Pass the PSA RT Flashcards
list the CYP450 drug inducers and their effect
decrease effective drug level
: Phenytoin, Carbamazepine, Barbiturates, Rifampicin, Alcohol (chronic excess), Sulphonylureas
CYP450 inhibitors and their effects
increase the effective drug level
: Allopurinol, Omeprazole, Disulfarim, Erythromycin, Valproate, Isoniazid, Ciprofloxacin, Ethanol (acute intoxication), Sulphonamides.
list drugs to be stopped before surgery
Insulin, Lithium, Anticoagulants, Antiplatelets, COCP/HRT, K / potassium sparing diuretics, Oral hypoglycaemics, ACEx / ARB
COCP stopped 4 weeks before. Lithium one day before. Diuretics/ACEx day of surgery.
COCP and surgery
stop 4 weeks before, start 2 weeks ater
lithium and surgery
stop one day before
common drugs metabolised by CYP450 and thus at risk of interactions with other drugs
warfarin COCP theophylline steroids tricyclics pethidine statins
prescribing routine
Patient details Reaction / allergies Sign chart Check contraindications Check route for each drug Prescibe intravenous fluids if needed Prescribe VTE prophylaxis if needed Prescribe anti-emetic if needed Prescribe analgesia if needed
pro bleeding drugs, stop if bleeding risk/bleeding
PRO-BLEEDING DRUGS – aspirin, ‘parins, warfarins, DOACs -> stop if active bleeding or risk of bleed
steroid side effects
stomach ulcers, thin skin, oedema, heart failure, osteoporosis, infection, diabetes, Cushing’s syndrome
NSAIDs side effects
– renal failure, heart failure, asthma, indigestion, clotting abnormalities (aspirin is okay in renal and heart failure and asthma)
beta blockers, calantag risks
– low blood pressure, bradycardia
electrolyte disturbance
ACEx, diuretics
ACEx side effect
cough
beta blockers and asthma
worsen acute HF/wheeze
calcium channel blockers side effects
peripheral oedema, flushing
diuretics side effect
renal failure
spironolactone side effects
high potassium, gynaecomastia
furosemide side effect
GOUT
meds with NBM patients
still receive oral drugs
antiemetic dosing
Antiemetics don’t change dose regardless of the route e.g. cyclizine 50mg 8 hourly, metaclopramide 10mg 8 hourly
max IV potassium rate
Don’t give IV potassium at more than 10mmol/hour ever.
describe process for prescribing replacement fluids
Replacement: give 0.9% saline unless:
- Sodium high or sugar low -> give 5% dextrose
- They have ascites -> give human-albumin solution instead (saline will worsen)
- Very low systolic blood pressure <90mmHg (try colloids as stays in vasc space)
- Shocked from bleeding -> give blood
speed of replacement fluids
- If shocked (obs off) -> 500ml stat and reassess obs + UO
- If oliguric -> 1L over 2-4 hours with careful monitoring of obs + UO response
how to estimate how fluid deplete someone is
500ml if UO alone reduced, 1L if UO reduced and tachy, 2L if signs of shock and low UO
example of standard adult maintenance fluids regime
Adults – 3L total / 24hr, Elderly – 2L total / 24 hr 8 hourly bags adult, 12 hourly elderly
Standard regime of 1L saline, 2L 5% dextrose provides adequate levels of most things
Add 20mmol of KCl in two of the bags (need 40mmol per day) – but be led by U+Es!
what should be done before each bag of fluids?
reasses pt
fluid status
palpate bladder
U+Es
contraindication compression stockings
peripheral vascular disease
what not to give if recent ischaemic stroke
Don’t give heparin or warfarin to recent ischaemic stroke
choice of antiemetic
- cyclizine is a good choice in almost all cases, except cardiac, give metaclop then.
who to avoid metaclopramide in?
