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PSA > Pharmacology > Flashcards

Pharmacology Flashcards

1
Q

Define Affinity

A

the tendency of a molecule to bind to a receptor

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2
Q

Define Efficacy

A

how well an agonist achieves a response

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3
Q

Define an antagonist

A

A chemical that opposes the action of another chemical.

Therefore, antagonists should have no action on their targets in the absence of an agonist.

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4
Q

Drugs that can cause hyperkalaemia (10)

A

THANKS CYCLE PENines
T: Trimethoprim
H: Heparin (LMWH - inhibition of aldosterone synthesis)
A: ARBs and ACE-Is (reduce aldosterone -> potassium retention)
N: NSAIDs
K: K+ sparing diuretics
S: Succinyl choline

CYCLE: Cylosporins and Tacrolimus
PENines: Pentamidine

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5
Q

Drugs that can cause hypokalaemia (7)

A 
DIG CBT
D: Diuretics and laxatives
I: Insulin
G: Gentamicin
C: Corticosteroids (Pred)
B: Beta-2-agonists
T: Theophylline
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6
Q

Drugs that can cause hypercalcaemia (2)

A
  • Vit D

- Thiazide diuretics

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7
Q

Drugs that can cause hypocalcaemia (3)

A
  • Bisphosphonates
  • Corticosteroids
  • Loop diuretics
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8
Q

Drugs that can cause hypernatraemia (1)

A
  • Lithium
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9
Q

Drugs that can cause hyponatraemia (5)`

A
  • Antidepressants (SSRIs, tricyclics)
  • Laxatives
  • Loop diuretics
  • Thiazide diuretics
  • Potassium-sparing diuretics
  • Sulfonylureas
  • Carbamazepine
  • Vincristine
  • Cyclophosphamide
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10
Q

Drugs that should be stopped before surgery? (8)

A
  • Aspirin (unless recent ACS, coronary artery stent or ischaemic stroke) -> replace with LMWH or unfractionated heparin
  • COCP
  • MAOIs
  • Lithium (24 hrs before major surgery only, monitor fluids and electrolytes in minor surgery)
  • Potassium-sparing diuretics on morning of surgery
  • ACE-Is and ARBs 24 hrs before
  • Herbal medicines
  • Let surgeon know if on tricyclic antidepressants
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11
Q

Drugs to be stopped in AKI

A

Direct nephrotoxics:

  • ACE-Is (small creatinine rise expected when initiating, recheck in 1 week)
  • ARBs
  • Diuretics (Furosemide, Potassium-sparing)
  • NSAIDs
  • Contrast media

Stop in AKI:

  • Allopurinol (can accumulate) - max of 100 mg OD until improves
  • Hypoglycaemic agents - modified-release
  • Gentamicin/Vancomycin
  • Lithium
  • Methotrexate
  • Metformin (avoid if GFR <30)
  • CCBs
  • Tetracyclines
  • Trimethoprim
  • Statin (if rhabdomyolysis)
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12
Q

Drugs that can cause confusion

A

Sedatives:

  • Benzos
  • Opioids
  • Glucocorticoids (Prednisolone)
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13
Q

Drugs that can cause hyperglycemia

A
  • Glucocorticoids (Pred)
  • Atypical antipsychotics (Clozapine)
  • Thiazide diuretics
  • Statins
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14
Q

Trimethoprim:

  • Dose, CI, Cautions, SEs
  • Interaction
  • Pregnancy
A
  • Dose: 200 mg BD for 3 days (7 days in males
  • CI: Blood dyscrasias
  • Cautions:
    • Blocks folate metabolism, may exacerbate pre-existing folate deficiency, generally doesn’t prevent short term use (do NOT prescribe with methotrexate)
    • Porphyrias
    • Renal dysfunction: half dose if eGFR < 15
  • SEs: Diarrhoea, vomiting, electrolyte imbalance, headache, nausea, skin reactions
  • Interactions: METHOTREXATE
  • Teratogenic in FIRST TRIMESTER
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15
Q

Nitrofurantoin:

  • Dose, CI, Cautions
  • Pregnancy
A
  • Dose: 50 mg QDS for 3 days (7 days in males)
  • Avoided if eGFR less than 45
  • Used with caution if eGFR 30-44 (short course only: 3-7 days)
  • CI: Porphyrias, G6PD deficiency, eGFR < 45
  • Cautions:
    • Anaemia, DM, electrolyte imbalance, folate deficiency, urine may be yellow/brown
  • Teratogenic at TERM
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16
Q

Anticoagulation before surgery

A
  • If AF-related stroke/TIA then need formal anticoagulation with treatment dose LMWH
  • Without this Hx, no need for formal anticoag
  • BNF recommends that if INR > 1.5 before elective surgery, phytomenadione (Vit K) 1-5 mg PO using IV prep is indicated
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17
Q

