OPIC drugs Flashcards
Indications for Alendronate?
Treatment of postmensopausal osteoporosis
Treatment of osteoporosis in men
Prevention and treatment of corticosteroid- induced osteoporosis in post-menopausal women not receiving HRT
What is the dose for Alendronate?
10mg daily for all indications
Post-menopausal osteoporosis 10mg daily or 70mg once weekly
Contraindications of alendronate?
Abnormalities of oesophgus, hypocalcaemia (as alendronate can decrease serum calcium), other factors which delay emptying (stricture or achlasia)
Advice to pts when prescribing Alendronte?
30 mins before eating
Sit upright
Side effects of Alendronate?
Oesophagitis, osteonecrosis of the jaw/external auditory canal, gastrointesitnal disorders, joint swelling, vertigo
Drug- Drug Interactions for alendronate
NSAIDs- increase risk of GI irritation
Deferasirox (iron chelator)- SEVERE, increased risk of GI bleeding
Indications of Baclofen?
Pain of muscle spasm in palliative care
Hiccup due to gastric distension in palliative care
Chronic severe spasticity from disorders e.g MS or traumatic partial section of spinal cord
Severe chronic spasticity unresponsice to oral antispastic drugs
Baclofen dose?
Pain of muscle spasm in palliative care: Oral 5-10mg 3 times a day
Hiccup due to gastric distension in palliative care: Oral 5mg twice daily
Baclofen dose for chronic severe spasticity resulting from dsorders e.g MS or traumatic partial section of spinal cord
Oral
Initially 5mg 3 times a day, gradually increased
Maintenance up to 60mg daily in divided doses
Review treatment if no benefit within 6 weeks achieving max dose
Max dose- 100mg per day
Baclofen dose for : severe chronic spasticity unresponsice to oral antispastic drugs
Intrathecal injection
Test dose 20-50 micrograms to be given over at least 1 min via catheter or LP, then increased in steps of 25 micrograms (max 100 micrograms),
Contraindications of intrathecal/ oral baclofen?
Intrathecal- local infection, systemic infection
Oral- active peptic ulceration
Side effects of Baclofen?
Confusion
Constipation
Depression
Diarrhoea
Dizziness
Dry mouth
Euphoric mood
Hallucination
Headache
Hyperhidrosis
Gi disorder (oral use)
Myalgia
chills
Interactions with baclofen?
Clozapine- can cause constipation, concurrent use might increase risk of intestinal obstruction, increase risk of hypotension, CNS depressent affects
Levodopa- Baclofen decreases the absorption of Levodopa
Indications of Colchicine?
Acute gout
Short-term prophylaxis during initial therapy with allopurinol and uricosuric drugs
Prophylaxis of familial MEditerraenean fever
Dose of Colchincine?
Acute gout- Oral- 500 micrograms 2-4 times a day until symptoms relieved, max 6mg per course, do not repeat course within 3 days
Prophylaxis - oral- 500 micrograms 2x daily
Prophylaxis of familial Mediteraanean fever- 0.5-2mg once daily
Side effects of Colchicine?
Abdo pain
Diarrhoea
Nausea
Vomitting
Interactions with Colchincine?
CYP3A4 inhibitors- reduce dose by 75%/ avoid in potent inhibitors - clarithromycin, verapamil, grapefruit, ketoconazole
Atorvastatin- can cause Rhabdomyolysis
Bezafibrate- rhabdomyolsis
P-glycoprotein inhibitors- avoid
Indication for Adcal D3?
Prevention and treatment of vitamin D and calcium deficiency
Side effects of Adcal D3?
Colecalciferol component:
Abdominal pain; headache; hypercalcaemia; hypercalciuria; nausea; skin reactions
Calcium carbonate component: (SE are uncommon)
Constipation; diarrhoea; hypercalcaemia; nausea
What is Adcal D3 made up of?
Calcium carbonate (750 mg) and vitamin D3 (200 I.U.)
What are important interactions of Adcal D3?
- other calcium carbonate containing antacids - can impair absorption.
- thiazides - increase risk of hypercalcaemia
- Doxycycline - calcium carbonate will decrease absorption of doxy.
- Adcal leaflet: thyroxine, bisphosphonates, iron or fluoride medicines, tetracycline or quinolone antibiotics - need to keep these meds 4 hours apart from AdcalD3.
Indication for amitriptyline?
- Abdominal pain or discomfort (in patients who have not responded to laxatives, loperamide, or antispasmodics)
- Neuropathic pain
- Migraine prophylaxis, Chronic tension-type headache prophylaxis
- Emotional lability in multiple sclerosis
- (Major depressive disorder - not recommended due to fatality in overdose)
Interactions for amitriptyline?
Main issues - hypotension, hyponatraemia, constipation.
