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Fall 4 > Monitoring Drug Therapy > Flashcards

Monitoring Drug Therapy Flashcards

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1
Q

What is the importance of monitoring? (3)

A
  1. Aid diagnosis
  2. Effectiveness of treatment
  3. ADRs
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2
Q

What can be monitored from blood tests? (6)

A
  1. Urea and electrolytes
  2. Haematology
  3. Renal function
  4. Liver function
  5. Cardiac enzymes
  6. TDM - Therapeutic drug monitoring
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3
Q

What can be monitored from clinical observations? (6)

A
  1. BP, Pulse
  2. Oxygen saturation
  3. Resp rate
  4. Urine output, fluid balance
  5. Pain score
  6. Blood glucose
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4
Q

What is the purpose for checking Urea and electrolyte levels?

A 
1. They provide essential info that indicate:
Renal function
Hydration status
Assess disease state
Identify possible ADRs
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5
Q

Why are Creatinine levels measured?

A

Help to determine the estimated GFR

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6
Q

Whats the normal level of sodium and what do abnormal levels indicate?

A

Normal levels are between 133-146mmol/L

Regulated by aldosterone (RAAS system)

Abnormal levels usually indicated water loss/imbalance.

LOW levels - HYPOtension
HIGH levels - HYPERtension

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7
Q

What is the function of sodium? (3)

A

Extracellular cation
Pumped by Na/K ATPase
Maintains normal function of muscles and nerves

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8
Q

What is the RAAS system?

A

Renin–angiotensin–aldosterone system.

  1. Regulates fluid balance and blood pressure.
  2. System activates when low bp or blood volume – homeostatic response to increase bp and CO.
  3. Aldosterone is a minerolocorticoid (secreted from adrenal cortex) which enhances Na+ reabsorption and promotes K+ excretion
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9
Q

What are the causes (5) and symptoms (6) of Hypernatraemia?

A

Na >146mmol/L
Causes:
1. Insufficient water intake
2. Excessive water loss
3. Too much Na retention or from diet
4. Pharmacological - Corticosteroids, NSAIDs & Lithium toxicity
5. Excess adrenocorticoid hormones e.g Cushings syndrome

Symptoms:

  1. Fever
  2. Tachycardia
  3. Hypertension
  4. Dizziness
  5. Increased thirst
  6. Oedema
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10
Q

What are the causes (3) of Hyponatraemia?

A

Na

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11
Q

What are the symptoms (6) of Hyponatraemia?

A

Symptoms:

  1. Headache
  2. Nausea
  3. Vomiting
  4. Cramps
  5. Circulatory failure
  6. Postural Hypotension
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12
Q

Describe potassium and its role in the body?

A
  1. 5-5.3 mmol/L
  2. Largely intracellular whos needs are met from dietary sources.
  3. Essential for maintaining muscle contractility
  4. Maintains fluid balance, nerve impulse function and muscle function
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13
Q

What are the causes of Hyperkalaemia?

A 
K>5.3mmol/L
Causes:
1. Renal failure 
2. Metabolic acidoisis
3. K+ supplements 
4. Drugs: ACE inhibitors, Beta Blockers, Heparin
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14
Q

At what level of K+ reduces the blood pH reduced by 0.1?

A

K+ increase 0.6 mmol/L

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15
Q

How do beta-blockers cause hyperkalaemia?

A

They suppress catecholamine-stimulated renin release, thereby decreasing aldosterone synthesis and decrease cellular uptake of potassium

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16
Q

What occurs when K+ levels reach over 6mmol/L?

A

Cardiac Toxcitity

  1. Arrhythmia
  2. Tachycardia
  3. Ventricular fibrillation
  4. Asystole - (condition where the heart ceases to beat)
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17
Q

Treatment options of hyperkalaemia? (5)

A
  1. Stop offending medication
  2. Resistrict potassium intake
  3. IV calcium gluconate 10%
  4. Infusion of insulin + glucose
  5. Ion exchange resins e.g Calcium resonium
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18
Q

How do you treat Hypovolaemic hypornatraemia?

