheptadine
Hydroxyzine
Ketotifen
Promethazine

Examples of non-sedating antihistamines:

Acrivastine
Bilastine
Cetirizine
Desloratadine
Fexofenadine
Levocetirizine
Loratadine
Mizolastine
Rupatadine

Question 24

What is agranulocytosis?

Answer 24

Bone marrow does not make enough white blood cells, including neutrophils. Neutrophils are required to fight infections.

Signs and symptoms: sudden fever, chills, sore throat, weakness in your limbs, sore mouth and gums, mouth ulcers, bleeding gums

Causes: carbimazole, NSAIDs, methotrexate, clozapine, quinine, sulfasalazine

Question 25

NSAIDs

Answer 25

Non-selective: Aspirin, naproxen, ibuprofen, diclofenac
Selective: celecoxib
GI: piroxicam, ketoprofen, and ketorolac trometamol are associated with the highest risk; indometacin, diclofenac, and naproxen are associated with intermediate risk, and ibuprofen with the lowest risk

Question 26

What is SJS?

Answer 26

Stevens-Johnson Syndrome

Affects skin, mucous membranes, genitals and eyes
The syndrome often begins with flu-like symptoms, followed by a red or purple rash that spreads and forms blisters. The affected skin eventually dies and peels off.
Facial swelling and swollen lips covered in crusty sores are common features of Stevens-Johnson syndrome.
The mucous membranes inside your mouth, throat, eyes and genital tract may also become blistered and ulcerated.

Drug causes:
allopurinol
carbamazepine
lamotrigine
nevirapine
the "oxicam" class of anti-inflammatory drugs (including meloxicam and piroxicam)
phenobarbital
phenytoin
sulfamethocazole and other sulfa antibiotics
sertraline
sulfasalazine

TEN is a severe form of SJS

Question 27

Which drugs should not be stopped abruptly?

Answer 27

Antihypertensives- rebound hypertension- tachycardia
Anticoagulants
Antidepressants- MAOI
Benzodiazepines
Steroids- adrenal glands reduce production of cortisol when taking steroids and if abrupt withdrawal then low level of cortisol in body=weakness, nausea, vomiting, diarrhoea, and abdominal pain
Opioids- withdrawal symptoms: restlessness, anxiety, diarrhea, and generalized pain
Seizure medication- withdrawal: agitation, confusion, and disorientation
Thyroid medications- rapid heartbeat, fever, fainting, and if left untreated, coma

Question 28

Antidepressant medications

Answer 28

Venlafaxine associated with withdrawal so not suitable for non-adherent patients
SSRIs for mild depression (citalopram)- first-line, safer in overdose, better tolerated
Cannot start MOAI straight after stopping SSRI as increased risk of serotonin syndrome
SSRI V TCA- TCA higher adverse effects, toxic in overdose, SSRI less sedating, fewer antimuscarinic effects and fewer cardiotoxic effects
MAOI dangerous interaction with some food and drugs- require specialist
Review use every 1/2 weeks at start
Continue for 4 weeks before trying alternative
In remission continue for 6 months
SSRI associated with hyponatremia
Associated with suicidal thoughts
TCA given once daily at night (long half-life)
TCA not suitable for children or elderly
MAOI best in phobic, depressed, atypical, hypochondriacal, hysterical
MAOI- Other antidepressants should not be started for 2 weeks after treatment with MAOIs has been stopped (3 weeks if starting clomipramine or imipramine). Conversely, an MAOI should not be started until: at least 2 weeks after a previous MAOI has been stopped (then started at a reduced dose)
at least 7–14 days after a tricyclic or related antidepressant (3 weeks in the case of clomipramine or imipramine) has been stopped
at least a week after an SSRI or related antidepressant (at least 5 weeks in the case of fluoxetine) has been stopped

Question 29

Lipid modification

Answer 29

important to take other medicines at least 1 hour before or 4–6 hours after taking this new medicine
= colestyramine

management of high triglycerides
= Ezetimibe can be used to manage high
triglycerides when a statin alone is not sufficient

Patient taking amiodarone
=atorvastatin. (max 20mg) Statins are the first-line option for reducing cardiac risk in patients with high cholesterol. Note the interaction between amiodarone and simvastatin in the BNF (patients should still be
monitored for myopathy if atorvastatin has been started