Avoid metoclopramide in Parkinson’s or young women (dyskinesia risk)
paracetamol prescribing
no more than 4 grams a day, check not OD through co-presc co-codamol, PRN.
prescribing regular pain relief exmples
- paracetamol 1 g 6hourly OR co-codamol 30/500 2 tablets 6 hourly
pain relief PRN prescribing standard regimes
paracetamol 1g 6 hourly, codeine 30mg 6 hourly, MST 10mg 6 hourly, ibuprofen 400mg 8 hourly
prescribing for neuropathic pain
pregabalin 75mg 12 hourly, duloxetine specifically for diabetic neuropathy pain
drugs that can cause low potassium
thiazides, loop diuretics (NB all diuretics cause low sodium)
drugs that can cause high potassium
ACE inhibitors, spironolactone (potassium, sparing diuretics)
drugs that can trigger indigestion/uclers
- ibuprofen / NSAIDs, oral steroids
common drugs that trigger AKI
NSAIDs, ACE inhibitors
drugs causing constipation
opiates, esp codeine
avoid this drug in asthma or bronchoconstriction
NSAIDs (obvs BBs too)
can continue aspirin if no evidence of wheeze, only exception
their favourite drug error
They like questions with co-codamol and paracetamol combined OD – CHECK
what never to co prescribe with methotrexate
Never prescribe folate-inhibiting Abx with methotrexate! E.g. trimethoprim
what should you do with ISupp drugs if signs of sepsis / raised inflamm markers?
– if signs of sepsis / raised inflamm markers, WITH-HOLD
specific time limit for no LMWH/heparins post isch stroke
no heparin-style VTE prophylaxis for 2 months post stroke!
deal with calcium channel blocker peripheral oedema
key side effect to know is peripheral oedema. Stop if so. + stop any furosemide or diuretic used to ‘treat’. Due to the drug, not heart failure.
what shouldn’t be given alongside warfarin
Don’t give LMWH alongside warfarin – too much bleeding risk.
what shouldn’t be prescribed alongside verapamil?
Don’t give verapamil alongside bisoprolol – risk of bradycardia and hypotension
IV insulin
– only for sliding scale – only short-acting insulins i.e. Novorapid, Actrapid
common drugs causing SIADH and hyponat
carbamazepine and antipsychotics
microcytic anaemia
– iron deficiency anaemia, thalassaemia, sideroblastic anaemia
normocytic anaemia
– ACD, acute blood loss, haemolytic anaemia, chronic RF
macrocytic anaemia
B12/folate deficient, excess alcohol, liver disease, hypothyroid, ‘M’ diseases of the blood i.e. multiple myeloma, myelodysplasia, myeloproliferative disorder
high neutrophils
– bacterial infection, tissue damage (inflam, infarct, ca), steroids
low neutrophils
– viral infections, clozapine, carbimazole, carbamazepine, chemotherapy
high lymphocytes
viral infection, lymphoma, CLL
high platelets
reactive = bleeding, tissue damage (x3), post-splenectomy
low platelets
- infection, drugs (penicillamine-RA), myeloma (Ms), heparin, DIC, ITP, HUS
hypernatraemia
– dehydration, drips (excess IV saline), drugs with high sodium, diabetes insipidus
hyponat hypovol
fluid loss (D+V), diuretics, Addison’s
hyponat euvol
SIADH, hypothyroidism, psychogen polydipsia
hyponat hypervol
heart failure, renal failure, liver failure
SIADH causes
– SCLC, infection, abscess, drugs (carbamazepine, antipsych), head injury
hypokalaemia
– drugs (loop and thiazide diuretics), inadequate intake / GI loss, renal tubular acidosis, endocrine (Cushing’s, Conn’s)
hyperkalaemia
