Miscellaneous Flashcards
A patient presents at the pharmacy complaining of mild diarrhoea, elevated temperature and some other flu-like symptoms. On further questioning they tell you that they returned from Bolivia three months ago. What do you do/ what product do you recommend for this patient?
Refer to GP ASAP, don’t recommend a product.Bolivia is in South America and this area has Malaria. Patient could be displaying Malaria symptoms- refer in case.
What are the target levels of gentamicin in treating endocarditis?
Post-dose one hour PEAK serum concentration: 3-5 mg/LPre-dose TROUGH serum concentration: less than 1mg/L
A patient presents a prescription for Clobazam tablets, with no extra endorsements. What is the issue?
Clobazam is an SLS item. This means it can be prescribed for certain conditions only as listed in the drug tariff it can only be prescribed for epilepsy. You should ask the patient what the indication is and return the prescription to the prescriber for endorsement of SLS if it is for epilepsy.
Which epilepsy drugs should prescribers ensure the same brand is maintained?
PhenytoinCarbamazepinePhenobarbital Primidone(all the P’s!)
What is Atropine used as a reversal agent for?
Overdose of beta blockers!
What should be recommended for strained muscles?
RICE- Rest, Ice, Compression, ElevationIbuprofen good as its anti-inflammatoryRemember must be over 16 years old to buy ibuprofen, nurofen, paracetamol etc
A patient comes in to your pharmacy requesting an emergency supply as he is on holiday, he is on Zopiclone, simvastatin and Tramadol. What do you do?
I can give him a max 5 day supply of his Zopiclone as this is a Schedule 4 (Part I) CD.I can give him max 30 days supply of his Simvastatin as this is a POM.Tramadol is a schedule 3 CD therefore cannot be given as an emergency supply, only CD that can in Phenobarbital for epilepsy.
What age does one have to be to buy Curanail?
18 years and over
What is the active ingredient in Curanail 5% nail lacquer?
amorolfine
When should people requesting Curanail 5% nail lacquer be referred?
Should only be sold OTC for treatment of MILD cases of fungal nail infectionFor treatment of 2 NAILS MAX- any more and refer!Patients with underlying conditions, which predispose for fungal nail infection (impaired circulation, diabetes mellitus, immunosuppression)
A patient on warfarin presents with an INR of 5.0, their usual range is 2.0- 3.0. They have recently started taking St Johns Wort for a mild depressive episode. What is going on here?
St Johns Wort is a CYP450 enzyme INHIBITOR.Warfarin is metabolised by CYP450. Metabolism is decreased, warfarin levels rise, thins blood even more and INR increased.
What parkinsons drug is known to cause a sudden onsets of drowsiness, so people should be careful driving?
Pramiprexole
What vitamin should pregnant women avoid?
Vitamin A Do not eat liver or liver products, such as pâté, because these are very high in vitamin A.
Pregnant women should take Folic acid and Vitamin D supplements. When? Dose?
Folic acid 400mcg for first trimester (12 weeks)Vitamin D 10mcg- whole of pregnancy and breastfeeding.
In an anaphylactic reaction, how would you expect the pulse to be?
Weak!also may lose conciousness, confusion, dizziness
When is “prescribed for an animal under my care” needed on Vet prescriptions?
For CD’s!!Prescribed under the veterinary cascade is needed for all other prescriptions
Is the strength of medication needed when entering in the POM book?
Only when MORE than one strength is available. Think in exam- is this the only strength
Use By date vs Expiry date?
Use by= end of previous monthExpiry= end of current month
A patient has an INR of 8.5 but is not experiencing any bleeding. What should be done?
Hospital admission needed: stop warfarin and give phytomenidione 5mg daily.
What drugs need to be handled with care?
Finasteride MethotrexateVinocristeine injection
What is first line for preventing post-menopausal osteoporosis?
Bisphosphonates- alendronic acid, risedronateBisphosphonates are used for both preventing and treating post menopausal osteoporosis.Other options (2nd line):HRTCalcitriol
Which NSAID has the most favourable thrombotic safety profile?
Naproxen
What is strontium?
Bone formation stimulantUsed in osteoporosisContra-indicated: Current/ previous VTETemporary/ prolonged immobilisationUncontrolled HTN
What vaccination produces small fluid-filled spots at the injection site?
BCG
What can phenytoin cause you to become deficient in?
Folate
Which antidepressant is recommended first line in children?
Fluoxetine
What antibiotics are used to treat C. diff?
Metronidazole or VancomycinUsually prescribe a 10-14 day course of these
What is tonsillitis most commonly caused by?
Mostly Viral e.g. adenovirus, rhinovirus Also by Streptocococcus bacteria
Non-blanching rash = ?
Meningitisrefer to hospital ASAPMeans it does not disappear with a glass
Tacrolimus, an immunosuppressant, has been prescribed with fluconazole. What do you need to do?
Interaction!Tacrolimus is metabolised by CYP450Fluconazole is an enzyme inhibitorTherefore need to reduce the dose of tacrolimus, increased levels could lead to nephrotoxicity- monitor renal function
What happens to MCV and Hb in:Iron deficient anaemiaB12 deficient anaemiaFolate deficient anaemia
Iron deficient: BOTH MCV and Hb LOWB12 deficient: MCV HIGH, Hb LOWFolate deficient: MCV HIGH, Hb LOWFor iron deficient- give ferrous sulphateB12 deficient- give hydroxycabalaminFolate deficient- give Folic acid
A patient with asthma requests to buy Feminax Ultra (Naproxen 250mg) OTC. What do you do?
Naproxen= NSAIDNSAIDs cautioned in asthma due to risk of bronchospasm.Should ask patient if they have used NSAIDs before- if yes and was okay- sell but indicate need to have blue inhaler to hand just in case. If previous bronchospasm- probably would not sell.Check they are over 15- licensed age to buy
What are bacterial throat infections caused by?
Group A beta-haemolytic streptococcus(Streptococcus pyogenes)”Strep throat”
What virus is glandular fever caused by?
Epstein Barr virus
What do strefen lozenges contain?
Flubiprofen 8.75mgNSAID used for sore throatscan only be used in over 12ymax 5 lozenges in 24 hr, fo max 3 days
A 17 year old comes into your pharmacy asking for Galcodeine linctus for an unproductive, dry cough that they have had for the last month now. What do you do?
Do not sellCodeine linctus is not allowed to be used in under 18’s according to MHRA advice- risks outweigh benefits.Also the cough has been present for 3 weeks- referral symptom!
A patient has been using Nexium OTC for some time now, with no symptom improvement. You decide to refer, how long will they have been trying Nexium for?
Over 2 weeksNexium= Esomeprazole.If symptoms do not improve after 2 weeks on a PPI then refer.
What are the side effects of omeprazole?
WhaHeadacheDiarrhoeaConstipationAbdominal pain N&V FlatulenceRemember its all the GI SEs!
What PPI’s can be bought OTC?
Omeprazole 10mg: (Zanprol) P (TT OD)Esomeprazole 20mg (Nexium) GSLPantoprazole 20mg (Pantoloc) PRabeprazole 10mg P
Omeprazole increases the concentrations of C_______ and T_______Voriconazole increases the conc of O_______Omeprazole decreases absorption and therefore activity of K______ and I________
Omeprazole increases [Cilostazol] for peripheral vascular disease and [Tacrolimus] used after transplants.Voriconazole increases the conc of OmeprazoleOmeprazole decreases the absorption of Ketoconazole and Itraconazole due to it decreasing intragastric activity (as do all PPIs)
Calcium, magnesium and alluminium containing antacids can interact with which drugs?
These antacids chelate with the following to form insoluble complexes and therefore reduce their absorption:TetracyclinesQuinolonesImidazoles (Ketoconazole)Phenytoin PenicillamineBisphosphonatesSO avoid taking antacids at the same time as these drugs!
Which dyspepsia medications are cautioned in patients with heart disease?
Antacids containing sodium (effects fluid balance)Alginates (as usually sodium alginate)
Which metal ion in antacids can cause Contipation? Which can cause diarrhoea?
Constipation- Calcium and AluminiumDiarrhoea- Magnesium
What PPI has a marked interaction with Clopidogrel?
Antiplatelet effect definitely reduced by omeprazole and esomeprazole.Possibly, but not so much by lansoprazole, pantoprazole and rabeprazole. Pantoprazole safest PPI to use or switch to a H2 antagonist.
Once Ispaghula husk sachets have been made up, what should be done?
Drink it as soon as effervescence subsides! Otherwise the drink ‘Sets’ and becomes undrinkable
What is the issue with prolonged use of lactulose in children?
Development of dental caries (teeth breakdown)
What should patients avoid taking at the same time as bisacodyl (a stimulant laxative- Dulcolax)?
Antacids and MILKBisocodyl are enteric coated, these can break down the coating and lead to dyspepsia and gastric irritation
Which laxatives work fastest? Which have intermediate? Which take longest?
Stimulants quickest- 6-12 hours (Glycerol suppositories 30 mins), but can cause diarrhoea and abdo pain.Lactulose and bulk forming take 48-72 hours for effects to be seen, bulk forming slightly faster.Softeners are the slowest- take 3 days or more
What is the safest laxative to use in pregnancy?
Fibre supplementation and BULK- forming laxatives safest. Ispaguhula husk first line.Stimulants and macrogols (osmotic) are safe but stimulants may cause diarrhoea and abdominal pains.
Why should caffeine drinks be avoided in constipation?
Caffeine can act as a diuretic and make constipation worse.Diuretics can cause constipation as they act to get rid of excess fluid- they can cause dehydration and therefore constipation.
What medications do we need to be wary of when recommending travel sickness treatments. Hint these products contain Hyoscine and antihistamines such as cinnarizine, promethazine and meclozine
These drugs have ANTI-CHOLINERGIC side-effects: be careful of other drugs that have these due to the additive effects e.g. Tricyclic Antidepressants (e.g. Amitriptyline)Butyrophenones e.g. HaloperidolPhenothiazines e.g. Chlorpromazine
Anti-travel sickness medications can cause drowsiness. What must you ask people requesting these?
Whether this will be a problem- i.e. are they going to be driving?Contain things like promethazine which is very sedating
What is gastroenteritis caused by?
Virus- the Rotavirus (especially in children)Also campylobacter in adults- bacteria- most common cause of food poisoning in the UK
Which anti-emetics should be avoided in Parkinsons disease? what is the drug of choice?
AVOID dopamine antagonists that cross the BBB as these will worsen Parkinsons- MetoclopromideProchlorperazineThese will interact with alcohol because they cross the BBB.Anti-emetic of choice- Domperidone (10-20mg TDS) as this is a dopamine antagonist that does not cross the BBB
What anti-sickness medication is available OTC? what are the brand names of these?
Prochlorperazine- Buccastem M (indicated for migraine related N and V)Bismuth- pepto bismol- settles stomach
If Nausea and Vomitting have been present for over __ hours, Motilium cannot be recommended OTC. What age is Motilium licensed in?
Motilium contains DomperidoneLicensed OTC for Nausea and Vomitting if less than 48 hours duration!Licensed for use in over 16 years
When should vomitting in children be referred?
In neonates- up to 1 month old- ReferUnder 1 year old lasting over 24 hoursProjectile vomitting in under 3 monthsFailure to respond to OTC
What is the best thing to recommended for a sore throat in pregnant women?
CANNOT have strepsils as these have a high alcohol content- manufacturer advises avoidCan have soothersOr simple linctus
What are the 3 most common bacterial organisms implicated in cystitis?
E Coli (Over 80% cases)StaphylococcusProteus
What is pyelonephritis?
A complication of cystitis- where bacteria moves from bladder up ureter into Kidney. Symptoms- fever, chills, flank pain Patient requires a 7 day course of ciprofloxacin 500mg BD.Refer if a patients cystitis symptoms have lasted over 5-7 days as they may have developed pyelonephritis.
How many days does cystitis need to be present for to warrant referral?What age groups with cystitis should we refer?
Present for over 7 days - as could have developed into pylonephritits (travelled up to kidney).Children under 16 years- refer as could indicate urethral abnormality getting it this youngWomen over 70 years- more susceptible to complications
What symptoms present with cystitis would warrant referral?
Vaginal discharge- could indicate vaginal infection (vaginitis) HeamaturiaAssociated fever/ flank pain- could indicate pyelonephritis (moved up to kidney- Upper UTI)
What does DYS meanI.e.DysphagiaDysmennorheaDyspepsiaDysuria
PAINFUL:SwallowingPeriodsDigestionUrination
Potassium Citrate containing products can be given to patients with cystitis. Who should these be avoided in (Hint: what medications?)
Anyone on:Potassium-sparing diuretics;SpironolactoneEplerenoneAmilorideACE inhibitorsRisk of hyperkaleamia!
Sodium Citrate containing products can be given to patients with cystitis. Who should these be avoided in?
Patients with hypertension (as salt increases BP)Patients with heart disease Renal impairmentPregnant women- these should be referred anyway
What is the OTC dose and counselling for use of Azithromycin (Clamelle) for treatment of confirmed asymptomatic chlamydia?
