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Hypokalaemia causing drugs
Bendroflumethazide (thiazides) and loop
Hyperkalaemia causing drugs
ACEin, potassium sparing diuretics, tacrolimus, heparin
Max Iv potassium rate
10mmol/hr
Antiemetic options
cyclizine 50mg 8-hrly IV/IM/oral
Metoclopramide 10mg 8hrly IV/IM (heart failure)
Metoclopramide ci
parkinsons, young women (dyskinesia, acute dystonia)
Paracetamol max/day
4g/day (8x500mg) Co-codamol.
Steroid side effects
Stomach ulcers, thin skin, edema, right and left heart failure, osteoporosis, infection (inc candida), diabetes, cushings syndrome
NSAIDS/ibuprofen side effects
No urine systolic dysfunction- Heart failure asthma Indigestion dyscrasia
pre operative drug changes
I LACK OP INsulin Lithium anticoag/plt COCP/HRT K-sparing diuretics oral hypoglycaemics peridonopril (+ other acein)
when to stop COCP for surgery
4 weeks before
when to stop litihium for surgery
day before
ACEin/K sparing stop for surgery
day of surgery
anticoag when stop for surgery
warfarin 5 days before
anti platelets day before
heparin day before
insulin when stop for surgery
variable
cough as se- what is the medication?
ace in
indigestion causes
steroids, nsaids
constipation causes
cocodamol, codeine
methotrexate cautions
give weekly, no trimethoprim or co-trimoxazole- folate antagonists. Give folic acid alongside to reduce BM toxicity.
peripheral oedema cause
CCB e.g. amlodipine
post stroke caution
no heparin 2 months e.g. enoxaparin
CCB caution
not with beta blockers- bradycardia
e.g. verampil
asthma cautions
beta blockers, nsaids, aspirin (can use with caution)
COCP ci
migraine with aura
insulin route
S/c unless sliding scale IV actrapid and novarapid
agranulocytosis which drug
clozapine. immediately cease and refer to haem
Neutrophilia which drug
steroids
Neutropenia which drug
chemo or radiotherapy. clozapine, carbimazole. carbamazepine.
thrombocytopaenia which drug
penicilliamine (RF) reduced production
Heparin increased destruction
SIADH- low na which drug cause
carbamezepine, antipscyh
intrinsic renal failure which drug
gentamicin, vancomycin, tetracycline, (ACEin), NSAIDS, contrast, lithium
TSH ranges with levothyroxine
<0.5 decrease dose
0.5-5 nill action
>5 increase dose
cholestasis drugs
flucloxacillin, coamoxiclav, nitrofuratoin, steroids, sulphonylreas
hepatitis drugs
paracetamol od, statins, rifampicin.
digoxin tox sx
Confusion, nausea, visual halos and arrhythmias
lithium tox sx
Early: tremor
Intermediate: tiredness
Late: arrhythmias, seizures, coma, renal failure and diabetes insipidus
phenytoin tox sx
Gum hypertrophy, ataxia, nystagmus, peripheral neuropathy and teratogenicity
Gentamicin/vancomycin se
Ototoxicity and nephrotoxicity
Gentamicin monitoring
IE: peak- 3-5
trough <1
Everything else: 5-10 peak
<2 trough
peak adjust dose, trough adjust interval
gentamicin dose
5-7mg/kg OD
renal failure or IE: 1mg/kg 12 hourly- divided daily dosing.
Warfarin INR too high
<6 reduce dose
6-8 omit 2 days then reduce
>8 (and no bleeding) omit warfarin and give 1-5mg oral vit k
if minor bleed with INR >5 give 1-2mg vit k phytomenadione IV NOT ORAL!
