Passmed Pharm Mushkies Flashcards
Diclofenac C/I?
Any form of cardiovascular disease
Best CVS profiles of the NSAIDs?
Naproxen and low-dose ibuprofen
S/e of spinal anaesthesia?
- Hypotension
2. Sensory and motor block, nausea, urinary retention
C/I of epidural anaesthesia?
- Confine pt to bed
- Catheter required
- Infection
- Epidural haematoma
Morphine metabolism?
Liver
Pethidine potency?
10% of morphine
Neuropathic pain mx?
- Amitryptiline or Pregabalin
- Amitryptiline AND pregabalin
- Pain specialist with tramadol in the interim
Diabetic neuropathic pain mx?
Duloxetine
Amiodarone-induced hypothyroidism?
Thought to be due to the high iodine content of amiodarone causing a Wolff-Chaikoff effect
Amiodarone-induced thyrotoxicosis types?
- AIT Type I = excess iodine induced thyroid hormone synthesis, goitre present
- AIT Type II = amiodarone related destructive thyroiditis, goitre absent
Mx of AIT Type I?
Carbimazole or potassium perchlorate
Mx of AIT Type II?
Corticosteroids
Wolff-Chaikoff effect?
An autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating iodide
Safest anti-epileptics in pregnancy?
Carbamazepine and lamotrigine
HTN in pregnancy?
Labetalol
HTN in asthmatic pregnancy?
Nifedipine
Chloramphenicol in pregnancy?
Grey baby syndrome
Lithium in pregnancy?
Ebstein’s anomaly
Tetracyclines in pregnancy?
Discoloured teeth
Warfarin in pregnancy?
Craniofacial abnormalities
Digoxin MOA?
- Decreases conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and flutter
- Increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump.
- Also stimulates vagus nerve
Mx of digoxin toxicity?
- Digibind
2. Correct arrhythmias, monitor potassium
St Johns Wort inducer/inhibitor?
Inducer
4 causes of serotonin syndrome?
- SSRIs
- MAO-inhibitors
- Ecstasy
- Amphetamines
3 features of serotonin syndrome?
- Neuromuscular excitation = hyperreflexia, myoclonus, rigidity
- ANS excitation = hyperthermia
- Altered mental state
Mx of serotonin syndrome?
- IV fluids
- Benzodiazepines
- Severe –> serotonin antagonists e.g. chlorpromazine
Heparin MOA?
Activating antithrombin III
Unfractionated heparin MOA?
Forms a complex which inhibits thrombin, factors 9,10,11,12
LMWH MOA?
Increases action of antithrombin III on factor Xa
4 s/es of heparins?
- Bleeding
- Thrombocytopenia
- Osteoporosis
- Hyperkalaemia (inhibition of aldosterone secretion)
Heparin monitoring?
APTT
LMWH monitoring?
Anti-Factor Xa
Heparin OD Mx?
Protamine sulphate
Mefloquine c/i?
Hx of anxiety or depression
Ciclosporin s/e?
Everything is increased
- HTN
- K+
- Hair
- Gums
- Glucose
- Tremor
4 indications of ciclosporin?
- Organ transplantation
- RhA
- Psoriasis
- UC
3 s/es of amlodipine?
- Headache
- Flushing
- Ankle oedema
Verapamil MOA?
Negatively inotropic
Diltiazem MOA?
Negatively inotropic
Nifedipine/amlodipine MOA?
Peripheral vascular smooth muscle relaxation
2 s/es of metformin?
- Lactic acidosis
2. GI s/e
Gliptins s/e?
Pancreatitis
Glitazones 4 s/es?
- Weight gain
- Fluid retention
- Liver dysfunction
- Fractures
Sulfonylureas s/es?
- Hypos
- Weight gain and increased appetite
- SIADH
- Cholestatic liver dysfunction
Why does alcohol lead to polyuria?
Inhibits ADH secretion by blocking calcium channels in the neurohypophyseal nerve terminal
Nausea in hangovers?
Vagal stimulation of the vomiting centre
Tremors after alcohol?
Increased glutamate production by neurones to compensate for the previous inhibition by ethanol
3 drugs used for alcohol addiction?
- BZDs for acute withdrawal
- Disulfiram = inhibition of acetaldehyde dehydrogenase
- Acamprosate = NMDA receptor agonist, reduces craving
3 s/e of rifampicin?