2 x 500mg tablets (1g) as a STAT dose Should be taken at least 2 hours after any food or any drink other than water (Ideally take before bed). Partner should also take this (don’t need +ve test).Licensed for over 16 yearsCommon side effects: GI upset, nausea, vomitting, abdo discomfort, visual disturbance, dizziness, headache, flatulence
What is classed as ‘Recurrent’ cystitis or Thrush?
Cystitis: 2 episodes in the last 6 monthsor 3 episodes in the last 12 monthsThrush: 2 episodes in 6 months4 episodes in 12 months These patients should be referred
Which antihistamine, licensed for motion sickness (but don’t see it used very often) may be abused?
Cyclizine It crosses the BBB and can cause hallucinatory effects
What are the side effects of EHC?
HeadacheNauseaDizziness Stomach painMentrual painNausea is the most common
Promethazine containing products can be taken for motion sickness. What condition is promethazine cautioned in?
Glaucoma
What is the organism causing the majority of thrush cases?
Candida Albicans
What two more serious conditions can vaginal thrush present similarly to?
Bacterial Vaginosis- linked to pelvic inflammatory disease, most common cause of discharge, requires antibiotics (Metronidazole)Trichomoniasis- C. trachomatis- protozoal infection: can cause infertility Dominant feature of thrush= Vulval itching, discharge
What ages should be referred with thrush?
Under 16’s (as not common in this age group)Over 60’s (less common after menopause because of hormonal changes?)
After how many days of treatment should thrush cases be referred?
after 7 days if symptoms persist
Can men be treated for thrush?
Yes- If a woman has thrush it is advised that her partner is also treated using the clotrimazole cream on his penis.
What are the treatment options OTC for thrush?
Clotrimazole cream 2% w/w for external10% w/w for internal (note these are stronger than the creams used for e.g. athletes foot and jock itch where 1% is used)Fluconazole oral 150mg STAT
Can pregnant women be treated for thrush OTC? what about diabetics? What about 18 year old girls? What about a man requesting thrush cream?
Pregnant women- refer (as OTC products not licensed and can be difficult to treat)Diabetics- Refer as thrush could indicate poor glyceamic control18 year old girl you can treat (must refer under 16’s)Man requesting cream is fine as partner may have it and men can use the clotrimazole cream on their penis or take a fluconazole STAT dose.
What strength is the Canesten pessary used for thrush?
500mg of clotrimazoleShould be inserted at night so that it doesn’t fall out in the day
When should you refer a patient seeking insomnia medication?
Chronic insomnia (lasts longer than 3 weeks)If its an adverse effect to medicationChildren under 16 yearsProstatic Hypertrophy Closed angle glaucomaThis is because antihistamines recommended for insomnia can exacerbate the symptoms of these.
What conditions can antihistamines exacerbate the symptoms of?
Closed angle glaucoma- as they can cause pupil dilation Prostatic hypertrophy- as antihistamines can increase urine frequency
What drugs are available OTC for insomnia? What classification are these?
Diphenhydramine (NYTOL)Promethazine (SOMINEX, PHENERGAN)These are both sedating antihistamines All P meds
What drugs could cause a patient to have insomnia?
Fluoxetine- this is mildly stimulatingMAOI’s: e.g. Phenelzine, Tranylcypromine, Rasageline, Selegiline CorticosteroidsPhenytoinTheophylline (FACT-P)
What are the side effects of antihistamines, especially the doses of ones used in insomnia?
Anticholinergic side effects:Dry mouthConstipationBlurred visionTINNITUS
What interactions can Nytol and Sominex have?
Sleep meds containing diphenhydramine and promethazine antihistamines:TCA’s: antimuscarinic and sedative effects are potentially enhanced by co-administration of antihistamines. Also MAOI’s in previous 2 weeks (long half life so stays in the body)
What are the interactions of antihistamines?
TCA’s: antimuscarinic and sedative effects are potentially enhanced by co-administration of antihistamines. Also MAOI’s in previous 2 weeks (long half life so stays in the body)Co-administration of antifungal imidazoles (eg, ketoconazole, itraconazole) and macrolide antibiotics (eg, erythromycin, clarithromycin) is to be avoided: these drugs raise the plasma concentration of second-generation antihistamines (loratadine, ceterizine- newer, non sedating)
What are the first generation and second generation antihistamines??
First generation: Older, sedating onesDiphenhydramine Promethazine Second generation: newer less sedatingLoratidine, Ceterizine
OTC sleep medication should not be used long term. When is a it recommended that they see their doctor?
If they are still struggling after 2 weeks of using OTC meds.Over 3 weeks of no sleep is classed as chronic insomnia.
What is the difference between Nits and Lice?
Lice are the actual living thingsNits are the empty egg shell that stick to hairPresence of Nits does not necessarily mean lice infestation. A live lice needs to be seen for OTC treatment to commence.
Insecticides and Dimeticone are available OTC to treat head lice. Can you name some insecticides? What is the difference?
Insecticides: Permethrin (LYCLEAR), Malathion (DERBAC M). This kills both lice and eggs off.Apply for 10 minutes. Most people cured after single application- but can be re-applied after 7 days if needed. Dimeticone (HEDRIN) traps and suffocates lice but may not kill eggs. Apply for 8 hours and definitely re-apply after 7 days, as it is less effective than Lyclear.
Which product (LYCLEAR OR HEDRIN) is preferred in headline treatment?
Lyclear (Permethrin)Only needs to be applied for 10 mins (8 hours for hedrin- dimeticone).Usually effective in one dose (Hedrin have to repeat in 7 days)Safe in asthmatics But Hedrin- can use in pregnancy
What is the licensing (age, pregnancy) for Lyclear (permethrin) and Hedrin (Dimeticone)?
Both for over 6 months oldHedrin possibly safer in pregnancyLyclear definitely safe in asthma
Which headlice treatment is preferred in asthma?
LyclearHedrin is not safe in asthma. Is is alcohol based. Contains dimeticone
How should rivaroxiban be taken?
With foodFood massively affects it’s absorption
A patient on a statin is started on fusidic acid tablets for a staphylococcal skin infection. What do you recommend?
Fusidic acid increases the concentration of statins significantly, increasing the risk of myopathy and rhabdomylosis. It is recommended that the statin is withheld during treatment and for 7 days after the last dose of fusidic acid due to the long half life.
A doctor wants to start a macrolide in a patient with pneumonia. The patient is also taking atorvastatin 80mg. What do you advise?
Withold the statin through the 7 day treatment course, as the macrolide (e.g. erythromycin, clarithromycin) will interact and increase statin levels, increasing risk of myopathy and rhabdomylosis.
What does one cycle of CPR involve?
30 chest compressions followed by 2 rescue breaths.
How do you respond to a choking child?
Give up to 5 back blows followed by 5 abdominal thrusts. If this does not work then call 999.
What drugs are used in the management of hypotension?
Noradrenaline/ norepinephrine (vasoconstrictor)Phenylephrine Dopamine (Sympathomimetic ionotrope that increases cardiac output)
What may turn your stools black?
Iron containing products- e.g. ferrous sulphatePepto Bismol
What are patients on Hydroxychloroquine (used for Rhumatoid arthritis and lupus erythematosus) advised to report?
Any problems with vision e.g. blurred as it can cause Ocular Toxicity and this is screened for.
Which painkiller has a risk of overdosing an infant if used in breast-feeding women due to a maternal variation in capacity to metabolise?
Codeine
How can desmopressin (a hormone, used for urinary incontinence) effect electrolytes?
Can cause Hyponatreamia
What is nystagmus?
Involuntary movement of eyelidsstimulants may cause this
What diuretics for treating oedema would be less appropriate in someone with CKD?
Potassium sparing diuretics, e.g. Amiloride and Triamterene.This is because there is a high risk of hyperkalaemia in renal impairment.
What electrolyte disturbance do ACE inhibitors cause?
HYPERKALEAMIA!
If a pregnant woman is going abroad to an area renowned for malaria, what preventative measures are there for her?
Proguanil can be given in the usual doses during pregnancy as benefit of prophylaxis in malaria outweighs risk. I.e. not 100% safe in pregnancy but not contra-indicated as would be safer to give than risk her getting malaria. Ensure the mother has adequate folate supplements!
Tetracyclines should NOT be given to patients under the age of?
12 years oldDoxycycline is a tetracycline!
What is Desferrioxamine mesilate (Deferoxamine) used for?
Deferoxamine is a chelating agent, used to remove excess iron from the body
What has long term use of Tetracycline antibiotics (e.g. Doxycycline, Oxytetracycline, Tetracycline, Minocycline) Been associated with?
Tetracyclines have been associated with discoloration of growing bones and teeth. Minocycline: Pigmentation of various body sites including skin, nails, bone, mouth and eyes
What does the black upside down triangle mean in the BNF?
New to the market or used for a new indicationHighlights need to report any ADRsGenerally stays with the drug for 5 years
What is first line treatment for women with threadworm that are pregnant?
strict hygiene measures for six weeks (e.g. cut finger nails and launder bedding and towels on a daily basis).Not enough safety info on Mebendazole (antielmintics), manufacturer states avoid, however if hygeine measures don’t work, could consider it.
Which antisecretory and mucosal protectant drugs is a potent uterine stimulant?
Misoprostol
What bacteria cause impetigo?
Staphylococcus aureus or Streptococcus pyogenes
What two vitamins are lacking in megoblastic aneamias, and therefore what are there treatments?
Folate - Treat with folic acid 5mg daily for 4 monthsVitamin B12- treat with Hydroxocobalamin- given by IM injection Most megoblastic aneamias result from a lack of either one of these. Establish the cause asap, if not possible can treat with both.
What does aminophylline (used in asthma) do to Lithium?
It increases Lithiums excretion
Daktocort cream and ointment vary slightly in their storage instructions. What are these?
Daktocort cream: store in a fridge (2-8 degrees) Daktocort ointment: store below 25 degrees (kept at room temp)
Once Oramorph® concentrated 20 mg/mL solution has been opened, what is the expiry date?
4 months
Co-amoxiclav oral suspension (reconstituted)- how long is the expiry?
7 days
Systane eyedrops are lubricant eye drop containing propylene glycol, used for relief of burning/ irritation from dry eyes. What is their expiry?
Discard any remaining solution 6 months after first opening
If a doctor requests Rifaximin (antibiotic for travellers’ diarrhoea) as an emergency supply, whats the number of days you will provide?
3 days (as it is a 3 day course)An orally administered antibiotic could be given in the smallest quantity that will provide a full course of treatment
What class of antibiotics are commonly used in treatment of acne?
The tetracyclines (Doxycycline, Lymecycline, Minocycline, Oxtetracycline, Tetracycline)
What B vitamin is Thiamine?
B1
What B vitamin is hydroxycabalmin (used in anaemia)
B12
What B vitamin is Pyridoxine?
Vitamin B6Note: pyridoxine is used in isoniazid induced neuropathy- isoniazid is one of the drugs used in TB (part of RIPE) so often used in TB patients. Don’t get confused with Pyrazinamide (bactericidal drug used in TB treatment, the P in RIPE)
This antipsychotic drug is cautioned in aggressive patients as even low doses may aggravate symptoms of aggression
Sulpiride
What are the trigger factors for GORD?
Drugs which cause lower oesophageal sphincter relaxation (e.g. calcium channel blockers and theophylline)smokingalcohol obesity.
What drugs seen in epilepsy can induce their own metabolism?
Phenobarbitone will induce the metabolism of itselfAs will carbamazepine
Counselling points for GTN tablets?
If the patient experiences chest pain, they should take a tablet immediately by putting it under the tongueThe tablets should preferably be taken sitting down The tablets should not be transferred to another container Facial flushing may occur after taking the tablets
What is Melaena?
Black tarry stoolsWould be a red flag symptomPatients on etrapenem (carbapenem antibiotic) may experience this side effect
What is Hyperaesthesia?
Excessive skin sensitivity to non-painful stimuli Caused by medication such as Nilotinib (chemo drug)
What is the medical term for excessive sweating?
Hyperhidrosis
Which laxative is cautioned in diabetics?
Lactulose (due to its sugar content- lactose, galactose, epilactose)
What kind of laxative is Methylcellulose?
Bulk forming laxative that also acts as a faecal softener.
which laxative can be used to prevent risk of hepatic encephalopathy?
Lactulose
What is ecchymosis?
BruisingSE of warfarin
Azathrioprine is a drug that requires reporting of blood disorder symptoms, what is this drug?
An immunosuppressant Used in chrons, RA, transplant rejection, severe eczemaNeed to look out for bone marrow suppression symptoms of bruising, bleeding or infection
What is Hypertrichosis?
an increase in hair growth
What effect can lactulose have on warfarin?
Can enhance the anticoagulant effects
A patient taking ergotamine for treatment of her migraines. She says to you shes lost feeling in her fingers since starting it. What could this mean?