Examples:
* Amantadine (a weak dopamine agonist) - increases risk of hypotension
* Amlodipine - increases risk of hypotension
* Baclofen - hypotension
* Thiazide diuretics - hypotension and hyponatraemia
* B blockers (atenolol, bisoprolol) - hypotension
* Carbamazepine - decreases exposure to amitriptyline
* Chlordiazepoxide - both this and amitriptyline = have depressive effects
* Citalopram - hyponatraemia
* Clozapine - an antipsychotic. this + ami = cause constipation
* Lithium - neurotoxicity
* Oxybutynin - ++ antimusc effects
Drug class of amitriptyline?
tricyclic antidepressant
Side effects of amitriptyline?
- Anticholinergic syndrome
- drowsiness
- QT interval prolongation
Elderly patients are particularly susceptible to many of the side-effects of tricyclic antidepressants; low initial doses should be used, with close monitoring, particularly for psychiatric and cardiac side-effects.
Amitriptyline impact on falls in elderly?
V bad! Significantly increased the risk of fall-related injuries in elderly
Indication of co-careldopa?
Parkinson’s disease
(Initially 25/100mg 3x a day, then increased in steps of 12.5/50mg once daily)
`
Class of co-careldopa?
Dopamine precursor
What makes up co-careldopa?
Carbidopa and Levodopa
Side effects of co-careldopa?
Common
* reduced appetite
* Nausea and vom
* dizziness when getting up
* Insomnia
* Uncontrollable twitching, twisiting or dyskinesias (writhing movements)
Serious
* Implule control disorder - pathological gambling, high sex drive
* dopamine dysregulation syndrome - crave higher dose
* feel sleepy/fall asleep suddenly during day
* hallucinations
* anxiety and/or depression, suicidal ideation
Interactions to be aware of for co-careldopa?
Carbidopa part
* iron - iron decreases the exposure to oral Carbidopa.
Levodopa part
* Baclofen - increases SE as decreases absorption of Ldopa
* Ldopa + Thiazides, Bblockers, CCBs, ACEi = all increase risk of Hypotension
* Clozapine - a D2 antagonist
* Antipsychotics - haloperidol, droperidol (these are also used for nausea and vom)
Why does co-careldopa increase risk of falls in elderly?
Sudden onset of sleep, postural hypotension, confusion
Doxazosin - drug class?
Alpha-adrenoceptor blockers
Doxazosin - what is indication?
Hypertension
Benign prostatic hyperplasia
Note: dose is 1mg daily then doubled every 1-2weeks, max 8mg daily for BPH, max 16mg daily for HTN
Side effects of doxazosin?
- Hypotension - Dizziness, weakness, sleepy
- headaches
- peripheral odema of feet, ankles, fingers
- UTIs
- GI discomfort
- Chest pain and SOB
Interactions for doxazosin?
- Sildenafil, Tadalafil - significant hypotension
- Meds that reduce BP or affect HR- SSRIs, baclofen,GTN, co-careldopa, Bblockers, thiazides
- ketoconazole (for fungal infections) - increases exposure to Doxazosin
Doxazosin and how it affects risk of falls?
- Postural hypotension
- Dizziness
Drug class of macrogol?
Osmotic laxative
Indication for macrogol?
Constipation - chronic constipation
Side effects of macrogol?
Most common: Flatulence; gastrointestinal discomfort; nausea; vomiting
Contraindications for macrogol?
- Ileus
- intestinal obstruction;
- intestinal perforation
- risk of intestinal perforation
- severe inflammatory bowel disease
- toxic megacolon
Interactions with macrogol?
Medicines that can not be taken at same time as macrogol as it reduces their efficacy:
* Levetiracetam
* Phenytoin
How does macrogol influence risk of falling?
Increases risk of falling- laxatives can increase the urgency to void with resulting higher risk of falling
What class of drug is prednislone in?
Corticosteriods
Indications for prednisolone?
- Acute exacerbation of COPD
- Asthma - mild to moderate, severe, life threatening
- Local treatment of inflammaion - topical to eye
- Suppress inflammatory conditions or allergies
- Idiopathic thrombocytopenic purpura
- UC, Chron’s
- Myasthenia Gravis
- PMR, GCA
- Cluster headaches - short term prophylaxis
Side effects of prednisolone?
Quite a lot
* Behavioural changes and mood changes, psychotic disorders
* Cataracts (subcapsular)
* Cushing’s syndrome
* Fluid retention
* HTN
* Tiredness
* GI discomfort
* Headaches
* Hirsutism
* Increased risk of infection
* Osteoporosis
* Peptic ulcers
* Nausea
* Skin reactions
* Sleep disorders
* Increased weight
* DM control impaired
Interactions for prednisolone?
Drugs that cause hypokalaemia when given with pred:
* Amiodarone
* Citalopram
* Clarithromycin
* Haloperidol
* Ondansetron
Drugs that increase GI bleeding risk:
* Diclofenac
* Ibuprofen
* Naproxen
* Aspirin
Other:
* Live vaccines - increase risk of infection
* Digoxin - increased dig tox risk
* Phenytoin - decrease exposure to pred
* Warfarin - pred increases effects of warfarin - so need to check INR
Prednisolone and the risks of elderly using this?
