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Focused 2 > Pharmacology > Flashcards

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)

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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

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3
Q

What is meloxicam?

A

NSAID used short term for OA, long term for RA/ ankylosing spondylitis

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4
Q

What are 6 complications of ACE inhibitors?

A
  1. Dry cough
  2. First-dose hypotension
  3. Hyperkalaemia
  4. Urticaria
  5. Altered taste
  6. renal impairment
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5
Q

What is the conversion between oral morphine and subcutaneous morphine?

A

Oral morphine is twice the dose of subcutaneous morphine

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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

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7
Q

What is preferred to morphine in palliative patients with renal impairment?

A
  • Oxycodone if mild/moderate
  • if severe, alfentanil, buprenorphine, fentanyl
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8
Q

What are 4 things that may be useful for metastatic bony pain?

A

1 opioids
2 bisphosphonates
3 radiotherapy
4 denosumab

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9
Q

How do you get from oral codeine / tramadol dose to oral morphine?

A

Divide by 10

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10
Q

When is activated charcoal offered in paracetamol overdose?

A

If present within 1 hour of ingestion

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11
Q

What are 4 indications for NAC in paracetamol overdose?

A
  1. Paracetamol level on or above treatment line which joins >100mg/kg at 4 hours and >15mg/kg at 15 hours
  2. Staggered overdose / timing uncertain
  3. Patients presented 8-24h after ingestion if dose >150mg/kg
  4. Patients presenting >24h if jaundiced / hepatic tenderness / raised ALT
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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)

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13
Q

What is the management of anaphylactoid reaction to NAC?

A

stop infusion then restart at slow rate

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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

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15
Q

What is the definition of a staggered overdose?

A

not taken within 1 hour

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16
Q

What are 8 examples of live attenuated vaccinations?

A
  1. BCG
  2. MMR
  3. intranasal influenza
  4. rotavirus
  5. polio
  6. yellow fever
  7. oral typhoid
  8. chickenpox / shingles
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17
Q

3 inactivated vaccination preparations?

A
  • IM influenza
  • rabies
  • hepatitis A
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18
Q

What are 3 toxoid (inactivated toxin) vaccinations?

A
  • tetanus
  • diphtheria
  • pertussis
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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

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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
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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
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22
Q

What is the effect of P450 enzyme inducers on the COCP?

A

Will reduce its effectiveness - as metabolised more quickly

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23
Q

What are 8 examples of P450 enzyme inducers?

A
  • rifampicin
  • carbamazepine
  • phenytoin
  • phenobarbitone
  • smoking
  • chronic alcohol use
  • St John’s Wort
  • griseofulvin
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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
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25
Q

What is the treatment of major bleeding (e.g. intracerebral haemorrhage) with warfarin?

A

stop warfarin, give 5mg vitamin K IV and give prothrombin complex concentrate IV

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26
Q

What is prothrombin complex concentrate (PCC)?

A

solution containing coagulation factors II, VII, IX and X - designed to reverse warfarin

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27
Q

Following raised INR at what INR can warfarin be restarted?

A

INR <5.0

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28
Q

What is the management of INR >8, minor bleeding?

A

stop warfarin, give IV vitamin K 1-3mg
repeat vit K if INR still too high after 24h

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29
Q

What is the management of INR <8.0, no bleeding?

A

stop warfarin ,give PO vitamin K 1-5mg (use IV preparation orally)
repeat dose if still too high after 24h

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30
Q

What is the maangement of INR 5.0-8.0 with minor bleeding?

A

stop warfarin, give IV vitamin K 1-3mg

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31
Q

What is the management of INR 5.0-8.0 with no bleeding?

A

Withold 1 or 2 doses of warfarin, reduce subsequent maintenance dose

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32
Q

What is the risk of of using ACEis with aortic stenosis?

A

May result in hypotension

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33
Q

What is a key drug interaction of ACEis?