Numbness or tingling of the extremities in patients taking ergotamine may be a result of peripheral vasospasm.
Which of the NOAC’s interacts with the rate limiting CCB Verapamil?
DABIGATRANVerapamil may increase the plasma concentration of dabigatranDose reduction of Dabigatran therefore required
What CCB can cause gum hyperplasia (enlargement of gums)?
Nifedipine
Which insulin can be used as an alternative to the classic soluble insulin in the cases of diabetic emergencies?
Insulin Aspart
What is bradycardia and what is tachycardia?
Bradycardia= slow heart rate, below normal resting rateTachycardia= fast heart rate, above normal resting rate
What is misoprostol used for?
Used for gastric ulcers caused by NSAIDSAlso used to terminate pregnancy (aborting agent) as it is a potent uterine stimulant
Simvastatin taken with the Fibrate drugs can cause increased risk of Rhabdomyolisis. Which fibrate is absolutely contra-indicated with Simvastatin?
Gemfibrozil- do not use with a statinBezafibrate- max dose of simvastatin= 10mg
How should GTN tablets be dispensed for patients?
Dispense in the manufacturers original pack and endorse accordingly.This is because the drug is hygroscopic (will absorb moisture from the air) and the manufacturers original packaging consists of a amber glass bottle with screw caps lined with aluminium foil. Do not remove from this- only dispense OP’s, cannot be broken down. Do not put any cotton wool or wadding in bottle! Only foil as a cushioning material. If it is absolutely necessary to break it down: dispense in amber glass containers with screw caps lined with aluminium foil, filled with aluminium foil as a cushioning material.The tablets have an 8 week expiry after pack is opened.
How long is the expiry date once GTN tablets are opened?
8 weeks.As GTN tablets are hygroscopic and will absorb moisture, therefore after 8 weeks they are not to be used.
How should NICORANDIL (potassium channel opener used in Myocardial ischaemia) be dispensed?
Keep in original package in order to protect from moisture- it is hygroscopic! Special blister pack with a sieve desiccant to absorb moisture- do not remove from this.
Nicorandil is a medication that needs to be stored in its original blister pack to avoid moisture. After opening, how many days expiry does it have?
Each blister strip should be used within 30 days of opening.
Does a woman aged 50 presenting a prescription for HRT have to pay?
YesOnly hormonal preparations for contraceptive purposes are exempt from this charge, if she was over 60 however she would not have to pay!
What is chloroform water actually used for when added to formulations?
It is an anti-bacterialVery unpleasant stuff- no bacteria will grow
Why is Colestyramine contra-indicated in complete biliary obstruction?
Because its mechanism is to bind to bile acids and prevent their re-absorption to promote conversion of cholesterol into bile acids and therefore clear LDL cholesterol (used in Hyperlipidaemias). So it would not be effective if the bile ducts were blocked.
First line for hypertension in pregnancy?
Labetolol Then methyldopa or nifedipine (unlicensed) can be used second line
How often is bowel cancer screening?
every 2 years
What is the difference between:Hyoscine butylbromideANDHyoscine hydrobromide
Butylbromide = less sedating (buscopan: IBS)Hydrobromide = more sedating (travel sickness/EOL: quells/ampules)
What do you think this patient is being treated for, Rx:- insulin (novorapid)- dextrose- salbutamol 5mg Nebules QDS
Hyperkalaemia
In which situations might you need to give oral potassium?
- Taking digoxin - don’t want hypokalaemia2. Secondary hyperaldosterosim 3. To replace GI losses e.g. chronic diarrhoea
Treatment: Potassium over 6.5 mmol/L (severe hyperkalaemia)
- Calcium Gluconate 10%2. Insulin & glucose3. Salbutamol (nebs/IV)
Treatment: Potassium mild (5.5-5.9 mmol/L) & moderate (6.0-6.4 mmol/L)
Callcium polystyrene sulfonate resin (Calcium Resonium®) with regular Lactulose
Treatment: Hypokalaemia (<3.0mmol/L)
Oral or IV supplementation with potassium chloride
At least how many times its volume must potassium chloride be diluted and mixed well?
50 times
For peripheral infusions, what concentration should potassium chloride not exceed?
40mmol/L
Max rate
20mmol/hr
Name the enzyme inhibitors (SICKFACES.COM)
Sodium valproateIsoniazid / itraconazoleCimetidineKetoconazoleFluconazole / fluoxetineAlcohol (acute, binge) / AmiodaroneChloramphenicolErythromycin + clarithromycinSulphonamides (co-trimoxazole)CiprofloxacinOmeprazoleMetronidazoleAlso:Grapefruit juice
Name the enzyme inducers (SCRAP GPSS)
SulphonylureasCarbamazepineRifampicinAlcohol (chronic)PhenytoinGriseofulvinPhenobarbitalSt John’s WortSmoking
What are the main interactions with amiodarone?
- Amiodarone inhibits warfarin metabolism- enhanced anticoagulant effect2. Increased risk of bradycardia, AV block, myocardial depression with beta blockers 3. Risk of ventricular arrhythmias with lithium4. Plasma concentration of digoxin increased by amiodaroneAmiodarone has a very long half life so there is potential for drug interactions to occur weeks/months after stopping treatment
What are the common interactions with digoxin?
- Plasma conc of digoxin increased by amiodarone (enzyme inhibitor)2. Plasma conc of digoxin increased by erythromycin (enzyme inhibitor)3.. Plasma conc of digoxin reduced by rifampicin (enzyme inducer)4. Plasma conc of digoxin reduced by St John’s Worst (enzyme inducer)5. Increased toxicity of digoxin if hypokalaemia occurs with loop and thiazide diuretics6. Plasma conc of digoxin increased by CCBs
What are the common interactions with lithium?
- Risk of lithium toxicity with ACEi (excretion reduced)2. Risk of lithium toxicity with NSAIDs (excretion reduced)3. Sodium depletion with loop and thiazide diuretics (excretion of lithium reduced)4. Risk of ventricular arrhythmias with amiodarone
What are the common interactions with methotrexate?
- Increased risk of infection with vaccines2. PPIs at high doses reduce clearance of methotrexate increasing risk of toxicity3. Penicillins increases risk of methotrexate toxicity4. Trimethoprim- both folate antagonists, increased risk of side effects and nephrotoxicity
What are the common interactions with phenytoin?
- Effects of phenytoin enhanced by NSAIDs2. Amiodarone inhibits phenytoin metabolism3. Phenytoin accelerates metabolism of warfarin4. Cimeditine inhibits metabolism of phenytoin 5. Plasma conc of phenytoin increased by fluoxetine6. St John’s Wort reduces plasma conc of phenytoin7. Ciprofloxacin affects the concentration of phenytoin8. Decreases efficacy of combined contraceptive pill9. Phenytoin decreases exposure to NOACS
What are the common interactions with theophylline?
- Increased risk of convulsions with quinolones e.g. ciprofloxacin2. Plasma conc of theophylline reduced by St John’s Wort3. Plasma conc of theophylline reduced by rifampicin4. Plasma conc of theophylline increased by cimetidine5. Plasma conc of theophylline increased by fluconazole6. Smoking can increase theophylline clearance and increased doses of theophylline are therefore required
What are the common interactions with warfarin?
- Anticoagulant effect increased by NSAIDs2. Anticoagulant effect increased by fluconazole3. Anticoagulant effect increased by statins4. Anticoagulant effect increased by ciprofloxacin, erythromycin, metronidazole5. Anticoagulant effect reduced by griseofulvin6. Anticoagulant effect reduced by antiepileptics7. Alcohol effects anticoagulant control8. Anticoagulant effect antagonised by Vitamin K 9. Anticoagulant effect enhanced by cranberry juice
What is the risk of consuming tyramine based food and drink e.g. cheese if on MAOIs?
Hypertensive crisis
How does alcohol interact with TCAs and mirtazapine?
Increased sedative effect
What are the main interactions with combined oral contraceptives?
- Enzyme inducing drugs increase metabolism of contraceptives. Additional contraceptive precautions should be taken for 4-8 weeks after stopping treatment - Some ABX may reduce efficacy of the pill by impairing bacterial flora responsible for recycling ethinylestradiol e.g. ampicillin, amoxicillin, doxycycline. Additional precautions are required for duration of treatment and for 7 days after stopping
What are the main interactions with progesterone only contraceptives?
Efficacy reduced by enzyme inducers Additional protection is needed for duration of treatment and 4 weeks after
What are the main interactions with sympathomimetics e.g. pseudoephedrine?
NAME?
What are the main interactions with Orlistat?
NAME?
What is a pharmacokinetic interaction?
These occur when one drug alters the absorption, distribution, metabolism, orexcretion of another drug, thus increasing or reducing the amount of drug availableto produce its pharmacological effects.
What is a pharmacodynamic interaction?
This is where effects of one drug are changed by the presence of another drug at itspharmacological site of action.e.g. electrolyte imbalance, combined toxicity, antagonising effects
What PPI does clopidogrel interact with and what would be an alternative?
Omeprazole and esomeprazoleLansoprazole would be an alternative
What drug can cause blue vision and which drug can cause yellow vision in overdose
Blue vision can be cause by slidenafil and yellow vision is a sign of digoxin toxicity alongside nausea and vomiting
Which SGLT is not licensed to be used with pioglitazone for triple therapy
Dapagflozin
What is drug interaction?
the modifications of effects of one drug by another drug (poly-pharmacy)
What is drug interaction? Pharmacodynamics (PD)
(“what the drug does to the body”)related to the pharmacological activity of the interacting drugs leading to either:synergistic effect, 1+1 > 2or antagonistic effect, 1+1 < 2
What is drug interaction? Pharmacokinetic (PK)
(“what the body does to the drug”)related to the effect of a drug on another on physical disposition of the drug, i.e. movement of drug thru the bodyabsorptiondistributionmetabolismelimination
Effects of drug interactionIncreased effect: Additive or Synergisticeffect
BAD - Increased toxic effectGOOD - Increased therapeutic effectto produce synergistic therapeutic effectse.g. several antibiotic combinationsPenicillin-Streptomycin
PD interactions arise when one drug changes the response of target or non-target tissues to another drug:• Synergism
– Penicillin-Streptomycin– Digoxin toxicity with diuretic induced potassium wasting
PD interactions arise when one drug changes the response of target or non-target tissues to another drug:• Antagonism
– Beta adrenoceptor antagonist diminish the effectiveness of b-adrenoceptor agonists such as salbutamol– Antidote: agents with a specific action against the activity or effect of drugs involved in poisoning cases
PK absorption eg. Altered pH; The non-ionized form of a drug is more lipid soluble and more readily absorbed from GIT than theionized form does.-Ex1., antacids (aluminum or magnesiumhydroxide) Increase the pH and Reduce absorption of acidic drugs
digoxin (heart conditions),phenytoin (epilepsy),chlorpromazine (schizophrenia)isoniazid (tuberculosis)Therefore, these drugs must be separated by at least 2h in the time of administration of both.
PK absorption eg H2 antagonists increase the pH and Reduce absorption of acidic drugs:
digoxin (heart conditions),phenytoin (epilepsy),chlorpromazine (schizophrenia)isoniazid (tuberculosis)Therefore, these drugs must be separated by at least 2h in the time of administration of both.
Altered motility: Atropine (non-selective muscarinic blocker) Increase absorption of cyclosporine due to the increase of stomach emptying time and Increase the toxicity of cyclosporineexample of - PD - PK absorption- PK excretion- PK metabolism- PK distribution
PK absorption
Chelation - Iron may chelate ciprofloxacin, resulting in decreased absorptionexample of - PD - PK absorption- PK excretion- PK metabolism- PK distribution
PK absorption
PK interactions (2): Distribution
• Drugs in bloodstream often bound to plasma proteins;• Only unbound drugs can leave blood to affect target organs;• Low albumin levels can increase availability of drugs and potentiate their effects;• Competitive: drugs with higher affinity to albumin are capable to displace others, leading to increase concentration of freedrug (therefore yield more drug response):Phenytoin (90%)Tolbutamide (96%)Warfarin (99%) –>AspirinSulfonamidesPhenylbutazone
PK interaction (3):Metabolism
the most drug-drug interactions are metabolism based (diagram)Phase I metabolism: involves oxidative metabolism via the Cytochrome P450 (CYP) family of enzymes
Enzymatic induction
Inducer: Drug that will increase the synthesis of CYP450 enzymese.g. barbiturates, bzd, hydantoin antiepileptics, glucocorticoids, rifampicin, griseofulvin, St. John´s wort, smoking, grilled meat, chronic alcoholintake – increaseSCRAP GPSS-Decrease the effect of several drugs, e.g.cardiotonics, steroid hormones, coumarinanticoagulantsN.B enzyme induction involves protein synthesis. Therefore, it needs time up to 3 weeks to reach a maximal effect
Enzymatic inhibition
SICKFACES.COMInhibitor: Drug that will decrease the metabolism of a substratee.g. some macrolides, quinolones, sulfonamides, some antimycotics (e.g. ketoconazole, fluconazole), isoniazid, metronidazole, chloramphenicol,amiodarone, verapamil, diltiazem, quinidine, SSRI, proton pump inhibitors, cimetidine, garlic, ginkgo, grapefruit juice-Increase the effect of several drugsInhibition of the enzyme may be due to the competition on its binding sites , so the onset of action is short may be within 24h.