neutropenic sepsis tx
IV piperacillin with tazobactam and gentamicin
UTI in preg mx
no trimethoprin- folate antagonist
Addisons caution
Increase hydrocortisone with infection or illness
HF acute mx
40mg IV furosemide
AF caution
can use diltazem but worsens fluid retention as CCB
Neuropathic pain
amitriptylline TCA. i.e. 10mg nightly
STEMI MX
ABC. O2 if sats <94% Aspirin 300mg oral Morphine 10mg IV with metoclopramide 10mg IV GTN spray Primary PCI Atenolol 5mg Oral
NSTEMI mx
ABC. O2 if sats <94%
Aspirin 300mg oral
Morphine 10mg IV with metoclopramide 10mg IV
GTN spray
Clopidogrel 300mg, enoxaprin 1mg//kg bD SC
Atenolol 5mg Oral
LVF mx acute
ABC and o2 Sit patient up Morphoine 5-10mg IV with metoclopramide 10mg IV GTN spary Furosemide 40-80mg IV CPAP
Unstable arrthymia mx
Synchronised DC shock (3 attempts)
amiodarone 300mg IV 10-20 min and repeat shock then amiodarone 900mg over 24 hours.
Anaphylaxis mx
ABC, o2 Remove cause Adrenaline 500mcg of 1:1000 IM Chlorphenamine 10mg IV Hydrocortisone 200mg IV Astham tx with wheeze amend drug allergys box on chart
Acute asthma mx
ABC
100% o2 via non-rebreather
salbutamol 5mg neb (20-30 mins repeat with oxygen driven)
Hydrocortisone 100mg IV (6hrly) or pred 40-50mg oral
Magnesium sulphate 1.2-2g over 20 mins
Ipratropiium 500 mcg neb]
Theophylline.
Pneumonia tx
ABC High flow o2 antibioitics: amoxicillin or co-amoxiclav, paracetamol IV fluids
Pulmonary Embolism tx
High flow O2, morphine 5-10mg IV with metoclopramide 10mg IV
Rivaroxaban- Initially 15 mg twice daily for 21 days, then maintenance 20 mg once daily
GI bleeding mx
ABC with o2 non breather 2 large bore cannulae catheter with strict fluid monitoring cross match 6 units correct clotting abn endoscopy stop nsaids, aspirin, warfarin, heparin
Bacterial meningitis mx
ABC, high flow o2, iv fluids, dexamethasone iv unless immmunocompr. LP with CT head
2g cefotaxime QDS/cephtriaxone (2-4g) min 10 days (if over 50 add amoxicillin)
epileptic seizure mx
ABC, recovery position with o2
Status epilepticus mx
ABC, recovery position with o2 Lorazepam 2-4mg IV or diazepam/midazolam buccal 10mg repeat diazepam after 2 mins inform anaesthetist phenytoin intubate then propofol.
Stroke mx
ABC CT head to exclude haemmorage
if <80 and <4.5 hrs ago thrombolysis
aspirin 300mg oral
transfer to stroke
Hyperglycaemia mx
ABC,
IV fluid 1L stat then 1L over 1 hour then 2, 4, 8.
Fixed dose insulin. 1 unit/mL; with 0.9% saline infuse at a fixed rate of 0.1 units/kg/hour.
Monitor Bm, K, pH and ketones.
CONTINUE WITH LONG ACTING
AKI tx
ABC cannula and catheter with strict fluid monitoring IV fluid 500ml stat then 1L 4 hrly. Monitor U&E and fluid balance treat cuase.
Stop allopuriol, acein, arbs, nsaids, metformin, acculumating drugs.
Acute poisoning mx
ABC
Cannulae catheter strict fluid balance
supportive IV fluids and analgesia
Correct electrolyte abn
Reduce absorption if <1hr: gastric lavage (unless caustic), whole bowel irrigation (iron/lithium), charcoal (dose dependent)
N-acetyl cysteine if paracetamol at 4 hours above line on normogram
Naloxone )opiates in slow breathing or low GCS
Flumazenil benzo
Lamotrigine se
Rash, rarely Stevens–Johnson syndrome
Carbamazepine se
Rash, dysarthria, ataxia, nystagmus, ⇓Na, neutropenic sepsis
Phenytoin se
Ataxia, peripheral neuropathy, gum hyperplasia, hepatotoxicity
Sodium Valporate se
Tremor, teratogenicity, tubby (weight gain
COPD tx
smoking cessation, inhaled therapy
Alzheimers tx
Acetylcholinesterease inhibitors. Donezepil, rivastigmine, galantamine.
