Miscellaneous Flashcards
Which drugs have teratogenic effects?
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
Which drugs require monitoring during renal impairment?
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
Which drugs require therapeutic monitoring?
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
Which drugs interact with smoking?
COAT: Clozapine Olanzapine Aminophylline Theophylline
What are important interactions to look out for?
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
What are the signs of sepsis?
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)
Red flag symptoms
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
Which drugs cause hypokalaemia?
BLASTT: Beta-2 agonists Loop diuretics Aminophylline Steroids Theophylline Thiazide diuretics
Symptoms- muscle weakness, confusion, arrhythmias, hypotonias
Which drugs cause hyperkalemia?
CAPTAIN HAT: Ciclosporin ACE inhibitors Potassium-sparing diuretics Trimethoprim ARBs NSAIDs Heparin Aldosterone antagonists Tacrolimus
Symptoms- Tachycardia, sudden death
Which drugs cause hyponatremia?
DANG CAT: Diuretics Antidepressants NSAIDs Gabapentin Carbamazepine Aldosterone antagonists Trimethoprim
Symptoms: muscle weakness, headache, nausea, drowsiness, confusion
Which drugs cause hypernatremia?
Diuretics Sodium bicarbonate Sodium chloride Corticosteroids Anabolic steroids Adrenocorticotrophic steroids Androgens Oestrogens Symptoms: muscle weakness, confusion, thirst
Which drugs cause hypocalcaemia?
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
Which drugs cause hypercalcaemia?
LETTT
Lithium Estrogens Thiazide diuretics Teriparatide Tamoxifen
Symptoms: abdominal pain, vomiting, constipation, polyruria, confusion
Which drugs cause hypophosphatemia?
Chronic diuretic and antacid use
Symptoms: muscle weakness, respiratory or heart failure, seizures, or comas.
What causes hyperphosphatemia?
advanced renal insufficiency; hypoparathyroidism and pseudohypoparathyroidism.
Symptoms: fatigue, SOB, anorexia, N+V, sleep disturbances
What drugs cause hypomagnesaemia?
Loop and thiazide diuretics Proton pump inhibitors Aminoglycoside antibiotics Amphotericin B Digitalis Cisplatin Cyclosporine
Causes: Diarrohea
Ketoacidosis
Alcohol
Symptoms: Fits, tetany, arrhythmias
Which drugs cause hypermagnesemia?
Antacids
Symptoms: Hypotension, CNS depression
What are high risk drugs as per the GPHC?
Antibiotics Anticoagulants Antidiabetic drugs Antihypertensives Chemotherapy Insulins Drugs with a narrow therapeutic index Non-steroidal anti-inflammatory drugs Methotrexate Opiates Parenteral drugs
Drug and food interactions
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
Serotonin syndrome
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.
Sildenafil
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
Tripple whammy?
ACEi/ARB
Diuretic
NSAID
Antihistamines
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
What is agranulocytosis?
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
NSAIDs
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
What is SJS?
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
Which drugs should not be stopped abruptly?
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
Antidepressant medications
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
Lipid modification
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
Vitamins
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
Vaccines
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).
Statin Strengths
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.
Patient factors when dispensing
Age, allergies, weight, immune status, renal function, hepatic function, pregnancy/ breastfeeding, other conditions, previous antibiotic treatment, other medications, routes of administration
Biguanides
Metformin
Sulfonylureas
glibenclamide, gliclazide, glimepiride, glipizide, tolbutamide
Thiazolidinediones
pioglitazone
DPP-4 inhibitors
alogliptin, linagliptin, saxagliptin, vildagliptin, sitagliptin
GLP-1 agonists
exenatide, exenatide LAR liraglutide, lixisenatide,dulaglutide, semaglutide
SGLT2 inhibitors
dapagliflozin, canagliflozin, empagliflozin, ertugliflozin
Heart Failure
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
Meningitis
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