When an enzyme inducer (e.g.carbamazepine) is administered with an inhibitor (verapamil) -> the effect of the __________ will be predominant
inhibitor
Omeprazole Inhibits oxidative metabolism of A. aspirinB. diazepamC. sertralineD. clarithromycin
B. diazepamOmeprazole has actual adverse influences on the pharmacokinetics of medications such as diazepam, carbamazepine, clozapine, indinavir, methotrexate, tacrolimus, mycophenolate mofetil, clopidogrel, digoxin, itraconazole, posaconazole, and oral iron supplementation.
PK interaction (4): Excretion
Drugs are eliminated from the body as an unchanged drug or metabolite– Renal excretion is the major route ofelimination;– affected by renal function and urinary pH
Drug-Foodinteractions
Tetracycline interacts with Milk (Ca2+ ) -> Unabsorpable complexWarfarin (diagram)Vitamin K-containing foods
Drug-Disease interactions
HEART : b1 adrenergic receptors - Heart rate & ContractilitySMOOTH MUSCLE -airway & vasculature:b2 adrenergic receptors -> Relaxation & dilationDrug ADR: homologous targets•Non-selective b antagonists, e.g. Propranolol, are contraindicated in patients with asthma
Drug-Disease interactions:Contraindications of atropine
1- Patients with angle closure glaucoma2- Patients with shallow anterior chamber3- Senile hyperplasia of the prostate4- Patients with gastric ulcer(increase symptoms due to slowing gastric emptying)
Changes in absorptionAlteration -GI motility
Alteration/ actionGI motility - Increased GI motility caused by metoclopramide may decrease cefprozil absorption (2nd gen cephalosporin)
GI alkalinization by omeprazole may decrease absorption of A. amantadineB. dapsoneC. metronidazoleD. ketoconazole
D. ketoconazolechanges in absorption PK
GI flora - Decreased GI bacterial flora caused by an antibiotic admin could decrease bacterial production of vitamin K augmenting anticoagulant effect of
warfarin
Changes in absorptionAlteration -Drug metabolism in wall of intestine
Drug metabolism in wall of intestine -certain antidepressants is that phenylephrine could potentiate a spike in blood pressure; TCAs and MAOIMAO acts to break down neurotransmitters like norepinephrine (and dopamine and serotonin); thus, MAOIs act to increase the amount of these chemicals in our synapses. Monoamine oxidases (MAO) are in the wall of GI tract. NE = main neurotransmitter of SNS and works to immediately increase our BP. Thus, a sympathomimetic like phenylephrine + MAOI, which is also stimulating the sympathetic system, has the potential to elevate BP into a hypertensive crisis.
Incidentally, MOA is involved in other body processes including the breakdown of tyramine, an amino acid involved in BP regulation. Tyramine helps release more NE. Thus, to prevent hypertensive crises, patients who take MAOIs should stay away from..
foods rich in tyramine like strong/aged cheeses, cured meats, yeasts, beers and dried fruits.
Phase II metabolism
conjugates the previously oxidized molecule with a water soluble weak acid (glucouronic acid, tauric acid, etc) enhancing overall water solubility
How to do drug-drug interactions occur
Drug-drug interaction always due to interaction at phase I enzymes (i.e. cytochrome P450)
Passive tubular reabsorption example
Sodium bicarbonate. Increases lithium clearance and decreases its actionAntacids Increases salicylates clearance and decreases its action
What happens when pH increases
Ionisation doesn’t occur as it only occurs at acidic pH
PK interactions: Absorptiona)b)c)d)
a) altered pHb) altered motilityc) altered intestinal bacteria florad) chelation
which drugs have strong affinity to protein binding
Phenytoin (90%)Tolbutamide (96%)Warfarin (99%)
which drugs have weak affinity
AspirinSufonamidesPhenylbutazone
Non selective antimuscarinic drugs should never be used to
Non selective antimuscarinic drugs should never be used to treat acid-peptic disease.
Active tubular secretion
NAME?
Passive tubular reabsorption
NAME?
Pharmacokinetic drug interactions
• Changes in GI absorption• Displacement from plasma protein binding• P450 Mediated– Enzyme inhibition– Enzyme induction• Decreased renal elimination
Drug-Herb interactions
• St John’s Worte.g. cyclosporin• Ginkgo biloba• Kava• Garlic
Clinically significant to pharmacist perspective for interactions – what to look for
- Vulnerable patient groups– Elderly– Multiple drug therapies (poly-pharmacy)– Renal or hepatic impairment– Chronic or serious illness2. Particular groups of drugs:• Narrow therapeutic index• Enzyme inducers• Enzyme inhibitors
Sirolimus & grapefruit juice
Plasma concentration of sirolimus increases by grapefruit juice
Clozapine & cytotoxics
Avoid use of cytotoxics with clozapine due to possible increased risk of ventricular arrhythmias
Theophylline & phenobarbital
Metabolism of theophylline accelerated by phenobarbital
Tetracyclines & zinc
Absorption of tetracyclines possibly reduced by zinc (give atleast 2-3 hours apart)
Lithium & metronidazole
Increased risk of lithium toxicity when given with metronidazoleSICKFACES.COM
Narrow therapeutic index
digoxin, theophylline, warfarin, ciclosporin, phenytoin, carbamazepine
Enzyme inducers out of the following:A. CarbamazepineB. CiprofloxacinC. WarfarinD. AmiodaroneE. KetoconazoleF. PhenytoinG. DiltiazemH. Rifampicin
carbamazepinephenytoinrifampicin
Enzyme inhibitors out of the following:A. AmiodaroneB. CiprofloxacinC. St Johns WortD. VerapamilE. FluoxetineF. OmeprazoleG. KetoconazoleH. Diltiazem
amiodarone, ciprofloxacin, diltiazem, fluoxetine, verapamil, ketoconazole
Phenytoin and Amiodarone
Amiodarone increases phenytoin concentrationNB: Amiodarone is an enzyme inhibitor.Due to amiodarones long half life: potential for interaction several months after discontinuation
Phenytoin and Warfarin
Phenytoin (p450 enzyme INDUCER) induces warfarins metabolism, decreases warfarin concentration, reduced anti-coagulation effect, decreases INR
Phenytoin and COC
Phenytoin (a p450 enzyme inducer) accelerates metabolism of Oestrogens, reducing their effectivenessPatient should be changed to an IUD
Phenytoin and Fluoxetine
Fluoxetine increases phenytoin concentration
Phenytoin and Theophylline
Theophylline decreases phenytoin concentration
Phenytoin and St Johns Wort
St Johns Wort decreases phenytoin concentration(St Johns Wort is an enzyme inducer)
Phenytoin and Fluconazole
Fluconazole increases phenytoin concentration (Fluconazole enzyme inhibitor part of SICKFACES)
Phenytoin and Cimetidine
Cimetidine increases phenytoin concentration (Cimetidine enzyme inhibitor part of SICKFACES)
Phenytoin and Diltiazem
Diltiazem increases phenytoin levels, and diltiazems own effects are decreased by phenytoin
Phenytoin and Rate limiting CCB’s
Phenytoin decreases effects of Verapamil and Diltiazem and also Felodipine
Amiodarone and Grapefruit Juice
Grapefruit Juice increases levels of AmiodaroneGrapefruit Juice is an enzyme inhibitor
Amiodarone and warfarin
Amiodarone increases warfarin levelsEnhances anti-coagulant effects, increased bleed riskAmiodarone is an inhibitor of some of the CYP450 enzymes.
Amiodarone and Simvastatin
Increased risk of MyopathyMax dose of Simvastatin: 20mgThis is not the same with Atorvastatin etc but still monitor for mypopathy
Amiodarone and beta blockers and Rate-limiting CCB’s diltiazem and verapamil
Increased risk ofBradycardiaMyocardial depressionAV blockWhen given with beta blockers/ rate limiting CCB
Amiodarone and Lithium
Increased risk of Ventricular Arrhythmias(poss associated with QT prolongation)Also both effect THYROID function
Theophylline + enzyme inhibitors:Cimetidine, Fluconazole, Ketoconazole, Ciprofloxcin, Erythromycin
Theophylline levels increased as it is metabolised by the CYP450 enzymes
Theophylline + enzyme Inducers:Carbamazepine, Alcohol, Phenobarbital, Phenytoin, Rifampicin, St Johns Wort(SCRAP GP’s)
Theophylline levels decreased
Theophylline and Quinolone antibiotics e.g. Ciprofloxaxin, Levofloxacin
Increased risk of SEIZURESThese BOTH lower seizure threshold
What do diltiazem and Verapamil (rate limiting CCBs) do to Theophyllines concentration?
Increase itthese are CYP3A4 enzyme inhibitors!
NSAIDs and warfarin/ phenindione
NSAIDs increase warfarin levels- increased anticoagulant effectNSAIDs, like warfarin, have a high affinty for Albumin. They displace warfarin off the protein= more free warfarinSo remember the interaction is not because both drugs can increase bleed risk- NSAIDs actually increase the levels of warfarin
SSRI’s and TCA’s and warfarin
SSRI’s and TCA’s will increase warfarin levels- increased anticoagulant effect
Statins and warfarin
Only statin that interacts: RosuvastatinIncreased effects of warfarin
Clopidogrel and warfarin
Anti-coagulant effect enhance (both thin blood)- increased risk of bleeds
Orlistat + Antiepileptics
Possible increased risk of convulsions- orlistat lowers seizure threshold
Methotrexate and Phenytoin
Do not use together- both deplete Folate
Methotrexate and Trimethoprim/ Co-trimoxazole (trimethoprim + Sulfamethoxazole)
Do not use together- both deplete folate- haematological blood toxicity riskSulfamethoxazole also increases methotrexate toxicity
Methotrexate and Ibuprofen
Methotrexate toxicity increased by NSAIDs due to decreased renal excretion
Methotrexate and Flucloxacillin
Methotrexate toxicity increased by all penicillins due to decreased renal excretion
Methotrexate and Clozapine
Neutropenia risk increased
PPI’s and Methotrexate
Increased risk of Methotrexate toxcity as excretion decreased
ALOT of antibiotics interact with Methotrexate. Can you think of any?
Trimethoprim/ co-trimoxazole (folate depletion)The following increase methotrexate toxicity:CiprfloxacinDoxycyclineTetracyclineSulfonamide (Sulfamethoxazole)
If in doubt, whats that ONE DRUG that seems to have interactions with everything?!
CICLOSPORIN(an immunosuppressant)
Which OTC medication can possibly interact with ANTI-EPILEPTICS and increase the risk of CONVULSIONS?
ORLISTAT (Alli)
Carbamazepine is an enzyme inducer, but is itself metabolised by the CYP450 system. Which other enzyme inducers may reduce the concentration of carbamazepine?
Phenytoin (May also reduce phenytoins conc)RifabutinSt Johns Wort
What drugs, used in hypertension, can increase the risk of Myopathy?
DiltiazemVerapamilAmlodipineRanolazineMAX SIMVASTATIN DOSE= 20mg for all of these!!
Drugs interacting with Gentamicin/ Vancomycin?
NEPHROTOXIC DRUGS:Ciclosporin (immunosuppressant)Tacrolimus (immunosuppressant)CephalosporinsOTOTOXICITY:Loop diuretics (furosemide)
What kind of OTC products should patients with high BP avoid?
SOLUBLE preparations e.g. effervescentDue to high SODIUM content
Spironolactone + ACEi/ARB
Potassium sparing diuretic given with postassium elevating drugs: HYPERKALEAMIA
Spironolactone + Tacrolimus
Potassium sparing diuretic given with postassium elevating drug Tacrolimus: Hyperkaleamia
Furosemide + Vancomycin
Increased risk of Ototoxicity
Digoxin + Diuretics
Diuretics (thiazides and loops) can cause HypokaleamiaDigoxin toxicity is precipitated by low potassium!!Give potassium sparing diuretics/ potassium chloride to manage
Eplerenone (potassium sparing diuretic) is metabolised by the CYP450 enzyme system
Its concentration is increased by clarithromycin and itraconazole onlyIts concentration is reduced by all the enzyme inducers
What drugs may cause hypoglyceamia and therefore reduce the amount of insulin a patient needs?
ACE inhibitors!Other oral antidiabetics
NSAID + quinolone (ciprofloxacin, Levofloxacin)
Possible increased risk of seizures
NSAID + Diuretics
Increased risk of nephrotoxicityNSAIDs will also antagonise the diuretic effects: Fluid retention! Can cause ankle swelling and high blood pressure with chronic use
NSAIDs + anti-hypertensives (beta-blockers, CCB’s, ACE inhibitors, alpha-blockers [tamsulosin, doxazosin] nitrates)
NSAIDs themselves can cause high BPThey antagonise the hypotensive effects of these drugs
Which opioid can enhance the anticoagulant effect of coumarins (warfarin)
Tramadol
Which antibiotic can reduce the effectiveness of most of the opioids, including fentanyl, morphine, codeine, methadone?