- if they do fall - have increased fracture risk
- risk of delirium, depression, mania
- increased risk of worsening/onset of glaucoma and cataracts –> increases risk of falling
- impaired wound healing
Indication for tamsulosin?
BPH
Main drug interactions for tamsulosin?
- Phosphodiesterase type-5 inhibitors - sildenafil, tadalafil –> increases hypotension
- Aprepitant - prevents N+V after emetogenic chemo –> increases exposure to tamsulosin
- Bblockers - atenolol, bisoprolol –> increase hypotension
- CCBs, ACEi –> hypotension
- Levodopa –> hypotension
- Amitriptylline –> hypotension
(listed ones common in elderly care)
Side effects of tamsulosin?
- Dizziness
- Sexual dysfunction
Other: constipation; diarrhoea; headache; nausea; palpitations; postural hypotension; rhinitis; skin reactions; vomiting
What is drug class of tamsulosin?
Alpha-adrenoceptor blockers
Impact of tamsulosin on falls?
- For alpha1-selective adrenoceptor blockers, prescription potentially inappropriate (STOPP criteria) in elderly:
- in those with symptomatic orthostatic hypotension or micturition syncope (risk of precipitating recurrent syncope)
- in those with persistent postural hypotension i.e. recurrent drop in systolic blood pressure ≥ 20 mmHg (risk of syncope and falls).
Due to hypotension and risk of syncope – increase risk of falls
Amiodarone drug class?
Class III Antiarrhythmics
Indication for amiodarone?
Treatment of arrhythmias
Usually when other frugs are ineffective or contra-indicated
Main side effects for amiodarone?
Sandilands lec:
Pulmonary fibrosis, hepatic inury, increased LDL chol, thyroid disease, photosensitivity, optic neuritis (PFTs, LFTs, TFTs)
*BNF: *
Oral use:
Constipation; corneal deposits; hypothyroidism; movement disorders; photosensitivity reaction; sleep disorders; taste altered; vomiting
Parenteral use:
Hypotension
Main interactions for amiodarone?
There are so many !!!
From Sandilands lecture: Digoxin, warfarin - increases anticoag effect
A select few from BNF
* Bblockers - acebutolol, bisoprolol –> increase risk of bradycardia
* Aminophylline - cause hypokalaemia
* thiazides - cause hypokalaemia
* ciclosporin - amiodarone increases conc of ciclosporin
* citalopram - prolongs QT interval
* colchicine - amiodarone increases exposure to colchicine
* dexamethasone - hypokalaemia and torsade de pointes
* Haloperidol - prolong QT interval
* prednisolone - hypokalaemia
* Risperidone - prolong QT interval
* Salbutamol, salmeterol - hypokalaemia
* Simvastatin - A increases exposre of Sim
Amiodarone and the elderly - what are risks?
Amiodarone could be part of STOPP criteria as 1st line antiarrhythmic in supraventricular tachyarrythmias.
Increases risk of syncope –> increased risk of falls
What is Entacapone?
Prevents peripheral breakdown of levodopa by inhibiting catechol-O-methyltransferase, allowing more levodopa to reach the brain.
Indications and dose for Entacapone?
Adjunct to co-beneldopa or co-careldopa in Parkinsons disease with ‘end- of-dose’ motor fluctuations- 200 mg to be given with each dose of levodopa with dopa- decarboxylase inhbitors
Max- 2g a day
Contraindications of entacapone?
Hx of neuroleptic malignant syndrome, hx of non-traumatic rhabdomyolysis, phaeochromocytoma
Side effects of Entacapone
Abdo pain, confusion, constipation, diarrhoea, dizziness, hallucinations, nausea, sleep disorders, vomitting
DDIs of Entacapone?
Isocarboxazid, Phenelzine, Tranycypromine: increase risk of elevated BP
Methyl and Levodopa: entacapone increases exposure so adjust dose
Indications and dose for oxybutynin?
Urinary frequency, urgency, incontinence and neurogenic bladder instability.
Immediate release:
Adult: initially 5mg, 2-3 times a day, increased if necessary up to 5 mg, 4 times a day
Elderly: Initially 2.5-3mg twice daily, increased if tolerated to 5mg twice a day
Modified release
Adult: Initially 5mg once daily, increased in steps of 5mg every week, adjusted according to response; max 20 mg per day.
**Transdermal application **
Apply 1 patch twice weekly, patch is to be applied to clean, dry, unbroken skin on abdomen, hip or buttock.
Patch should be removed every 3-4 days and site replacement on different area, same area should be avoided for 7 days.
Contraindications for Oxybutynin?