NMDA antagonist- memantine
Crohns mx
Induce remission with pred 30mg daily oral
Severe: hydrocortisone 100mg 6hrly IV.
Rectal hydrocortisone if rectal disease.
Maintaining remission with azathioprine or 6-mercaptopurine. (check TPMT)
Rheumatoid arthritis mx
methotrexate with DMARD (sulfasalazine or hydroxychloroquine)
Flare: Im methlypred 80mg
Short term nsaids ibuprofen with lansoprazole.
if failure to respond to two DMARDS- infliximab.
Fever mx
Tx cause. 4g paracetamol
Constipation mx
Stool softener: Docusate sodium. Good for impactino
Bulking agents: isphagula husk (CI in impaction and colonic atony) takes days to work
Stimulant laxatives: senns, bisacodyl (not in acute abdo), exacerbate cramps
osmotic: lactulose/phosphate enema: exacerbate bloating.
HTN when to treat
Treat if >150/95 or >135/85 with existing or high risk of vascular disease, hypertensve organ damage.
HTN target BP
<80yrs <140/85 in clinic and <135/85 for ambulatory or home.
if over 80 then add 10.
HTN Treatment
Under 55/t2dm: Acein or ARB
then add CCB or thiazide
then add the other out of CCB and thiazide
> 55 or black: CCB
then add ACei or ARB or thiazide
then CCB + thiazide + acein or arb
refer if uncontrolled on max dose of 4 drugs.
Heart failure mx
Acein-lisinopril 2.5m g daily plus beta blocker e.g. bisoprolol 1.25mg daily.
if mild: add arb
if moderate/black: add hydralazine 25mg 8hrly and isosorbide mononitrate 20mg 8 hrly
mod-sev: spironolactone 25mg daily.
CHADVASC
congetive heart failure (or LHF) Hypertension Age >75 2 points DM Stroke or TIA (2 points) Vascular disease (peripheral or IHD) Age 65-74 Sex (female)
0= aspirin 75mg daily
1 aspirin or warfarin with INR 2.5 target
Score >2 warfarin with inr target 2.5
DM mx
education, dietary and exercise advice.
CV risk mx: aspirin 75mg daily if any significant risk or over 50 with t2dm
simvastatin 20-40mg daily if any significant rf or over 40 in t2dm
Annual rv: ACR (diabetic nephropathy), >3mg/mmol- ace in
blood glucose lowering therapy.
Glucose lowering therapy
if Hba1c >48: metformin 500mg with breakfast oral. if low or normal weight or high creatinine use sulphonylurea instead gliclazide 40mg with breakfast oral.
then increase dose to max tolerated
then add sulphonylurea (gliclazide)
if already gliclazide add gliptin (dpp4 inhibitor e.g. sitagliptin
if still over 48 add insulin.
Skin infection mx
flucloxacillin 500mg 6 houly for 7 days.
domperidone caution
safe for use in parkisons as does not cross bbb
Parkinsons meds to avoid
metoclopramide, haloperiodol.
HTN in pregnancy caution
avoid ramipril as teratogenic. Use labetalol
HTN in pregnancy tx
Labetolol 100 mg BD, dose to be increased at intervals of 14 days; usual dose 200 mg BD, increased if necessary up to 800 mg daily in 2 divided doses, to be taken with food, higher doses to be given in 3–4 divided doses; maximum 2.4 g per day.
Tamoxifen cautions
Increases endometrial cancer risk, increases warfarin efficacy high INR, increases VTE risk.
Metformin Caution
causes lactic acidosis
Gliclazide se
risk of hypoglycaemia. sulphonylurea. taken in morning.
Methotrexate monitoring
have full blood count and renal and liver function tests repeated every 1–2 weeks until therapy stabilised, thereafter patients should be monitored every 2–3 months.
be advised to report all symptoms and signs suggestive of infection, especially sore throat
Warfarin cautions
significant bleeding risk, alcohol enzyme inhibition. chronic excess enzyme induction.