RIFAMPICIN!! (enzyme inducer)
Opioids can reduce BP (hypotensive)Their hypotensive and sedative effects are increased by alcohol. What happens if given with MAOIs?
Possible CNS excitation or depressionHypotension or hypertension can occur(remember MAOIs can cause hypotensive crisis)
Clopidogrel + enzyme inhibitors
Some of the enzyme inhibitors (erythromycin, cimetidine, ciprofloxacin, fluconazole, ketoconazole) actually REDUCE clopidogrels antiplatelet effect!- dont get confused in exam!
Clopidogrel + PPI’s
Antiplatelet effect REDUCED by omeprazole and esomeprazolePantoprazole safest PPI to use, or H2 antagonist
Sotalol + loop or thiazide diuretics
risk of ventricular arrhythmias caused by sotolol is increased by diuretics due to their hypokaleamia effect
Lithium + ACE inhibitors
ACE inhibitors will decrease the excretion of lithium!(Nothing to do with electrolyte disturbance)
Lithium + Beta blockers
No interaction!
Lithium + Aminophylline/ Theophylline
These will increase the excretion of lithium, reducing its levels
NSAIDs + Lithium
Excretion of lithium reduced by NSAIDs so increased risk of Lithium Toxicity!
Lithium + SSRIs
Increased risk of CNS effects, lithium toxicity(think SSRI’s cause hyponatreamia- sodium levels effect lithium)
Methotrexate and Aspirin
Methotrexate toxicity increasedAs Aspirin and NSAIDs decrease methotrexate excretion
Doxycycline + Isotretinoin
Severe headache/ visual disturbance due to cranial (brain) hypertension
Atorvastatin and clarithromycin
increased risk of myopathy
Co-trimoxazole + Spironolactone
Increased risk of hyperkaleamia
Metronidazole + Mebendazole
severe skin reaction
Baclofen + ACE inhibitors
Baclofen enhances hypotensive effect
Baclofen + beta blockers
Baclofen enhances hypotensive effect
Alpha blockers (sildenafil) + nitrates (isosorbide mononitrate)
Enhanced hypotension effects
HB, a 76-year old, 40 kg patient wishes to purchase the following herbal products. Which would you NOT sell based on the following patient record information? Current medications: Warfarin (Coumadin) 2.5mg daily x 2 years. Donepezil (Aricept) 5 mg daily x 2 months I-Ginkgo biloba II-Evening primrose oil III-Vitamin B complexa. I onlyb.III only side effectsc.II and IIId.All of these optionse.I and II
A gingko biloba risk of bleeding
A child has ingested an unknown substance and has evidence of respiratory depression. This symptom is usually found with poisoning due to:a.Amphetaminesb.Atropinec.Mushroomsd.Kerosenee.Opioids
The correct answer is e.The main toxic side effect of opioids is respiratory depression.
Joan Linscombe approaches you confidentially stating that she has a problem, every month for the last 5 months and has tried Miconazole and Clotrimazole ovules, 3 day therapy as per her prescribers guidance. Both were effective, but the problem recurs frequently. This time her symptoms include frequent urination and thirst. She had her menstrual period ten days ago, but it is unpredictable. She has not been to her doctor for almost a year. Based on this information, you would be MOST concerned that she could be which of the following options?a.Using the incorrect product. Recurrent infections respond better to 6-day therapyb.Overusing non-prescription antifungals and the subsequent bacterial overgrowth is contributing to her recurrent bacterial infectionsc.Diabetic and the sugar spilling into her urine may be causing the recurrent yeast infectionsd.Undergoing pre-menopausal symptoms and the fluctuation in vaginal pH is contributing to her recurrent yeast infectionse.Diabetic, but the yeast infections could not be associated with the sugar in her urine
The correct answer is c. The polydipsia and polyuria are the most worrying symptoms here, diabetics are more prone to all types of infection including those of the urinary tract. She is not overusing the antifungals as she is following her prescribers guidance which seems not to be excessive. Dependent on the services available at the pharmacy a dipstick urinalysis for pathogenic or hyperglycaemic markers could be performed, which may aid in further diagnosis by a suitably qualified healthcare professional.
A patient complains of headache and his blood pressure is 120/80. His medications include hydrochlorothiazide and hydralazine. Which of the following would seem most likely?a.The headaches are secondary to thiazide-induced hypokalemiab.The headaches are secondary to hydralazine therapyc.The headaches are probably unrelated to drug therapyd.The headaches are related to hydralazine-induced agranulocytosise.The headaches are caused by an temporary increased blood pressure
B headaches are secondary to hydralazine therapyHydralazine = vasodilator works by relaxing blood vessels. It produces a fall in peripheral resistance and a decrease in arterial BP, effects which induce reflex sympathetic cardiovascular responses. The concomitant use of a beta-blocker will reduce these reflex effects and enhance the anti-hypertensive effect. The use of hydralazine can result in sodium and fluid retention, producing oedema and reduced urinary volume. These effects can be prevented by concomitant administration of a diuretic.Se: tachycardia, palpitations, headache,
Which of the following statements is FALSE about blood drug monitoring?a.Carbamazepine often requires monitoringb.Sodium valproate often requires monitoringc.Digoxin often requires monitoringd.Drugs which have significant pharmacokinetic variability often need monitoringe.Monitoring should be performed immediately after the first dose
The correct answer is e.The main drugs which require therapeutic monitoring include those with:- narrow target rangesignificant pharmacokinetic variability- a reasonable relationship between plasma concentrations and clinical effects- established target concentration range- availability of cost-effective drug assay.
MD, a 17 year old, presents with a purpuric skin rash. She wonders if she is having another flare-up of her eczema, but this rash looks different to previous presentations. Her patient medical record reveals the following: Allergies: penicillin History: eczema x 2.5 years epilepsy x 1 month Current medications: Betamethasone Cr 0.05% bid prn x 2.5 years Ethinyl estradiol/ levonorgestrel x 10 months Phenytoin 200mg qhs x 1 month. What is the most probable cause of her skin rash?a.An acute flare-up of her eczemab.A reaction to phenytoinc.A reaction to oral contraceptivesd.An interaction between ethinyl estradiol with levonorgestrel and phenytoine.A reaction to the steroid
The correct answer is b.Phenytoin is a highly effective and widely prescribed anticonvulsant agent. Phenytoin is however, associated with both dose related side effects and hypersensitivity reactions. 5-10% of patients using phenytoin have a skin reaction.
The best definition for “Phlebotomy” is which of the following?a.The act or practice of opening a vein for letting or drawing blood as a therapeutic or diagnostic measureb.The act or practice of opening a artery for letting or drawing blood as a therapeutic or diagnostic measurec.The branch of medicine and biology concerned with immunityd.The branch of medicine and biology concerned with arthritic conditionse.The branch of medicine and biology concerned with respiratory secretions
The correct answer is a. 1. The removal of blood from a vein, usually with a needle and syringe or other container, for diagnostic or therapeutic purposes, as in the treatment of hemochomatosis. 2. The removal of blood from a vein with a cutting instrument, formerly done to reduce blood volume as a treatment of disease. In both senses also called venesection.
Which of the following is a cause of hyperkalemia?a.Acidosisb.Crush injuryc.ACE inhibitord.Hypoaldosteronisme.All of these options
The correct answer is e.Medication that interferes with urinary excretion: ACE inhibitors and angiotensin receptor blockers Potassium-sparing diuretics (e.g. amiloride and spironolactone) NSAIDs such as ibuprofen, naproxen, or celecoxib The calcineurin inhibitor immunosuppressants ciclosporin and tacrolimus The antibiotic trimethoprim The antiparasitic drug pentamidine Mineralocorticoid deficiency or resistance, such as: Addison’s disease Aldosterone deficiency Some forms of congenital adrenal hyperplasia Type IV renal tubular acidosis (resistance of renal tubules to aldosterone)
Regarding cholesterol therapy, the goal is to achieve which of the following?a.Reduce LDL and raise triglyceridesb.Reduce LDL and raise HDLc.Raise LDL and raise HDLd.Raise LDL and reduce triglyceridese.None of these options
The correct answer is b.Total cholesterol LDL (low-density lipoprotein cholesterol, also called “bad” cholesterol) HDL (high-density lipoprotein cholesterol, also called “good” cholesterol)Triglycerides (fats carried in the blood from the food we eat. Excess calories, alcohol, or sugar in the body are converted into triglycerides and stored in fat cells throughout the body.)
Mr. H is seeking advice about this wife, Mrs. H (aged 30). They have just returned from their holiday in Australia and Mrs. H is complaining of a stiff inflamed lower leg. He says it is quite red and hot. She is not taking any medication except her usual combined oral contraceptive pill, What is the most appropriate advice?a.Seek medical help immediatelyb.Sell ibuprofen 400mg and tell her to take it regularly for five daysc.Recommend that she follows the RICE approach and seek further advice if no improvement after seven daysd.Sell aspirin for DVT prophylaxise.Make an appointment to see her GP
The correct answer is a. The patient has been on a long haul flight (above 6 hours). The symptoms he is describing could be a potential DVT which requires urgent medical referral. Management of this condition if often sough from a hospital where low molecular weight heparin (LMWH) is usually given. It is an important part of a pharmacists daily job to look out for these types of “red flag” warning signs that a patients life may be in danger and then be able to sign post correctly.
Which of the following tests will give a decreased test result in patient suffering from renal failure?a.Serum Creatinineb.Blood Urea Nitrogenc.Creatinin clearanced.Urea breath Teste.All of these options
C
Which of the following medicines will increase Theophylline serum levels if combined with Theophylline?a.Carbamazepineb.Tobacco smokingc.Phenytoind.Ciprofloxacin HCle.All of these options
The correct answer is d.
Patient name: DA Age: 60 years old Gender: male Allergies: No known allergies Medical conditions: Type 2 Diabetes, Hypercholesterolemia, Occasional angina Other: Half-marathon walker, eats grapefruit Medications: Atorvastatin (Lipitor) 20 mg qhs - start 2 yrs ago Metformin (Glucophage) 500 mg TID - start 2 yrs ago Sildenafil (Viagra) 100 mg hs prn - start 2 months ago Nitroglycerin (Nitrolingual) 0.4 mg Spray 1-2 sprays sl prn -initiate-start 3 weeks ago DA requests a repeat of his sildenafil (Viagra) prescription. You would be concerned about all of the following EXCEPT:a.Atorvastatin with grapefruitb.Sildenafil with nitroglycerinc.Metformin with atorvastatind.Heart conditions and marathonse.Sildenafil with grapefruit
correct answer is c.As the patient has angina the marathon running may be an issue, the others and standard interactions.
Which one of the following is least likely to cause a significantly elevated level of ALT (SGPT)?a.Viral hepatitisb.Diabetesc.Congestive heart failured.Liver damagee.Transient ischaemic event
The correct answer is e. Significantly elevated levels of ALT (SGPT) often suggest the existence of other medical problems such as viral hepatitis, diabetes, congestive heart failure, liver damage, bile duct problems, infectious mononucleosis, or myopathy, so ALT is commonly used as a way of screening for liver problems. Elevated ALT may also be caused by dietary choline deficiency. However, elevated levels of ALT do not automatically mean that medical problems exist. Fluctuation of ALT levels is normal over the course of the day, and they can also increase in response to strenuous physical exercise.
Patient Name: FJ Age: 40 years old Allergies: No known allergies History: Smoker Current medications: Zopiclone 7.5 mg qhs prn x 30 FJ presents the following new prescription: Clarithromycin 500mg bid x 7 days Metronidazole 500 mg bid x 7 days Bismuth subsalicylate (Pepto Bismol) ii tabs qid x 7 days What is the most likely diagnosis according to this new prescription drug regimen?a.Helicobacter pylori infection induced peptic ulcerb.Salmonella intestinal infectionc.Intestinal amoebiasisd.Escherichia coli intestinal infectione.Gardnerella vaginitis
The correct answer is aALT is commonly measured clinically as a part of a diagnostic evaluation of hepatocellular injury, to determine liver health. When used in diagnostics, it is almost always measured in international units/liter (IU/L). Significantly elevated levels of ALT (SGPT) often suggest the existence of other medical problems such as viral hepatitis, diabetes, congestive heart failure, liver damage, bile duct problems, infectious mononucleosis, or myopathy, so ALT is commonly used as a way of screening for liver problems.
Which of the following is an example of an enzyme inhibitor?a.Grisoefulvinb.Phenytoinc.Phenobarbitoned.Fluconazolee.Smoking cigarettes
The correct answer is d.