A
  1. Replacement with IV NaCl 0.9%

2. Fluid restriction, diuretics and sodium restriction

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19
Q

How do you treat Euvolaemic Hyponatraemia?

A

Treat the immediate cause such as hormone replacement. IF not feasible, water restriction isn’t recommended.

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20
Q

How do you treat someone with symptomatic issues of Hypo/hyperatraemia?

A

Use hypertonic saline 3% infusion

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21
Q

Describe how Hypokalaemia is caused when K+ is more than 3.5mmol/L?

A
  1. Inadequate intake
  2. Loss from GI secretions
  3. Redistribution between ECF and ICF
  4. Mineralocorticoid excess e.g. hyperaldosteronism
  5. Anaemia- immature RBCs
  6. Drugs: Diuretics, Salbutamol, Theophylline, corticosteroids
  7. Low potassium levels increase the resting membrane potential which means a great stimulus is needed to produce an action potential
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22
Q

Describe the symptoms that you feel when K+ falls below 2.5mmol/L (hypokalaemia)?

A
  1. Muscular weakness 2. Tetany 3. Respiratory failure 4. Paralysis 5. Cardiac Arrhythmias 6. Sudden death
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23
Q

How do you treat Hypokalemia?

A
  1. Pottasium effervescent tablets 2. Intravenous pottasium (usually mixed with glucose or sodium chloride) at 20-40mmol/l 3. BANANAS
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24
Q

Describe calcium and its role in the body? How are the levels of calcium affected too?

A
  1. Parathyroid hormone, Vitamin D metabolites (calcifedol and calcitriol), calcitonin are hormones which control it
  2. Structural element in bones and teeth
  3. Mediates vasoconstriction/dilation, nerve impulse transmission, muscle contraction and secretion of hormones (insulin)
  4. Co-factor for enzymes and protein
  5. Levels are affected by high or low albumin concentration
  6. 40 to 50% are bound to plasma proteins and only free calcium is active
  7. Levels of calcium must be adjusted for high or low albumin
  8. Interpreting calcium results- corrected calcium favoured
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25
Q

Describe what Hypercalcaemia is?

A
  1. The decreased serum PTH and increased serum calcitonin 2. It stops the calcium from being absorbed by the GI tract, decreases bone reabsorption, and increases calcium excretion from the kidneys
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26
Q

Describe how hypercalcaemia is caused?

A
  1. Malignancies
  2. Hyperparathyroidism
  3. Dehydration
  4. Pharmacological reasons- antacids, calcium salts, thiazides and androgens, levothyroxine, lithium, excess vitamin D 5. Bone disease
27
Q

Describe hypercalcaemia symptoms?

A
  1. GI disturbances: anorexia, nausea and vomiting, constipation 2. Mental symptoms: fatigue, depression, psychosis 3. Headaches and generalised muscle weakness 4. Polyuria and increased thirst
28
Q

What are signs of long term hypercalcaemia and how do you treat it?

A
  1. Developing gallstones, reduced renal function, coma and death

Treatment:

  1. Discontinue and review drugs that promote it (thiazides, vitamin D analogues, calcium supplements) and correct dehydration.
  2. Bisphosphonates
  3. Steroids
  4. Cinacalcet (for renal dialysis patients with parathyroid dysfunction)
29
Q

Describe what Hypocalcaemia is?

A
  1. Increased Serum PTH and decreased serum calcitonin 2. Encourages increased GI absorption of calcium - Increased bone reabsorption - Decreased renal calcium excretion
30
Q

Describe how hypocalcaemia is caused?

A
  1. Hypoparathyroidism 2. Malnutrition 3. Renal failure 4. Pharmacological (loops and bisphosphonates) 5. Inadequate vitamin D production/action
31
Q

Describe hypocalcaemia symptoms?