drugs (K-sparing diuretics, ACE inhibitors), renal failure, Addison’s, haemolysed sample, DKA
elevated urea
If elevated, either AKI or upper GI bleed (normal creatinine, not dehydrated)
pre renal AKI incl urea/cr and causes
70% - urea rise outstrips creatinine rise e.g. urea 19 but creat normal range – cause is dehydration / shock of any cause (sepsis, bleeds, renal artery stenosis)
renal AKI incl urea/cr and causes
10% - urea just raised, creatinine very high e.g. urea 9, create 300 –
ischaemia
drug damage
inflammation
cause is ischaemia, nephrotoxic Abx, ACEx, NSAIDs, imaging contrast, rhabdomyolysis, gout crystals, GN, vasculitis, cholesterol
Nephrotoxic Abx = gentamicin, vancomycin, tetracyclines
post renal AKI incl urea/cr and causes
20% - obstruction - urea just raised, creatinine very high e.g. urea 9, create 300 – cause is stones, cancers, BPH, aneurysm
Hepatocyte injury / cholestasis markers
bilirubin, ALT, AST, ALP
liver synthetic function
albumin, clotting factors
raised ALP
- fracture, posthepatic liver damage, cancers, Paget’s, pregnancy, hyperparathyroid osteomalacia, surgery
prehepatic jaundice
– isolated raised bilirubin – haemolysis, Gilbert’s
hepatic juanidce
bilirubin raised, AST/ALT raised – hepatitis, cirrhosis, ca, HF, fatty liver
post hepatic jaundice
– bilirubin raised, ALP raised – stones, cholestatic drugs, PB/SC, tumours
drugs causing cholestasis
fluclox, coamox, nitrofurantoin, steroids, sulphonylureas
TSH levels
– normal is 0.5-5, decrease thyroxine if lower, increase if higher
low t4 and cause
- hypothyroid. If TSH high – primary, if TSH low – secondary i.e. pituitary
high t4 and cause
– hyperthyroid. If TSH low – primary, is TSH high – secondary i.e. pit tumour
digoxin ECG changes
igoxin – ST segments down-sloping in all leads
narrow therpeutic index drugs
digoxin, theophylline, lithium, phenytoin, gentamicin, vancomycin
digoxin toxicity
confused, nausea, visual halos, arrhythmia
lithium toxicity
= tremor then tiredness then arrhythmia / seizure / coma / RF
phenytoin toxicity
= gum hypertrophy, ataxia, nystagmus, peripheral neuropathy
gent/vanc toxciity
ototoxic
nephrotoxic
to remember with poor kidneys and vanc/gent
need reduced doses than normal toa void toxiity
treating drug toxicigy
- Stop drug 2. Give IV fluids 3. Give antidote if available
drug monitoring - altering dose
– if out of range at 1hr post dose, increase dose. If out of range just before next dose, adjust interval of dosing.
gentamicin doseing
high dose regimen 5-7mg/kg for most, if renal failure then divided-daily-dosing at 1mg/kg. nomogram – should fall within 24 hr area when plotted, switch if falls outside this.
paracetamol OD
– if plasma level above the line 4 hrs after ingestion , NAC is needed
warfarin and INR responses
aim 2.5 for most, 3.5 for metallic valves. If major bleed – STOP it, give PT complex + 5-10mg IV vitamin K. if INR > 8, give 1-5mg oral vit K and omit. If 6-8 omit for 2 days and lower dose.
anti HTN drugs and illness
should normally stop antihypertensives when someone is unwell as vitals usually off
bHCG +Ve urine dip, remembe what drug change
Ensure you cancel the COCP prescription if someone is bHCG positive on urine dip!
none of this drug type in pregnancy
No folate antagonists in pregnancy!! Neural tube defects. So no trimethoprim etc
in hosp on neb salbutamol, stop what?