Patient Name: HR, Age: 79 yo, Allergies: Allopurinol Current medications: Zopiclone 7.5 mg hs prn Hydrochlorothiazide 25 mg daily Potassium chloride 600 mg (slow K) ii bid Digoxin 0.25 mg daily HR has a prescription for: Verapamil SR 240 mg daily Upon reviewing the patient record, you would:a.Call the doctor regarding a possible hydrochlorothiazide interactionb.Call the doctor to decrease the dose of verapamilc.Dispense as written; warn the patient to notify you of any new gastrointestinal symptomsd.Call the doctor regarding a potential digoxin interactione.Call the doctor regarding a potential verapamil hypersensitivity
The correct answer is e. Serum digoxin concentration rise by 60-75% due to decreased renal tubular secretion and nonrenal clearance mechanisms. Additionally, there appears to be a synergistic effect of slowing impulse conduction and muscle contractility, leading to bradycardia and possible heart block.
ALT is most commonly measured clinically as a part of a diagnostic evaluation of which of the following?a.Hepatocellular injuryb.Brain injuryc.Cardiac injuryd.Respiratory injurye.Ocular nerve degradation
The correct answer is a. ALT is commonly measured clinically as a part of a diagnostic evaluation of hepatocellular injury, to determine liver health. When used in diagnostics, it is almost always measured in international units/liter (IU/L). Significantly elevated levels of ALT (SGPT) often suggest the existence of other medical problems such as viral hepatitis, diabetes, congestive heart failure, liver damage, bile duct problems, infectious mononucleosis, or myopathy, so ALT is commonly used as a way of screening for liver problems.
Which of the following options would be considered the most common cause of HYPOcalcemia?a.Ricketsb.Osteomalaciac.Renal failured.Massive blood transfusione.Idiopathic hypoparathyroidism
The correct answer is c
Which of the following white blood cells is capable of phagocytosis?a.Basophilb.Eosinophilc.Lymphocyted.Neutrophile.Platelets
The correct answer is d.Phagocytosis is the process by which a cell can ingest and digest other cells. The two WBCs that are phagocytic in nature are neutrophils and monocytes.
Torsade de pointes is a lethal complication of ventricular tachycardia.It can be caused by drugs such as sotalol and hypokalaemia.What is the treatment for Torsades de Pointes?A. IV Mg SulfateB. IV amiodaroneC. IV sodium chloride D. IV flumenazil
A iv mg sulfate
Mrs L comes into the pharmacy complaining of congestion and productive cough. She takes lisinopril 5mg regularly for her BP.Which product can you sell her?A. Robitussin chesty coughB. SudafedC. Lemsip max sinus and fluD. Day and night nurse caps
A correct. Guaifenesin expectorajt. If you’re taking medicines for highblood pressureyou shouldn’t takeRobitussinmucus cough and congestion relief as well, because the pseudoephedrine may make yourblood pressuremedicine less effective.B. Sudafed has pseudoephedrineC. Lemsipproducts contain decongestants (paracetamol and phenylephrine) which constrictbloodvessels; this may worsen raisedBP. ThereforeLemsip, which contains decongestant, should not be taken.D. Day; paracetamol, pseudoephedrine, pholcodineNight; paracetamol, promethazine, dextromethorphan
Match the antidotes to the drug1. Protamine sulfate2. Pyridoxine3. Physostigmine4. IV Flumenazil 5. Naloxone6. Glucagon7. Activated charcoal8. N- acetylcysteine9. PhytomenadioneA. IsoniazidB. BenzodiazepinesC. Beta blockersD. AcetaminophenE. Many toxins F. HeparinG. AnticholinergicsH. WarfarinI. Opioids
Naloxone = opioidsPhysostigmine = anticholinergics Protamine sulfate = heparinPyridoxine = isoniazidGlucagon = beta blockersN- acetylcysteine = acetaminophen Phytomenadione = warfarinFlumenazil = benzodiazepines Activated charcoal = many toxins
Match the vitamin to the following statements.Vitamin A, B, C, D, E, K1. Helps with the common cold2. Deficiency can cause scurvy3. Contraindicated pregnancy 4. Deficiency can cause rickets5. Tocopherol6. Green leafy veg7. Given to all newborns to prevent neonatal haemorrhage 8. Deficiency petechiae9. Warfarin + vitamin => enhanced anticoagulation 10. Antioxidant effect11. Deficiency beriberi12. Thiamine
- Helps with the common cold - C2. Deficiency can cause scurvy - C3. Contraindicated pregnancy - A4. Deficiency can cause rickets - D5. Tocopherol - E6. Green leafy veg - K7. Given to all newborns to prevent neonatal haemorrhage - K8. Deficiency petechiae - B3 (niacin) and C9. Warfarin + vitamin => enhanced anticoagulation - K10. Antioxidant effect - C11. Deficiency beriberi - B112. Thiamine - B1
Max sumatriptan you can take in 24 hrs?A. 4 tabsB. 6 tabsC. 2 tabsD. 1 tabsE. No restrictions on maximum dose
Max dose 300mg in 24 hrs Comes in 50mg or 100mgB
What dose of prednisolone would you expect for an acute asthma attack?A. 30 - 40mg for 5 daysB. 30 - 40mg for 3 daysC. 40 - 50mg for 5 daysD. 40 - 50mg for 3 days
C. 40 - 50mg for at least 5 days
The MHRA released advice regarding Domperidone, in particularly the duration of its use. The advice restricts the dose, indication and duration of use, due to the risk of serious cardiac side-effects.How many days should Domperidone be prescribed for?A) Up to 3 daysB) Up to 4 daysC) Up to 5 daysD) Up to 7 days
D 7 daysDomperidone is no longer indicated for the relief of n+v in children < 12 yrs or those weighing < 35 kg. A European review concluded that domperidone is not as effective in this population as previously thought and alternative treatments should be considered. Healthcare professionals are to use the lowest effective dose for the shortest possible duration (max. treatment duration should not usually exceed 1 week).
You are currently conducting a medication history for Mr N who was admitted to the ward this morning.You gather that he is currently on:Tegretol® Prolonged Release 200mg: 1 BDSertraline 50mg: 1 ODRamipril 10mg: 1 ODParacetamol 500mg: 1-2 QDS PRNHe presented being confused, lethargic and generally fatigued. You review his blood results and find that there is an electrolyte disturbance.Based on the medication Mr N is taking, and the clinical presentation he presented with, which electrolyte disturbance is most likely to have occured?A) HypokalaemiaB) HyponatremiaC) HypernatremiaD) Hypocalcemia
Carbamazepine => hyponatraemiaSertraline => hyponatraemiaB
You are conducting an anti-depressant medication review with 79 yo Mr PL. You have been seeing Mr PL who was commenced on Sertraline 50mg 1 OD a year and a half ago since the passing of his wife. Today Mr PL informs you he feels as though he does not need this medication anymore and is informing you, he is in a much better place. He has, over the last week or so started to wonder if he can come off this medication.How long should antidepressant treatment be continued in Mr PL followingremission?A) 1 weekB) 4 weeksC) 6 monthsD) 12 months
CThe dose should preferably be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge (6 months in patients who have been on long-term maintenance treatment).
Mr A, 47 years old, has been coming into the practice to talk about their ongoing depression. Mr A has been undergoing psychological and psychosocial interventions, however this has not seemed to help. The GP is looking at possible pharmacological treatment options. Mr A is at very low risk of self-harm and has no other medical problems. Which of the following treatments below would be most appropriate?A) CitalopramB) AmitriptylineC) ClozapineD) Phenelzine
A. SSRIs are better tolerated and are safer in overdose than other classes of antidepressants and should be considered first-line for treating depression.Citalopram = SSRIAmitriptyline = TCAClozapine = antipsychotic Phenelzine = moai
Miss R, has been diagnosed with epilepsy. She has come into the practice to see the GP after having a seizure yesterday. Whilst having a seizure, she injured herself resulting in being in severe pain. What would be the least appropriate analgesic to prescribe to Miss R?A) ParacetamolB) TramadolC) CodeineD) Naproxen
BSeizuresare a rare side effect of tramadol. Tramadol-relatedseizuresare short, tonic-clonic seizuresthat, like other drug- related seizures, are self-limiting. Thisoccurs at both low and high doses.
Mr I has presented a prescription for some Matrifen® (Fentanyl) patches. You are counselling Mr I on these patches, as this is the first time he has had them.Which of the following statements is most appropriate regarding counselling for these patches?A) Remove and change patch every 72 hours, place replacement patch on the same area.B) Remove and change patch every 48 hours, place replacement patch on a different area.C) Remove and change patch every week, place replacement patch on a different area.D) Remove and change patch every 72 hours, place replacement patch on a different area.
D
The MHRA released advice regarding Metoclopramide, inparticularly the duration of its use. The advice reinforces the fact, that prolonged use can possibly cause serious neurological adverseeffects.How many days should Metoclopramide be prescribed for?A) Up to 3 daysB) Up to 4 daysC) Up to 5 daysD) Up to 7 days
CIn adults > 18 yrs, metoclopramide should only be used for prevention of postop, radiotherapy-induced, delayed (but not acute) chemotherapy-induced, and symptomatic treatment of n+v, including that associated with acute migraine (where it may also be used to improve absorption of oral analgesics ~gastric stasis);Only be prescribed for short-term use (up to 5 days);Usually 10 mg, up to tds; max. daily dose 500mcg/kg;IV doses be given as slow bolus over at least 3 min;Oral liquid formulations be given via an appropriately designed, graduated oral syringe to ensure dose accuracy.This advice does not apply to unlicensed uses of metoclopramide (e.g. palliative care).
You are carrying out a polypharmacy medication review with Mr N.C. As part of the review you check his adherence and compliance to his medication regime.Mr N.C informs you that on the whole he is happy with his medications, apart from one.This particular medication which is part of Mr N.C treatment regime is causing him a dry mouth which does not like, and therefore does not take it regularly as he should.Which of the medications below is likely to be the cause for Mr N.C dry mouth?A) SalbutamolB) SalmeterolC) Beclometasone DipropinateD) Tiotropium
DTiotropium is an antimuscarinic bronchodilator. It works by relaxing and opening the air passages to the lungs to make breathing easier.Tiotropium acts mainly on M3 muscarinic receptors located in the airways to produce smooth muscle relaxation and bronchodilation. Most common adverse effect is dry mouth 👄
Mr L, 58 years old has come into the practice today to see his regular GP. Mr L has recently been experiencing pain in his back.Below is the list of medication Mr Lis currently taking.Priadel 400mg TabletsLevothyroxine 100mcg TabletsOlanzapine 10mg TabletsWhat would be the least suitable analgesic to prescribe, considering Mr L’s medication?A) NaproxenB) ParacetamolC) CodeineD) Meptazinol
ATaking lithium along with NSAIDs might increase the risk of lithium side effects. Avoid taking lithium supplements and NSAIDs at the same time. Some NSAIDs include ibuprofen, indomethacin, naproxen, piroxicam, aspirin, and others.
Miss U, 73 years old is new to the practice. You are currently conducting a meds reconciliation from her previous practice notes.From the notes you can see that she has been stabilised on a brand of Lithium Citrate for 20 years, and her bloods from the last 3 years all show Lithium being in range.She also has her annual secondary care mental health review with the psychiatry team.How often should Miss U come in for monitoring for her Lithium?A) 2 weeklyB) MonthlyC) 3 monthlyD) 6 monthly
DRoutine serum-lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable, then every 3 months for the first year, and every 6 months thereafter. Patients who are 65 years and older, taking drugs that interact with lithium, at risk of impaired renal or thyroid function, raised calcium levels or other complications, have poor symptom control or poor adherence, or whose last serum-lithium concentration was 0.8 mmol/litre or higher, should be monitored every 3 months. Additional serum-lithium measurements should be made if a patient develops significant intercurrent disease or if there is a significant change in a patient’s sodium or fluid intake.
Which of the following treatments for gout do not induce fluid retention and can be co-administered with anticoagulants?A. FebuxistatB. NaproxenC. AllopurinolD. CanakinumabE. Omeprazole
The use ofcolchicineis limited by the development of toxicity at higher doses. However unlike NSAIDs, it does not induce fluid retention; moreover, it can be co-administered with anticoagulants.
A pt of yours suffers from gout and standard treatment has not been effective. He has recently had his gouty arthritis attack making it the 4th one this year. What drug can be initiated at this stage?A. methotrexateB. benzodiazepineC. xanthine oxidase inhibitorD. interleukin-1 inhibitorE. corticosteroid
An interleukin-1 inhibitor, such ascanakinumab, can be considered for treatment of frequent gouty arthritis attacks (at least 3 in the previous 12 months) in patients who have an inadequate response to standard treatment.
A pt has been started on allopurinol which has been titrated up to a higher dose every four weeks to reach <300micromol/L serum uric acid. He has recently had an acute gout attack fir which he was given colchicine in hospital. For how long should he continue to take colchicine for? A. 7 daysB. 30 daysC. 28 daysD. 3 monthsE. 6 monthsBonus: if the patient were contraindicated to the use of colchicine what is the alternative?