A

Diuretics when high dose E.g >80mg furosemide per day; high risk of hypotension

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34
Q

What are considered acceptable rises in creatinine and potassium when starting ACEi?

A

Increase in serum creatinine up to 30%, K+ up to 5.5 acceptable

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35
Q

Which emergency contraception should you exercise caution for patients with asthma?

A

Ulipristal (EllaOne)

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36
Q

How long after intercourse can Ulipristal (EllaOne) be used for UPSI?

A

120 hours

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37
Q

How long after intercourse can levonorgestrel (levonelle) be used after UPSI?

A

72 hours

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38
Q

When can hormonal contraception be started after use of Ulipristal (EllaOne) vs levonorgestrel (levonelle)?

A

EllaOne - 5 days after
Levonelle - straight away

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39
Q

Can EllaOne / levonelle be used within the same menstrual cycle more than one?

A

Yes, both can

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40
Q

What is the guidance for breastfeeding and EllaOne/ levonelle?

A

Levonelle (levonorgestrel) - can continue breastfeeding
EllaOne (Ulipristal) - breastfeeding should be delayed for one week

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41
Q

When can copper IUD be used for UPSI?

A

Up to 5 days after UPSI or 5 days after ovulation date (day 14)

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42
Q

If a patient wants the copper coil removed after insertion for UPSI when should it be done?

A

Wait at least until after next period

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43
Q

If a patient wants the copper coil removed after insertion for UPSI when should it be done?

A

Wait at least until after next period

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44
Q

What is the mechanism of ulipristal acetate (EllaOne)?

A

selective progesterone receptor modulator

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45
Q

What is agomelatine?

A

used in treatment of depression - agonist at melatonin receptors - improves sleep quality

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46
Q

What is the commonest side effect of SSRIs?

A

gastrointestinal symptoms

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47
Q

Which SSRI is the best post-myocardial infarction?

A

sertraline - more evidence for safe use than other antidepressants

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48
Q

What could prompt you to prescribe another drug alongside SSRIs and why?

A

if also on NSAID - PPI as can increase risk of GI bleeding

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49
Q

Should SSRIs be given in combination with warfarin / heparin?

A

no - avoid, consider mirtazapine

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50
Q

What is the interaction between SSRIs and triptans?

A

increased risk of serotonin syndrome

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51
Q

After what time period should patients be reviewed after starting SSRIs?

A

2 weeks; 1 week if age 25 or at risk of suicide

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52
Q

What are 4 types of drugs whihc can cause staining of the teeth?

A
  1. tetracyclines - intrinsic staining
  2. chlorhexidine mouthwash - removable with polishing
  3. iron salts in liquid form
  4. co-amoxiclav suspension
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53
Q

For how long should patients be continued on an SSRI if they have a good response to antidepressant therapy?

A

at least 6 months after remission

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54
Q

What drug group is most commonly implicated in intrinsic staining of the teeth?

A

tetracyclines - if given in utero until 12 years of age

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55
Q

Over what time period should SSRIs be stopped?

A

over 4 weeks

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56
Q

Which SSRI doesn’t need tapering over 4 weeks when stopped?

A

fluoxetine

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57
Q

What is the guidance re SSRIs and pregnancy?

A

weigh up beneits and risks when deciding

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58
Q

How does atropine work to treat symptomatic bradycardia?

A

increases firing of the sinoatrial node (SA) and conduction through the AV node, opposes action of vagus nerve

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59
Q

What is the risk with SSRIs in pregnancy?

A

first trimester - increased risk of congenital heart defects
third trimester - persistent pulmonary hypertension of the newborn

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60
Q

What are 4 causes of gingival hyperplasia?

A
  1. Phenytoin
  2. Ciclosporin
  3. Calcium channel blockers (esp nifedipine)
  4. AML
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61
Q

Which antibiotic have ruptured Achilles tendon / tendinopathy as a side effect?

