Monitoring

Question 1

ACE inhibitors

Answer 1

Check U+Es prior to starting treatment and 1– 2 weeks after, and on increasing dose

Question 2

ARBs

Answer 2

Check U+Es prior to starting treatment and 1– 2 weeks after, and on increasing dose

Question 3

Beta blockers

Answer 3

Monitor the lung function of patients with obstructive airways disease who are taking beta blockers

Question 4

CCB

Answer 4

ECG and BP

Question 5

Cardiac glycosides

Answer 5

Plasma digoxin level (routinely taken 6 hours post dose, unless toxicity suspected) *
* Target plasma digoxin level should be 1– 2 microgram/L *
* U+Es and eGFR

Question 6

Nitrates

Answer 6

BP should be monitored when GTN is given as an IV infusion, and systolic BP should not be allowed to fall below 90 mmHg

Question 7

Statins

Answer 7

Check baseline lipids before starting statins *
* Check TFTs before starting statins *
* Check LFTs after 3 months of therapy and after 1 year

Question 8

Warfarin

Answer 8

INR will be monitored by GP by a finger prick blood test * * Initially patient will have a blood test every day for 1 week, then once a week until INR at a satisfactory level and after that every 3 months

Question 9

NOACs and DOACs

Answer 9

• No need for INR monitoring * * Monitor patient for signs of bleeding or anaemia * * Check eGFR before and after starting treatment

Question 10

Heparin

Answer 10

Measure FBC (platelets) and U+Es (serum K + ) before starting treatment. * * Calculate creatinine clearance to ensure patient’s renal function is appropriate for the dose they will be prescribed. If patient’s creatinine clearance <30 ml/min, they should be prescribed a halved dose of enoxaparin. * * Review dose if there is a change in the patient’s renal function * * Discontinue if thrombocytopenia occurs

Question 11

Xanthine derivatives

Answer 11

Monitor plasma-theophylline concentration 4– 6 hours after modified release; target plasma aminophylline should be 10– 20 mg/L * * Plasma potassium should be monitored in severe asthma

Question 12

Leukotriene receptor antagonists

Answer 12

PEFR measurement will show improvement * * Check FBC for agranulocytosis and ask about symptoms suggestive of serious side-effects

Question 13

Anti-emetics

Answer 13

ECG (prolonged QT) in patients taking 5-HT 3 -receptor antagonists or phenothiazines

Question 14

Diuretics

Answer 14

Monitor fluid and electrolyte balance and serum osmolality and review cardiac, pulmonary and renal function * * Monitor serum potassium level during treatment * * Consider measuring daily weights in patients using diuretics for relief of fluid overload

Question 15

Immunosuppressants

Answer 15

Monitor BP and ECG (risk of cardiomyopathy) * * Monitor LFTs and U+Es (renal function)

Question 16

Levothyroxine

Answer 16

• Baseline ECG when starting drug * * TFTs should be done 3 months after starting treatment or changing a dose, followed by annual TFTs once patient is stable * * Assess maternal thyroid function before conception, at diagnosis of pregnancy, during 2nd and 3rd trimesters and after delivery * * Consider supplementation with vitamin D in long-term treatment with levothyroxine

Question 17

Metformin

Answer 17

Monitor renal function before starting therapy and at least once a year

Question 18

Thiazolidiones

Answer 18

Before starting pioglitazone treatment, assess patients for risk factors of bladder cancer and investigate any unexplained haematuria * * Monitor closely for signs of heart failure especially in patients with a history of cardiovascular disease * * Check LFTs at baseline and then every 2– 6 months * * Discontinue if patient develops jaundice

Question 19

COCP

Answer 19

BP and weight prior to starting treatment and at every 3– 6 months review, before issuing a repeat prescription