Warfarin colours
White 0.5mg
Brown 1mg
Blue 3mg
Pink 5mg
Target INR
2.5- af, dvt, pe
recurrent vte or mechanical valve- 3.5
Warfarin monitoring
initially weekly then monthly INR
ACEin caution
dehydration, D&V. AKI risk. do not prescribe with NSAIDs. do not use in aortic stenosis.
ACEin monitoring
check renal function and potassium 1-2 weeks after initiation. and after each dose change.
Steroids co-prescribe
bisphosphonate (e.g. alendronic acid). Ranitidine or PPI (omeprazole) if at risk. DOnt stop suddenly. Monitor for HTN and DM.
Citalopram
Photosensitivity, increased suicidality, dry mouth.
Serotonin syndrome
agitation, temperatures, hallucinations.
Alendronic acid
Weekly. not with calcium salts or food. swallowed with full glass of water and remain upright for 30 mins afterwards.
1%
1g in 100ml or 10mg in 1ml
ACEin
give in evening to avoid postural hypotension.
GTN
glyceryl trinitrate. 2 sprays sublingual
Vancomycin
Renal dysfuncton changes the dosage. Measure renal function before treatmetn
Statins
Should check liver function as is metabolised by the liver. increases myopathy risk check ALT/AST before. CI if >3x normal range. Check at 3 and 12 months.
Check CK is patient at increased risk of myopathy.
Phenytoin
Reference range (40-80micromols/L) measured at trough. COnsider seizure control also.
Lithium
Sample 12 hours after last dose. 0.4-0.8mmol/L. Tox at >1.5mmol/L
Routine serum lithium conc weekly after initiation and after each dose change until stable. then 3 monthly after.
Low sodium increases lithium toxicity so dietary changes.
Methotrexate
Must monitor FBC once stabilised every 2-3months.
Can do xray chest as baseline.
Dont start with abn liver function
renally excreted.
Olanzapine
Check fasting blood glucose at baseline, at 4-6 months then yearly.
Psych
ECG if CVS history.
OCP
check BP prior to prescribing.
amiodarone monitoring
T3/4 and TSh must be checked. Baseline chest xray. Can cause abn LFTs. Renal function not applicable. Caution in hypokalaemia due to increased arrythmia risk.
Carbimazole
Check neutrophil count if sore throat- agranulocytosis. FBC.
Associated with hepatic disorders.
Digoxin monitoring
renally excreted so monitor digoxin levels in renal impairment. Also measure if tox suspected, non-compliance or inadequate effect.
Monitor renal function and electrolytes. Hypokalaemia increases risk of tox.
Sodium valproate monitoring
Monitor liver function before therapy and during first 6 months (especially in patients most at risk)
Measure full blood count and ensure no undue potential for bleeding before starting and before surgery.
No need to measure plasma conc.
Sodium valproate cautions
Can cause pancreatitis.
Consider vit d supplementation if pt at risk of osteoporosis.
Change dose based on monitoring in renal impairment.
Clozapine monitoring
Monitor FBC. weekly for 18 weeks. then fortnightly up to 1 year. then monthly. Monitor for 4 weeks after discontinuation also. Stop permanantly if leukocytes <3000/mm3, or neutrophils <1500/mm3.
Blood conc measured in certain situations.
Observe during initiation (hypotension and convulsions)
Lipids and weight at baseline, at frequent intervals in first 3 months, then 3monthly for 1st year. then yearly. (other psychotics is just baseline, frequently in 1st 3 months then, yearly.
fasting blood glucose tested at baseline, after one months’ treatment, then every 4–6 months.
Patient, prescriber, and supplying pharmacist must be registered with the appropriate Patient Monitoring Service.
Anti-psychotics monitoring
Lipids and weight at baseline, frequently in 1st 3 months then, yearly.
Fasting blood glucose at baseline, 4-6 months and then yearly.
monitor prolactin at the start of therapy, at 6 months, and then yearly.