The following is for all antimuscuranics:
Angle closure glaucoma, gastro-intestinal obstruction, intestinal atony, myasthenia gravis, paralytic ileus, pyloric stenosis, severe UC, significant bladder outflow obstruction, toxic megacolon, urinary retention.
What are the cautions of oxybutynin when prescribed in the elderly?
- to treat extrapyramidal side-effects of antipyschotic medication
- in delirium or dementia (risk of exacerbation of cognitive impairment), narrow angle glaucoma, or chronic prostastism (risk of urinary retention)
- If two or more antimuscarinic drugs prescribed concomitantly (risk of increased antimuscarinic toxicity)
Side effects for
1) antimuscarinics
2) Oxybutynin
1) constipation, dizziness, drowsiness, dry mouth, dyspepsia, flushing, headache, nausea, palpitations, skin reactions, urinary disorders, visions disorders, vomitting
2) diarrhoea, dry eyes (with oral use), transdermal use : GI discomfort, increased infection risk
DDIs for Oxybutynin?
Clozapine- together can cause severe constipcation–> increased risk of intestinal obstruction
Zonisamide- Increases the risk of overheating and dehydration- avoid in kids
What is Ropinerole?
Used in Parkinsons, alone or as an adjunct to co-beneldopa or co-careldopa
Restless legs syndrome
What class of drug is Allopurinol?
xanthine oxidase inhibitors.
Reduces the production of uric acid in the body. High levels of uric acid may cause gout attacks or kidney stones
What is the indication for allopurinol?
- Prophylaxis of gout
- Prophylaxis of uric acid and calcium oxalate renal stones
- Prophylaxis of hyperuricaemia associated with cancer chemotherapy
What are the side effects of allopurinol?
Common:
- Rash
Uncommon:
- Hypersensitivity
- Nausea
- Vomiting
Rare:
- Vertigo, visual impairment, drowsiness, peripheral neuropathy, paraesthesia, ataxia, aplastic anaemia, agranulocytosis, diabetes mellitis, cataract, bradycardia, coma, depression
What is the impact on falls of allopurinol ?
Some rare complications could increase risk of falls:
Malaise, vertigo, visual impairment, drowsiness, peripheral neuropathy, paraesthesia, ataxia, cataract, bradycardia, coma, depression
What are important interactions of allopurinol?
- Azathioprine (haematological toxicity)
- Bendroflumethiazide (hypersensitivity)
-Enalapril / Lisinopril (hypersensitivity and haem rxns) - Indapamide (hypersensitivty)
- Amoxicillin (skin rash)
Cautions when initiating allopurinol?
Ensure adequate fluid intake (2–3 litres/day)
Hyperuricaemia associated with cancer therapy- start allopurinol treatment before cancer therapy
thyroid disorders
What class of drug is Cinnarizine ?
Sedating antihistamine
What indications for Cinnarizine ?
Relief of symptoms of vestibular disorders, e.g. vertigo, tinnitus, nausea, and vomiting in Ménière’s disease
Motion sickness
What side effects of Cinnarizine ?
Common:
- Drowsiness
- GI discomfort
- Nausea
-Weight increase
Uncommon:
- Fatigue
- vomiting
- hyperhidrosis
Unknown frequency :
- Parkinsonism
-tremor
- movement disorders
What impact on falls for Cinnarizine ?
- Can make pts drowsy
- can induce parkinsonism / movement disorders
What important interactions of Cinnarizine ?
Isocarboxazid - (Monoamine-oxidase A and B inhibitors) increase the risk of antimuscarinic adverse effects
Betahistine - decreases the effect of betahistine
Alcohol - depressant effects
Alprazolam - depressant effects
What are contraindications / cautions for Cinnarizine?
Contra-indication: Acute porphyrias
Cautions: Epilepsy, Parkinson’s, prostatic hypertrophy, angle-closure glaucoma
What class of drug is digoxin?
What are the indications for digoxin?
- ‘Rapid digitalisation’ or maintenance in AF or atrial flutter
- Heart failure (pts in sinus rhythm)
What are the side effects of digoxin?
Common:
arrhythmias, cardiac conduction disorder, cerebral impairment, diarrhoea, dizziness, nausea, vision disorders, skin reaction
Uncommon:
depression
Rare:
Appetite decreased, confusion, psychosis, thrombocytopenia
What is the impact on falls from Digoxin?
Can cause arrhythmias - syncope and LOC
Dizziness
vision disorder
confusion
psychosis
could all add to likelihood of a fall
What are some important interactions with Digoxin?
Amiodarone - increase exposure to digoxin
Azithromycin - increased concentration of digoxin
Beclometasone - increase digoxin toxicity
Bendroflumethiazide - increase digoxin toxicity
ciclosporin - increase conc. of Digoxin
clarithromyciin - increase conc. of digoxin
what are monitoring requirements for digoxin?
For plasma-digoxin concentration assay, blood should be taken at least 6 hours after a dose.