Sumatriptan

  • Doses (PO, SC, Intranasal)
  • CIs, Cautions
  • SEs
  • Pregnancy
A
  • Dose:
    • PO 50-100 mg for 1 dose, followed by 50-100 mg after at least 2 hrs if required
    • SC 3-6 mg for 1 dose, followed by 3-6 mg after at least 1 hr if required
    • Intranasal 10-20 mg in one nostril, again after at least 2 hrs if required
  • CIs: IHD, mild uncontrolled HTN, mod-sev HTN, peripheral vascular disease, previous cerebrovascular accident, previous MI, previous TIA, Prinzmetal’s angina
  • Cautions: Predisposing coronary artery disease factors, elderly, Hx of seizures, mild controlled HTN, risk factors for seizures
  • SEs: Dizziness, drowsiness, dyspnoea, flushing, myalgia, nausea, vomiting, pain, skin reactions, temp sensation altered
  • Pregnancy: best to avoid if possible due to limited evidence
  • Consider dose reduction to 25–50 mg in mild to moderate hepatic impairment
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18
Q

Propranolol

  • Dose
  • CIs and cautions
  • SEs
A
  • Dose: 80 - 240 mg daily in divided doses
  • CIs: Asthma, COPD, hypotension, bradycardia, metabolic acidosis, 2nd or 3rd degree AV block, severe peripheral arterial disease, sick sinus syndrome, uncontrolled HF, pheochromocytoma, Prinzmetals angina
  • Cautions: DM, myasthenia gravis, portal hypertension, psoriasis, may mask hypoglycaemia or thyrotoxicosis
    • Elderly STOPP criteria:
      • In combo with verapamil or diltiazem
      • With bradycardia (HR<50bpm)
      • DM with frequent hypoglycaemia episodes
      • History of asthma requiring
  • SEs: abdo discomfort, confusion, depression, diarrhoea, dizziness, dry eye, dyspnoea, erectile dysfunction, fatigue, headache, HF, nausea, paraesthesia, PVD, rash, sleep disorder, syncope, visual impairment, vomiting
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19
Q

Topiramate

A
  • Dose: 50 - 100 mg daily, two divided doses, taken at night. Start with 25 mg OD for 1 week, increased in steps of 25 mg each week, max 200 mg daily
  • ENZYME INDUCER
  • Risk of suicidal thoughts and behaviour
  • Cautions: acute porphyria’s, risk of metabolic acidosis
  • Pregnancy: Use of highly effective contraception and fully informed of risks or avoid altogether
  • Breastfeeding: AVOID
  • Renal impairment: half dose if creatinine clearance < 70
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20
Q

Drug-induced liver injury (8 drug causes)

A
  • Flucloxacillin and Co-Amoxiclav
    • Cholestatic hepatitis and jaundice
    • Idiosyncratic, not dose-related
    • Onset may be delayed for up to 2 months following Tx
  • Paracetamol
    • Causes a dose-dependent acute liver injury → can lead to acute liver failure
  • NSAIDs
    • Idiosyncratic hepatitis, resolves in most cases after the termination of drug therapy
    • Classically causes a cholestatic hepatitis
    • Aspirin can also cause hepatitis but tends to be dose-related
  • Anti-TB drugs (RIPE)
    • Can cause liver injury
  • Methotrexate
    • Severe fibrosis and cirrhosis if not adequately monitored
  • Amiodarone
    • Steato hepatitis
  • Statins: can cause a mild transaminitis (raise in AST/ALT), monitor LFTs in those with mild liver disease
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21
Q

Typical dose of:

Paracetamol

A

0.5 - 1 kg QDS

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22
Q

Typical dose of:

Ibuprofen

A

200- 400 mg TDS

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23
Q

Typical dose of:

Codeine

A

30 - 60 mg QDS

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24
Q

Typical dose of:

Co-codamol

A

2 tabs QDS

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25
Q

Typical dose of:

Cyclizine

A

50 mg TDS

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26
Q

Typical dose of:

Metoclopramide

A

10 mg TDS

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27
Q

Typical dose of:

Amoxicillin

A

500 mg TDS

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28
Q

Typical dose of:

Clarithromycin

A

500 mg BD

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29
Q

Typical dose of:

Lansoprazole

A

15-30 mg OD

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30
Q

Typical dose of:

Omeprazole

A

20-40 mg OD

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31
Q

Typical dose of:

Aspirin

A

75-300 mg OD

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32
Q

Typical dose of:

Clopidogrel

A

75-300 mg OD

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33
Q

Typical dose of:

Atenolol

A

25-100 mg OD

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34
Q

Typical dose of:

Ramipril

A

1.25-10 mg OD

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35
Q

Typical dose of:

Furosemide

A

20 mg OD to 80 mg BD

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36
Q

Typical dose of:

Amlodipine

A

5-10 mg OD

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37
Q

Typical dose of:

