Monitoring for Common Medications Flashcards
What are the monitoring requirements for ACEi?
- Urea
- Electrolytes (Hyperkaleamia)
- Creatinine and eGFR at baseline.
And regulary.
A 20% drop in renal function upon initiation is acceptable.
BP - might limit how far dose can be increased.
Stop when K+ >6mmol/L, if cough develops etc.
Risk factors for adverse renal effects: diabetes, NSAIDs, dehydration (sick day rules).
What are the things to be aware with ACEi other than monitoring? [4]
- A 20% drop in renal function upon initiation is acceptable.
- BP - might limit how far dose can be increased.
- Stop when K+ >6mmol/L, if cough develops etc.
- Risk factors for adverse renal effects: diabetes, NSAIDs, dehydration (sick day rules).
When do we stop ACEi?
- Contraindicated etc.
- When K+ >6mmol/L
- IF renal function drops more than 20%.
What is the monitoring for Aldosterone antagonists? [4]
- Renal function
- U+Es as can cause hyperkalaemia.
- Weight loss if to treat oedema
- BP
What are the monitoring requirements with antibiotic use? [5]
- Temp
- Heart rate
- CRP, WBC, ESR
- TDM: gentamicin, vancomycin, teicoplanin.
Also remember the IV/ORal switch - review if possible every 48 hours.
What are the monitoring requirements for ACHinhibitors? [3]
- Baseline renal
- Baseline liver
- Monitor for side effects.
What are the monitoring requirements for amiodarone? [5]
- TSH, T3/4
- LFTS
- U+Es
- ECG
- All the above at baseline and every 6 months
Need to monitor TSH every 6 months and then after amiodarone is discontinued for 3 months.
WARFARIN - more frequent INR monitoring will be needed - consider switching to a DOAC if possible?
Many drug interactions and a long halflife.
Apart from monitoring requirements, what else should we be aware of for amiodarone? [3]
- Can cause hypo and hyperthyroidism
- Warfaring interaction! more frequent INR monitoring needed.
- Has many drug interactions and a long half-life.
What are the monitoring requirements for antipsychotics? [12]
At baseline:
- BP
- HbA1c
- FBC
- LFTs
- U+Es
- Lipids
- Smoking status
- Weight
- BMI
- TSH
- Prolactin
- ECG
Monitoring needs to occur until the patient is stablised and then ever 6/12 weeks.
Every 12 months repeat those needed for each specific patient.
What needs to be monitored with beta blockers?
What are the cardioselective ones?
- Heart rate
- BP
- Clinical status
Cardioselective: bisoprolol, atenolol.
What CIs with BBs? [3]
Asthma = nope. COPD = nope, UNLESS for AF or HF and then it should be a cardioselective one.
Diabetes: use a cardioselective one, they can mask the symptoms of hypos and worsen peripheral neuropathy.
What monitoring is needed for CCB? [3]
- BP
- Development of oedema.
- Avoid rate limiting CCB in HF. Amlodipine or felodipine can be used if essential.
Carbimazole monitoring [4]
- Baseline FBC, WBC, LFTs, TFTs
- Warn patient to tell doctor immediately if sore throat, mouth ulcers, bruising, fever, malaise, or non-specific illness develops
- Ongoing TSH monitoring every 4-6 weeks after initiation, once maintenance dose achieved every 3moths.
- Since carbimazole is a vitamin K antagonist, the effect of anticoagulants could be intensified. Additional monitoring of PT/INR should be considered, especially before surgical procedures.
Why does additional monitoring of PT/INR need to be considered when using carbimazole and anticoagulants?
Since carbimazole is a vitamin K antagonist, the effect of anticoagulants could be intensified. Additional monitoring of PT/INR should be considered, especially before surgical procedures.
Clopidogrel monitoring
Signs and symptoms of bleeding
Corticosteroid monitoring [5]
- Osteoporosis - especially post menopausal women and the elderly in general.
- Diabetes - prednisolone can raise BG levels.
- Depression
- Infection.
- Use the lowest dose possible for shortest time in patients with HF
Digoxin monitoring [2]
Not rountinely done.
Electrolytes and renal function due to risk of
- Hypercalceamia
- Hypokalaemia
And the signs of toxicity are nausea, vomiting and visual disturbances.
