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USMLE® Step 1 flashcards
1
Q
  1. How do ADRs in the elderly frequently present
A

Adverse reactions often present in the elderly in a vague and non-specific fashion.
Confusion is often the presenting symptom (caused by almost any of the commonly used drugs).
Other common manifestations are constipation (with antimuscarinics and many tranquillisers) and
postural hypotension and falls (with diuretics and many psychotropics).

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2
Q
  1. Medicines can be defective due to a fault in manufacture, what should this not be confused with? 3 marks
A

ADR

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3
Q
  1. What is the usual time frame for onset of a non-immediate drug allergy? 2 marks
A

Non-immediate reactions, without systemic involvement (onset usually 6–10 days after first drug exposure or 3 days after second exposure)

Cutaneous reactions, e.g. widespread red macules and/or papules, or, fixed drug eruption (localised inflamed skin)
Non-immediate reactions, with systemic involvement (onset may be variable, usually 3 days to 6 weeks after first drug exposure, depending on features, or 3 days after second exposure)

Cutaneous reactions with systemic features, e.g. drug reaction with eosinophilia and systemic signs (DRESS) or drug hypersensitivity syndrome (DHS), characterised by widespread red macules, papules or erythroderma, fever, lymphadenopathy, liver dysfunction or eosinophilia
Toxic epidermal necrolysis or Stevens–Johnson syndrome
Acute generalised exanthematous pustulosis (AGEP)

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4
Q
  1. List 2 immediate rapidly evolving drug allergies? 2 marks
A

Anaphylaxis, with erythema, urticaria or angioedema, and hypotension and/or bronchospasm. See also Antihistamines, allergen immunotherapy and allergic emergencies
Urticaria or angioedema without systemic features
Exacerbation of asthma e.g. with non-steroidal anti-inflammatory drugs (NSAIDs)

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5
Q
  1. What ADR associated with NSAIDs is more common in the elderly? 4 marks
A

Bleeding associated with aspirin and other NSAIDs is more common in the elderly who are more likely to have a fatal or serious outcome. NSAIDs are also a special hazard in patients with cardiac disease or renal impairment which may again place older patients at particular risk.

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6
Q
  1. What do the following 3 abbreviations stand for? BAN NCL SPC 3 marks
A
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7
Q
  1. How are summaries of product characteristics processed before being included in the BNF? 7 marks
A
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8
Q
  1. What food(s) should be avoided by patients prescribed ibrutinib? 2 marks
A
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9
Q
  1. List 4 potential severe interactions for grapefruit juice? 8 marks
A
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10
Q
  1. What is the important safety information for metoclopramide? 2 marks
A
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11
Q
  1. What pharmacodynamic interaction(s) are identified for St Johns Wort? 2 marks
A
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12
Q
  1. What can reduce or abolish the effects of coumarins? 3 marks
A
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13
Q
  1. What advice should be given regarding erlotininb and smoking? 2 marks
A
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14
Q
  1. What food and lifestyle information should be given to a patient taking moclobemide? 3 marks
A
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15
Q
  1. What fruits and juice should be avoided when taking panobinostat? 3 marks
A
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16
Q

For the drug of your choice; give a detailed
explanation of its mechanism of action. Discuss any issues that arise as a result
of this mechanism of action, explaining how the mechanism produces these
issues. 10 marks

A

Bisoprolol is a beta-1 antagonist which selectively binds to the orthosteric site of the beta 1 adrenergic receptors within the heart (Cardiac myocytes) to prevent the natural ligands epinephrine and norepinephrine from binding, by occupying the beta 1 receptors. Bisoprolol prevents receptor activation, thereby reducing heart rate, myocardial contractility and renin release which in turn lowers the heart rate and blood pressure. Patients who have bradycardia, second- or third-degree atrioventricular block, cardiogenic shock, severe asthma or chronic obstructive pulmonary disease should not receive this medication as the effect poses significant risks such as complete heart block, asystole, bronchospasm due to its effects on heart rate, myocardial contractility and bronchial smooth muscle.