Levothyroxine

A

25-200 micrograms OD

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38
Q

Typical dose of:

Metformin

A

500 mg OD to 1 g BD

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39
Q

Typical dose of:

Atorvastatin

A

10-80 mg OD (at night)

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40
Q

Typical dose of:

Simvastatin

A

10-40 mg OD (at night)

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41
Q

Drugs that lower seizure threshold (8)

A
  • Alcohol/cocaine/amphetamines
  • Quinolones: ciprofloxacin, levofloxacin
  • Aminophylline and theophylline
  • Bupropion
  • Methylphenidate (ADHD med)
  • Mefenamic acid
  • P450 Inducers / inhibitors
  • Withdrawal of benzos, baclofen, hydroyzine
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42
Q

Drugs not administered daily? (7)

A
  • Bisphosphonates: Weekly (Can be daily or monthly too)
  • Hydroxocobalamin: 2-3 monthly
  • Injectable antipsychotics: Weekly-monthly
  • Methotrexate: Once a week
  • Injectable RA drugs: Every 2 weeks
  • Goserelin: 3 monthly
  • Implants: 3 monthly
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43
Q

Presentation of rhabdomyolysis

A
  • Muscle swelling and tenderness
  • Weakness
  • Grey/brown urine
  • Raised CK
    May lead to:
  • Renal failure
  • Hyperkalaemia
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44
Q

What can increase risk of rhabdomyolysis?

A

STATINS plus:

  • older age
  • female
  • genetics
  • renail impairment
  • concomitant diltiazem (max statin dose = 20 mg)
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45
Q

Tx of rhabdomyolysis

A
  • IV fluids
  • Consider sodium bicarb
  • Monitor K+
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46
Q

Known teratogenics (10)

A
  • ACE-Is and ARBs
  • Antiepileptics, e.g. valproate, carbamazepine, phenytoin
  • Cytotoxic agents
  • Sex hormones
  • Statins
  • Lithium salts
  • Thalidomide
  • Warfarin
  • Retinoids
  • Abx - tetracyclines, trimethoprim, quinolones, aminoglycosides, sulphonamides
  • Sulfonylureas
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47
Q

Gentamicin monitoring

A

Multiple daily dose:

  • Peak (1hr post dose): 3-5 mg/litre
  • Trough (pre next dose): < 1 mg/litre

If peak is high: decrease dose
If trough is high: increase intervals

Once daily dose:

  • 6-14 hrs after start of infusion
  • Targets concentration < 1 mg/litre
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48
Q

Warfarin strengths and tablet colours

A

500 micrograms - White
1 mg - Brown
3 mg - Blue
5 mg - Pink

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49
Q

Typical dose of:

Warfarin

A

1 mg - 15 mg (average = 5 mg)

OD, same time each day, usually evening

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50
Q

Drugs that should be avoided in HF?

A
  • Thiazolididiones (e.g. pioglitazone)
  • Verapamil/Dialtezam
  • NSAIDs/glucocorticoids (fluid retention)
  • Class I antiarrhythmics (flecainide, lidocaine, quinidine)
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51
Q

Cytochrome P450

Substrates (8)

A
  • Warfarin
  • COCP
  • Statins
  • Nifedipine
  • Theophylline
  • Tricyclics
  • Corticosteroids
  • Pethidine
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52
Q

Cytochrome P450

Inducers (10)

A

GPRS Cell Phone (Inducer = electric = phone)

  • Griseofulin
  • Phenytoin
  • Rifampicin
  • Sulfonylureas
  • Carbamazepine
  • Phenobarbitone
  • Topiramate
  • Smoking
  • St John’s Wort
  • Alcohol - CHRONIC
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53
Q

Cytochrome P450

Inhibitors (12)

A

SICKFACES.COM (Inhibitor = inhibit getting better = sick)

  • Sodium Valproate
  • Isoniazid
  • Cimetidine
  • Ketoconazole
  • Fluconazole/Miconazole
  • Acute alcohol, grapefruit juice
  • Chloramphenicol
  • Erythromycin
  • Sulfonamides
  • Ciprofloxacin
  • Omeprazole
  • Methotrexate
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54
Q

Monitoring Requirements

Levothyroxine

A
  • Annual TFTs if on maintenance
  • After dose adjustment -> wait 6/8 weeks then check TFTs
  • Acute illness may affect results
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55
Q

Monitoring Requirements

Amiodarone

A
  • TFTs before Tx and every 6 months after

- Associated with both hypo- and hyper- thyroidism

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56
Q

Monitoring Requirements

Digoxin

A
  • Heart rate monitored before administration
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57
Q

Monitoring Requirements

Gentamicin

A
  • Narrow therapeutic window -> plasma concentration
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58
Q

Monitoring Requirements

Methotrexate

A

Before, every 1-2 weeks unstable, 2-3 months after:

  • FBC (neutropenia), including ESR
  • LFTs
  • Renal function

Baseline CXR and then if pulmonary toxicity occurs

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59
Q

Monitoring Requirements

Adalimumab

A
  • Evaluate for active/inactive TB

- If prev treated for TB, monitor every 3 months for recurrence

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60
Q

Monitoring Requirements

Carbamazepine

A
  • FBC (neutropenia) - look out for SORE THROAT
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61
Q

Monitoring Requirements

Clozapine

A
  • FBCs - leucocytes and differential blood counts
  • WCC monitoring weekly for 18 weeks, then fortnightly for 1 year, then monthly
  • Close medical supervision during initiation (risk of hypotension and convulsions)
  • Lipids and weight at baseline, frequent intervals during first 3 months, 3 monthly for one year, then yearly
  • Fasting blood glucose at baseline, 4-6 months then annually
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62
Q

Monitoring Requirements

Lithium

A

Serum-lithium concentration (0.4 - 1 mmol/litre)

  • Higher end in acute treatment
  • Measure 12 hr post dose after at least 4 days
  • Measure weekly until stabilised
  • Measure every 3 months thereafter
  • Cardiac function regularly
  • TFTs, renal function, calcium and BMI every 6 months
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63
Q

Lithium

Adverse effects

A
  • Fine hand tremor
  • Nausea
  • Weight gain
  • Metallic taste
  • Mild polydipsia
  • Polyuria
  • Alteration of renal function
  • Diabetes insipidus
  • Hyperparathyroidism
  • Hyperthyroidism
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64
Q

Lithium

Toxicity

A
  • Severe hand tremor
  • Vomiting and diarrhea
  • Blurred vision
  • Muscle weakness
  • Ataxia
  • Dysarthria
  • Confusion
  • Nystagmus
  • Renal failure
  • Seizures
  • Coma
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65
Q

Lithium

Interactions

A

ACE-I - increases conc
Diuretics - hypokalaemia and increases concs
NSAIDs - increases concs
Sodium-containing compounds - decreases concs

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66
Q

Acetylcysteine indications in paracetamol overdose

A
  • There is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
  • The plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
  • > 150 mg/kg
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67
Q

Tx of anaphylaxis

A
  • ABCDE
  • Adrenaline
  • IV fluids
  • Oxygen: 15l/min reservoir mask
  • Antihistamines - Chlorphenamine
68
Q

Symptoms of hypoglycemia

A
  • Sweating
  • Anxiety
  • Blurred vision
  • Confusion
  • Aggression
69
Q

What drugs can mask hypoglycemia?

A

Beta-blockers, e.g. propranolol, atenolol

70
Q

Tx of hypoglycemia

A
  • Conscious patients - 10 - 20 g of short-acting carbohydrate (e.g. glass of Lucozade, non-diet drink, three or more glucose tablets, glucose gel)
71
Q

What is lipodystrophy

A

Present as atrophy/lumps of SC fat at the insulin injection site.

  • Can be prevented by rotating injection site
  • May cause erratic insulin absorption
72
Q

Digoxin
Toxicity

Features

A
  • Diarrhoea
  • N+V
  • Confusion
  • Anorexia
  • Palpitations
  • Hallucinations
  • General malaise
  • Blurred vision
  • Weakness
  • Arrhythmias
  • Syncope
73
Q

Digoxin
Toxicity

Susceptibility factors

A
  • More likely in older adults and in hypokalaemia
  • Renal failure
  • Myocardial ischaemia
  • Hypomagnesaemia
  • Hypercalcaemia
  • Hyponatraemia
  • Alkalosis
  • Hypoxia
  • Hypoalbuminaemia
  • Hypothermia
  • Hypothyroidism
74
Q

Digoxin
Toxicity

Management

A
  • Stop digoxin
  • Measure urea and electrolytes (potassium and creatinine) and correct
  • Monitor heart rhythm and BP
  • Digibind antidote
75
Q

Digoxin
Toxicity

Drugs that increase susceptibility

A
  • Amiodarone - half digoxin dose
  • Ciclosporin
  • Erythromycin
  • Verapamil - reduction of digoxin of 30-50%
  • Spironolactone
  • Quinine
  • Diltiazem
76
Q

Best opioids in renal impairment?

A
  • Mild-mod: oxycodone can be used in place of morphine

- Severe: alfentanil, buprenorphine and fentanyl

77
Q

Treatment of bone pain in palliative care?

A
  • Strong opioids
  • Bisphosphonates
  • Radiotherapy
  • Denosumab
78
Q

First-line opioid treatment in palliative care

A

Offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain

If no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain.
For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required

79
Q

How do you increase opioids in palliative care?