inhaler prescrioption
acute pulmonary oedema, vitals off
40mg IV furosemide
AF+asthma
digoxin,
might not have calcium channel blockers and can’t havebeta blockers
emergency drug apporach
ABCDE approach always – will usually ask re specific management, but don’t forget basic resus if not yet done in Q! e.g. prescribing oxygen / fluids
STEMI drugs
15L oxygen non rebreather, 300mg aspirin, morphine 5-10mg IV with 50mg cyclizine IV, GTN spray / tablet, bisoprolol 2.5mg
NSTEMI drugs to add
clopidogrel 300mg and fondaparinux 2.5mg OD s/c
acute LVF drugs
morphine 5-10mg IV with cyclizine 50mg IV, GTN spray/tab, furosemide 40mg IV +/- repeat dose
Adverse features+tachy >125bpm drugs
DC shock synchro x3, amiodarone 300mg IV over 10-20mins, followed by 900mg over 24 hrs
Narrow complex tachy drugs
irregular – possible AF = beta blocker / diltiazem, digoxin or amio if HF, if regular = vagal then adenosine 6mg rapid IV, repeated twice more
broad complex tachy and drugs
regular = amio 300mg over an hour, then 900mg over 24hrs, SVT+BBB = treat as narrow complex SVT, irregular = if torsades de pointes give magnesium 2g over 10 mins
anaphylaxis drugs
– oxygen, adrenaline 500 mcg of 1 in 1000 IM, chlorphenamine 10mg IV, hydrocortisone 200mg IV, amend allergies box!!
acute asthma dugs
oxygen, 5mg salbutamol neb, 100mg hydrocortisone IV if deadly / pred 40-50mg oral if moderate, 500mcg ipratropium nebs, aminophylline if deadly only
acute COPD ex drugs
add antibiotics if evidence of infection. Move down from high flow O2 to 28% Venturi and review with regular ABGs
oxygen, 5mg salbutamol neb, 100mg hydrocortisone IV if deadly / pred 40-50mg oral if moderate, 500mcg ipratropium nebs, aminophylline if deadly only
pneumonia drugs
amoxicillin, co-amox, clarithromycin etc (depends on HAP/CAP, typical/atyp)
PE drugs
– oxygen, morphine 5-10mg IV, cyclizine 50mg IV, enoxaparin treatment dose (1.5mg/kg/24 hours UNLESS risk factor, in which case 1mg/kg/12hrs). if adverse – thrombolyse, ITU
GI bleeding management drugs
– oxygen, cannula x2, catheter+fluid monitor, saline 500ml bolus, x match 6 units of blood, correct clotting if PT >1.5x normal (give FFP unless warfarinised, in which case give PT complex), if platelets «50 give platelets too, do OGD, stop NSAIDs/aspirin/warf/heparin (8Cs)
bacterial meningitis drus
if GP, 1.2g benzylpenicillin. High flow oxygen, dexamethasone IV, LP +/- CT, 2g cefotaxime, consider ITU (prob acyclovir cover too, but quite toxic IV)
seizures/stat epilepticus drugs/manage
ABCDE, secure airway, prevent aspiration of vomit, screen provoking factors, if 5+ minutes then lorazepam 2-4mg IV or buccal midazolam 10mg, repeat diazepam 10mg IV if still fitting, phenytoin infusion last resort, then intubation with propofol
stroke drugs, manage
- if any evidence of bleed on CT then discuss with neurosurgeons + don’t give aspirin / thrombolysis. If ischaemic = thrombolyse if <4.5 hrs ago + under 80 yrs, 300mg aspirin, stroke unit
DKA drugs, management
– fluids are key (1L saline stat then extra 1L bags over 1hr then 2 hrs then 4 hrs then 8 hrs), 50 units Actrapid in 50ml 0.9% saline at 0.1units/kg/hr. aim dec ketones 0.5 /hr. add 20-40mmol KCl to bags depending on K levels on VBGs. Add 10% dextrose at 125ml/hr once glucose <14. Find trigger and treat!