Patients with schizophrenia should have physical health monitoring (including cardiovascular disease risk assessment) at least once per year.
c.diff
broad-spec esp cephalosporins or ciprofloxacin.
ACEin Side effects
hypotension, electrolyte abn (hyperkalaemia), AKI, dry cough. hyponatraemia.
Beta blocker side effects
Hypotension, bradycardia, wheeze in asthmatics, worsens acute heart failure (helps chronic). Cold extremities. Fatigue.
CCB side effects
hypotension, bradycardia, peripheral oedema, flushing
Diuretic side effects
hypotension, electrolyte abn, AKI, subclass dependent effects.
Heparin side effects
Haemorrhage (esp in renal failure or <50kg), heparin-induced thrombocytopaenia.
Warfarin side effects
Haemorrhage, pro-coagulant in first few days (co-prescribe heparin until INR >2)
Aspirin side effects
Haemorrhage, peptic ulcers and gastritis, tinnitus in large doses.
Digoxin side effects
N&V, blurred vision, confusion, drowsiness, xanthopsia (yellow green vision). Low K augments effect. high levels limit effect.
Amiodarone side effects
pulmonary fibrosis, thyroid disease (hypo and hyper), skin greying, corneal deposits.
Lithium side effects
early- tremor
Intermediate- fatigue
Late- arrythmias, seizures, coma, renal failure, diabetes insipidus.
Haloperidol side effects
dyskinesias (acute dystonic reactions), drowsiness.
Fludrocortisone side effects
hypertension, sodium and water retention
Statin side effects
Myalgia, abdominal pain, increased ALT/AST (mild), rhabdomyolysis (mildly raised CK).
Drugs with narrow therapeutic index
warfarin, digoxin, phenytoin
Drugs that need careful titration of dose to effect
Antihypertensives, antidiabetic
Low GCS/acidosis
metformin
Enzyme inducers
PC BRAS: Phenytoin Carbamazepine Barbituates Rifampicin Alcohol chronic Sulphonylureas
Enzyme inhibitors
ketoconazole, ciprofloxacin, erythromycin, grapefruit juice. AODEVICES: Allopurinol Omeprazole Disulfiram Erythromycin Valproate Isoniazid Ciprofloxacin Ethanol (acute) Sulphonamides.
Interactions with alcohol
GI bleeding- NSAIDS
Lactic acidosis- metformin
Increased anticoagulation: warfarin (acute alcohol- enzyme inhibition)
Reduced anticoagulation: warfarin (chronic alcohol- enzyme induction).
Hypertensive crisis: Monoamine oxidase inhibitors
Sweating, flushing, N&V: metronidazole and disulfiram.
Sedation: barbituates, opiods and benzodiazepines.
Augmentin
Co-amoxiclav
hypoglycaemia management
If conscious- sugar rich snack 10-20g glucose.
Glucagon 1mg IM/SC/IV - if unconscious or unsafe swallow and no IV access.
IV glucose 20% 100ml = 20g of glucose or glucose 10% 100ml = 10g of glucose
give 10-20g. 15-20 mins
Bendroflumethaizide
increases gout
Give potassium max rate
20mmol/hour
Hyperkalaemia
DREAD Drugs Renal failure Endocrine (addisons) Artefact (repeat bloods) DKA (blood sugar)
Hyperkalaemia treatment
10ml 10% IV calcium gluconate and 10 Units actrapid insulin with 100ml 20% IV dextrose and nebulised salbutamol.
Anaphlaxis
15L/min Oxygen via non-rebreather mask
500 micrograms (0.5mg) of 1:1000 adrenaline IM.
10mg Chlorphenamine IV
200mg Hydrocortisone IV stat
T2DM with renal impairment
Not metformin if GFR <30. Give gliclazide (sulphonylurea).
Metoclopramide
10mg IV prokinetic antiemetic
cannot use in bowel obstruction or first few days post abdo surgery.
Clarithromycin
Avoid statins CYP3a4 inhibitor increase tox and se.