Monitoring of patient parameters
Monitor serum electrolytes and renal function. Toxicity increased by electrolyte disturbances.
What are some contraindications for digoxin?
Hypercalcaemia (risk of digitalis toxicity); hypokalaemia (risk of digitalis toxicity); hypomagnesaemia (risk of digitalis toxicity);
hypoxia (risk of digitalis toxicity);
recent myocardial infarction;
severe respiratory disease;
sick sinus syndrome;
thyroid disease
In the elderly when should STOPP criteria be applied to Digoxin?
Prescription potentially inappropriate (STOPP criteria):
- heart failure with normal systolic ventricular function (no clear evidence of benefit)
- long-term dose greater than 125 micrograms daily if eGFR less than 30 mL/minute/1.73 m2 (risk of digoxin toxicity if plasma levels not measured)
Indications for haloperidol
- Maintenance in schizophrenia (IM)
- Treatment of persistent aggression / psychotic symptoms in dementia when non-pharmacological treatments have failed
- acute treatment of delirium in adults when non-pharmacological treatments have failed
2mg a day or oral haloperidol is equivalent to 15mg / week depot injection
Class of haloperidol
Antipsychotics, first-generation (depot injections)
Side effects of haloperidol
Common:
Agitation, arrhythmias; constipation; dizziness; drowsiness; fatigue; hyperglycaemia; hyperprolactinaemia; hypotension (dose-related); insomnia; leucopenia; movement disorders; muscle rigidity; neutropenia; parkinsonism; postural hypotension (dose-related); QT interval prolongation; rash; seizure; tremor; urinary retention; vomiting;
Impact on falls from haloperidol
Delirium risks: constipation / urinary retention
Falls / Syncope risks: postural hyptonsion, arrythmia, QT prolongation
Important interactions for haloperidol
Smoking if started or stopped - need to adjust dose
Aminophylline - hypokalaemia torsades des pointes
Amiodarone - both prolong QT interval
Beclometasone - hypokalaemia
Chlorpromazine - prolong QT
Citalorpram - prolong QT
Clarithromycin - prolong QT
Clozapine - can also cause constipation - obstruction
What are some contraindications and cautions for haloperidol?
Contraindications:
CNS depression, long QT syndrome, dementia with Lewy Bodies, Parkinson’s, Torsade de pointe, ventricular arrhythmia, recent MI, uncompensated heart failure, hypokalaemia\
CautionsL
depression, diabetes (raise blood sugar) epilepsy, MG, Parkinson’s, angle-closure glaucoma
Indication for clopidogrel?
- Prevention of atherothrombotic events in percutaneous coronary intervention (adjunct with aspirin) in patients not already on clopidogrel
- TIA for patients with aspirin sensitivity
- Acute ischemic stroke for pts with aspirin hypersensitivity
- Prevention of atherothrombotic events in PAD or within 35days of MI, or 6m of ischaemic stroke
- prevention of ACS without ST elevantion (given with aspirin)
- Prevention of atherothrombotic and thromboembolic events in pts with AF and at least one RF for a vascular events (with aspirin) , and warafin is unsuitable
Contraindication for clopidogrel?
Active bleeding
Risk of clopidogrel in elderly?
High risk of bleeding
BNF says: Prescription potentially inappropriate (STOPP criteria) with concurrent significant bleeding risk, such as uncontrolled severe hypertension, bleeding diathesis or recent non-trivial spontaneous bleeding
Common SE for Clopidogrel?
Diarrhoea; gastrointestinal discomfort; haemorrhage; skin reactions
Class of clopidogrel?
Antiplatelet
Interactions for clopidogrel?
Alteplase
Apixaban / Rivaroxaban
Aspitin
Citalopram
Dalteparin/ Enoxaparin
Diclofenac and ibuprofen
Glitazones - (pioglitazone) - clop increases exposure to pio
Prasugrel, Ticagrelor
Warfarin
Grapefruit
Class of furesomide?
Loop diuretic
Indications for furesomide?
Oedema
Resistant oedema
Resistant hypertension
Cautions of furesomide with elderly?
- Need lower doses - as more prone to side effects
- treating HTN with this –> hypotension –> falls
- Can cause urinary retnetion in men with BPH
Side effects for furesomide?
Dizziness; electrolyte imbalance; fatigue; headache; metabolic alkalosis; muscle spasms; nausea (common for all loop diuretics)
Interactions for furesomide?
Cause hypokalaemia:
Amiodarone
Citalopram
Haloperidol
Hydroxychloroquine
Risperidone
Amifampridine (used to treat Lambert-Eaton myasthenic syndrome)
Sildenafil
Increase risk of hypotension:
Bisoprolol
Haloperidol
Risperidone
Digoxin - digoxin toxicity
Class of ibuprofen?
NSAIDs
Indication for ibuprofen?
Pain and inflammation in rheumatic disease and MSK disorders.