- Orange secretions
- Hepatitis
- Flu-like symptoms
Isoniazid MOA?
Inhibits mycolic acid synthesis
3 s/e of isoniazid?
- Peripheral neuropathy
- Hepatitis
- Agranulocytosis
Isoniazid inhibitor or inducer?
Inhibitor
Pyrazinamide MOA?
Converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I
S/e of pyrazinamide?
- Hepatitis
- Arthralgia
- Myalgia
- Hyperuricaemia causing gout
Ethambutol MOA?
Inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan
S/e of ethambutol?
Optic neuritis
Notable verapamil s/e?
Constipation
BB 4 s/e?
- Bronchospasm
- Fatigue
- Cold peripheries
- Sleep disturbance
Nitrates 3 s/es?
- Headache
- Tachycardia
- Postural hypotension
Nicorandil 3 s/es?
- Headache
- Flushing
- Anal ulceration
Sildafenil MOA?
PDE-V inhibitor, cause vasodilation through increase in cGMP leading to smooth muscle relaxation in blood vessels supplying the corpus cavernosum
3 PDE-V inhibitors?
- Sildafenil = Viagra
- Tadalafil = Cialis
- Vardenafil = Levitra
C/Is to PDE-V inhibitors?
- Nitrates
- Hypotension
- Recent stroke/MI
Viagra notable s/e?
Blue pill causes blue discoloration of vision
PDE-V s/es?
- Visual disturbances
- Nasal congestion
- Flushing
- Headache
- GI s/e
Which Abx can lower seizure threshold?
Quinolones e.g. ciprofloxacin
Quinolones MOA?
Inhibit Topoisomerase II (DNA gyrase) and Topoisomerase IV –> inhibit DNA synthesis –> bactericidal
Quinolone resistance MOA?
Mutations to DNA gyrase and efflux pumps which reduce intracellular quinolone concentration
Quinolones s/e?
- Lower seizure threshold
- Tendon damage
- Cartilage damage
- QT prolongation
Quinolone c/i?
- Pregnancy/breastfeeding
2. G6PDD
Initial pain management of acute pancreatitis?
IV morphine in 1-2mg boluses until comfortable
Salicylate poisoning mx?
Haemodialysis
Opioid OD mx?
Naloxone
BZD OD mx?
Flumazenil
TCA OD Mx?
- IV bicarbonate may reduce risk of seizures and arrhythmias
Lithium OD Mx?
- Normal saline
- Haemodialysis
- Sodium bicarbonate
Warfarin OD Mx?
- Vit K
2. Prothrombin complex
Heparin OD Mx?
Protamine sulphate
BB OD Mx?
- If bradycardic then atropine
2. In resistant cases glucagon may be used
Ethylene glycol poisoning Mx?
- Fomepizole = inhibitor of alcohol dehydrogenase
- Ethanol
- Haemodialysis
Methanol poisoning Mx?
- Fomepizole or ethanol
2. Haemodialysis
Organophosphate poisoning Mx?
Atropine
Digoxin OD Mx?
Digoxin-specific Ab fragments
Iron OD Mx?
Desferrioxamine
Lead OD Mx?
- Demercaprol
2. Calcium edetate
CO OD Mx?
- 100% oxygen
2. Hyperbaric oxygen
Cyanide OD Mx?
- Hydroxycobalamin
2. Combination of amyl nitrite, sodium nitrite and sodium thiosulphate
4 s/e of finasteride?
- Impotence
- Decreased libido
- Ejaculation disorders
- Gynaecomastia and breast tenderness
Finasteride MOA?
5a reductase inhibitor
Finasteride effect on PSA?
Decreases PSA
Metformin MOA?
Biguanide that activates AMP-activated protein kinase (AMPK) –> increases insulin sensitivity and decreases hepatic gluconeogenesis
C/I to metformin?
- CKD
- Recent MI
- Severe dehydration
Drug metabolism Phase I and Phase II reactions?
1, Phase I reactions = oxidation, reduction, hydrolysis. Mainly performed by the P450 enzymes but some drugs are metabolised by specific enzymes, for example alcohol dehydrogenase and xanthine oxidase. Products of phase I reactions are typically more active and potentially toxic
2. Phase II reactions = conjugation. Products are typically inactive and excreted in urine or bile. Glucuronyl, acetyl, methyl, sulphate and other groups are typically involved
Where do the majority of Phase I and II reactions take place?
