Pharmacology Flashcards
1
Q
What is the only lipid modifying drug that may be considered in pregnancy (and what is the risk)?
A
Bile acid sequestrants or resins e.g. colesevelam (can cause fat solube vitamin deficiency on prolonged use)
2
Q
What is the NICE advice regarding lipid modifying therapy in pregnancy?
A
pregnant women/ women planning to conceive must not use lipid modifying therapy due to potential for fetal abnormality + should be stopped 3 months before trying to conceive
3
Q
What is meloxicam?
A
NSAID used short term for OA, long term for RA/ ankylosing spondylitis
4
Q
What are 6 complications of ACE inhibitors?
A
- Dry cough
- First-dose hypotension
- Hyperkalaemia
- Urticaria
- Altered taste
- renal impairment
5
Q
What is the conversion between oral morphine and subcutaneous morphine?
A
Oral morphine is twice the dose of subcutaneous morphine
6
Q
What is a good starting regime of oral morphine for someone without other comorbidities?
A
Total 20-30mg MR morphine and 5mg oramorph as breakthrough; e.g. 15mg MR morphine BD
7
Q
What is preferred to morphine in palliative patients with renal impairment?
A
- Oxycodone if mild/moderate
- if severe, alfentanil, buprenorphine, fentanyl
8
Q
What are 4 things that may be useful for metastatic bony pain?
A
1 opioids
2 bisphosphonates
3 radiotherapy
4 denosumab
9
Q
How do you get from oral codeine / tramadol dose to oral morphine?
A
Divide by 10
10
Q
When is activated charcoal offered in paracetamol overdose?
A
If present within 1 hour of ingestion
11
Q
What are 4 indications for NAC in paracetamol overdose?
A
- Paracetamol level on or above treatment line which joins >100mg/kg at 4 hours and >15mg/kg at 15 hours
- Staggered overdose / timing uncertain
- Patients presented 8-24h after ingestion if dose >150mg/kg
- Patients presenting >24h if jaundiced / hepatic tenderness / raised ALT
12
Q
Over what time frame is N-acetylcysteine now recommended to be infused over and why?
A
1 hour (rather than 15 minutes) due to risk of anaphylactoid reaction (non Ig-E mediated mast cell release)
13
Q
What is the management of anaphylactoid reaction to NAC?
A
stop infusion then restart at slow rate
14
Q
What is the name of the criteria for liver transpant in acute liver failure in paracetamol overdose + what are they?
A
King’s College Criteria
pH <7.3, 24h after ingestion
or all of:
* prothrombin time > 100
* creatinine >300
* grade 3 or 4 encephalopathy
15
Q
What is the definition of a staggered overdose?
A
not taken within 1 hour
16
Q
What are 8 examples of live attenuated vaccinations?
A
- BCG
- MMR
- intranasal influenza
- rotavirus
- polio
- yellow fever
- oral typhoid
- chickenpox / shingles
17
Q
3 inactivated vaccination preparations?
A
- IM influenza
- rabies
- hepatitis A
18
Q
What are 3 toxoid (inactivated toxin) vaccinations?
A
- tetanus
- diphtheria
- pertussis
19
Q
What is a multivalent vs monovalent vaccination?
A
Multivalent - protect against multiple strains or subtypes of a pathogen
Monovalent - confer immunity against one strain of a pathogen
20
Q
What is the advice if a women misses 2 or more COCPs?
A
- take the last pill (even if it means taking 2 pills in one day)
- use condoms/abstain for 7 days
- if missed pill in week 1: use emergency contraception if had unprotected sex in pill free week/week 1
- if week 2: after 7 consecutive days of taking pill no need for EC
- if week 3: finish pills in current pack and omit pill-free period
21
Q
What anti-TB drugs can affect INR in patients on warfarin and how?
A
- Rifampicin - P450 enzyme INDUCER - increases warfarin metabolism so DECREASES INR
- Isoniazid - P450 INHIBITOR reduces warfarin metabolism so INCREASES INR
22
Q
What is the effect of P450 enzyme inducers on the COCP?
A
Will reduce its effectiveness - as metabolised more quickly
23
Q
What are 8 examples of P450 enzyme inducers?
A
- rifampicin
- carbamazepine
- phenytoin
- phenobarbitone
- smoking
- chronic alcohol use
- St John’s Wort
- griseofulvin
24
Q
What are 13 examples of P450 inhibitors?
A
- ciprofloxacin
- erythromycin
- isoniazid
- cimetidine
- omeprazole
- amiodarone
- allopurinol
- ketoconazole, fluconszole
- sertraline, fluoxetine
- ritonavir
- sodium valproate
- acute alcohol intake
- quinupristin
25
What is the treatment of major bleeding (e.g. intracerebral haemorrhage) with warfarin?
stop warfarin, give 5mg vitamin K IV and give prothrombin complex concentrate IV
26
What is prothrombin complex concentrate (PCC)?
solution containing coagulation factors II, VII, IX and X - designed to reverse warfarin
27
Following raised INR at what INR can warfarin be restarted?