A

Next dose should be 30-50% more

80
Q

General factors that may potentiate warfarin

A
  • Liver disease (impaired synthesis of Vit K)
  • P450 inhibitors
  • Cranberry Juice
  • Drugs that displace warfarin from albumin, e.g. NSAIDs
  • Inhibit platelet function, e.g. NSAIDs
81
Q

Prescribing in asthma

NSAIDs

A
  • 10-20% with asthma will experience worsening of symptoms/bronchospasm after NSAIDs
  • NSAID-induced asthma is uncommon in children
  • Risk is increased in those with nasal polyps or middle-aged
82
Q

Prescribing in asthma

Beta-blockers

A
  • May cause bronchospams

- Best avoided

83
Q

Prescribing in asthma

Adenosine

A
  • Contraindicated in asthma and COPD

- Verapamil can be used as an alternative

84
Q

Tx of C.Diff

A 
First-line = Metronidazole (mild-mod disease)
Second-line = Vancomycin (severe disease)
85
Q

SIADH causes

A

Characterized by hyponatraemia secondary to dilutional effects of excessive water retention

  • Sulfonylureas
  • SSRIs, tricyclics
  • Carbamazepine
  • Vincristine
  • Cyclophosphamide
86
Q

When should you add a second diabetes drug?

And which drugs?

A

HbA1c > 58 mmol/mol (7.5%)

sulfonylurea
gliptin
pioglitazone
SGLT-2 inhibitor

87
Q

HbA1c targets

A 
Lifestyle:
- 48 mmol/mol
Lifestyle and metformin:
- 48 mmol/mol
Any drug which may cause hypolglycemia (e.g. lifestyle and sulfonylurea):
- 53 mmol/mol
88
Q

When should you add a third diabetes drug?

And which drug?

A

If HbA1c rises to or remains about 58 despite two meds:

  • metformin + gliptin + sulfonylurea
  • metformin + pioglitazone + sulfonylurea
  • metformin + sulfonylurea + SGLT-2 inhibitor
  • metformin + pioglitazone + SGLT-2 inhibitor
  • OR insulin therapy should be considered
89
Q

If there are no signs of hypoxia, when is oxygen therapy not routinely used?

A
  • MI and ACS
  • Stroke
  • Obstetric emergency
  • Anxiety-related hyperventilation
90
Q

Oxygen management of COPD patient

A

Before the availability of blood gas use:

- 28% venturi mask at 4l/min and aim for 88-92%

91
Q

Prescribing in ischaemic heart disease

A

Use with caution:

  • NSAIDs
  • Oestrogens (COCP, HRT)
  • Varenicline
92
Q

Breastfeeding

Drugs to avoid (8)

A
  • antibiotics: ciprofloxacin, tetracycline (lymecycline/doxycycline) chloramphenicol, sulphonamides (sulfasalazine)
  • psychiatric drugs: lithium, benzodiazepines
  • aspirin
  • carbimazole
  • methotrexate
  • sulfonylureas (glipizide, glimepiride)
  • cytotoxic drugs
  • amiodarone
93
Q 
Breastfeeding
Safe drugs (7 groups)
A
  • antibiotics: penicillins, cephalosporins, trimethoprim
  • endocrine: glucocorticoids (avoid high doses), levothyroxine*
  • epilepsy: sodium valproate, carbamazepine
  • asthma: salbutamol, theophyllines
  • psychiatric drugs: tricyclic antidepressants, antipsychotics**
  • hypertension: beta-blockers, hydralazine
  • anticoagulants: warfarin, heparin
    digoxin
94
Q

What defines severe C.diff?

A
  • WCC >15 109/L;
  • acutely rising blood creatinine (e.g. >50% increase above baseline);
  • temperature >38.5°C; or
  • evidence of severe colitis (abdominal signs, radiology).
95
Q

Glucocorticoid SEs

A

Endocrine

  • impaired glucose regulation
  • increased appetite/weight gain
  • hirsutism
  • hyperlipidaemia

Cushing’s syndrome

  • moon face
  • buffalo hump
  • striae

Musculoskeletal

  • osteoporosis
  • proximal myopathy
  • avascular necrosis of the femoral head

Immunosuppression

  • increased susceptibility to severe infection
  • reactivation of tuberculosis

Psychiatric

  • insomnia
  • mania
  • depression
  • psychosis

Gastrointestinal

  • peptic ulceration
  • acute pancreatitis
  • ophthalmic
  • glaucoma
  • cataracts

suppression of growth in children
intracranial hypertension
neutrophilia

96
Q

When do you need to taper withdrawal of systemic corticosteroids?