HHS drugs and management
– very high sugars and osmolarity (2Na+2K+urea+gluc) + crucially, NO ketones. Similar management to DKA except insulin may not be needed. Give prophylactic LMWH. Insulin rate if needed is 0.05u/kg/hr
hypoglyc<3 manage
can eat -> give juice/biscuits, can’t eat -> IV 100ml 20% glucose. If no cannula, give 1mg IM glucagon.
acute renal failure management / drugs
cannula+strict fluid monitoring, 500ml IV stat then 1L 4 hourly, find cause + order bloods, ABG, urinalsis, US kidneys, check drugs for nephrotoxics. Complications fluid overload, hyperkalaemia, acidosis. U+Es and fluid balance are the most crucial!
acute poisoning /OD manage/drugs
- IV fluids and pain relief if not OD on pain relief. If within 1 hour, pump stomach and irrigate bowel if Lithium or iron, consider charcoal. Give generous fluids. NAC for paracetamol if above nomogram line. Naloxone if opiates. Flumazenil if benzo OD.
chronic HF prescribing
– lisinopril 2.5mg daily, bisoprolol 1.25mg daily, if can’t use ACEx do candesartan 4mg daily. If can’t have either do hydralazine or nitrate. Increase doses as needed. Add spironolactone 25mg daily if still not achieving symptom relief. Specialist reassessment to consider sacubritril valsartan, digoxin, ivabradine.
AF stroke prevention
CHA2DS2VASc score – score 1 anticoag men, score 2 anticoag women. HASBLED score – don’t anticaog if 3+ score.
AF treatment prescribe
rhythm control if acute presentation <48 hrs -> d/c cardiovert, amiodarone, flecanide if not StructHD. Rate = >48hrs -> start with either bisoprolol 2.5mg or diltiazem 120mg daily. Combo therapy of the two +/- digoxin if not working to control symptoms.
Digoxin monotherapy only if sedentary AF.
signs more likley stable angina
if exertion / emotion triggered and no vom / sweating.
STEMI diagnose
– if trop raised, NSTEMI if depression or normal ECG. STEMI if ST elevation or new LBBB. Check 12 hour trop to see if cont rise.
stable angina manage drug
GTN spray PRN, aspirin / statin / BP mods, an antianginal + one of atenolol or amlodipine. Inc dose if still symptoms. If uncontrolled on 2x antianginals, refer for PCI or CABG.
COPD chronic drugs;/mx
smoking cessation + nicotine replacement + bupropion /vareniciline for cravings. Only start inhaled therapies once smoking advice+vax+physio+comorbids dealt with and they have SOB. Offer salb + tiotropium. If steroid responsive, move to salmeterol + ICS. If not, do salmeterol + long acting muscarinic.
asthma drug guidelines
SABA PRN then low dose ICS then inhaled LABA (in MART format), then consider increasing ICS dose or adding LTRA, refer after this
diabetes cons mx
lifestyle advice, cardio secondary prevention (75mg aspirin if >50 type 2 or any cardiac RFs) (atorvastatin 20mg if any RF or >40 in T2DM), annual complications review = ACR (indicates kidney damage or need for ACEx if >3mg/mmol).
type 2 diabetes drugs order
lifestyle intervention + >48 HbA1c 1. Metformin 2. If rises to 58+, add any of other oral drugs 3. Add insulin on top of triple therapy if still 58+
side effects with metformin
Always try modified release metformin before deciding they can’t have Metformin
pioglitazone warning
Be careful with pioglitazone if heart failure, bladder ca risk or bone fracture risk.
glutides
GLP1 agonists continue
Only continue GLP1 agonists if HbA1c reduces by 11+ and they lose weight.
Parkinsonsdrugs
first line is co-beneldopa or co-careldopa unless the pt has very mild disease and is concerned about the finite period of benefit -> then give ropinirole (dop ag) or rasagiline (MAOi
epilepsy drugs
2 unprovoked seizures or 1 with features suggestive of high risk of recurrence
myolconic siezure dtug
valproate male, levetiracetam female
tonic seiz drugs
valproate male, lamotrigine female
no thank
-
abscence seiz drugs
ethosuximide or valproate
seizure drugs are valproate for everything but focal which is carbamazepine
gen tonic clonic seiz drugs
¬valproate for males, lamotrigine for females
common antiepiletpic SEs
lamotrigine = rash
carbamazepine = rash, dysarth, nystagmus,
phenytoin = ataxia, gum hyperplasia, peripheral neuropathy,
valproate = tremor, teratogenic, weight gain
Levetiracetam = fatigue, mood disorders, agitation
alzhimer’s drugs
if mild / moderate -> donepezil, rivastigmine, galantamine, if moderate/severe then give memantine.