Statins
Take at night, avoid grapefruit, not in liver disease, avoid clarithromycin, myositis stop medication.
Angio-oedema
ACEin, months later due to accumulation of bradykinin
Sick day rules
2x normal dose. During sepsis.
dyspepsia
magnesium carbonate 10ml oral
Dalteparin dose
5000 units S/c OD - prophylactic dose
Enoxaparin dose
40mg/4000 units s/c od - prophylactic dose
Paracetamol dose
500mg 4 hourly oral. WITH INDICATION and FREQUENCY. on as required chart.
IV abx r/v
3 days as often can be stepped down to oral
when to give laxatives
before bed. oral nightly
Monitoring of chest infection
O2 sats or ABG- more accurate and specific. Otherwise RR.
Tacrolimus monitoring
trough level before morning or evening dose. 6-10ng/ml post transplant
Vancomycin monitoring
trough 10-15mg/l. renally excreted.
Steroids
Hypokalaemia
Bumetanide
Hypokalaemia
Elderly
> 65yrs
Chloramphenicol
increases phenytoin level
Mild UC
<6 stools a day and no other symptoms
Oral 30mg prednisolone OD
Severe UC
> 6 stools a day and systemically unwell.
Hydrocortisone 100mg IV 6 hourly.
Hyperkalaemia with ECG changes
10ml 10% calcium gluconate IV repeated every 15 mins until ECG normalises (max 50ml).
Digoxin loading dose
500mcg IV. Maintenance is 62.5-125 mcg daily.
pruritis
codeine se
Spironolactone
hyperkalaemia, diuretic, aldosterone antagonist. potassium retention, gynaecomastia.
Converting phenytoin
normal dose x 0.92 = new dose with capsules or whatever it is
1st line medical management for GAD
Sertraline or paroxetine
DVT
Rivaroxaban, apixaban
IV phenytoin
ECG as cardiac arrythmias
SSRI cx
rash- side effect indicattive of potential serious systemic reaction
takes 6 weeks
Patients <50kg
dose-adjustmentt e.g. enoxaparin. also lower dose paracetamol to avoid hepatotoxicity
Confusion
Morphine, metoclopramide, anticholinergics, antipsychotics, antidepressants, anticonvulsants, histamine H2 receptor antagonists, digoxin, beta blockers, corticosteroids, NSAIDS, abx.
Alcohol withdrawl
vitamin b substances with ascorbic acid (pabrinex Iv high potency 2 pairs 10ml by iv infusion over 30 mins 8 hourly.
DKA
soluble insulin 50 units in sodium chloride 0.9% 50ml by iv infusion at a rate of 0.1units/kg/hr.
Folic acid
low risk 400mcg before conception and up to week 12 of pregnancy.
high risk i.e. family history of neural tube defects. 5mg daily. until week 12 of pregnancy.
Adrenaline
IM 0.5ml of 1 in 1000 = 500mcg.
HRT
can increase BP, stop if >160/95. sodium and fluid retention.
Statins and liver function
3x upper limit with transaminases discontinue.
phytomenadione vit k 2mg po
if inr >1.5 on the day before surgery, use phytomenadione vit k 1-5mg PO using iv preparation.
Statins
looking for a >40% reduction in non-HDL cholesterol.
Digoxin
bradycardia
for second episode of c.diff
oral vancomycin
COCP
monitor bp
opioids in renal impairment
not renal excreted so can use in renal impairment
Hyponaturaemia
thiazides ssri siadh spirinolactone
Breakthrough pain
keep same drug, dose is 1/6 of 24 hour dose,
INR surgery day
if <1.5 give oral vit k 1-5mg phytomenadione
Rivaroxaban
give with food
evening hyperglycaemia
increase morning insulin by 10%
Tardive dyskinesthia
stop drug and give terbutaline
Dystonia (olyguric crisis or extra-pyramidal)
procyclidine
Peripheral vascular disease
dont give beta adrenoceptor blockesr e.g. atenolol
CK >5 times upper limit discontinue
If resolve then restart at lower level
