Part 1

Question 1

Drugs that may require reduced dosing in elderly and side effects

Answer 1

Question 2

Drugs with potential teratogenic effects

Answer 2

Question 3

Drugs to be aware in common diagnoses

Answer 3

Question 4

Common drug interactions

Answer 4

Question 5

Drugs that may cause constipation

Answer 5

Question 6

Drugs that may cause constipation

Answer 6

Question 7

Drugs that may cause confusion

Answer 7

Question 8

Drugs that may cause diarrhea

Answer 8

Question 9

Drugs that may cause dyspepsia

Answer 9

Question 10

Drugs that may cause falls/dizziness

Answer 10

Question 11

Drugs that may cause hearing loss

Answer 11

Question 12

Tremor causing drugs

Answer 12

Question 13

Red flag signs in children (infection)

Answer 13

Several red (high risk) signs and symptoms:
tachypnoea (RR >60/min)
temperature ≥ 38°C
pale, mottled skin
lethargy

Question 14

What do ADR frequency equate to in percentage

Answer 14

Question 15

Common side effects of Loop diuretics (e.g. furosemide)

Answer 15

dehydration, renal impairment, hypokalaemia.

Question 16

Common side effects of Non-steroidal anti-inflammatory drugs (e.g. ibuprofen)

Answer 16

gastrotoxicity, renal impairment, hypertension.

Question 17

Common side effects of Opioid analgesics (e.g. morphine)

Answer 17

constipation, confusion, drowsiness, urinary retention.

Question 18

Examples of drugs in which plasma level or biomarker monitoring is required

Answer 18

digoxin, gentamicin, vancomycin, antipsychotics, lithium and phenytoin

Question 19

Gentamycin monitoring

Answer 19

• There are no nationally-accepted guidelines for monitoring once-daily dose regimens.
• Although there are still some advocates for monitoring peak and trough levels with once-daily dosing, that approach is much more time-consuming and more difficult to interpret.
• For most patients, a nomogram is the method of choice in order to confirm or modify dosing intervals. For a daily dose of 7 mg/kg/day, the Hartford nomogram can be used.
• Gentamicin levels should be taken between 6–14 (16-18 in our guideline) hours after the start of the infusion (the Urban-Craig nomogram is an alternative for a daily dose of 5mg/kg/day)
• Normal/stable renal function: re-check gentamicin levels every 2-3 days
• Impaired renal function: gentamicin level required before each dose
• If the dose is adjusted, repeat levels should be taken 18 - 22 hours after the dose change
• U&Es should be checked every 2-3 days (daily if CrCl < 40ml/min)
• All patients prescribed more than one dose of gentamicin should have a fluid balance chart completed and urine output should be closely monitored

Question 20

Once daily vs multiple daily gentamycin safety and effectiveness

Answer 20

Once-daily dosing of gentamicin has been shown to be at least as effective as and not more toxic than a multiple-daily dosing regimen

Question 21

Contra-indication to gentamycin

Answer 21

Myasthenia gravis

Question 22

Who is once daily dosing of gent not appropriate?

Answer 22

Once-daily dosing not appropriate in:
- Endocarditis or Pregnancy - use multiple-daily (conventional) gentamicin dosing regimens
- Ascites, Burns, Cystic Fibrosis - refer to Microbiologist

Question 23

Interpreting once daily dosing gent and when should it be measured

Answer 23

Post-dose Level

• <1 mg/L
  Continue gentamicin at current dose
  1-2mg/L
  Wait until the level is <1mg/L and then HALVE current dose, give this dose, then re-check levels 18-22 hours post-dose
  ->2mg/L
  STOP gentamicin and contact Consultant Microbiologist or Pharmacist for advice

Normal/stable renal function: re-check gentamicin levels every 2-3 daysImpaired renal function: gentamicin level required before each dose

Question 24

Gentamycin treatment duration

Answer 24

DO NOT continue treatment for longer than 5 days without discussion with Microbiology or referral to the Microbiology ward round on Tuesdays and Thursdays

Question 25

Lithium monitoring

Answer 25

Samples taken at least 6 hours post-dose. Target concentration is 0.4–1.0 mmol/L.

Question 26

Vancomycin target levels and when test should be taken

Answer 26

A pre-dose (trough) concentration should be taken after 3–4 doses. Target concentration 10–15 mg/L (15–20 mg/L for severe infections or less sensitive organisms)

Question 27

Digoxin target levels and when test should be taken

Answer 27

Samples should be taken at least 6 hours post-dose. Efficacy is best determined with a clinical endpoint (e.g. heart rate). The risk of toxicity increases progressively at concentrations >1.5 microgram/L (1.92 nmol/L), and becomes likely at concentrations >3.0 microgram/L (3.84 nmol/L).