Chron’s remission drugs
mild flare = 20-40mg prednisolone OD, severe flare = 100-500mg hydrocortisone TDS IV, if any rectal disease, use rectal hydrocortisone too.
Chron’s maintaining remission
azathioprine or 6 mercaptopurine (which is the metabolised product)
azathioprine check pre prescribin
Must check TPMT enzyme levels before starting azathioprine as some people have very low levels and will need artificially lower dosing to avoid liver + BM toxicity.
rheumarth chronic managemtnt
methotrexate, other DMARD, then try infliximab
paracetamol max daily dose
4 grams
laxatives caution
caution! Never give if evidence of obstruction!
types of laxative
Osmotic = lactulose or phosphate enema (avoid in acute abdo or IBD) Stimulant = Senna, bisacodyl (avoid in acute abdo)
bulking agent, stool softener
Bulking agent = isphagula husk (good for impaction)
Stool softener = docusate sodium PO or arachis oil rectally (good for impaction, beware nut allergy for the oil)
diarrhoea drugs
– ONLY treat if non infectious cause! It is flushing out the bug. After negative MC+S, can give loperamide 2mg up to 3 hourly or codeine 30mg oral up to 6 hourly.
insomnia dtugs
start with 7.5mg zopiclone for adults and 3.75mg for elderly (try sorting the environment etc first as it is a falls risk!)
HTN guidelines
t2dm or less than 55non blak = ACEx, then CCB/thiazide then triple then alpha or spiro
old or black = CCB, then add ACEx or thiazide, then triple, then alpha or spiro
BP targets
younger than 80
140/90
over 80
150/90
salbutamol warnings
ensure to counsel about overuse if getting tachycardia / tremor
steroids counselling
3 weeks+ course to be avoided if possible as then adrenal dependent
no sudden stopping
abx prescribing
With abx, start with the lower dose in the range e.g. if 0.5-1g 6 hourly, start @ 500mg
cyclizine side effects counsel
has some antimuscarinic side effects + sedating action
amitriptyline warning
can worsen antimuscarinic effects in combo + worsen cog decline in old
neutropaenia drugs
carbamazepine, carbimazole, clozapine
vasc dement
75mg aspirin daily + antiHTN drug (Depending on potassium)
consider dx in elderly confused
also consider NPH and B12 deficiency
dopamine antagonist common drugs, beware
Metaclopramide and haloperidol -> beware in Parkinson’s + endo
*although, domperidone (same mech) can be used as doesn’t cross BBB
beware with allergie
TAKE CARE WITH ALLERGIES – question stem will often mention one, ensure you process that and bear in mind – often rules out the first line. Sneaky.
treat PE
PE – treat with treatmnet dose low molecular weight heparin (check correct for weight provided)
contraception Qs
they like to ask about drugs that induce enzymes and affect efficacy
contraception contraindications
migraine, hypertension, porphyrias, breast ca, any coag disorder, 15+ cigarettes daily >35yrs, SLE, any VTE history, <6 weeks postpartum, stroke Hx
warning for prescribing by weight
CHECK maximum dose (when you calculate by mg/kg you may exceed this – in this case, use max recommended)
antihypertensive drugs preg
Offer anti HTN drugs to women pregnant with chronicBP > 140/90. Labetalol > nifedipine > methyldopa
gout and renal impairmeetn
Give IM methylpred in gout if severe and renal imairment, alongside colcicine.
want to conceive and on ramipril
- stop ACEx as teratogenic + convert to labetalol with f/up – blood pressure does not fall until the second trimester
breast ca + tamoxifen
increases risk of VTE so warn about DVT+PE. Tamoxifen also increases risk of endometrial ca. common side effect of hot flushes.