A
  • received more than 40mg prednisolone daily for more than one week
  • received more than 3 weeks of treatment
  • recently received repeated courses
97
Q

BNFc
Symbols

POM

A

Prescription only medicine

98
Q

BNFc
Symbols

CD2, CD3, CD4-1, CD4-2
x1 example

A

Controlled drugs according to Misuse of Drugs Act and Misuse of Drugs Regulations 2001 (updated 2014)

e.g. Midazolam = CD3

99
Q

BNFc
Symbols

Box - half white, half black

A

Less suitable for prescribing or is not prescribable

e.g. Dentinox, Colic Drops

100
Q

BNFc
Symbols

NHS crossed out

A

Not prescribable under the NHS

e.g. flurazepam capsules

101
Q

BNFc
eGFR calculations

a) Neonate
b) Child > 1yr

A

a) 30 x height (cm) / serum creatinine (micromol/litre)

b) 40 x height (cm) / serum creatinine (micromol/litre)

102
Q

Type I allergic reaction

Symptoms and onset

A
  • Usually occur within minutes to 2 hours of exposure, not always with the first dose
  • Symptoms can occur very rapidly with parenteral drug admin (median time to cardiac arrest in fatal anaphylaxis is 5 mins
  • Itching, urticaria, hypotension, angioedema, wheeze
103
Q

NB re urticaria

A
  • Can arise due to infection alone so important to determine if the onset was prior to initiation of antibiotic? And did it occur for longer than a few hours after meds stopped?
104
Q

ACE-I and angioedema

A

Can cause pure angioedema, which can arise many years after the drug has been taken uneventfully

105
Q

Non-allergic drug reactions x5

A
  • Morbilliform rash
  • Erythema multiforme (target lesions)
  • Fixed drug eruptions (erythematous plaques recur in same place each time causative drug is taken - paracetamol, tetracyclines, NSAIDs)
  • Photosensitivity
  • Vaccination in presence of high pre-existing antibody levels can result in itchy induration 6-8 hrs later (NO allergic, not harmful)
106
Q

Difference between morbilliform and urticaria

A
  • Morbilliform rash lesions enlarge and become confluent over several days
  • Urticaria lesions subside and reappear in different areas
107
Q

Cross Reacting Drugs

Penicillin (2)

A 
- Penicillins and cephalosporins
1st and 2nd gens (pha/fa) - avoid: cefalexin, cefadroxil, cefazolin, cefuroxime, cefoxitin
3rd gens (one/ten/ime) - use with caution: cefuroxime, cefotaxime, ceftazidime, ceftriaxone, cefixime
  • Penicillins and carbapenems (doripenem, ertapenem, imipenem, meropenem)
  • Can safely prescribe aztreonam
108
Q

Common causes of allergic drug reactions (8) (

A
  • Chlorhexidine
  • Opioid analgesics
  • Non beta-lactam antimicrobials
  • Penicillins and beta-lactams
  • NSAIDs
  • Plasma expanders (hespan, dextran)
  • Muscle relaxants
  • Radiocontrast media
109
Q

Agents that cause allergic reactions during anesthesia (6)

A
  • Antimicrobials - notably co-amox and teicoplanin
  • Chlorhexidine
  • Colloids
  • Neuromuscular blocking agents (NMBAs), e.g. rocuronium
  • Patent blue injection (die for delineating lymph nodes)
  • Misc medicines (ondansetron, propofol)
110
Q

Tx of mild and mod allergic reactions

A
  • No systemic reaction
  • Fast-acting oral antihistamine (Chlorphenamine)
  • Have IM epinephrine available
111
Q

Define severe allergic reaction

A
  • Hypotension
  • Laryngeal oedema
  • Wheeze
  • SpO2 < 92%
  • Impaired consciousness
112
Q

First-line Tx for anaphylaxis

a) Adult/Child > 12 yrs
b) Child 6-12 yrs
c) Child < 6 yrs

A

a) 500 micrograms (0.5mL) IM adrenaline (300 if administered by self)
b) 300 micrograms (0.3mL) IM adrenaline
c) 150 micrograms (0.15mL) IM adrenaline

113
Q

Anaphylaxis antihistamine doses

a) Adult/Child > 12 yrs
b) Child 6-12 yrs
c) Child 6 months - 6 yrs
d) Child < 6 months

A

a) 10 mg
b) 5 mg
c) 2.5 mg
d) 250 micrograms/kg

Given slow IV or IM

114
Q

Anaphylaxis hydrocortisone doses

a) Adult/Child > 12 yrs
b) Child 6-12 yrs
c) Child 6 months - 6 yrs
d) Child < 6 months

A

a) 200 mg
b) 100 mg
c) 50 mg
d) 25 mg

Given slow IV or IM
Take at least 2 hrs to work but may help reduce risk of persistent/biphasic reaction

115
Q

How long should you monitor someone after anaphylaxis?

Follow-up meds?