The liver
What is zero order kinetics?
Metabolism which is independent of the concentration of the reactant, due to metabolic pathways becoming saturated resulting in a constant amount of drug being eliminated per unit time
4 drugs exhibiting zero order kinetics?
- Phenytoin
- Aspirin
- Heparin
- Ethanol
What % of the UK population are deficient in hepatic N-acetyltransferase?
50%
Heparin-induced thrombocytopenia (HIT) is prothrombotic or not?
Is prothrombotic
Why should metformin be stopped following an MI?
Due to a risk of lactic acidosis
6 features of opioid abuse?
- Pinpoint pupils
- Watering eyes
- Rhinorrhoea
- Drowsiness
- Yawniing
- Needle track marks
First line txs for opioid dependence?
Methadone or buprenorphine
4 drugs to avoid in CKD?
- Abx = tetracycline, nitrofurantoin
- NSAIDs
- Lithium
- Metformin
5 drugs causing lung fibrosis?
- Amiodarone
- Methotrexate
- Cytotoxics e.g. bleomycin
- Nitrofurantoin
- DA agonists = bromocriptine, cabergoline
2 main indications of alpha blockers?
- BPH e.g. tamsulosin
2. HTN e.g. doxazosin
3 precipitators of lithium toxicity?
- Dehydration
- Renal failure
- Drugs = thiazides, ACEi/ARBs, NSAIDs, metronidazole
What should be done before using flecainide in AF?
Echo to look for structural heart disease
Flecainide?
- Slows conduction of AP by acting as a sodium channel blocker
2 indications for flecainide?
- AF
2. WPW
C/I to flecainide?
- Post-MI
- Structural heart disease
- Atrial flutter
- Sinus node dysfunction
Who is responsible for collating and assessing the Yellow Card reports?
Medicines and Healthcare products Regulatory Agency (MHRA)
Characteristic amoxicillin s/e?
Rash with infectious mononucleosis
Characteristic co-amoxiclav s/e?
Cholestasis
Characteristic flucloxacillin s/e?
Chloestasis
Characteristic Erythromycin s/e?
- GI upset
2. Prolongs QT interval
Characteristic ciprofloxacin s/e?
- Lowers seizure threshold
2. Tendonitis
Characteristic metronidazole s/e?
Reaction following alcohol ingestion
Characteristic doxycycline s/e?
Photosensitivity
Characteristic trimethoprim s/e?
- Rashes incl. photosensitivity
- Pruritis
- Suppression of haematopoiesis
Amiodarone s/e?
- Neuro = peripheral neuropathy
- Eyes = corneal deposits
- Thyroid
- Heart = bradycardia, QT prolongation
- Lungs = fibrosis
- Liver = cirrhosis
- Skin = slate grey, thrombophlebitis, photosensitivity
Digoxin toxicity fx>
1, Generally unwell
- Arrhythmias
- Gynaecomastia
4 Urinary retention drugs?
- Anticholinergics
- TCA
- Opioids
- NSAIDs
Ecstasy aka?
MDMA, 3,4-Methylenedioxymethamphetamine
Ecstasy poisoning features?
- Neuro = agitation, anxiety, confusion, ataxia
- CVS = tachycardia, HTN
- Hyponatraemia
- Hyperthermia
- Rhabdomyolysis
Doxazosin MOA?
Alpha 1 blocker
Each 200mg tablet of amiodarone releases how much free iodine?
6mg
Alpha 1 agonist?
Decongestants e.g. phenylephrine
Alpha 2 agonist?
Glaucoma e.g. topical brimonidine
Alpha antagonists?
- BPH e.g. tamsulosin
2. HTN e.g. doxazosin
B1 agonist?
Inotrope e.g. dobutamine
B1 antagonist?
- Non-selective = atenolol
2. Selective = bisoprolol
B2 agonist?
Bronchodilators e.g. salbutamol
B2 antagonists?
Propranolol, labetalol
DA Agonist?
- Parkinsons disease e.g. Ropinorole
2. Prolactinoma
DA Antagonist?
- Antipsychotics
2. Antiemetics e.g. metoclopramide/domperidone
GABA agonist?