gliclazdie SU and hypoglyc
counsel on this risk – take regular meals + take tab with breakfast.
key methotrexate info
they like this topic. Need regular FBC to check for neutropaenia. Only take once a week. Never give alongside folate antagonists e.g. trimethoprim cotrimoxazole. Give folate too.
alcohol and drug
acute intoxication inhibits enzymes whereas chronic excess induces ( either bad with things like warfarin). Warfarin tabs are colour coded by mg size.
warfarin remember for Qs
major adverse effect is bleeding. Avoid inducers/inhibitors
starting on ACEx
inc risk hyperkalaemia, cough common, be careful if unwell (D+V) as inc risk of AKI. ACEx and diuretics can cause renal failure. Monitor 2 weeks post starting ACEx, especially in CKD.
steroids long term
if predicted to take for >3 months, and elderly, start on bisphosphonate eg. Alendronate. Consdier giving PPI too as small inc risk of peptic ulcers. Long term risk of hyperglycaemia. Never stop abruptly or get Addisonian crisis. Risk of HTN. (learn steroid risks and SEs)
antidepresants counsel
– always counsel about seeking help as some may feel worse in the initial phase after starting them. May take six weeks for improv.
citalopram
makes you more photosenstive. SSRIs can cause dry mouth.
Agitation, raised temp and hallucination
and on SSRI
s = serotonin syndrome, life threatening. on
insulinand ill
Always counsel that increases in basal insulin are needed when ill. But don’t increase regular insulin unless eating!
rotate insulin sites
Must rotate injection sites or get lipodystrophy.
bisphosphonates counsel
once weekly usually. Don’t take alongside Adcal at same time of day. Avoid food 2 hours after alendronate. Take with full glass of water and remain upright for 30 mins afterwards.
HRT counselling
risk of breast ca higher for combined OP HRT than oestrogen-only. Excess breast ca persists for 10 years post HRT stopping. No inc risk with vaginal preparations. Not protective vs RFs e.g. HD
calculation Qs
write them out on paper! Do common sense test at the end.
1% prepartion =
1g in 100ml / 10mg in 1 ml
enoxaparin
need good renal func
presc abx
If Abx prescribed, should have stop/review date. Generally 5 days unless UTI,bone.
clinical improv and abx
convert to oral
when to give acex and diuretics
Prescribe ACEx for the evening as risk of postural drop. Give diuretics in the am
when to give drugs
follow bnf
other drugs in Q stem
Ensure you get the right dose for the right indication. If any other drugs are mentioned in the stem, you must always check for interactions.
exam tip!
always look at wording
may ask FIRST drug needed etc
manage hyperkal
– insulin and dextrose first, second line salbutamol. The cal gluc. E.g. 10 units actraid in 100ml of 20% dextrose.
best antiepileptic in preg
Lamotrigine excellent safety profile in pregnancy!
when phenytoin for seizures
Phenytoin only for stat epilepticus or no swallow as can go IV
when to avoid metformin
if creatinine >150. Better for overweight pt as suppresses appetite
why choose SU over metformin
Choose sulphonylurea if normal or underweight e.g. gliclazide (oral hypoglycaemic)
statins and myopathy
- a personal or family history of muscular disorders, previous history of muscular toxicity, a high alcohol intake, renal impairment, hypothyroidism, and in the elderly. Check CK in these patients. Other patients can just have ALT
statins monitoring
– LFTs on starting (can’t start if 3x normal), again at 3 and 12 months. Must stop if 3x rise.
drug tip
Always consider drug doses in context of pt – if too many SEs but ‘normal’ level, reduce and vice versa.
lithium counselling
See lithium toxicity effects at 1.5mmol/L +. Take levels at 12 hrs post last dose. Take levels weekly until stable then 3 monthly. Sodium depletion inc risk of toxicity – stable diet.