INR <5.0
28
What is the management of INR >8, minor bleeding?
stop warfarin, give IV vitamin K 1-3mg
repeat vit K if INR still too high after 24h
29
What is the management of INR <8.0, no bleeding?
stop warfarin ,give PO vitamin K 1-5mg (use IV preparation orally)
repeat dose if still too high after 24h
30
What is the maangement of INR 5.0-8.0 with minor bleeding?
stop warfarin, give IV vitamin K 1-3mg
31
What is the management of INR 5.0-8.0 with no bleeding?
Withold 1 or 2 doses of warfarin, reduce subsequent maintenance dose
32
What is the risk of of using ACEis with aortic stenosis?
May result in hypotension
33
What is a key drug interaction of ACEis?
Diuretics when high dose E.g >80mg furosemide per day; high risk of hypotension
34
What are considered acceptable rises in creatinine and potassium when starting ACEi?
Increase in serum creatinine up to 30%, K+ up to 5.5 acceptable
35
Which emergency contraception should you exercise caution for patients with asthma?
Ulipristal (EllaOne)
36
How long after intercourse can Ulipristal (EllaOne) be used for UPSI?
120 hours
37
How long after intercourse can levonorgestrel (levonelle) be used after UPSI?
72 hours
38
When can hormonal contraception be started after use of Ulipristal (EllaOne) vs levonorgestrel (levonelle)?
EllaOne - 5 days after
Levonelle - straight away
39
Can EllaOne / levonelle be used within the same menstrual cycle more than one?
Yes, both can
40
What is the guidance for breastfeeding and EllaOne/ levonelle?
Levonelle (levonorgestrel) - can continue breastfeeding
EllaOne (Ulipristal) - breastfeeding should be delayed for one week
41
When can copper IUD be used for UPSI?
Up to 5 days after UPSI or 5 days after ovulation date (day 14)
42
If a patient wants the copper coil removed after insertion for UPSI when should it be done?
Wait at least until after next period
43
If a patient wants the copper coil removed after insertion for UPSI when should it be done?
Wait at least until after next period
44
What is the mechanism of ulipristal acetate (EllaOne)?
selective progesterone receptor modulator
45
What is agomelatine?
used in treatment of depression - agonist at melatonin receptors - improves sleep quality
46
What is the commonest side effect of SSRIs?
gastrointestinal symptoms
47
Which SSRI is the best post-myocardial infarction?
sertraline - more evidence for safe use than other antidepressants
48
What could prompt you to prescribe another drug alongside SSRIs and why?
if also on NSAID - PPI as can increase risk of GI bleeding
49
Should SSRIs be given in combination with warfarin / heparin?
no - avoid, consider mirtazapine
50
What is the interaction between SSRIs and triptans?
increased risk of serotonin syndrome
51
After what time period should patients be reviewed after starting SSRIs?
2 weeks; 1 week if age 25 or at risk of suicide
52
What are 4 types of drugs whihc can cause staining of the teeth?
1. tetracyclines - intrinsic staining
2. chlorhexidine mouthwash - removable with polishing
3. iron salts in liquid form
4. co-amoxiclav suspension
53
For how long should patients be continued on an SSRI if they have a good response to antidepressant therapy?
at least 6 months after remission
54
What drug group is most commonly implicated in intrinsic staining of the teeth?
tetracyclines - if given in utero until 12 years of age
55
Over what time period should SSRIs be stopped?
over 4 weeks
56
Which SSRI doesn't need tapering over 4 weeks when stopped?
fluoxetine
57
What is the guidance re SSRIs and pregnancy?
weigh up beneits and risks when deciding
58
How does atropine work to treat symptomatic bradycardia?
increases firing of the sinoatrial node (SA) and conduction through the AV node, opposes action of vagus nerve
59
What is the risk with SSRIs in pregnancy?
**first trimester** - increased risk of congenital heart defects
**third trimester** - persistent pulmonary hypertension of the newborn
60
What are 4 causes of gingival hyperplasia?
1. Phenytoin
2. Ciclosporin
3. Calcium channel blockers (esp nifedipine)
4. AML
61
Which antibiotic have ruptured Achilles tendon / tendinopathy as a side effect?
fluoroquinolones e.g. ciprofloxacin
62
What are 5 risk factors for Achilles tendinopathy with fluoroquinolones?
1. Age >60 years
2. Corticosteroid therapy
3. Renal failure
4. Diabetes mellitus
5. History of MSK disorders
63
What is the treatment of symptomatic bradycardia?
atropine - 0.5-1mg IV; may repeat every 3-5 minutes up to maximum 3mg
64
What drug should be given immediately after thrombolysis is given for MI?
heparin (UFH or LMWH)
65
What should be done in patients taking AEDs who need an antidepressant medication?
seek specialist advice - as all antidepressants lower seizure threshold. **SSRIs / sertraline** are preferred option
66
Which antidepressants should be avoided in patients taking triptans for migraine?
SSRIs
67
Which antidepressants interact with MAOIs?
SSRIs
68
What is meant by a live attenuated vaccination?
virus / bacteria has been weakened via genetic modification of the pathogen
69
Which antidepressants may be sedating and what is the DVLA advice?
mirtazapine, trazodone, lofepramine; DVLA advises people should not drive during this time if affected
70
What is a key adverse effect of carbamazepine?
aplastic anaemia - needs FBC monitoring (also drug interactions - CYP450 inducer)
71
What is a key side effect of cabergoline?