Post op analgesia
Dental pain
Caution of ibuprofen in elderly?
- Increased risk of gastric ulcers
- Increases CVS risk in pts with heart failure, PAD, cerebrovascular disease, IHD, uncontrolled HTN
- MAsks symptoms on infection - e.g. bacterial complications of varicella –> worsen outcomes
SE for ibuprofen?
GI discomfort
Skin reactions e.g. rash
Rare / v rare:
AKI
Anaemia
Haemorrhage
Liver disorder
Interactions for ibuprofen?
Increase risk of bleeding:
- Alteplase
- Apixaban
- aspirin
- beclometasone inhaler
- clopidogrel
- dexamethasone
- enoxaparin
- methylprednisolone, prednisolone
- rivaroxaban
- warfarin
Increases risk of AKI:
- thiazides
- ceftriaxone
Increases risk of seizures
- ciprofloxacin –> when given with ibuprofen
Increases risk of toxicity:
- methotrexate
Increases risk of hyperkalemia:
- ciclosporin
- lisinopril , ramipril
- spironolactone
Drug class of lorazepam?
Benzodiazepines
Indications for lorazepam?
- short term use in anxiety - oral
- acute panic attacks - IM
- conscious sedatuon for procedures
- status epilepticus / febrile convulsions
*
Caution of benzodiazepines use with elderly?
- can exacerbate respiratory failure
- is a sedative –> get reduced sensory stimuli and impaired balance –> increase risk of falls
Side effects of lorazepam?
Specifically for elderly: Confusion + Ataxia
Common for lorazepam : Apnoea; asthenia; coma; disinhibition; extrapyramidal symptoms; hypothermia; memory loss; speech slurred; suicidal behaviours
Interactions for lorazepam?
increases CNS depressive effect:
* Amitriptyline
* Baclofen
* Gabapentin
* Haloperidol
* Oxycodone
Class of drug - Ramipril?
ACEi
Indication for Ramipril?
- Hypertension
- Symptomatic HF (adjunct)
- Prophylaxis after MI (w/ clinical evidence of HF)
- Prevention of CVS events in pts w/ atherosclerosis CVD or DM and at least one other RF for CVD
- Nephropathy
Cautions with Ramipril in elderly?
- Hyperkalaemia –> muscle weakness; diarrhea; weak, slow, or irregular pulse; paresthesia; abdominal cramping; nausea; irritability; or even sudden collapse
- Postural hypotension
SE for ramipril?
All ACEi: (only listed some)
* Angiodema (more common in black pts)
* Dizziness
* Dyspnoea
* Palps
* Renal impairment
* Vertigo
Ramipril
* GI disorders
* increased risk of infection
* muscle spasms
* flushing
* asthma exacerbation
Indication and dose of Ropinirol?
Parkinsons Oral: Immediate release tablets: Initially 750 micrograms daily in 3 divided doses, then increased in steps of 750 micrograms daily, dose to be increased at weekly intervals, increased to 3mg daily in 3 divided doses and then increased 1.5-3mg in 3 divided doses. MAX 24mg a day
Parkinsons: Modified release medicines: Initially 2mg once daily for 1 week then 4mg once daily and increased in steps of 2mg at intervals of at least 1 week. Max 24mg per day
Moderate to severe restless legs: Initially 250 micrograms once daily for 2 days, increased if tolerated to 500 micrograms once daily for 5 days, then increased if tolerated to 1 mg once daily for 7 days, then increased in steps of 500 micrograms daily, adjusted according to response, dose to be increased at weekly intervals; usual dose 2 mg once daily, doses to be taken at night; maximum 4 mg per day.
When do you need to adjust the dose of Ropinirol?
Higher doses may be required if used with levodopa
Cautions for Ropinirol?
Elderly
Major Pyschotic disorders
Severe CVS disease- risk of HYPOtension
Side effects of Ropinirol?
Confusion
Dizziness
Drowsiness
Fatigue
GI Discomfort
Hallucinations
Movement disorders
Causes
Peripheral oedema
Sleep disorders
Syncope
What can you use Trimethorpim to treat?
Resp tract infections
Prophylalxis of recurrent UTIS
Mild/moderate Pneumocystis jirovecii pneumonia
Acne resistant to other antibacterials
Invasive salmonella infection
Acute diverticulitis (in comb with metronidazole)
Acute prostatitis
Acute pyelonepthritis
UTIs
Dose for Trimethroprim for UTIs?
Lower UTI: 200mg BDS for 3 days (7 days in males)
Catheter associated UTI: 200mg twice daily for 7 days (14 if upper urinary tract symptoms are present/ acute pyelonephritis)
Prophylaxis of recurrent UTI? 100mg once daily at night, alternatively 200mg for 1 dose, following exposure to a trigger
Contra-indications/ cautions of trimethoprim?
Contraindications: Blood dycrasias
Cautions: acute porphyrias, elderly, predisposition to folate deficiency
Side effects of Trimethoprim?