Benzodiazepines, Baclofen
GABA antagonist?
Flumazenil
H1 antagonist?
Antihistamine e.g. loratidine
H2 antagonist?
Antacids e.g. ranitidine
Muscarinic agonist?
Glaucoma e.g. pilocarpine
Muscarinic antagonists?
- Atropine for bradycardia
- Ipratropium for bronchodilation
- Oxybutinin for urge incontinence
Nicotinic receptor agonist?
- Nicotine
- Varenicline (smoking cessation)
- Depolarising muscle relaxant e.g. suxamethonium
Nicotinic receptor antagonists?
Non-depolarising muscle relaxants e.g. atracurium
Oxytocin receptor agonist?
Inducing labour e.g. syntocinon
Oxytocin receptor antagonists?
Tocolysis e.g. atosiban
Serotonin receptor agonist?
Triptans e.g. zolmatriptan
Serotonin receptor antagonist
Anti-emetics e.g. ondansetron
Motion sickness Mx?
Hyoscine > cyclizine > promethazine
When should allopurinol be started?
2 weeks after an acute attack has settled
Skin complications of allopurinol?
- Severe cutaneous adverse reaction (SCAR)
- Drug reaction with eosinophilia and systemic symptoms (DRESS)
- SJS
3 interactions of allopurinol?
- Azathioprine
- Cyclophosphamide
- Theophylline
Yellow tinting of vision?
Digoxin
Ondansetron MOA?
5-HT3 antagonist
5-HT1 agonist?
Sumatriptan
5-HT2 antagonist?
Pizotifen
5-HT3 antagonist?
Ondansetron
Diabetes drug that causes pancreatitis?
Gliptins
Gentamicin MOA?
Aminoglycoside
S/e of gentamicin?
- Ototoxicity = irreversible, due to auditory or vestibular nerve damage
- Nephrotoxicity = accumulates in renal failure, lower doses and more frequent monitoring required
C/I of gentamicin?
Myasthenia gravis
Gentamicin dosing?
- Both peak (1 hour after administration) and trough levels (just before the next dose) are measured
- If the trough (pre-dose) level is high the interval between the doses should be increased
- If the peak (post-dose) level is high the dose should be decreased
BNF CD meaning?
Controlled drug
BNF PoM meaning?
Prescription only medicine
BNF NHS with cross meaning?
Not prescribable on NHS
BNF black triangle meaning?
Newly licensed medication
BNF black and white box meaning?
A preparation that is less suitable to prescribe
When should lithium level be monitored?
12 hours post dose
When should ciclosporin levels be measured?
Trough levels immediately before dose
When should digoxin levels be measured?
At least 6 hours post dose
Rifampicin P450?
Inducer
Isoniazid P450?
Inhibitor
Smoking P450?
Inducer (affects CYP1A2, which smokers require more aminophylline)
Cocaine MOA?
Blocks uptake of DA, NA and HT
S/e of cocaine>
- CVS = MI, tachy, HTN, QRS widening, QT prolongation, disssection
- Neuro = seizures, hypertonia, hyperreflexia, mydriasis
- Psych = agitation, psychosis, hallucinations
Abdo pain/rectal bleeding after cocaine?
Ischaemic colitis
Cocaine toxicity mx?
Benzodiazepines
- CP = + GTN
- HTN = + sodium nitroprusside
Phenytoin monitoring time?
Immediately before next dose (trough levels)
St Johns Wort P450?
Inducer
Transaminases in the 10,000s?
Paracetamol OD
Severe renal impairment heparin choice?
UFH
Most highly negatively inotropic calcium channel blocker?
Verapamil
Breakthrough analgesia dose?
1/6th of the total daily opioid dose
Salicylate OD blood gas?
Mixed respiratory alkalosis and metabolic acidosis
Salicylate overdose fx?
- Hyperventilation
- Tinnitus
- Seizures
Mx of aspirin OD?
- ABC, charcoal
- Urinary alkisation with IV sodium bicarb
- Haemodialysis
Drugs causing photosensitivity?
- Amiodarone
- Tetracyclines, sulphonamides, ciprofloxacin
- Thiazides
- NSAIDs
- Psoralens
- Sulphonylureas
Carboxyhaemoglobin levels in smokers?