Pulmonary fibrosis
72
What 2 drugs can affect the absorption of levothyroxine?
- calcium carbonate
- iron
(Take at least 4h apart)
73
What are 7 adverse effects of loop diuretics?
1. Hypotension
2. Ototoxicity
3. Hyponatraemia, hypokalaemia, hypomagnesaemia, hypocalcaemia
4. Hypochloraemic acidosis
5. Renal impairment
6. Hyperglycaemia
7. Gout
74
What is the mechanism of action of loop diuretics?
Inhibit Na-K-Cl cotransporter in thick ascending loop of Henle, reducing absorption of NaCl
75
What are the 2 most common drug causes of drug induced lupus erythematosus (DILE)?
- procainamide
- hydralazine
(Also isoniazid, minocycline, phenytoin)
76
What pattern of antibodies are seen in DILE? (4 key features)
1. ANA positive 100%
2. dsDNA negative
3. **Anti-histone antibodies** in 80-90%
4. anti-Ro, anti-Smith +ve in 5%
77
What are the key features of drug-induced lupus erythematosus?
- malar rash
- pulmonary involvement E.g. pleurisy
- myalgia
- arthralgia
Renal and neuro involvement rare
78
What are 3 types of drugs which can cause purpura in adults?
1. Quinine
2. Antiepileptics
3. Anti thrombotics
79
What are 11 causes of drug-induced seizures?
1. bupropion
2. antidepressants e.g. TCAs, venlafaxine
3. dyphenhydramine
4. tramadol
5. amphetamine
6. isoniazid
7. cocaine, lidocaine
8. MDMA
9. lithium
10. antipsychotics e.g. clozapine, barbiturate withdrawal
11. benzodiazepines
80
What electrolyte abnormality is most likely to occur with furosemide and prednisolone taken together?
hypokalaemia
81
What are 3 types of influenza vaccination?
1. **whole inactivated virus**
2. **split virion** (virus particles disrupted by detergent treatment)
3. **subunit** (mainly haemagglutinin and neuraminidase)
82
What does the cholera immunisation involve?
inactivated Inaba and Ogawa strains of Vibrio cholerae with recombinant B-subunit of the cholera toxin
83
What are 7 indications for BCG vaccination?
1. infants in **UK** where incidence **>40/100 000**
2. infants w **parent/grandparents** born in country where incidence **>40 /100 000**
3. unvaccinated **contacts** of respiratory TB (tuberculin neg)
4. unvaccinated **new entrants** <16y born/lived in country with incidence <40 /100 000
5. **healthcare workers**
6. **prison staff**
7. staff of **care home for elderly**
8. working with **homeless** people
84
What other disease does the BCG also offer limited protection against?
leprosy
85
What is the only exception to performing a tuberculin skin test prior to performing the BCG?
children <6 yeras old with no contact with TB
86
When can other vaccinations be given in relation to BCG?
can be given at same time, but if not administered simultaneously there should be a 4 week interval
87
What are 5 contraindications to BCG?
1. previous BCG vaccination
2. past history of tuberculosis
3. **HIV**
4. **pregnancy**
5. positive tuberculin test (Heaf or Mantoux)
88
What is the cut off age for BCG?
not given to anyone over age of 35
89
What is the management of beta blocker overdose?
- atropine if bradycardic
- glucagon if severe
Haemodialysis not effective
90
What can be an early sign of aspirin (salicylate) overdose?
Tinnitus
91
What metabolic derangement may be seen with aspirin (/ salicylate) overdose?
Initially respiratory alkalosis then metabolic acidosis
92
What is the treatment of salicylates (e.g. aspirin) overdose?
- General - ABC, charcoal
- urinary alkalinisation with IV sodium bicarbonate (increases urinary excretion)
- haemodialysis
93
What are 6 indications for harmodialysis in aspirin (/salicylate) overdose?
1. Serum concentration > 700mg/L
2. Metabolic acidosis resistant to treatment
3. Acute renal failure
4. Pulmonary oedema
5. Seizures
6. Coma
94
Why does salicylate overdose (e.g. aspirin) cause sweating and pyrexia?
salicylates cause the uncoupling of oxidative phosphorylation leading to decreased adenosine triphosphate production, increased oxygen consumption and increased carbon dioxide and heat production
95
What are 11 drugs which can cause a hepatocellular picture of DILI?
1. paracetamol
2. sodium valproate
3. phenytoin
4. MAOIs
5. halothane
6. anti-TB: isoniazid, rifampicin, pyrazinamide
7. statins
8. alcohol
9. amiodarone
10. methyldopa
11. nitrofurantoin
96
What are 11 drugs which can cause a cholestatic picture of DILI?
1. COCP
2. flucloxacillin
3. co-amoxiclav
4. erythromycin
5. anabolic steroids
6. testosterone
7. chlorpromazine
8. prochlorperazine
9. sulphonylureas
10. fibrates
11. nifedipine
97
What are 3 types of drugs which can cause liver cirrhosis?