Question 20

SSRI

Answer 20

Review patient every 1– 2 weeks initially after starting an SSRI. Consider switching antidepressant if the patient does not respond after at least 1 month of treatment (or if the patient does not respond in 6 weeks in the case of elderly patients). Continue drug for an additional 2– 4 weeks in cases of partial response (BNF 2017) * * Following remission, antidepressant treatment should be continued at the same dose for at least 6 months (about 12 months in the elderly), or for at least 12 months in patients receiving treatment for generalized anxiety disorder (as the likelihood of relapse is high). Patients with a history of recurrent depression should receive maintenance treatment for at least 2 years (BNF 2017) * * Follow-up should be arranged for patients after cessation of treatment with an antidepressant

Question 21

Lithium

Answer 21

Narrow therapeutic window and high toxicity risk * * Monitor plasma lithium levels, which should be 0.4– 1 mmol/L * * When starting lithium, measure patient’s weight and check FBC, U+Es, TFTs, eGFR and obtain an ECG. Check serum lithium levels 1 week after initiation of therapy and after every dose adjustment (NICE 2014, CG185) * * Note that blood lithium levels should be checked 12 hours after last dose

Question 22

Antipsychotics and clozapine

Answer 22

Before an antipsychotic is started, measurement of weight, waist circumference, pulse rate and blood pressure should be checked and an assessment of the patient’s general health, including blood tests, should be performed; the doctor may also wish to obtain an ECG (NICE 2014, CG178) * * For patients starting clozapine: monitor FBC weekly for 18 weeks, then fortnightly until 1 year; after 1 year monitor FBC every 4 weeks

Question 23

AED

Answer 23

• General: ask about seizure activity and side-effects of anti-epileptic drug when reviewing patient * * Carbamazepine: check U+Es (if confusion or falls occur) and monitor plasma carbamazepine levels (target 4– 10 mg/L) * * Sodium valproate: check baseline FBC and repeat FBC before any invasive procedures, check baseline LFTs and then repeat LFTs every 6 months

Question 24

Methotrexate

Answer 24

Narrow therapeutic window and high toxicity risk * * Baseline FBC, U+Es and LFTs then measurements every 2 weeks until 6 weeks after dose has stabilized and then monitor FBC, U+Es and LFTs every 6– 12 months afterwards (Richards and Aronson, Oxford Handbook of Practical Drug Therapy , 2005, p. 499) * * Some clinicians obtain a CXR before starting methotrexate

Question 25

Bisphosphonates

Answer 25

Correct any electrolyte abnormalities before starting treatment and monitor U+Es for serum calcium and phosphate levels during treatment * * DEXA scans * * The MHRA advises that the need to continue bisphosphonate therapy should be reassessed periodically based on the benefits and risks to the individual concerned, particularly in patients who have been taking bisphosphonates for ≥5 years

Question 26

Nitrofuratoin

Answer 26

Monitor FBC during long-term treatment * * Monitor lung function in long-term use

Question 27

Paracetemol

Answer 27

Monitor levels 4 hours after if worried about overdose

Question 28

Digoxin

Answer 28

No routine monitoring required
Consider toxicity if a person is confused, has nausea, disturbance of colour
Take 6 hours after dose

Question 29

Theophylline

Answer 29

Plasma-theophylline concentration is measured 5 days after starting oral treatment and at least 3 days after any dose adjustment. A blood sample should usually be taken 4–6 hours after an oral dose of a modified-release preparation

Question 30

Gentamicin levels

Answer 30

Multiple daily dose regimen: one hour (‘peak’) serum concentration should be 5–10 mg/litre ; pre-dose (‘trough’) concentration should be less than 2 mg/litre.

Question 31

Hyperkalemia treatment

Answer 31

Capillary blood glucose should be monitored throughout the insulin-glucose infusion due to the risk of hypoglycaemia. The Renal Association guidelines on the management of hyperkalaemia advise blood glucose levels should be monitored at regular intervals up to 12 hours following the administration of an insulin-glucose infusion.