DOAC monitoring [4]
Baseline:
- PT
- LFT
- BP
- Renal function (DABIGATRAN - 80% renally cleared)
Not monitored after that but be aware of signs and symptoms of bleeding e.g. aneamia.
When would we reduce the dose of DOAC? [3]
two of the followiing apply:
- > 80 yrs
- Renal impairment
- <60kg
AVOID in pregnancy: LMWH.
What levothyroxine monitoring is needed? [4]
Baseline:
1. TSH then every 6-8 weeks until euthyroid and at a further 6-12 months after.
- Closer monitoriing in patients with cardiac disease.
- Patients taking warfarin will need to have more frequent/vigilant INR checks as it can alter anticaogulant.
- Diabetics: Insulin of OHA doses may need to be increased.
What LMWH monitoring is there? [5]
Baseline:
1. Renal function and weight to determine dose.
- FBCs, U+Es, LFts and clotting screen.
- If patient is taking for longer than 4 days then we should monitor the platelet counts due to risk of HIT.
- Anti factor Xa assay is only appropriate in certain cases: renal impairment, obese, pregnancy, children.
- Common side effects: bleeding and injection site reactions.
All heparins increase
Potassium levels: hyperkaleamia
Why should we monitor platelet counts if using lmwh longer than 4 days?
HIT
Loop diuretics such as furosemide and bumetanide require what monitoring? [3]
U+Es: can cause hyponatremia and hyperkalaemia.
Monitor weight loss.
Issues with renal function.
What monitoring accompanies metformin use? [2]
- Serum creatinine baseline and then annually.
Renal impairment can cause metformin accumulation and lactic acidosis - 0.1% occurence but like 50% fatality.
- HbA1c obvo.
What monitoring accompanies NSAID use? [2]
- Creatine clearance: PG inhibition reduces renal blood flow.
- High risk of AKI in renal impairment/failure, concurrent use with ACEI/Diuretic/ARB, elderly or with long term monotherapy.
What monitoring and issues accompany PPI use? [3]
- U+Es due to hyponatreamia risk.
- Osteoporisis -> increased risk of bone fractures.
- Risk of C.diff when used with broad spectrum antibiotics.
What monitoring accompanies opioid use? [3]
- Adverse effects: constipation and nausea: prescribe appropriately.
- Pain relief effectiveness
- Respiratory depression signs for patient and carers to recognise.
SSRI monitoring requirements [8]
- Potential risk of increased suicidal ideation initially – inform patient of this and monitor patients at high risk closely.
- Check for response – may get a response in first week, usually patients get some response within first 2 weeks. If no response by 2-4 weeks, switch to a different antidepressant – caution with tapering and cross over.
- Bleeding risk – monitor for signs of bleeding.
- Serotonin syndrome
- Medications that increase bleeding should be identified and this risk managed – SSRIs may potentiate by inhibiting serotonin uptake by platelets.
- Lower doses may be required in elderly patients.
- Can cause withdrawal symptoms if stopped abruptly.
- TCA might be more appropriate in pregnancy.
Statins monitoring [8]
- LFTs
- CK
- Lipids: TC, non-HDL, HDL, triglycerides
- Smoking
- BP
- BMI
- TSH: hypothyroidism predisposes to myopathy
- Discontinue if ALT/AST levels 3x upper limit.
Other things:
CI in preg
Caution in patients with history of alcohol/liver disease
What monitoring is there with UFH? [5]
- Baseline: LFTs, renal function, clotting screen, APTT, FBC, (platelets).
- Efficacy monitoring via APPT. Dose adjusted according to response.
- Higher risk of HIT than in LMWH so need to monitor platelet count after 4 days of treatment.
- Risk of hyperkaleamia so U+Es.
- Can use in renal impairment due to very short half life.
What monitoring needs to accompany warfarin use?
Check baseline INR, FBC, LFTs and clotting screen
INR monitoring – every ½ days initially, weekly, 4 weeks and then every 12 weeks once stable.
Target INR is 2-3 or 2.5-3.5 in patients with mechanical heart values.
In AF – should calculate patientsC TTR, if not appropriate consider adherence problems and switching patient to a DOAC.
Tetarogenic in pregnancy.
Slower loading in patients with AF.