1. methotrexate
2. methyldopa
3. amiodarone
98
What is the mechanism of action of sildenafil?
aka viagra - phosphodiesterase V inhibitor. cause vasodilation via increase in cGMP leading to smooth muscle relaxation in blood vessels supplying corpus cavernosum
99
When should sildenafil be taken for its use in erectile dysfunction?
approx 1 hour before sexual activity (short acting)
100
What are 3 contraindications to PDE5 inhibitors?
1. nitrates + nicorandil
2. hypotension
3. recent stroke or MI (wait 6 months)
101
What are 6 side effects of phosphodiesterase type 5 inhibitors?
1. visual disturbances - blue discoloration; also NAION
2. nasal congestion
3. flushing
4. GI side effects
5. headache
6. priapism
102
What are 3 common side effects of dihydropyridine CCBs (amlodipine, nifedipine, felodipine)?
headache, flushing ankle swelling
103
Which calcium channel blockers can cause tachycardia?
short acting dihydropyridines e.g. nifedipine - cause peripheral vasodilation which can cause reflex tachycardia
104
What are 5 common side effects of verapamil?
1. heart failure
2. constipation
3. hypotension
4. bradycardia
5. flushing
105
What are 4 common side effects of diltiazem?
1. hypotension
2. bradycardia
3. heart failure
4. ankle swelling
106
What is the most common side effect of sildenafil?
headache
107
What are 4 situations when diclofenac is contraindicated?
1. ischaemic heart disease
2. peripheral arterial disease
3. cerebrovascular disease
4. congestive heart failure (NYHA 2-4)
108
Is St. John’s Wort an inducer or inhibitor of P450?
Inducer - effectiveness of warfarin / COCP reduced
109
What drug monitoring is required for statins?
LFTs - baseline, 3 months, 12 months
110
What drug monitoring is required for amiodarone?
TFT, LFT, U&Es CXR at baseline
TFT & LFT every 6 months
111
What drug monitoring is required for methotrexate?
FBC, LFT, U&Es before treatment then weekly until stabilised, then every 2-3 months
112
What is the recommended monitoring for azathioprine?
FBC and LFT before treatment; FBC weekly for first 4 weeks; then FBC and LFT every 3 months
113
What is the recommended monitoring for lithium?
TFT and U&E before starting
Lithium level weekly until stabilised then every 3 months
TFT and U&E every 6 months
114
What is the recommended monitoring for sodium valproate?
LFT and FBC before starting treatment then LFT periodically during the first 6 months
115
What is the recommended monitoring for glitazones?
LFT before treatment, then regularly during treatment
116
What is the advice for switching between types of COCP with different progesterones?
BNF suggests omitting pill free period (FSRH advice contradicts)
117
What are 5 types of cytotoxic agents?
1. Alkylating agents
2. Cytotoxic antibiotics
3. Antimetabolites
4. Acts on microtubules
5. Topoisomerase inhibitors
+ other
118
What is the mechanism of action of cyclophosphamide?
Alkylating agent - causes cross-linking in DNA
119
What is an example of an alkylating cytotoxic agent?
Cyclophosphamide
120
What are 3 side effects of cyclophosphamide?
1. Haemorrhagic cystitis
2. Myelosuppression
3. Transitional cell carcinoma
121
What are 2 examples of cytotoxic antibiotics?
1. Bleomycin
2. Anthracyclines e.g. doxorubicin
122
What is the mechanism of action if bleomycin?
Degrades preformed DNA
123
What is a key side effect of bleomycin?
Pulmonary fibrosis
124
What is the mechanism of action of anthracyclines e.g. doxorubicin?
Stabilises DNA-topoisomerase II complex, inhibits DNA and RNA synthesis
125
What is a key adverse effect of anthracyclines e.g doxorubicin?
Cardiomyopathy
126
What are 4 examples of antimetabolite cytotoxic drugs?
1. Methotrexate
2. Fluorouracil
3. 6-mercaptopurine
4. Cytarabine
127
What are 4 adverse effects of methotrexate?
1. Myelosuppression
2. Pulmonary fibrosis
3. Liver fibrosis
4. Mucositis
128
What are 3 side effects of fluorouracil?
1. Myelosuppression
2. Mucositis
3. Dermatitis
129
What are 3 side effects of 5 fluorouracil?
1. Myelosuppression
2. Mucositis
3. Dermatitis
130
What is a key side effect of 6-mercaptopurine?
myelosuppression
131
What are 2 key side effects of cytarabine?
myelosuppression, ataxia
132
What are 2 examples of cytotoxic drugs that act on microtubules?
1. vincristine/vinblastine
2. docetaxel
133
What are 2 key side effects of vincristine?
1. peripheral neuropathy
2. paralytic ileus
134
What is a key side effect of vinblastine?
myelosuppression
135
What is a key side effect of docetaxel?
neutropenia
136
What is a key example of a topoisomerase inhibitor-type cytotoxic drug?
irinotecan
137
What is a key side effect of irinotecan?
myelosuppression
138
What are 3 key side effects of cisplatin?