EThe initiation or up-titration of urate-lowering therapy may precipitate an acute attack, and thereforecolchicineshould be considered as prophylaxis and continued for up to 6 months. A low-dose NSAID with gastro-protection is an alternative in patients who have contra-indications tocolchicine. If an acute attack develops during treatment, the urate-lowering therapy should continue at the same dosage and the acute attack treated separately.
Pityriasis rosea is a relatively common skin condition that causes a temporary rash of raised red scaly patches on the body. What is the name of the rash that appears in the first 2-3 days?A. Widespread rashB. Heralds patchC. Vitiligo
B
Which of the following is NOT associated with Lichenoid eruptions?ACEiNSAIDsMethyldopaNicorandil Gold
Lichenoid eruptions:MethyldopaChloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEiGoldNSAIDsOral Ucleration:NICORANDIL (and anal)PancreatinPenicillamineProguanil HClProtease inhibitors
Which of the following is NOT associated with oral ulceration?ACEiGoldPenicillamineChloroquineProguanil HClThiazide diuretics
Lichenoid eruptions:MethyldopaChloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEiGoldNSAIDsOral Ucleration:NICORANDIL (and anal)PancreatinPenicillamineProguanil HClProtease inhibitors
Which of the following IS associated with oral ulceration?MethyldopaChloroquine Thiazide diuretics GoldOral antidiabetics
Lichenoid eruptions:MethyldopaChloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEiGoldNSAIDsOral Ucleration:NICORANDIL (and anal)PancreatinPenicillamineProguanil HClProtease inhibitors NB: Stevens-Johnsons can present with extensive ulceration of the oral mucosa but usually not the only symptom.
Which of the following IS associated with Lichenoid eruptions ONLY?NSAIDsACEiChloroquineGold
Lichenoid eruptions:MethyldopaChloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEiGoldNSAIDsOral Ucleration:NICORANDIL (and anal)PancreatinPenicillamineProguanil HClProtease inhibitors
What drug used for copper poisoning/too much copper can also cause oral ulceration?
Penicillamine. Lichenoid eruptions:MethyldopaChloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEiGoldNSAIDsOral Ucleration:NICORANDIL (and anal)PancreatinPenicillamineProguanil HClProtease inhibitors
What drug which can be used for hypertension in pregnancy can also cause lichenoid eruptions?
Lichenoid eruptions:Methyldopa «_space;(Also labetolol and nifedipine [used less] when managing hypertension in pregnancy but they dont cause lichenoid eruptions)Chloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEiGoldNSAIDsOral Ucleration:NICORANDIL (and anal)PancreatinPenicillamineProguanil HClProtease inhibitors
What antimalarial can cause oral ulceration?
Lichenoid eruptions:MethyldopaChloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEiGoldNSAIDsOral Ucleration:Nicorandil (and anal)PancreatinPenicillamineProguanil HCl <
What drug which might be used for exocrine pancreatic defiency in CF may cause oral ulcerations?
Lichenoid eruptions:MethyldopaChloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEiGoldNSAIDsOral Ucleration:Nicorandil (and anal)Pancreatin «<
What antimalarial (which is not used in many areas due to resistance) can cause lichenoid eruptions?
Lichenoid eruptions:MethyldopaChloroquine «
What drug class commonly used in the management of hypertension could cause oral ulceration and/or lichenoid eruptions?
Lichenoid eruptions:MethyldopaChloroquine Thiazide diuretics (BendroFLUmethiazide - agranulocytosis)Antidiabetics Lichenoid eruptions + Oral ulceration:ACEi «
Which OTC antiplatelt/antipyretic/analgesic can cause oral ulceration? When would this happen?
Aspirin tablets allowed to dissolve in the sulcus for the treatment of toothache can lead to a white patch followed by ulceration.
What can stain the teeth?
- Brown staining of the teeth frequently follows the use of chlorhexidine mouthwash, spray or gel, but can readily be removed by polishing. 2. Iron salts in liquid form can stain the enamel black. 3.Superficial staining has been reported rarely with co-amoxiclav suspension.4. Intrinsic staining of the teeth is most commonly caused by tetracyclines. They will affect the teeth if given at any time from about the fourth month in utero until the age of twelve years; they are contra-indicated during pregnancy, in breast-feeding women, and in children under 12 years. All tetracyclines can cause permanent, unsightly staining in children, the colour varying from yellow to grey.
The risk of osteonecrosis of the jaw is substantially greater for patients receiving intravenous bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or for what disease?
The risk of osteonecrosis of the jaw is substantially greater for patients receiving intravenous bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or Paget’s disease. Paget’s disease of bone interferes with your body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue.
Patients with cancer may also be at risk of osteonecrosis of the jaw if they use which treatments?
Bevacizumab: VEGF targeter. Sunitinib: RTK inhibitor
Gingival overgrowth is a side effect seen most commonly caused by what three drugs?
- Phenytoin2. Sometimes ciclosporin3. Sometimes Nifedipine (and other CCB)
Which of the following drugs may cause an INCREASE in saliva production? BaclofenBupropion Clonidine Clozapine OpioidsTizanidine.
Xerostomia (decreased salivia):Antimuscarinics (anticholinergics)Antidepressants (including TCAs and SSRIs)Alpha-blockersAntihistaminesAntipsychoticsBaclofenBupropion ClonidineHydrochloride5HT1-agonistsOpioidsTizanidineExcessive use of diuretics. Increased saliva production:ClozapineNeostigmine
Which antipyschotic is associated with increased saliva production?
Xerostomia (decreased salivia):Antimuscarinics (anticholinergics)Antidepressants (including TCAs and SSRIs)Alpha-blockersAntihistaminesAntipsychoticsBaclofenBupropion ClonidineHydrochloride5HT1-agonistsOpioidsTizanidineExcessive use of diuretics. Increased saliva production:ClozapineNeostigmine
Which drug used in the treatment of myasthenia gravis can cause increased saliva production?
Xerostomia (decreased salivia):Antimuscarinics (anticholinergics)Antidepressants (including TCAs and SSRIs)Alpha-blockersAntihistaminesAntipsychoticsBaclofenBupropion ClonidineHydrochloride5HT1-agonistsOpioidsTizanidineExcessive use of diuretics. Increased saliva production:ClozapineNeostigmine
Which of the following drugs that can cause decreased saliva production (Xerostomia) is/are used as muscle relaxants?BaclofenBupropion ClonidineHydrochloride5HT1-agonistsOpioidsTizanidine
Xerostomia (decreased salivia):Antimuscarinics (anticholinergics)Antidepressants (including TCAs and SSRIs)Alpha-blockersAntihistaminesAntipsychoticsBaclofen: inhibits transmission at spinal level and also depresses the central nervous system. The dose should be increased slowly to avoid the major side-effects of sedation and muscular hypotonia (other adverse events are uncommon).Bupropion ClonidineHydrochloride5HT1-agonistsOpioidsTizanidine:an alpha2-adrenoceptor agonist indicated for spasticity associated with Multiple sclerosis or spinal cord injury.Excessive use of diuretics. Increased saliva production:ClozapineNeostigmine
Why might you see a patient prescribed clozapine also prescribed either glycopyrronium or even atropine eye drops under the tongue?
Clozapine can increase saliva production.
Pain in the salivary glands has been reported with what? (3)
Some antihypertensives: Clonidine HCl, Methyldopa. Vinca alkaloids.
Swelling of the salivary glands can occur with what? (4)
IodidesAntihyroid drugsPhenothiazinesSulfonamides (also NB sumatriptan is Cautioned in those with sensitivity to sulphonamides…. dont know why)
Which one of the following is the least appropriate thing to do when you suspect an adverse drug reaction? Consider alternative therapy if treatment of the original condition is still required.Consider altering the dose or temporarily stopping drug treatment if the benefit to harm balance of drug treatment is favourable. Consider the effects of concomitant therapy (drug interactions)Consider the possibilty of withdrawal effects if drug treatment is stopped suddenly. Consider stopping the use of the suspected drug with all ADRs
Only stop use of the suspected drug if ADR is serious or at the request of the individual, and avoid its use in future.
A patient commenced on enalapril 5mg OD two days ago, she tells you she has developed a rash all over her arms and legs and it is very itchy. Over the past few hours she has become breathless and feels like this is becoming progressively worse. Which of the following is most appropriate advice:The symptoms are not known to be caused by enalapril.She should see her GP as the dose of enalapril may need to be increased.She should stop taking the enalapril until she sees her GP.She is experiencing a side effect of enalapril, which is likely to disappear after continued use. She should seek urgent medical attention.
Urgent medical attention needed - progressive breathlessness - symptoms of angioedema which is a recognised side effect of ACEi
What high risk drugs are associated with taste disturbances?
Antibiotics: Clarithromycin, metronidazole.Antifungals: Terbinafine, griseofulvin. DMARDs: gold, penicillamine.High risk: Amiodarone, lithium, CVD: ACEiEndocrine: calcitonin, carbimazole, metforminOther: Protease inhibitors, zopiclone, phenidione.
What antifungals can cause taste disturbance?
Antibiotics: Clarithromycin, metronidazole.Antifungals: Terbinafine, griseofulvin. DMARDs: gold, penicillamine.High risk: Amiodarone, lithium, CVD: ACEiEndocrine: calcitonin, carbimazole, metforminOther: Protease inhibitors, zopiclone, phenidione.
What antibiotics can cause taste disturbance?
Antibiotics: Clarithromycin, metronidazole.Antifungals: Terbinafine, griseofulvin. DMARDs: gold, penicillamine.High risk: Amiodarone, lithium, CVD: ACEiEndocrine: calcitonin, carbimazole, metforminOther: Protease inhibitors, zopiclone, phenidione.
What DMARDs can cause taste disturbance?
Antibiotics: Clarithromycin, metronidazole.Antifungals: Terbinafine, griseofulvin. DMARDs: gold, penicillamine.High risk: Amiodarone, lithium, CVD: ACEiEndocrine: calcitonin, carbimazole, metforminOther: Protease inhibitors, zopiclone, phenidione.
What antidiabetic can cause taste disturbance?
Antibiotics: Clarithromycin, metronidazole.Antifungals: Terbinafine, griseofulvin. DMARDs: gold, penicillamine.High risk: Amiodarone, lithium, CVD: ACEiEndocrine: calcitonin, carbimazole, metforminOther: Protease inhibitors, zopiclone, phenidione.
What anxiolytic can cause taste disturbance?
Antibiotics: Clarithromycin, metronidazole.Antifungals: Terbinafine, griseofulvin. DMARDs: gold, penicillamine.High risk: Amiodarone, lithium, CVD: ACEiEndocrine: calcitonin, carbimazole, metforminOther: Protease inhibitors, zopiclone, phenidione.
The black triangle symbol identifies newly licensed medicines that require additional monitoring by the EMA. Products usually retain a black triangle for how long?
Usually 5 years but this can be extended if required. ALL suspected ADR should be reported for black triangle drugs.
Very common side effect means
greater than 1 in 10
Common side effect means
1 in 100 to 1 in 10
Uncommon side effect means
1 in 1000 to 1 in 100
Rare side effect means
1 in 10,000 to 1 in 1000
Very rare side effect means
Less than 1 in 10,000
Patients need to advice their doctor if they develop a painful skin rash with this medicine and it may need to be discontinued (oral anticoagulant)
Warfarin
OTC medicine associated with reports of QT prolongation and torsades de pointes, patients should not exceed 12mg daily.
Loperamide
Serious risk of chlororetinopathy typically occuring in one eye which these class of medicines
Corticosteroidshttps://www.gov.uk/drug-safety-update/corticosteroids-rare-risk-of-central-serous-chorioretinopathy-with-local-as-well-as-systemic-administration
Risk of potentially fatal paralytic ilues with this medicine, patients should tell their Dr before next dose (antipsychotic)
Clozapine
Male patients or their female partners are advised to use effective contraception during treatment and for 90 days after stopping this medicine used to prevent organ transplant rejection.
Mycophenolate:Women should use at least 1 method of effective contraception before and during treatment, and for 6 weeks after discontinuation—2 methods of effective contraception are preferred. Male patients or their female partner should use effective contraception during treatment and for 90 days after discontinuation.
Women using this medication to prevent organ transplant rejection should use at least 1 method of effective contraception before and during treatment and for 6 weeks after discontinuation.
Women should use at least 1 method of effective contraception before and during treatment, and for 6 weeks after discontinuation—2 methods of effective contraception are preferred. Male patients or their female partner should use effective contraception during treatment and for 90 days after discontinuation.
Live vaccines should be postponed for at least how long after high-dose (>7.5mg pred daily) are stopped?
3 months
Macrobid (nitrofurantoin MR)?
Take with or just after foodCan change urine colour - orange/brown
Statins that should be taken at NIGHT?And why?
SPFSimvastatinPravastatinFluvastatinDue to the short half-life? Cholesterol synthesis is greatest @ night
Doxycycline?
Avoid:Indigestion remediesAnything containing zinc/ironFor 1 hour before or 2 hours after taking doxyAvoid direct sunlight - can make you prone to sunburns 🥵
First dose of ramipril?