Up to 10%
Contrast CT, how long should metformin be stopped for?
48 hours after the scan due to risk of renal impairment
Fx of organophosphate poisoning?
SLUD CO
- Salivation
- Lacrimation
- Urination
- Diarrhoea
- CVS = hypotension, bradycardia
- Other = small pupils, muscle fasciculation
Can digoxin toxicity occur even if conc is within the therapeutic range>
Yes
Classic precipitating factor of digoxin toxicity?
Hypokalaemia
Metformin eGFR C/i?
If eGFR < 30
Methotrexate monitoring bloods?
FBC, TFT, U&E
Levetiracetam monitoring?
Not needed
Amiodarone monitoring?
- TFT, LFT, U&E, CXR prior to tx
2. TFT, LFT every 6m
Statin monitoring?
LFT at baseline, 3m 12m
ACEi mointoring?
U&E prior to tx, after increasing dose, and at least anually
Azathioprine monitoring?
FBC, LFT
Lithium monitoring?
- TFT, U&E prior to treatment
- Lithium levels weekly until stabilised then every 3 months
- TFT, U&E every 6 months
Sodium valproate monitoring?
- LFT, FBC before treatment
2. LFT ‘periodically’ during first 6 months
Glitazone monitoring?
LFT before and regularly during treatment
S/e of tamoxifen?
- Menstrual disturbance
- Hot flushes
- VTE
- Endometrial cancer
- Osteoporosis
How long after removal of tumour is tamoxifen usually used for?
5 years
UFH monitoring?
APTT
Cocaine on ABG?
Metabolic acidosis
Mechanism of aspirin ABG findings?
Respiratory alkalosis occurs early due to stimulation of the brainstem medullary respiration centre. This is later followed by metabolic acidosis, due to uncoupling of oxidative phosphorylation.
Chronic alcoholism magnesium?
Hypomagnesaemia
Hypomagnaesaemia associations?
- Hypokalaemia
- Hypocalcaemia
- Hypophosphataemia
- Metabolic acidosis
Causes of low magnesium?
- Drugs = Diuretics, PPIs
- TPN
- Diarrhoea
- Alcohol
- Hypokalaemia, hypocalcaemia
Mx of low magnesium?
- <0.4mmol/l = IV magnesium sulphate 40mmol over 24 hours
2. >0.4mmol/l = oral magnesium salts 10-20mmol per day
Adrenaline doses for anaphylaxis and cardiac arrest?
- Anaphylaxis = 0.5ml 1:1,000 IM
2. Cardiac arrest = 1ml 1:1000 IV
Most common s/e of sildafenil?
- Visual disturbances
- Nasal congestions
- Flushing
- GI side effects
- Headache
2 indications of finasteride?
- BPH
2. Male pattern baldness
4 s/e of finasteride?
- Impotence
- Decreased libido
- Ejaculation disorders
- Gynaecomastia and breast tenderness
Mx of accidental injection of adrenaline?
Local infiltration of phentolamine
Lithium excretion?
Renal
3 drugs that aspirin potentiates?
- Oral hypoglycaemics
- Warfarin
- Steroids
Confusion, pink mucosae and low grade pyrexia?
CO poisoning
Metformin not tolerated due to GI s/e?
Try a modified release formation
Drug causing cataracts?
Steroids
Drugs causing corneal opacities?
- Amiodarone
2. Indomethacin
3 drugs causing optic neuritis?
- Ethambutol
- Amiodarone
- Metronidazole
3 causes of oculogyric crisis?
- Antipsychotics
- Metoclopramide
- Postencephalitic Parkinson’s disease
Mx of oculogyric crisis?
IV antimuscarinic e.g. benztropine or procyclidine
Amiodarone interaction
- Decreased metabolism of warfarin
2. Increased digoxin levels
Theophylline OD Mx?
- Haemodialysis
2. Activated charcoal regardless of the time of presentation
Caution when using cyclizine?
In pts with HF as it may cause a fall in cardiac output
Cyclizine MOA?
H1-receptor antagonist that acts by blocking histamine receptors in the CTZ
Carbamazepine P450?
Carbamazepine is an inducer of the P450 system. This in turn increases the metabolism of carbamazepine itself - auto-induction
4 indications of Spironolactone?
- Ascites
- HF
- Nephrotic syndrome
- Conn’s