1. ototoxicity
2. peripheral neuropathy
3. hypomagnesaemia
139
What is a key side effect of hydroxyurea?
myelosuppression
140
What is the mechanism of action of quinolone antibiotics?
inhibit DNA synthesis by inhibiting topoisomerase II (DNA gyrase) and topoisomerase IV - bactericidal
141
What are 4 adverse effects of quinolones?
1. lower seizure threshold in patients with epilepsy
2. tendon damage (including rupture)
3. cartilage damage
4. lengthens QT interval
142
What drug used in concurrence with quinolones increases the risk of tendon damage?
steroids
143
What are 3 contraindications to quinolones?
1. pregnancy
2. breastfeeding
3. G6PD
144
What is the mechanism of organophosphate (e.g. pesticide) poisoning?
inhibition of acetylcholinesterase leading to **upregulation** of nicotinic + muscarinic cholinergic neurotransmission
| sarin gas = used in warfare, similar
145
What are 7 features of organophosphate insecticide poisoning?
1. salivation
2. lacrimation
3. urination
4. defecation/diarrhoea
5. cardiovascular: hypotension, bradycardia
6. small pupils
7. muscle fasciculation
146
What are 2 aspects of the management of organophosphate poisoning?
1. **atropine**
2. pralidoxime - unclear role
147
What is the mechanism of action of metformin?
* activation of AMP-activated protein kinase (AMPK)
* increases insulin sensitivity
* reduces hepatic gluconeogenesis
* reduce GI absorption of carbohydrates
148
What are 3 key side effects of metformin?
1. GI upset - nausea, anorexia, diarrhoea
2. reduced B12 absorption
3. lactic acidosis with severe liver disease or renal failure
149
What are 4 contraindications to metformin?
1. chronic kidney disease
2. recent myocardial infarction, sepsis, AKI, severe dehydration - tissue hypoxia (causes lactic acidosis)
3. iodine-containing x-ray contrast media
4. alcohol abuse (relative)
150
What are the rules regarding metformin use in chronic kidney disease?
* review if creatinine >130 umol/L (eGFR <45)
* stop if creatinine >150 (eGFR <30)
151
What should happen to a patient's metformin if they are having imaging involving iodine-containing contrast?
stop on day of procedure and for 48h afterwards
152
What is the mechanism of action of macrolides?
* inhibit bacterial protein synthesis by blocking translocation
* bacteriostatic
153
What are 5 adverse effects of macrolides?
1. prolongation of QT interval
2. GI side effects - nausea (less with clari)
3. cholestatic jaundice
4. P450 inhibitor
5. azithromycin - hearing loss + tinnitus
154
What is a key drug interaction of macrolides?
**statins** - macrolides inhibit cythochrome P450 isoenzyme CYP3A4 that metabolises statins; concurrent use significantly increases risk of **myopathy / rhabdomyolysis**
155
What is the difference in P450 enzyme inhibitors and inducers in terms of speed of onset?
inhibitors have rapid effects, whereas induction usually requires prolonged exposure to the inducing drug
156
What are the options for migraine prophylaxis and when should specific ones be avoided?
1. propranolol
2. topiramate - avoid in women of childbearing age
3. amitriptyline
157
Which anti-TB drug causes a peripheral neuropathy and how?
isoniazid - vitamin B6 deficiency
158
What is another name for vitamin B6?
pyridoxine
159
How can vitamin B6 deficiency caused by isoniazid be prevented?
prophylactic pyridoxine should be prescribed at the same time as isoniazid
160
What are 2 consequences of vitamin B6 deficiency?
1. peripheral neuropathy
2. sideroblastic anaemia
161
What is the mechanism of action of tamoxifen?
selective oestrogen receptor modulator (SERM) - acts as oestrogen receptor antagonist + partial agonist
162
What are 4 side effects of tamoxifen?
1. hot flushes (commonest)
2. menstrual disturbance - vaginal bleeding, amenorrhoea
3. VTE
4. endometrial cancer
163
How long is tamoxifen used for?
5 years following removal of tumour
164
What is an alternative SERM to tamoxifen and how does its side effect profile differ?
raloxifene - lower risk of endometrial cancer
165
What is the main indication for digoxin?
rate control in management of AF; also has positive inotropic properties so sometimes used for improving symptoms (not mortality) in HF
166
What is the mechanism of action of digoxin?
* decreases conduction through AV node, slows ventricular rate in AF and flutter
* increases force of cardiac muscle contraction due to inhibition of Na+/K+ ATPase pump. also stimluated vagus nerve
167
When is digoxin monitoring recommended and how?
if toxicity suspected only - concentration should be measured within 8-12h of last dose
168
What are 7 features of digoxin toxicity?
1. lethargy
2. nausea + vomiting
3. anorexia
4. confusion
5. yellow-green vision
6. arrhythmias (AV block, bradycardia)
7. gynaecomastia
169
Which electrolyte abnormality classically precipitates digoxin toxicity?
**hypokalaemia** (digoxin binds to ATPase pump on same site as potassium; hypokalaemia means dig binds more easily, increasing its inhibitory effects)
170
What are 8 drugs that can precipitate digoxin toxicity?