Attempt to take the first dose at bedtime - to avoid postural HTN
Flucloxacillin?
Take on an empty stomach1 hour before food OR 2 hours after food
Phenoxymethylpenicillin?(Penicillin V)
Take on an empty stomach1 hour before food OR 2 hours after foodOral solution - keep in the fridge!
Perindopril?
Take 30-60 minutes before food
How many missed doses of clozapine requires re-initiation?
2 (48 hours)
What can ferrous sulfate do to stools?
Faecal discolouration
Levothyroxine?
Take 30 minutes before food, other medicine and caffeine
What counts as sugar free?
Everything except:GlucoseFructoseSucroseNB: if it’s ‘hydro’ glucose = it’s SF
Lansoprazole
Take 30-60 minutes before food
Side effects: VERY Common definition?
1 in 10
Side effects: common definition?
1 in 100 to 1 in 10
Side effects: Uncommon definition?
1 in 1000 to 1 in 100
Side effects: Rare definition?
1 in 10,000 to 1 in 1000
Side effects: Very rare definition?
Less than 1 in 10,000 experience this
Class 1 MHRA defective medicines alert: requires action within?
24 hoursImmediate recall: because the product poses a serious or life threatening risk to health
Class 2 MHRA defective medicines alert: requires action within?
48 hoursthe defect could harm the patient but is not life threatening
Class 3 MHRA defective medicines alert: requires action within?
5 days the defect is unlikely to harm patients and is being carried out for reasons other than patient safety.
Class 4 MHRA defective medicines alert: requires action within?
Means caution in use onlyindicates that the product poses no threat to patient safety
By law, manufacturers must report to the MHRA any important defects in both medicines and medical devices. What can Warnings/ Alerts be issued about?
Defective medicinesproblems with devicesside effects associated with medicines and blood and blood products.
What does the black triangle mean?
Means this drug is recently on the market- so it prompts people that all ADR’s need to be reported with these drugs.Usually kept for 5 years
Endocrine disordersAnaphylaxisJaudineHeamorrhageRenal impairment Eye disordersfertility effects Are all examples of what?
‘Serious’ reactions that must be reported to MHRA in all circumstances.Any pro-longed hospitalisation, disabling, fatal, teratogenicity all must be reported.
Do all ADR’s in children have to be reported?
The BNF states they do!! ALL of them
What is Steven Johnsons Syndrome? What could cause it?
Severe hypersensitivity reaction: Ulcers and other lesions begin to appear in the mucous membranes, almost always in the mouth and lips, but also in the genital and anal regions. Rash usually appears all over the body bar the scalp.Drugs causing it examples: a lot of the anti-epilepticsLamotrigine (most common!)PhenytoinCarbamazepine
What could cause brown staining of the teeth?
Most common cause: Chlorhexidine mouthwashIron saltsIntrinsic staining: tetracyclines (usually only in children)
Osteonecrosis of the jaw can results from Bisphosphonate use. This is more common with IV or Oral?
IVBut all patients on bisphosphonates should have a dental check-up
What drug can cause gingival hyperplasia (gum enlargement)?
Phenytoin(also less commonly Nifedipine and ciclsporin)
Drugs which may cause taste disturbance?
metformin terbinafine (antifungal)lithiumACE inhibitors amiodaronemetronidazole
What is the definition of an unlicensed medicine?
A product that does not hold a marketing authorisation/ license for use in the UK. These medicines will not appear in the BNF because the BNF only lists products with a MA, they will only be made up in specials manufacturing units/ imported from other countries Be careful: the product itself may be listed but the specific strength you’re after is not: this would still be a special/ unlicensed
What is the definition of an off-label medicine?
The medicine has a UK marketing authorisation but it is being used for a different indication to that which it is marketed for. This will be stated under the ‘unlicensed use’ heading in the monograph: states “Not licensed for use in…” This does not mean it’s a unlicensed product, just means it’s being used for a condition out of its licensing
What is a licensed medicine?
A medicine that has a UK marketing authorisation, at that strength, that is being used for a condition it’s MA covers
What laboratory test is needed to confirm someone is suffering from a hypersensitivity reaction?
Full Blood Count and differential- to look for presence of IgE?
If you want to work out the bioavailability of a drug as an Oral Modified release prep, immediate release prep, oral solution etc, what should you always compare against?
Bioavailability of the drug as a parenteral solution given by IV bolus or IV infusion- this would show its complete absorption bioavailability
Medication errors, especially those that have gone out to the patient, even if they do not cause harm, should be reported to who?
NRLA- national reporting and learning system
In the case of an anaphylactic reaction, where should adrenaline auto-injector pens be administered?
Outer thigh!NB: the MHRA advise that an ambulance is called after every use of an auto-injector, even if symptoms are improving
When must the herbal remedy Echinacea be avoided, and why?
Should not be given to children under 12 years due to risk of severe allergic reaction outweighing any benefits
What is DRESS syndrome and what drugs may cause it?
Drug Rash with Eosinophilia and Systemic Symptoms. Characterised by rash, fever and patients should be advised to stop taking medication and seek medical attention.Carbamazepine (+ Steven Johnsons)OxcarbazepineEsilcarbazepineStrontium (a bisphosphonate)
The risk of serious skin related adverse drug reactions occurring with Carbamazepine (plus Oxcarbazepine and Esilcarbazepine) may be increased by the HLA-A*3101 allele found in patients of what ethnicity?
EuropeanJapanese
If a patient has an allergy, whether it be to a drug or to nuts or a food, what coloured wristband should they have in hospital?
Red
Which anti epileptic from the following should be used in a patient with Antiepileptic Hypersensitivity syndrome (AHS):CarbamazepinePhenytoinSodium ValproateLamotrigine Oxcarbazepine
Sodium Valproate! Safest in AHSAHS is rare but potentially fatal, and can occur with carbamazepine, lamotrigine, oxcarbazepine, phenytoin, phenobarbital and primidone. Sodium Valproate and gabapentin and Benzo’s are considered safe.
A patient takes the following medication:DiazepamAtenololErythromycinCaptoprilThey have developed Angioedema, swelling of the skin due to fluid build up with a hives like rash. Which medication is this likely to have been caused by?
CaptoprilACE inhibitors can cause angioedema, thought to be caused by the build up of bradykinin. Afro-carribean and black american patients are up to 4x more likely to get this.
A woman has a rupture in her achilles tendon, which drug is this likely to be down to:RamiprilCiclsporinFlupentixolCiprofloxacin Bezafibrate
Ciprofloxacin Quinolone antibiotics (Ciprofloxacine, Levofloxacin) have been associated with TENDONITIS
Which vitamin should be avoided in pregnancy, what is It found in?
Vitamin A- found in liver products, fish liver oils, carrots, eggsVitamin A helps with eye sight
What is vitamin B1, and what do we need it for?
ThiamineNeed it for nerves (hence why lack of it can cause Wernickes encephalopathy- biochemical lesions of the central nervous system causing memory loss and confusion)
What is vitamin B6, what do we need it for?
PyridoxineKey role in the nervous system- decreases the risk of Neuropathy associated with Isoniazid use (TB drug)Itself can cause neuropathy if used for long time at high doses!
What is vitamin B12 and what does it cause in deficiency?
B12= CobalaminDeficiency = Pernicious Anaemia (a type of Megaloblastic anaemia- MCV high, Heamoglobin low)Replacement= Hydroxycobalamin
What is Ascorbic acid? What is it used to treat?
Vitamin C- in oranges, peppers, broccoliUsed to treat scurvy (bleeding and inflamed gums and opening of wounds)
Name some of the Vitamin D analogues we give for vitamin D deficiency? What kind of conditions do you see these in?
For prevention of osteoporosisHypocalceamiaRicketsThey help promote calcium absorptionErgocalciferol (vit D2 + calciferol)Colecalciferol (Vit D3)alfacalcidol (hydroxylated vit D)Calcitriol (hydroxylated vit D)
What forms of Vitamin D should be given in renal impairment, and why?
Vitamin D requires hydroxylation by the kidney into its active form. Therefore in renal impairment, hydroxylated vitamin D is given in the form of:AlfacalcidolCalcitriolIf not renally impaired, standard Egocalciferol or Colecalciferol (Non hydroxylated) can be used.
What is the main function of Vitamin K? What foods is it found in?
Blood clotting- used for major bleeds with warfarinIt is found in green leafy vegetables- broccoli and spinach
What is the name of the Vitamin K used to reverse warfarin overdose bleeding? When should a patient stop taking warfarin and receive this?
Phytomenadione by Slow IV injectionINR > 8, or any major bleeding: Stop taking- A & E- phytomenadione + dried prothrombin complexINR > 8, minor bleeding: stop taking, A & E: Phytomenadione injectionINR > 8, No bleeding: stop taking, A & E, phytomenadione BY MOUTHINR > 5: minor bleeding: stop warfarin, A & E: Phytomenadione BY MOUTHINR > 5: no bleeding: Miss 1 or 2 doses of warfarin, reduce maintenance dose
What are the synthetic derivatives of folate, and when do we use these?
Folic acid- used for prevention of NTD’sFolic acid 400mcg in women of low riskFolic acid 5mg for those at high riskFolic acid 5mg for Megaloblastic anaemiasFolinic acid- given with methotrexate treatment to reduce methotrexates side effects
What drugs can produce a folate deficiency? (4)
MethotrexatePhenytointrimethoprim-sulfamethoxazolesulfasalazine
What kind of anaemia does folate deficiency cause?
Megaloblastic anaemia High Mean Cell Volume, Low Heamoglobin level
Can Vitamins be prescribed on NHS Rx’s as dietary supplements?
No- only for deficiency states
What is the risk of injectable Iron?
Serious Hypersensitivity Reaction with injections
What would be the signs of Magnesium deficiency?
Apathy (lack of enthusiasm) and muscle weakness
Symptoms of Low potassium?Usually when potassium falls below 2.5 mmol/ L
Weakness, drowsinessMuscle crampsLow BP (dizziness)Palpitations (arrhythmias)tingling/ numbnessConfusionConstipation!!
Symptoms of Low sodium (Hyponatreamia)?
CONFUSIONdrowsinessNausea & VomitingPersonality changesMuscle crampsWeakness
What is a benefit of using potassium sparing diuretics over potassium salts to correct potassium levels?
Potassium salts can cause nausea and vomitting
What is the normal potassium range?What is classed as severe Hyperkaleamia?
3.5 - 5.3 mmol/ LSevere: > 6.5 mmol/ L (risk of cardiac arrest- treat with calcium gluconate then insulin or bicarbonate)
Symptoms of Hyperkaleamia?
V similar to Hypokaleamia:Arrhythmiasmuscle weakness, tingling sensations, nausea
What is the normal sodium range?
133 - 146 mmol/L
What drugs may cause Hypernatreamia? (3)
CorticosteroidsPhenytoin Lithium
What drugs may cause Hyponatreamia? (5)
Diuretics- thiazide & LoopSSRI’sVasopressin (used in diabetes insipidus)CarbamazepineSulfonylureas
What is the rationale behind Oral Rehydration salts?
Intestinal absorption of sodium and water is enhanced by Glucose.There ORT contains sodium, potassium and glucose/ another carbohydrate (RICE) to replenish electrolytes lost in diarrhoea.
What can too rapid injection of Calcium salts cause?
Arrhythimas
What can magnesium salts cause and therefore be used as?
DiarrhoeaUsed as osmotic laxativeAlso used for seizures in pre-eclampsia and eclampsia (hypertension in pregnancy (pre-eclampsia) leading to convulsions- eclampsia)
What are acute prophoryias?
A hereditary disorder of Haem biosynthesis- list of drugs in the BNF that are unsafe in this condition eg HRT, COC’s, POP’s
Drugs causing Hypokaleamia (4)?
Thiazide & related diuretics Loop diuretics (e.g. furosemide) Beta 2 agonists (e.g. salbutamol) Insulin
Drugs causing Hyperkaleamia (5)?
K sparing diuretics (e.g. amiloride, Triamterene) + Aldosterone agonists (e.g. spironolactone, eplerenone) ACE inhibitors confusion, muscle twitching or spasms,NSAIDs Heparin
Drugs causing Hypermagnesaemia?
AntacidsMg supplementsRemember Mg may cause diarrhoea
Drugs cause Hypomagnesaemia? (4)
Thiazide and related diuretics Loop diuretics (e.g. furosemide) Digoxin Aminoglycosides (e.g. gent, vanc)
Hypernatreamia- symptoms?
Major symptom= thirstconfusionmuscle twitching/ spasms,
What electrolyte disturbance can long term PPI therapy (3 months- 1 year) cause ?
HypoMAGNESAEMIA
What can we use to correct Hypercalcaemia?
Bisphosphonates- they bind calcium! e.g. pamidronate
Vitamin C deficiency signs?
swollen gums, bleeding gums, gum hyperplasia
Vitamin B12 deficiency signs?
Cracked mouthMouth soresExtreme tirednessHeadaches