A

fluoroquinolones e.g. ciprofloxacin

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62
Q

What are 5 risk factors for Achilles tendinopathy with fluoroquinolones?

A
  1. Age >60 years
  2. Corticosteroid therapy
  3. Renal failure
  4. Diabetes mellitus
  5. History of MSK disorders
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63
Q

What is the treatment of symptomatic bradycardia?

A

atropine - 0.5-1mg IV; may repeat every 3-5 minutes up to maximum 3mg

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64
Q

What drug should be given immediately after thrombolysis is given for MI?

A

heparin (UFH or LMWH)

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65
Q

What should be done in patients taking AEDs who need an antidepressant medication?

A

seek specialist advice - as all antidepressants lower seizure threshold. SSRIs / sertraline are preferred option

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66
Q

Which antidepressants should be avoided in patients taking triptans for migraine?

A

SSRIs

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67
Q

Which antidepressants interact with MAOIs?

A

SSRIs

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68
Q

What is meant by a live attenuated vaccination?

A

virus / bacteria has been weakened via genetic modification of the pathogen

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69
Q

Which antidepressants may be sedating and what is the DVLA advice?

A

mirtazapine, trazodone, lofepramine; DVLA advises people should not drive during this time if affected

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70
Q

What is a key adverse effect of carbamazepine?

A

aplastic anaemia - needs FBC monitoring (also drug interactions - CYP450 inducer)

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71
Q

What is a key side effect of cabergoline?

A

Pulmonary fibrosis

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72
Q

What 2 drugs can affect the absorption of levothyroxine?

A
  • calcium carbonate
  • iron
    (Take at least 4h apart)
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73
Q

What are 7 adverse effects of loop diuretics?

A
  1. Hypotension
  2. Ototoxicity
  3. Hyponatraemia, hypokalaemia, hypomagnesaemia, hypocalcaemia
  4. Hypochloraemic acidosis
  5. Renal impairment
  6. Hyperglycaemia
  7. Gout
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74
Q

What is the mechanism of action of loop diuretics?

A

Inhibit Na-K-Cl cotransporter in thick ascending loop of Henle, reducing absorption of NaCl

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75
Q

What are the 2 most common drug causes of drug induced lupus erythematosus (DILE)?

A
  • procainamide
  • hydralazine
    (Also isoniazid, minocycline, phenytoin)
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76
Q

What pattern of antibodies are seen in DILE? (4 key features)

A
  1. ANA positive 100%
  2. dsDNA negative
  3. Anti-histone antibodies in 80-90%
  4. anti-Ro, anti-Smith +ve in 5%
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77
Q

What are the key features of drug-induced lupus erythematosus?

A
  • malar rash
  • pulmonary involvement E.g. pleurisy
  • myalgia
  • arthralgia
    Renal and neuro involvement rare
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78
Q

What are 3 types of drugs which can cause purpura in adults?

A
  1. Quinine
  2. Antiepileptics
  3. Anti thrombotics
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79
Q

What are 11 causes of drug-induced seizures?

A
  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
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80
Q

What electrolyte abnormality is most likely to occur with furosemide and prednisolone taken together?

A

hypokalaemia

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81
Q

What are 3 types of influenza vaccination?

A
  1. whole inactivated virus
  2. split virion (virus particles disrupted by detergent treatment)
  3. subunit (mainly haemagglutinin and neuraminidase)
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82
Q

What does the cholera immunisation involve?

A

inactivated Inaba and Ogawa strains of Vibrio cholerae with recombinant B-subunit of the cholera toxin

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83
Q

What are 7 indications for BCG vaccination?

A
  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
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84
Q

What other disease does the BCG also offer limited protection against?

A

leprosy

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85
Q

What is the only exception to performing a tuberculin skin test prior to performing the BCG?

A

children <6 yeras old with no contact with TB

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86
Q

When can other vaccinations be given in relation to BCG?

A

can be given at same time, but if not administered simultaneously there should be a 4 week interval

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87
Q

What are 5 contraindications to BCG?