1. amiodarone
2. quinine
3. verapamil
4. diltiazem
5. spironolactone
6. ciclosporin
7. thiazides
8. loop diuretics
171
What is the management of digoxin toxicity?
digibind, correct arrhythmias, monitorin K+
172
What should be done in patients on long term oral prednisolone who develop intercurrent illness?
double steroid dose
173
What are 2 key adverse effects of aminoglycosides e.g. gentamicin?
1. ototoxicity - auditory/vestibular nerve damage
2. nephrotoxicity - acute tubular necrosis
174
Is ototoxicity due to aminoglycosides reversible?
no - irreversible
175
What causes nephrotoxicity from gentamicin / aminoglycosides?
acute tubular necrosis
176
Concomitant use of which drug with aminoglycosides increases the risk of acute tubular necrosis?
furosemide
177
What is a contraindication to using aminoglycosides?
myasthenia gravis
178
When should aminoglycoside levels be measured and how should doses be adjusted?
* peak (1 hour after administration) - if too high, decrease dose
* trough - if too high, increase interval
179
What is the conversion from oral morphine to oral oxycodone?
divide by 1.5-2 to get oxycodone dose
180
How does transdermal fentanyl equate to oral morphine?
fentanyl 12mcg patch = morphine 30mg PO
181
Which opioid side effects tend to be transient vs persistent?
* transient: nausea, sedation
* persistent: constipation
182
What is the guidance for statins and pregnancy?
contraindicated in pregnancy (IUGR, fetal death)
183
What are 3 groups of adverse effects of statins?
1. myopathy - myalgia, myositis, rhabdomyolysis, raised CK
2. liver impairment - discontinue if serum transaminases persistently > 3 x ULN
3. increase risk of intracerebral haemorrhage
4. GI disturbances - very rarely pancreatitis
5. interstitial lung disease - rarely
184
What are 5 risk factors for myopathy in a patient taking statins?
1. advanced age
2. female sex
3. low BMI
4. multisystem disease e.g. DM
5. lipophilic statins > hydrophilic
185
What are 4 groups of patients who should take statins?
1. established CVD - stroke, TIA, IHD, PAD
2. QRISK >10%
3. T2DM - use QRISK
4. T1DM diagnosed > 10 years ago, or age > 40 or established nephropathy
186
What is he mechanism of action of statins?
decrease intrinsic cholesterol synthesis via inhibiting enzyme HMG-CoA reductase (rate limiting
187
Why does grapefruit juice have key drug interactions e.g. statins?
inhibits action of intestinal CYP3A4 which normally metabolises many drugs - increases their action
188
What are 4 important side effects of ACE inhibitors?
1. hyperkalaemia
2. first-dose hypotension
3. dry cough
4. **aniogoedema** - may occur up to 1 year after starting
189
What is the mechanism of action of benzodiazepines?
enhance effect of inhibitory neurotransmitter GABA by increasing frequency of chloride channels
190
What is NICE guidance on withdrawing a benzo?
* withdraw in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight
* if difficulty - switch patients to the equivalent dose of diazepam
* reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
191
How long can it take to withdraw from benzodiazepines?
from 4 weeks to a year or more
192
What are 9 features of benzodiazepine withdrawal syndrome?
1. insomnia
2. irritability
3. anxiety
4. tremor
5. loss of appetite
6. tinnitus
7. perspiration
8. perceptual disturbances
9. seizures
193
For how long can benzodiazepine withdrawal symptosm occur after withdrawal?
up to 3 weeks after stopping long-acting drug
194
What advice should be given when commencing patients on mefloquine for malaria prophylaxis?
* nightmares or anxiety may be prodromal of more serious neuropsychiatric event
* suicide and DSH can occur
* can continue for several months due to long-half life
195
Which patients is mefloquine contraindicated in?
anxiety, depression, schizophrenia, other psychiatric disorders
196
What is the most important counselling to give to a patient taking carbimazole?
attend for urgent medical review if develops symptoms of infection e.g. sore throat or fever
197
What is a key adverse effect of carbimazole?
* agranulocytosis
198
How is carbimazole usually used to treat thyrotoxicosis?
given in high doses for 6 weeks until patient becomes euthyroid before being reduced
199
What is the mechanism of action of carbimazole?
blocks **thyroid peroxidase** from coupling and iodinating the **tyrosine residues** on **thyroglobulin**, reducing thyroid hormone production
200
What is the mechanism of action of propylthiouracil?
* **same as carbimazole**: blocks thyroid peroxidase from coupling and iodinating tyrosine residuues on thyroglobulin, reducing thyroid hormone production
* **peripheral action**: inhibits 5'-deiodinase which reduces peripheral conversion of T4 to T3
201
What is the guidance about carbimazole in pregnancy?
crosses placenta but may be used in low doses during pregnancy
202
What are 2 first line options to treat hiccups in palliative care?
1. **chlorpromazine**
2. haloperidol
| gabapentin and dexamethasone also work
203
What is the treatment of local anaesthetic toxicity?
IV lipid emulsion
204
What is the maximum dose of lidocaine if given a) alone and b) with adrenaline?
a) 3mg / kg
b) 7 mg / kg
205
What are 2 things that increase the risk of lidocaine toxicity?