A

6-12 hrs

Pred for up to 3 days
Non-sedating antihistamine for up to 3 days
Recommend an alert band

116
Q

Other anaphylaxis Tx (4)

A
  • Neb or IV salbutamol
  • Ipratropium
  • Aminophylline
  • Magnesium
117
Q

MHRA advice re adrenalin auto-injectors

A

1) Carry two at all times
2) Ambulance phoned after every use even if symptoms improving
3) After administration - lie down with legs raised to maintain blood blow
4) Patient should not be left alone

118
Q

Mast tryptase measurements (3)

A
  • As soon as possible after emergency Tx has started
  • 1-2 hrs after onset of symptoms (no later than 4hrs)
  • At 24 hrs if possible
119
Q

Warfarin

Factors that increase sensitivity

A
  • Age > 70 yrs
  • Drug interactions, e.g. amiodarone
  • Hepatic impairment (baseline INR > 1.4)
  • Severe cardiac failure
  • TPN
  • Low albumin levels
  • Low BMI
120
Q

DOACs

Examples of thrombin inhibitors

A
  • Dabigatran
121
Q

DOACs

Examples of Factor Xa inhibitors

A
  • Apixaban
  • Edoxaban
  • Rivaroxaban
122
Q

Tamoxifen

Duration

A

Normal used for 5 yrs following tumour removal

123
Q

Tamoxifen

Adverse effects

A
  • Menstrual disturbance: vaginal bleeding, amenorrhoea
  • Hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
  • Venous thromboembolism
  • Endometrial cancer
124
Q

Analgesic ladder

Step 1

A

Non-opioid analgesics

  • NSAIDs, aspirin
  • Paracetamol
125
Q

Analgesic ladder

Step 2

A

Mild opioid analgesics

  • Codeine
  • Co-codamol (30/500)
  • Dihydrocodeine
  • Tramadol
126
Q

Analgesic ladder

Step 3

A

Strong opioid analgesics

  • Morphine
  • Methadone
  • Fentanyl
  • Oxycodone
127
Q

Paroxysmal supraventricular tachycardia

Acute Tx

A

Vagal manoeuvres:

  • Valsalva manoeuvre: e.g. trying to blow into an empty plastic syringe
  • Carotid sinus massage

Intravenous adenosine

  • Rapid IV bolus of 6mg → if unsuccessful give 12 mg → if unsuccessful give further 18 mg
  • Contraindicated in asthmatics - verapamil is a preferable option

Electrical cardioversion

128
Q

Paroxysmal supraventricular tachycardia

Prevention

A
  • Beta-blockers

- Radio-frequency ablation

129
Q

CCBs

Verapamil
Indications

A
  • Angina
  • HTN
  • Arrhythmias
130
Q

CCBs

Verapamil
Cautions

A

Should NOT be given with beta-blockers (heart block) or in HF

Due to being a highly negative inotrope

131
Q

CCBs

Verapamil
SEs

A
  • Constipation
  • Hypotension
  • Bradycardia
  • Flushing
132
Q

CCBs

Diltiazem
Indications

A
  • Angina

- HTN

133
Q

CCBs

Diltiazem
Cautions

A

Less negatively inotropic than verapamil but caution still needed if HF/beta-blockers

134
Q

CCBs

Diltiazem
SEs

A
  • Hypotension
  • Bradycardia
  • HF
  • Ankle swelling
135
Q

CCBs

Dihydropyridines
Examples

A
  • Amlodipine
  • Nifedipine
  • Felodipine
136
Q

CCBs

Dihydropyridines
Indications

A
  • HTN
  • Angina
  • Raynaud’s
137
Q

CCBs

Dihydropyridines
Catuions

A

Affects peripheral vascular smooth muscle more than myocardium so does not result in worsening HF but may therefore cause ankle swelling

138
Q

CCBs

Dihydropyridines
SEs

A
  • Flushing
  • Headache
  • Ankle swelling
139
Q

Drugs that exacerbate psoriasis

A
  • Beta-blockers
  • Lithium
  • Antimalarials (chloroquine and hydroxychloroquine)
  • NSAIDs
  • ACE inhibitors
  • Infliximab
  • Withdrawal of systemic steroid
  • Alcohol
140
Q

Drugs that can precipitate digoxin toxicity

A
  • Amiodarone
  • Diltiazem
  • Thiazides
  • Loop diuretics
  • Verapamil
  • Ciclosporin
  • Quinidine
141
Q

Which drug should be prescribed by trade/brand drug name?

A
  • Tacrolimus
142
Q

Drugs to increase during surgery?

A
  • Patients on long-term corticosteroids should have IV steroids at induction of anesthesia
143
Q

Drugs to stop before surgery?