A
  1. Tend to be asymptomatic if it’s mild hypocalcaemia 2. Severe cases- paraesthesia of face, tetany (muscle spasms), convulsions and paralysis
32
Q

Describe hypocalcaemia treatment?

A

Calcium Gluconate 10% (10-20ml) as a slow bolus (+ ECG)

33
Q

Describe phosphate and its role in the body? What do low levels indicate?

A
  1. Phosphate is acquired through diet 2. Low levels can be implicated in development of rickets where vitamin D levels are low 3. Regulate acid and base balance
34
Q

Describe the symptoms of low level of phosphate?

A
  1. Muscle weakness 2. Confusion 3. Respiratory difficulties
35
Q

Describe the causes Hypophosphataemia?

A
  1. Inadequate intake - malnourished patients - interference with absorption (e.g. antacids binding phosphate- disease process- Crohn’s disease) 2. Excessive loss - Diuresis - Dialysis - Alcoholism 3. Redistribution - phosphate my redistribute into cells - Can cause hormonal effects, respiratory alkalosis, rapid cellular uptake
36
Q

Describe how you can treat Hypophosphataemia?

A

. Oral phosphate (4-6 tablets daily) 2. Intravenous Phosphate 3. Monitoring of other electrolytes is essential as calcium and potassium can be affected - May need supplement calcium too especially if patient is hypocalcaemic

37
Q

Describe the causes Hyperphosphataemia?

A
  1. Renal impairment- accumulation of phosphate is common due inability to excrete it 2. Excess of vitamin D 3. Hypoparathyroidism 4. Acromegaly
38
Q

Describe the treatment Hyperphosphataemia?

A
  1. Phosphate intake ca be minimised by using “phosphate binders” 2. Taken at mealtimes to remove dietary phosphate 3. Calcium carbonate, aluminium hydroxide and sevelamer
39
Q

Describe magnesium and its role in the body?

A
  1. Essential for nerve and muscle function 2. Activates cellular enzymatic activity- metabolism 3. Accumulates in renal failure 4. Cause: Latrogenic and excessive antacids
40
Q

Describe the causes Hypomagnesaemia?

A
  1. Abnormal losses of magnesium from diet- secreted in GI fluid 2. Inadequate dietary intake 3. Chronic alcoholism 4. Accompanying hypokalaemia/hypocalcaemia 5. Pharmacological- Aminoglycoside antibiotics, Bisphosphonates, Immunosuppressants, prolonged diuretic therapy (loop and thiazide diuretics)
41
Q

Describe the treatment of Hypomagnesaemia?

A

Mg salts if needed (oral and IV)

42
Q

Describe how creatinine is produced and what the plasma concentration depends on?

A
  1. Produced continuously as a by-product of normal muscle metabolism and is eliminated by the kidneys 2. Plasma concentration depends on muscle mass and breakdown, and the ability of the kidney. - changes in creatinine levels can give an estimate of renal function
43
Q

Describe the stages of renal disease and what occurs in each of them?

A
  1. Pre-renal: reduced blood flow to kidneys- damage to aorta, dehydration causing hypovolaemia 2. Renal (intra-renal)- Kidney disease, renal artery 3. Post renal- kidney stone on urethra
44
Q

how do you calculate creatinine clearance? What is the equation?

A

Urine creatinine concentration x Urine flow rate Divided by serum creatinine concentration

45
Q

How do you calculate the renal function?

A
  1. By measuring the GFR (glomerular filtration rate) 2. Involves injecting a contrast dye into the kidney and monitoring the rate it travels in the kidney 3. You can estimate it using the MDRD equation
46
Q

What is the purpose of measuring the eGFR and CrCl?

A
  1. eGFR- capacity of the kidney 2. CrCl- kidney function
47
Q

Why is it important to measure renal function, what does a rapid fall in creatinine clearance mean?

A
  1. Rapid fall in creatinine clearance can be an indication of acute renal failure which can be prevented 2. Pharmacological treatment: nephrotoxic agents should be avoided, drug that are renally metabolised and excreted may require dose reductions
48
Q

Describe the function of urea?