Question 32

Levothyroxine

Answer 32

According to the BNF, thyroid-stimulating hormone (TSH) levels should be checked every 3 months from beginning therapy, until the level stabilises. Once the TSH level is relatively stable (two measurements that are close and within the normal reference range), TSH levels can be checked every year. Only FT4 if symptomatic.

Question 33

Furosemide

Answer 33

The best way to monitor the therapeutic benefit of diuretics in this situation is with daily weights, as it will allow you to assess how much fluid the patient is offloading.

Question 34

Lithium

Answer 34

BMI is monitored as lithium is associated with weight gain.
U&Es are monitored because lithium is associated with electrolyte disturbances and renal impairment.
TFTs are monitored as lithium can cause hypothyroidism.
ECGs are recommended in some patients due to the association of lithium and atrioventricular block as well as cardiomyopathy.

Question 35

Clozapine

Answer 35

The BNF currently recommends checking the FBC every week for the first 18 weeks, every second week up to 1 year, and then at monthly intervals.

Question 36

COCP

Answer 36

Body mass index and blood pressure should be recorded at each annual contraceptive review according to UK guidelines from the Faculty of Sexual and Reproductive Healthcare (FSRH). The FSRH guidelines advise if body mass index is above 35 kg/m2 women should be counselled to switch to an alternative contraceptive method.

Question 37

Ramipril

Answer 37

U&Es should be checked before commencing any ACE inhibitor to rule out electrolyte abnormalities and to assess baseline renal function (so that subsequent deterioration can be identified).

Question 38

Methotrexate

Answer 38

Patients on methotrexate are at risk of blood dyscrasias. This includes severe anaemia, leukopenia, and thrombocytopenia. Therefore, a full blood count is required. Additionally, methotrexate can lead to liver cirrhosis and so LFTs must also be checked. These blood tests should be checked every 1-2 weeks until therapy is stabilised. After this, patients can have their blood checked every 2-3 months.

Question 39

INR 2.5

Answer 39

The BNF recommends a target INR of 2.5 for patients with a bioprosthetic mitral heart valve.

Question 40

0.9% sodium chloride bolus 15 mins 500ml

Answer 40

Heart rate and blood pressure should be re-checked as part of an ABCDE re-assessment following a fluid bolus.

Question 41

Amiodarone

Answer 41

CXR: to provide a baseline as amiodarone can in some cases cause the development of interstitial lung disease
ECG (only required in the context of IV administration): to assess the current arrhythmia which is being treated and to provide a baseline for comparison (amiodarone can cause cardiac conduction disorders.
U&Es: hypokalaemia is a contraindication for the initiation of amiodarone therapy (due to increased risk of arrhythmia and QT prolongation)
TFTs: amiodarone can cause the development of thyrotoxicosis
LFTs: amiodarone is also associated with hepatotoxicity and treatment should be discontinued if severe liver function abnormalities or clinical signs of liver disease develop

Question 42

Theophylline

Answer 42

monitoring time would be after 4-6 hours.
For oral treatment, monitoring should be conducted 5 days after initiation
or 3 days after a dose adjustment.

Question 43

DOACS

Answer 43

The BNF recommends that the only regular monitoring that is required is for patient-reported symptoms - most importantly, given the action of rivaroxaban as an anticoagulant, episodes of bleeding or signs of anaemia.

Question 44

What needs to be considered for creatinine clearance with DOACs?

Answer 44

Edoxoban > rivaroxaban > apixban

Edoxaban

50%

Rivaroxaban

35%

Apixaban

27%

Question 45

Rampiril 1-2 weeks

Answer 45

Urea & electrolytes should be monitored 1-2 weeks after commencing an angiotensin-converting enzyme (ACE) inhibitor due to the risk of hyperkalaemia and a reduction in renal function. In addition, monitoring should occur after an increase in dose.

Question 46

Donezepil

Answer 46

ECG