A

I LACK OP

  • Insulin
  • Lithium (24 hrs before major surgery only, monitor fluids and electrolytes in minor surgery)
  • Anticoagulants/antiplatelets
  • COCP/HRT (4 weeks before)
  • K-sparing diuretics (on morning)
  • Oral hypoglycaemics (metformin could cause lactic acidosis, others could cause hypoglycemia)
  • Perindopril (and other ACE-Is/ARBs) - 24hrs before

NBs:

  • Aspirin (unless recent ACS, coronary artery stent or ischaemic stroke) -> replace with LMWH or unfractionated heparin
  • MAOIs
  • Herbal medicines
  • Let surgeon know if on tricyclic antidepressants
144
Q

Four drugs to know CIs for

A
  • Drugs that increase bleeding and a bleeding patient
  • Steroids
  • NSAIDs
  • Antihypertensives
145
Q

Anticoagulants/antiplatelets

CIs

A
  • Do not give if patient bleeding, suspected bleeding or at risk of bleeding (e.g. long prothrombin time due to liver disease)
  • Prophylactic heparin is CI in acute ischaemic stroke due to risk of bleeding into the stroke
  • Enzyme inhibitors (e.g. erythromycin) can increase warfarin effects
146
Q

Steroids

CIs

A

STEROIDS

  • Stomach Ulcers
  • Thin skin
  • Edema
  • Right and left heart failure
  • Osteoporosis
  • Infection (including candida)
  • Diabetes (commonly causes hyperglycemia and uncommonly progresses to diabetes
  • cushing’s Syndrome
147
Q

NSAIDs

CIs

A

NSAID

  • No urine (renal failure)
  • Systolic dysfunction (heart failure)
  • Asthma
  • Indigestion
  • Dyscrasia (clotting abnormality)
148
Q

Antihypertensives

CIs

A
  • Bradycardia with beta-blockers and some CCBs

- Electrolyte disturbances with ACE-Is and diuretics

149
Q

Antihypertensives

Specific SEs

A

= ACE-I: dry cough

  • B-Blockers: wheeze in asthmatics, worsening acute HF
  • CCBs: flushing and oedema
  • Diuretics: renal failure
  • Loop diuretics: gout
  • Potassium-sparing diuretics: hyperkalaemia and gynaecomastia
150
Q

Usual hospital blood clot prophylaxis and exceptions to rule

A
  • LMWH (Dalteparin 5000 units SC OD)
  • Exception: bleeding/at risk of bleeding/recent ischaemic stroke
  • Compression stockings
  • Exception: not in PAD - usually indicated by absent foot pulses, may cause limb ischaemia
151
Q

Usual antiemetic? Dose?

A
  • Cyclizine 50 mg 8-hourly IM/IV/oral
152
Q

When would you not use cyclizine? What’s the alternative and dose?

A
  • In cardiac cases as can worsen fluid retention

- Use Metoclopramide 10 mg 8-hourly IM/IV if heart failure

153
Q

When would you avoid Metoclopramide?

A
  • Parkinson’s disease

- Young women (risk of dyskinesia)

154
Q

Analgesic choice

No pain, PRN

A

Paracetamol 1 g up to 6 hrly PO

155
Q

Analgesic choice

Mild pain, PRN

A

Codeine 30 mg up to 6 hrly PO

Or Tramadol

156
Q

Analgesic choice

Severe pain, PRN

A

Morphine sulphate 10 mg up to 6 hrly PO (oramorph)

Strength usually 10mg/5mL
Then SC, then IV

157
Q

Analgesic choice

Mild pain, regularly

A

Paracetamol 1 g 6 hrly PO

158
Q

Analgesic choice

Severe pain, regularly

A

Co-codamol 30/500

2 tablets, 6 hrly, PO

159
Q

What should you be careful of with co-codamol?

A

It contains paracetamol (500 mg) so check patients other analgesics. Should not be having > 4 g in 24 hrs

160
Q

Primary questions in prescription review?

A
  • Are they risk of bleeding?
  • Are they taking too much paracetamol?
  • Are they in pain?
  • Do they have HF?
  • Do they have electrolyte imbalances?
  • Do they have renal/hepatic failure?
161
Q

Analgesia

First and second line for neuropathic pain?

A
  • FIRST: Amitriptyline (10 mg ON)

- Second: Pregablin (75 mg OD 12hrly)

162
Q

Analgesia

First line for diabetic neuropathy?

A
  • Duloxetine
163
Q

What does 1% mean in calculations?

A
  • 1g in 100 mL
    OR
  • 1g in 100g
164
Q

Which drugs might have different salt/base equivalents? Where to find in BNF?

A
  • Phenytoin
  • Digoxin
  • Sodium fusidate

Can find this info in dose equivalents and conversion section of drug.

165
Q

Prescriber mnemonic

A
  • P – Patient details
  • Re – REaction (allergy plus the reaction)
  • S – Sign the front of the chart
  • C – check Contraindications to each drug
  • R – check Route for each drug
  • I – prescribe Intravenous fluids if needed
  • B – prescribe Blood clot prophylaxis if needed
  • E – prescribe antiEmetic if needed
  • R – prescribe pain Relief if needed.
166
Q

Safest antiepileptics in pregnancy?

A
  • FIRST LINE = Lamotrigine

- Second line = Levetiracetam (caution in depression)

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