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17
Q

Bisoprolol is a beta-1 antagonist which selectively binds to the

A

orthosteric site of the beta 1 adrenergic receptors within the heart (Cardiac myocytes)

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18
Q

bisoprolol classification

A

beta1 antagonist

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19
Q

bisprolol binding prevents what

A

prevents natural ligands epinephrine and norepinephrine from binding, by occupying the beta 1 receptors

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20
Q

bisoprolol by preventing receptor activation does what

A

reducing heart rate and myocardial contractility and renin release leading to lower hr and bp

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21
Q

What conditions can you not use bisoprolol in

A

severe airways disease, heart blocks

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22
Q

Select one of the special populations, such
as elderly, children or pregnant women, and explain how pharmacokinetics would
be altered in this case. 10 marks

A
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22
Q

Elderly - Increased ill health leads to what

A

greater drug use

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22
Q

polypharmacy in elderly can lead to what

A

drug interactions

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23
Q

reduced organ function in elderly leads to what

A

sensitivity of drugs

24
Q

Elderly absorption is affected by what

A

delayed gastric emptying

25
Q

elderly distribution is affected by what

A

Distribution reduced body water to fat ratio –

affects distribution of fat soluble and water affects distribution of fat soluble and water
– Smaller volume – greater peak effect, but shorter half life

Decreased plasma proteins
– greater concentrations of extensively bound drugs such concentrations of extensively bound drugs such
as phenytoin, carbamazepine and valproate as phenytoin, carbamazepine and valproate

26
Q

elderly elimination can be affected by what

A
  • GFR and tubular secretion reduced GFR and tubular secretion reduced
  • Reduced elimination of water soluble drugs
  • Liver size decreases – but metabolism Liver size decreases – but metabolism does not alter greatly.
27
Q

elderly effect to CNS drugs

A

greater sensitivity to CNS drugs

28
Q

Drug interaction definition

A

when one drug/herbal medicine/food or drink or by environmental factors which alters the pharmacological effect of another drug such that the pharmacological effect of one or both drugs may be increased or decreased, or a new and unanticipated adverse effect may be produced

29
Q

Drug interaction effects on absorption

A

Absorption
Interactions during drug absorption may lower the amount of drug absorbed and decrease therapeutic effectiveness.

One such interaction occurs when the antibiotic tetracycline is taken along with substances such as milk or antacids, which contain calcium, magnesium, or aluminum ions. These metal ions bind with tetracycline and produce an insoluble product that is very poorly absorbed from the gastrointestinal tract.

30
Q

Drug interaction effects on distribution

A

Distribution
In addition, drug interactions may affect drug distribution, which is determined largely by protein binding. Many drugs are bound to proteins in the blood. If two drugs bind to the same or adjacent sites on the proteins, they can alter the distribution of each other within the body.

31
Q

Drug interaction effects on metabolism

A

Metabolism
Interactions of drugs during drug metabolism can alter the activation or inactivation of many drugs. One drug can decrease the metabolism of a second drug by inhibiting metabolic enzymes. If metabolism of a drug is inhibited, it will remain longer in the body, so that its concentration will increase if it continues to be taken. Some drugs can increase the formation of enzymes that metabolize other drugs. Increasing the metabolism of a drug can decrease its body concentration and its therapeutic effect.
Drugs can also interact by binding to the same receptor. Two agonists or two antagonists would intensify each other’s actions, whereas an agonist and an antagonist would tend to diminish each other’s pharmacological effects. In some interactions, drugs may produce biochemical changes that alter the sensitivity to toxicities produced by other drugs.
For example, thiazide diuretics can cause a gradual decrease in body potassium, which in turn may increase the toxicity of cardiac drugs like digoxin.

32
Q

Drug interaction effects on excretion

A

Excretion
Finally, in the case of drugs excreted by the kidney, one drug may alter kidney function in such a manner that the excretion of another drug is increased or decreased.