A
  1. End product of protein metabolism 2. Increases due to renal failure, increased catabolism, GI bleeding, dehydration 3. Decreases with low protein diet and water retention 4. Useful indicator of hydration when compared with creatinine - More than 15 suggests dehydration - Less than 15 supports renal impairment
49
Q

What is Haematology?

A

The examination of: 1. white bloods cells- increase if an infection is suspected 2. Red blood cells- essential for transporting oxygen to tissue, low levels indicate blood loss and anaemia 3. C-reactive protein- general marker for inflammation or infection

50
Q

What are the two main types of white blood cells?

A
  1. Neutrophils- increase in response to CRP seen in - bacterial infection, auto-immune disease, acute phase response, inflammation 2. Lymphocytes
51
Q

Describe red blood cells

A
  1. Also named erythrocytes 2. Platelets - reduced count - increased count- malignant disorders of bone, chronic inflammatory conditions, severe infectious illness, haemorrhage, surgery 3. Haemoglobin 4. Ferritin- iron status
52
Q

What is prothrombin time?

A
  1. A clotting factor that depends on vitamin K 2. Essential in activating clotting factors 3. Liver function impairment= absorption reduced= prothrombin production. PT will be increased.
53
Q

What is the international normalised ratio? (INR)

A

Used to monitor the anticoagulant effect of warfarin

54
Q

What is the activated partial thromboplastin time? (APPT)

A

Used for the monitoring of heparin

55
Q

Describe the clotting cascade sequence?

A
  1. Injured vessel- exposure to collagen to blood, damaged cell release phospholipids 2. Platelet plug formed- clotting cascade activated and prothrombin is converted to thrombin 3. Platelets and Fibrinogen to fibrin (clot)
56
Q

How do you monitor liver function tests?

A
  1. Liver function tests look at the expression of several enzymes in the liver which are raised due to damage 2. This includes ALT, AST, ALP, GGT - Bilirubin- breakdown from Hb - Albumin- protein made solely in liver - Coagulation (INR and PT)
57
Q

What are the type of damage that occurs to the liver overtime?

A
  1. Acute hepatitis- Damage to liver leads to excretions of enzymes (ALT and AST) and clearance of bilirubin is reduced 2. Chronic liver damage- results in fibrous scar tissue building up in liver- this impairs the synthetic function so albumin and clotting factors get reduced 3. Chloestasis- blockage- substances are usually secreted by the liver accumulate due to impaired metabolism or excretion
58
Q

What are the implications of hypertension and hypotension

A

Hypertension- increased risk of stroke, MY and renal impairment Hypotension- dizziness, falls and collapse

59
Q

What is postural hypotension?

A
  1. Sudden drop in blood pressure when patient changes position from lying and sitting to standing 2. Can be caused by medications, diuretics, antipsychotics - Leading cause of falls in the elderly
60
Q

What is the normal pulse rate of a patient?

A

60 to 70 beats per minute

61
Q

How does pyrexia (fever) usually start and at what temperature does hypothermia occur?

A
  1. Usually caused by infection 2. Hypothermic usually begins at 35 degrees
62
Q

Why is it important to measure urine output?

A
  1. Indicates renal function and fluid status (dehydration, overload with fluids) 2. Higher may mean oedema and lower may mean renal failure and require diuretics to encourage kidneys to work harder
63
Q

Why is it important to measure respiratory rate and how?

A
  1. Number of breaths taken per minute (12-16) - higher in patients with COPD and asthma 2. Drive by the level of carbon dioxide in blood 3. Patients may fail to expel the CO2 which affects the pH of the blood causing acidosis- leaves organs to fail 4. Opioid toxicity may cause low respiratory rate
64
Q

Why is it important to measure oxygen saturation?

A

Indicates level of oxygen circulating in blood

Fall 4 (15 decks)

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