Diarrhoea
Electrolyte imbalance
Fungal overgrowth
Headache
Nausea
Skin Reactions
Vomiting
DDIs of Trimethoprim?
Acenocoumarol: trimethoprim increases anticoagulant effect
Azathioprine and Mercaptopurine: Trimethoprim may increase the risk of haematological toxicity when given in Renal transplant patients?
Methotrexate: trimethoprim increases the risk of adverse effects when given with methotrexate
Warfarin: increases anticoagulant effect
Pyrimethamine: increases adverse effects
Dapsone: increases exposure to trimethoprim and vice versa
Colistimethate: Increases risk of nephrotoxicity
Indications and dose of Aspirin?
2ndary prevention of CVS disease, of DVT and PE (if decline anticoagulant), TIA (in combo with dipyridamole), ischaemic stroke not associated with AF: 75mg OD
Acutely, so post- stroke (due to AF), acute stroke, suspected TIA: 300mg OD 14 days
unstable angina, NSTEMI, STEMI: 300mg chewed
Contraindications of Aspirin
Active peptic ulceration; bleeding disorders; children under 16 years (risk of Reye’s syndrome); haemophilia; previous peptic ulceration (analgesic dose); severe cardiac failure (analgesic dose)
Interactions for ramipril?
- Allopurinol - increase sensitivity and get haematological reactions
- Azathioprine - increase risk of anaemia / leucopenia
- Everolimus (cancer drug) - increase risk of angiodema
- lithium - ACEi increase conc of lithium
- Ciclosporin, dalteparin, diclofenac - increase risk of hyperkalaemia
Hypotension risk:
Other HTN drugs
Amitriptyline
B blockers
Baclofen
Gliflozins - e.g. canagliflozin
Interactions for ramipril?
- Allopurinol - increase sensitivity and get haematological reactions
- Azathioprine - increase risk of anaemia / leucopenia
- Everolimus (cancer drug) - increase risk of angiodema
- lithium - ACEi increase conc of lithium
- Ciclosporin, dalteparin, diclofenac - increase risk of hyperkalaemia
Hypotension risk:
Other HTN drugs
Amitriptyline
B blockers
Baclofen
Gliflozins - e.g. canagliflozin
Aspirin dose as analgesia?
PO 300-600mg every 4-6 hours PRN, max 2.4g per day
PR: 450-900 every 4 hours, max 3.6 g per day
Drug class of sertraline ?
Selective Serotonin re-uptake inhibitors - SSRIs
Side effects Aspirin?
Dyspepsia, haemorrhage
Aspirin DDIs?
Any other antiplatelet/ anti coagulant
Methotrexate: can increase toxicity
Drugs that affect the kidney
Indications and dose for codeine phosphate?
Mild/moderate pain: PO 30-60mg every 4 hours PRN, max 240mg per day
Acute diarrhoea: 30mg 3-4 times a day, 15-60mg 3-4 times a day
Indication for Sertraline?
- Depressive illness
- OCD
- Panic disorder, PTSD, Social anxiety
Cautions of sertraline in the elderly?
- cause hyponatraemia –> falls risk
Interactions for sertaline?
Drugs that increase risk of bleeding:
* Apixaban
* Alteplase
* Clopidogrel
* Datearin
* Duloxetine - also increases risk of hyponatraemia – serotonin syndrome
* Ibuprofen, Naproxen
Phenytoin - increases risk of toxicity
Grapefruit - increases exposure to sertraline
Amitriptyline, Carbamazepine, thiazides, gabapentin - increases risk of hyponatraemia
Ondansetron - increases risk of serotonin syndrome
Contraindications of Codeine phosphate?
Opioids: Acute resp depression, comatose pts, head injury, raised ICP, risk of paralytic ileus
Codeine specifically: Acute UC, abx associated colitis, onditions where abdominal distension develops; conditions where inhibition of peristalsis should be avoided; known ultra-rapid codeine metabolisers
Cautions of codeine phosphate?
Drug dependence and addiciton
Central sleep apnoea
Elderly
Side effects of codeine phosphate?
Arrhythmias; confusion; constipation; dizziness; drowsiness; dry mouth; euphoric mood; flushing; hallucination; headache; hyperhidrosis; miosis; nausea (more common on initiation); palpitations; respiratory depression (with high doses); skin reactions; urinary retention; vertigo; vomiting (more common on initiation); withdrawal syndrome
DDIs od codeine phosphate?
Cloazpine- both cause constipation–> increased risk of intestinal obstruction
Isocarboxazid and Phenelzine and Tranylcypromine: codeine predicted to increase risk of CNS excitation or depression when given with this drug
Nalmefene and Naltrexone- decrease efficacy of codeine
Side effects of sertraline?