1. liver dysfunction
2. low protein states
206
What are 3 lidocaine drug interactions?
1. beta blockers
2. ciprofloxacin
3. phenytoin
207
What are the features of lidocaine toxicity?
Initial CNS over activity then depression as lidocaine initially blocks inhibitory pathways then blocks both inhibitory and activating pathways. Cardiac arrhythmias.
208
How does the action of bupivacaine differ from lidocaine?
much longer duration of action - may be used for topical wound infiltration at end of surgery with long duration of analgesic effect
209
What local anaesthetic is used for IV regional anaesthesia e.g. Biers block?
prilocaine
210
What are 2 situations when adding adrenaline to local anaesthetic is contraindicated?
1. patients taking MAOIs
2. Tricyclic antidepressants
211
Which LA can't be given in higher doses with adrenaline?
bupivacaine
212
What are 2 teratogenic effects of ACE inhibitors?
1. renal dysgenesis
2. craniofacial abnormalities
213
What is the teratogenic effect of alcohol?
craniofacial abnormalities
214
What is the teratogenic effect of aminoglycosides?
ototoxicity
215
What are 2 teratogenic effects of carbamazpine?
1. neural tube defects
2. craniofacial abnormalities
216
What are 2 teratogenic effects of cocaine?
1. intrauterine growth retardation
2. preterm labour
217
What are 2 teratogenic effects of smoking?
1. intrauterine growth retardation
2. preterm labour
218
What are 2 teratogenic effects of valproate?
1. neural tube defects
2. craniofacial abnormalities
219
What are 5 teratogenic effects of maternal diabetes mellitus?
1. macrosomia
2. neural tube defects
3. polyhydramnios
4. preterm labour
5. caudal regression syndrome
220
What is a teratogenic effect of chloramphenicol?
grey baby sydrome
221
What is a teratogenic effect of diethylstilbesterol?
vaginal clear cell adenocarcinoma
222
What is a teratogenic effect of tetracyclines?
discoloured teeth
223
What is a teratogenic effect of thalidomide?
limb reduction defects
224
What is a teratogenic effect of warfarin?
craniofacial abnormalities
225
What is the mechanism of action of clopidogrel?
antagonist of the P2Y12 adenosine diphosphate (ADP) receptor, inhibiting the activation of platelets
226
The concurrent advice of which drug with clopidogrel make it less effective?
PPIs (lansoprazole and pantoprazol OK - avoid omeprazole)
227
What is a key investigation in an unwell person taking aminosalicylates?
FBC - agranulocytosis is a key side effect
228
What are 6 side effects of sulfasalazine?
1. rashes -> Stevens Johnson syndrome
2. oligospermia
3. headache
4. Heinz body anaemia, megaloblastic anaemia
5. may colour tears - stained contact lenses
6. lung fibrosis
229
What are 5 side effects of mesalazine?
1. GI upset
2. headache
3. agranulocytosis
4. pancreatitis
5. interstitial nephritis
230
What are the neurological features of ecstasy poisoning?
* agitation
* anxiety
* confusion
* ataxia
231
What are the cardiovascular effects of ecstasy poisoning?
tachycardia, hypertension
232
What is the key electrolyte seen in ecstasy poisoning and why?
**hyponatraemia** - SIADH or excessive water consumption whilst taking MDMA
233
What are 5 effects of ecstasy poisoning?
1. neurological
2. cardiovascular - tachycardia, hypertension
3. hyponatraemia
4. **hyperthermia**
5. **rhabdomyolysis**
234
What is the management of ecstasy poisoning?
* supportive
* dantrolene for hyperthermia if simple measures fail
235
Which antiepileptic can cause weight gain?
sodium valproate
236
What effect does sodium valproate have on the P450 system?
inhibitor
237
What are 8 side effects of sodium valproate?
1. nausea
2. increased appetite + weight gain
3. alopecia - curly regrowth
4. ataxia
5. tremor
6. hepatotoxicity
7. pancreatitis
8. hyperammonemic encephalopathy
238
What are 3 abnormalities that may be seen on blood tests with sodium valproate?
1. thrombocytopenia
2. hyponatraemia
3. hyperammonemic encephalopathy
239
What treatment may be used if hyperammonemic encephalopathy develops secondary to sodium valproate?
L-carnitine
240
What is the first line choice for palliative patients with confusion and agitation in whom reversible causes have been ruled out?
haloperidol (other options: chlorpromazine, levomepromazine)
241
What can terminal agitation / restlessness be treated with?
midazolam
242
What is the mechanism of sulphonylureas?
* increase pancreatic insulin secretion (only effective if fuctional B-cells present
* bind to ATP-dependent K+ channel on cell membrane of pancreatic beta cells
243
What are 6 adverse effects of sulphonylureas?
1. hypoglycaemic episodes
2. weight gain
3. hyponatraemia - SIADH
4. bone marrow suppression
5. hepatotoxicity (cholestatic)
6. peripheral neuropathy
244
What is the treatment of benzodiazepine overdose?
* flumazenil
* many cases managed with supportive care only - flumazenil has risk of seizures
245
What is the management of tricyclic antidepressant poisonoing?