methotrexate monitoring
as with Lithium, regular FBC until stable, then 3 monthly. Only CXR if suspect SEs. Stop immediately if drop in WBCs/platelets. Don’t start if liver deranged. Toxicity more likely in renal dysfunction.
startingon antipsych
take baseline glucose! Can cause hyperglyc / diabetes. Only do baseline ECG if cardiac risk factors.
repeat presc COCP
Always retake BP when represcribing COCP .
amiodarone start and monitor
– baseline CXR is needed! Risk of pulmonary fibrosis. Monitor LFTs regularly. No renal probs with amio. Commence with caution if hypokalaemia – risk of arrhythmia.
agranulo drug moniotring
Always check FBC + neutrophils with anyone on agranulo risking drug + symptom/temps. (their favourites are carbimazole, clozapine, carbamazepine)
tip for drugs needing levels
Each of the drugs needing ‘levels’ have a monitoring section with specifics for levels required and when to take.
ACEx monitor
regular U+E monitoring and at every dose change.
when digoxin in AF
may be used in pt with risk of arrhythmia or hypotension instead of other `
digoxin monitor
Monitor serum creatinine for digoxin. Don’t routinely take plasma levels unless toxicity.
valproate SEs
hepatotoxicity, teratogenicity, pancreatitis
when clozapine and monitor
Clozapine only once failed on 2 other antipsych for schizophrenia.WEEKLY FBC for 18 weeks of treatment, then less often.
Low GCS + acidotic
metformin probably causing lactic acidosis.
Broad spec Abx (cephalosporin/ciprofloxacin) SE
c diff
heparins and underweight
if underweight <50kg – low platelets
aspirin SEs
haemorrahge, peptic ulcers, gastritis, tinnitus in large doses
digoxin SEs
xanthopsia (yellow/green visual perception incl halo vision).
Low potassium augments digoxin (toxic), high K+ reduces (doesn’t work)
nausea,vom, diarrhoea, confusion, drowsy,
amiodarone SEs
pulmonary fibrosis, thyroid either way, skin greying, corneal deposits
lithium SEs
early = tremor, then tiredness, late = arrhythmia, seizure, coma, RF, D insipidus
haloperidol SEs
dyskinesias + drowsiness
fludrocortisone SEs
hypertension, sodium/water retention
NSAIDS SEs
– renal failure, heart failure, asthma, indigestion, dyscrasia (clottingoff)
corticosterois SEs
stomach ulcers, thin skin, oedema, heart failure, osteoporosis, infection, hyperglycaemia, Cushing’s Syndrome
statins SEs
myalgia, abdo pain, liver enzymes up, rhabdomyolysis
dealing with statin myalgia
check CK + urine dip and exclude rhabdomyolysis, if symptoms unacceptable, switch to less myalgic statin e.g. atorva better than simva
synergistic effect bb and vera
beta blocker + verapamil = profound low BP and astyole
GI bleeding always check for these drugs
NSAIDs (aspirin, ibuprofen)
increased anticoag on warf
– acute alcohol + warfarin,
cause of hypertensive crisis
– Monoamine oxidase inhibitors (mocoblemide, resalagine)
Sweating/flushingvomiting –
disulfarim+metronidazole
nausea and vom with alcohol and abx
alcohol and metronidazole
sedating drugs
barbiturates, opioids, benzos
doxy SE
photosensitive rash
types of NSAIDs
aspirin, ibuprofen, naproxen, diclofenac (Motifene)
never co prescribe these
Never co-prescribe ACE inhibitors and NSAIDs!!!
brand names of drugs
Always look up any brand name as it masks the nature of the drug.
also a pot sparing diuretic
amiloride
Excess INR – no bleeding –
give phytomenadione (vitK1)
excess INR with bleeding
give vit K and prothrombin conc
pt with AF and thnn new abx and haematuria
If they give you a pt with AF and then they get haematuria with a new Abx, consider interaction with warfarin or anticaog.
anaphylaxis #1
secure airway
then adreneline and drugs