Specifically for sertaline:
* chest pain
* depression
* GI disorder
* Increased risk of infection
* Vasodilation
For all SSRIs:
* anxiety
* confusion
* dry mouth
* headache
* hyperhidrosis
* palpatations
* tinnitus
* urinary disorders
Drug class of warfarin?
Vitamin K antagonist
Indication for warfarin?
- prophylaxis of embolisation in rheumatic heart disease and AF
- prophylaxis after insertion of prosthetic heart valve
- Prophylaxis and treatment of VTE and PE
- TIAs
Cautions for warfarin use in elderly?
- bleeding risk
- may already be on an antiplatelet e.g. if have PAD, where there is no indication for /added benefit of anticoagulant
- prescribed but continued without being stopped (e.g. having for longer than 6m post 1st DVT without RF)
Interactions for warfarin?
Amiodarone, doxycycline, trimethoprim, prednisolone, paracetamol - increases anticoag effect
Amoxicillin - alters anticoag effect
Apixaban, Aspirin, other anticaog, antiplatelrts, SSRIs - increases bleeding risk
Carbamazepine, azathioprine - decreases effect of warfarin
Side effects of warfarin?
Haemorrhage
Rare and v rare - alopecia, nausea, vomiting
Drug classs of trospium?
Antimuscarinics, urinary
Indications for trospium?
Urinary frequency
Urinary urgency
Urge incontinence
What is Isosorbide mononitrate?
A nitrate
Cautions of trospium in elderly?
- Risk of antimuscarinic toxicity - when given for extrapyramidal SE of antipsychotic meds
- elderly w/ dementia, delirium, acute angle glaucoma, chronic prostatism
- If already prescribed 2+ antimuscarinic meds
Indications and dose for Isosorbide mononitrate?
Prophylaxis of angina, adjunct in CHF: PO, initially 20mg 2-3 times a day, alternatively initially 40mg BDS, and increased up to 120mg daily in divided doses
Prophylaxis of angina, adjunct in CHF for those who have not previously had a nitrate: initially 10mg bds and up to 120mg daily if necessary
Contraindications of nitrates?
Aortic stenosis; cardiac tamponade; constrictive pericarditis; hypertrophic cardiomyopathy; hypotensive conditions; hypovolaemia; marked anaemia; mitral stenosis; raised intracranial pressure due to cerebral haemorrhage; raised intracranial pressure due to head trauma; toxic pulmonary oedema
SE of trospium?
Abdo pain
Antimuscarinics in general : constipation, dizzy, drowsy, dry mouth, headache, nausea, tachy, urinary and vision disorders
Cautions for nitrates?
Elderly
HF
Hypothermia
HYpothyroidism
Hyoxaemia
Malnurtition
Cardioversion
Susceptibility to angle closure glaucoma
VQ abnormalities
Side effects for nitrates?
Arrythmias, asthenia, cerebral ischaemia, dizziness, drowsiness, flushing, headache, hypotension, N&V
DDIs nitrates
Avanafil, sildenafil, tadalafil: increased risk of hypotension with nitrates
Prilocaine and Dapsone: Increase risk of methaemoglobinaemia
Interactions for trospium?
- T decreases absorption of Levodopa
- Clozapine - both increase risk of constipation
- Antimuscarinic effects –> Amitriptylline, Baclofen, Cyclizine, Haloperidol, Hyoscine, Oxybutynin, Tolterodine, Tiotropium
What is Selegilline?
MAO-B inhibitor
What is Selegilline?
MAO-B inhibitor
Indication and dose for Selegilline?
Parkinsons Disease-alone or as an adjunct to co-beneldopa/ co-careldopa to reduce ‘end or dose’ deteriortation, symptomatic Parkinsonism- PO, initially 5mg once daily for 2-3 weeks, then increased if tolerating to 10mg daily- take in the morn
Using oral lyophilise: 1.25mg once daily, dose to be taken before breakfast
Contraindications of selegilline?
Active duodenal ulceration, active gastic ulceration, use with great caution in postural hypotension
Cautions of selegilline?
Angina; arrhythmias; duodenal ulceration; gastric ulceration; history of hepatic dysfunction; patients predisposed to confusion and psychosis; psychosis; uncontrolled hypertension
Side effects selegilline?
Arrhythmias;
arthralgia;
back pain;
confusion;
constipation;
depression;
diarrhoea;
dizziness;
dry mouth;
fall;
fatigue;
hallucination;
headache;
hyperhidrosis;
hypertension;
hypotension;
movement disorders;
sleep disorders
; tremor; vertigo
DDIS of selegilline?
DObutamine, dopamine, ephedrine,Adrenaline, isometheptene,ozanimod- increases risk of hypertensive crisis
Bambuterol, formoterol, indaceterol: increase risk of severe hypertension
Bupropion: Enhance the risk of serotonin syndrome
COCP: increases exposure to selegilline
Isocarboxazid, linezolid, phenelzine :Selegilline Predicted to increase risk of adverse effects when given this drug