* IV bicarbonate - reduce risk of seizures and arrhythmias
* lots of antiarrhythmics and dialysis unsafe / ineffective
246
What is the antidote to heparin poisoning?
protamine sulphate
247
What is the management of beta blocker overdose?
* atropine if bradycardic
* glucagon in resistant cases
248
What is the treatment for ethylene glycol poisoning?
* fomepizole - first line
* ethanol
* haemodialysis - refractory cases
249
What is the treatment of methanol poisoning?
fomepizole or ethanol
haemodialysis
250
What is the management of organophosphate insecticide poisoning?
atropine
251
What is the management of iron overdose?
desferrioxamine
252
What is the management of lead overdose?
dimercaprol, calcium edetate
253
What is the management of cyanide poisoning?
* hydroxocobalamin
* combination of amyl nitrite, sodium nitrite, sodium thiosulfate
254
What are 2 key side effects of metronidazole?
* disulfiram like reaction with alcohol
* increases anticoagulant effect of warfarin
255
What are 2 cardiovascular side effects of admiodarone?
1. prolonged QT interval
2. bradycardia
256
What are 3 dermatological side effects of admiodarone?
1. photosensitivity
2. 'slate-grey' appearance
3. thrombophlebitis and injection site reactions
257
What is the effect of amiodarone on warfarin / INR?
decreases warfarin metabolism leading to raised INR
258
Is sulfasalazine safe in pregnancy / breastfeeding?
yes - safe in both
259
What are 4 side effects of PPIs?
1. hyponatraemia, hypomagnesaemia
2. osteoporosis + fragility fractures
3. microscopic colitis
4. increased risk of C diff infections
260
What drugs can worsen symptoms of stress incontinence?
alpha blockers e.g. doxazosin - worsen stress incontinence by relaxing bladder outlet and urethra
261
What are 7 drug causes of thrombocytopenia?
1. Quinine
2. Loop diuretics - furosemide
3. NSAIDS
4. Antibiotics: penicillins, sulphonamides, rifampicin
5. Anticonvulsants: valproate, carbamazepine
6. Heparin
7. Abciximab
262
What are 7 drugs associated with lichenoid ruptions?
1. ACE inhibitors
2. NSAIDs
3. methyldopa
4. chloroquine
5. oral antidiabetics
6. thiazide diuretics
7. gold
263
What are 3 types of vaccinations which people with egg allergy should avoid?
1. influenza
2. MMR
3. yellow fever
264
Which antihypertensive limits the maixmum dose of simvastatin to 20mg OD and why?
amlodipine - weak inhibitor of CYP3A4 therefore concurrent use results in raised blood levels of simvastatin - doubles its effect
265
What are 5 examples of drugs which colchicine shouldn't be co-prescribed with?
1. clarithromycin
2. erythromycin
3. ritonavir
4. verapamil
5. itraconazole / ketoconazole
266
What are 6 contraindications to colchicine?
1. blood disorders
2. eGFR < 10
3. renal impairment
4. severe hepatic impairment
5. pregnant or breastfeeding
6. P glycoprotein inhibitors or strong CYP 3A4 inhibitor drugs
267
What are 5 side effects of cholestyramine?
1. constipation
2. tooth discolortion
3. tooth enamel erosion
4. premature tooth decay
5. increased riks of gallstones
268
What type of cholesterol are statins vs. fibrates effective at lowering?
* statins: LDL
* fibrates: triglyceride
269
What is a key side effect of nicotinic acid to treat raised cholesterol?
vasodilatation - facial flushing
270
What are 8 drug interactions of azathioprine?
1. allopurinol
2. febuxostat
3. co-trimoxazole / trimoethoprim - haem toxicity
4. warfarin
5. clozapine
6. ACE inhibitors
7. aminosalicylates
8. methotrexate
271
What are 8 drugs which can cause erectile dysfunction?
1. **antihypertensives: thiazide diuretics, beta blockers, spironolactone**
2. **Antidepressants**: SSRIs, TCAs, benzos, antipsychotics, phenytoin
3. 5-alpha reductase inhibitors e.g. finasteride
4. Digoxin
5. Opiates
6. H2 blockers
7. Anti-androgens e.g. bicalutamide
8. Luteinising hormone releasing agonists/antagonists to treat prostate cancer
272
What are 2 types of antihypertensives which can worsen glycaemic control in diabetics?
thiazides, beta blockers
273
What are 2 cautions for prescribing sulfasalazine?
1. G6PD deficiency
2. aspirin allergy or sulphonamide allergy
274
What is the hepatitis B vaccination made of?
**HBsAg** absorbed onto **aluminium hydroxide adjuvant** and is prepared from yeast cells using **recombinant DNA** technology
275
What are 7 SSRI discontinuation symptoms?
1. increased mood change
2. **restlessness**
3. difficulty sleeping
4. **unsteadiness**
5. sweating
6. GI symptoms: pain, cramping, diarrhoea, vomiting
7. paraesthesia + **electric shock sensations**
276
What is the maximum daily dose of citalopram?
* 40mg for adults
* 20mg for patients >65 years
* 20mg if hepatic impairment