33
Q

3 types of drug interactions

A

harmful, beneficial, or adverse drug reactions

34
Q

what is an ADR

A

an unwanted or harmful reaction which occurs after administration of a drug or drugs and is suspected or known to be due to the drugs

35
Q

what types of ADR are there

A

type A and type B (and type C and D, E)

36
Q

what is a type A ADR

A

agmented reactions are considered to be an exaggeration of the medicines normal effect when given at the usual dose i.e. hypotension with ACE inhibitors, dose dependent and predictable

37
Q

What is a type B ADR

A

bizzare reactions are effects that are not pharmacologically predictable and can include hypersensitivity reactions i.e. anaphylaxis

38
Q

what is a type C ADR

A

continuing reactions describe those that persist for a relatively long time i.e. bone wasting with certain drugs

39
Q

what is a type D ADR

A

delayed reactions which become apparent after some time on the meds i.e. allopurinol and anaemia

40
Q

what is a type E ADR

A

end of use reactions are associated with the withdrawal of a medicine i.e. insomnia after withdrawal of benzos

41
Q

why do some people get ADRs

A

Genetic polymorphisms:

  • CYP2D6
    – Poor vs. intermediate vs. rapid vs. ultra-rapid metabolisers
    – Codeine metabolism
  • Human Leucoctye Antigens (HLA)
    – HLA-B*1502
    – Carbamazepine, allopurinol, lamotrigine, flucloxacillin
    – Stevens-Johnson Syndrome
  • P-glycoproteins
    – Affect rate of absorption across cell walls e.g. gut
    – Ciclosporin, digoxin and dabigatran
42
Q

what authority do you report ADRs to?

A

the medicines and healthcare products regulatory agency (MHRA) - yellow card scheme

43
Q

How many key principles are there to remote prescribing

A

10

44
Q

Q: What is the first high-level principle for good practice in remote consultations and prescribing?

A

A: Make patient safety the first priority and raise concerns if the service or system does not have adequate patient safeguards.

45
Q

Q: Why is patient safety a concern in remote consultations and prescribing?

A

A: There may be limited access to a patient’s medical records, leading to risks such as unsafe prescribing and inadequate monitoring, especially for long-term conditions.

46
Q

Q: What should healthcare professionals do if they cannot prescribe safely during a remote consultation?

A

A: They should explain to the patient why it’s unsafe to prescribe and signpost them to appropriate services.

47
Q

Q: What must healthcare professionals obtain before proceeding with remote consultations?

A

A: Informed consent and ensure compliance with relevant mental capacity laws and codes of practice.

48
Q

Q: What should be done after a remote consultation to ensure continuity of care?

A

A: Make appropriate arrangements for aftercare and share relevant information with other healthcare providers involved in the patient’s care.

49
Q

Q: What is essential to document after making decisions in remote consultations?

A

A: Keep detailed notes that fully explain and justify the decisions made during the consultation.

50
Q

Q: What is the importance of understanding the limitations of remote prescribing?

A

A: Some medicines may not be suitable for remote prescribing without specific safeguards, especially when prescribing to vulnerable patients or those overseas.

51
Q

Q: What considerations should be made when offering remote services to patients overseas?

A

A: Healthcare professionals must check if they need to register with regulatory bodies in the relevant countries and ensure they have proper indemnity or insurance coverage.

52
Q

Q: What should healthcare professionals verify when working for remote service providers in other countries?

A

A: They should ensure there are established systems for regulation to protect patient safety and comply with legal and regulatory requirements for prescribing and dispensing medications.

53
Q

Q: What should healthcare professionals provide to patients during a remote consultation?

A

A: Information about all treatment options, including the option to decline treatment, in a way the patient can understand.

54
Q

Q: Which UK organizations have co-authored the high-level principles for remote consultations?

A

A: A range of healthcare regulators and organizations, including the General Medical Council and the General Pharmaceutical Council.

55
Q

Q: What should be done if a remote healthcare service identifies a potentially vulnerable patient?

A

A: Take appropriate steps to protect them, including following identity verification protocols and monitoring for risky behaviors.

56
Q

Q: How should remote healthcare providers manage risks associated with patient identity?

A

A: They should have systems in place to check patient identity and identify patterns of behaviour that may indicate serious concerns.

57
Q

Remote prescribing particularly vulnerable patients include

A

risk of self harm, substance or drug use disorders, long term condition, children attempting to access services intended for adults

58
Q

Q: What must healthcare professionals stay up-to-date with when providing remote healthcare?

A

A: Relevant training, support, and guidance specific to delivering healthcare in a remote context.

59
Q

what legislation controls the production and supply of medicinal products?

A

the medicines act 1968

60
Q
A

Non-Medical Prescribing Pharmacology Flashcards (3 decks)

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