Question 30

Vitamins

Answer 30

Supplement for calcium in renal impairment- alfacalcidol- Vitamin D aids the absorption of calcium.
Note this patient has renal disease so will need the activated form of vitamin D3
Total gastrectomy- A total gastrectomy is complete removal of the stomach and these patients need supplementation with vitamin B12
Vitamin to avoid during pregnancy- Vit A (retinol) (isotretinoin) (PPP)
Wernickes encephalopathy- Pabrinex is a vitamin B complex that is used in the initial management of Wernicke’s encephalopathy. This should be changed to oral thiamine when clinically appropriate

Question 31

Vaccines

Answer 31

HIV patients cannot receive live vaccines due to their weak immune system. So Fluenz Tetra (influenza vaccine) is not appropriate
Tetanus vaccine required for patients with wounds. Tetanus-prone wounds include compound fractures, certain animal bites and scratches, puncture-type injuries acquired in a contaminated environment (these are likely to contain tetanus spores), wounds or burns with systemic sepsis, and wounds containing foreign bodies—this list is not exhaustive. High-risk tetanus-prone wounds include any tetanus-prone wounds or burns that either show extensive devitalised tissue or require surgical intervention that is delayed more than 6 hours, or wounds that are heavily contaminated with material likely to contain tetanus spores (such as soil or manure).

Question 32

Statin Strengths

Answer 32

Low intensity (20–30% LDL-C reduction):
•	fluvastatin 20–40 mg daily
•	pravastatin 10–40 mg daily 
•	simvastatin 10 mg daily
Medium intensity (31–40% LDL-C reduction):
•	atorvastatin 10 mg daily
•	fluvastatin 80 mg daily
•	rosuvastatin 5 mg daily
•	simvastatin 20–40 mg daily
High intensity (more than 40% LDL-C reduction)
•	atorvastatin 20–80 mg daily
•	rosuvastatin 10–40 mg daily
•	simvastatin 80 mg daily.

Question 33

Patient factors when dispensing

Answer 33

Age, allergies, weight, immune status, renal function, hepatic function, pregnancy/ breastfeeding, other conditions, previous antibiotic treatment, other medications, routes of administration

Question 34

Biguanides

Answer 34

Metformin

Question 35

Sulfonylureas

Answer 35

glibenclamide, gliclazide, glimepiride, glipizide, tolbutamide

Question 36

Thiazolidinediones

Answer 36

pioglitazone

Question 37

DPP-4 inhibitors

Answer 37

alogliptin, linagliptin, saxagliptin, vildagliptin, sitagliptin

Question 38

GLP-1 agonists

Answer 38

exenatide, exenatide LAR liraglutide, lixisenatide,dulaglutide, semaglutide

Question 39

SGLT2 inhibitors

Answer 39

dapagliflozin, canagliflozin, empagliflozin, ertugliflozin

Question 40

Heart Failure

Answer 40

Symptoms: shortness of breath (dyspnoea and orthopnoea), fatigue, ankle swelling, nocturnal cough, sputum frothy and tinged red
Diagnosis: additional 3rd and 4th heart sounds, elevated JVP, ECG echo, BNP/NT-proBNP
Reduced ejection fraction: ACEi (monitor renal function and electrolytes, low dose at bedtime, titrate slowly), loop diuretic (furosemide), beta -blocker, MRA
Specialist treatment: ivabradine, valsartan, hydralazine, digoxin

Question 41

Meningitis

Answer 41

Symptoms: fever, vomiting/nausea, lethargy, irritability/unsettled behaviour, ill appearance, refusing food/drink, headache, muscle ache/joint pain, respiratory symptoms/signs or breathing difficulty.
Less common non-specific symptoms/signs include: chills/shivering, diarrhoea, abdominal pain/distension, sore throat/coryza or other ear, nose, and throat symptoms/signs.
More specific symptoms/signs include: non-blanching rash (petechial rash, purpuric), stiff neck, capillary refill time of more than 2 seconds, cold hands and feet, unusual skin colour, shock and hypotension, leg pain, back rigidity, bulging fontanelle, photophobia, kernig’s sign (person unable to fully extend at the knee when hip is flexed), brudzinski’s sign (person’s knees and hips flex when neck is flexed), unconsciousness or toxic/moribund state, paresis, focal neurological deficit including cranial nerve involvement and abnormal pupils, seizures.
Diagnosis: lumbar puncture for CSF
Management: neonates: Ampicillin 50 mg/kg or amoxicillin 25 mg/kg and cefotaxime 50 mg/kg or ceftazidime 50 mg/kg. Adults: Cefotaxime 2 g three times daily or ceftriaxone 2–4 g once daily