A
  1. previous BCG vaccination
  2. past history of tuberculosis
  3. HIV
  4. pregnancy
  5. positive tuberculin test (Heaf or Mantoux)
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88
Q

What is the cut off age for BCG?

A

not given to anyone over age of 35

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89
Q

What is the management of beta blocker overdose?

A
  • atropine if bradycardic
  • glucagon if severe
    Haemodialysis not effective
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90
Q

What can be an early sign of aspirin (salicylate) overdose?

A

Tinnitus

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91
Q

What metabolic derangement may be seen with aspirin (/ salicylate) overdose?

A

Initially respiratory alkalosis then metabolic acidosis

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92
Q

What is the treatment of salicylates (e.g. aspirin) overdose?

A
  • General - ABC, charcoal
  • urinary alkalinisation with IV sodium bicarbonate (increases urinary excretion)
  • haemodialysis
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93
Q

What are 6 indications for harmodialysis in aspirin (/salicylate) overdose?

A
  1. Serum concentration > 700mg/L
  2. Metabolic acidosis resistant to treatment
  3. Acute renal failure
  4. Pulmonary oedema
  5. Seizures
  6. Coma
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94
Q

Why does salicylate overdose (e.g. aspirin) cause sweating and pyrexia?

A

salicylates cause the uncoupling of oxidative phosphorylation leading to decreased adenosine triphosphate production, increased oxygen consumption and increased carbon dioxide and heat production

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95
Q

What are 11 drugs which can cause a hepatocellular picture of DILI?

A
  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
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96
Q

What are 11 drugs which can cause a cholestatic picture of DILI?

A
  1. COCP
  2. flucloxacillin
  3. co-amoxiclav
  4. erythromycin
  5. anabolic steroids
  6. testosterone
  7. chlorpromazine
  8. prochlorperazine
  9. sulphonylureas
  10. fibrates
  11. nifedipine
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97
Q

What are 3 types of drugs which can cause liver cirrhosis?

A
  1. methotrexate
  2. methyldopa
  3. amiodarone
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98
Q

What is the mechanism of action of sildenafil?

A

aka viagra - phosphodiesterase V inhibitor. cause vasodilation via increase in cGMP leading to smooth muscle relaxation in blood vessels supplying corpus cavernosum

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99
Q

When should sildenafil be taken for its use in erectile dysfunction?

A

approx 1 hour before sexual activity (short acting)

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100
Q

What are 3 contraindications to PDE5 inhibitors?

A
  1. nitrates + nicorandil
  2. hypotension
  3. recent stroke or MI (wait 6 months)
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101
Q

What are 6 side effects of phosphodiesterase type 5 inhibitors?

A
  1. visual disturbances - blue discoloration; also NAION
  2. nasal congestion
  3. flushing
  4. GI side effects
  5. headache
  6. priapism
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102
Q

What are 3 common side effects of dihydropyridine CCBs (amlodipine, nifedipine, felodipine)?

A

headache, flushing ankle swelling

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103
Q

Which calcium channel blockers can cause tachycardia?

A

short acting dihydropyridines e.g. nifedipine - cause peripheral vasodilation which can cause reflex tachycardia

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104
Q

What are 5 common side effects of verapamil?

A
  1. heart failure
  2. constipation
  3. hypotension
  4. bradycardia
  5. flushing
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105
Q

What are 4 common side effects of diltiazem?

A
  1. hypotension
  2. bradycardia
  3. heart failure
  4. ankle swelling
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106
Q

What is the most common side effect of sildenafil?

A

headache

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107
Q

What are 4 situations when diclofenac is contraindicated?

A
  1. ischaemic heart disease
  2. peripheral arterial disease
  3. cerebrovascular disease
  4. congestive heart failure (NYHA 2-4)
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108
Q

Is St. John’s Wort an inducer or inhibitor of P450?

A

Inducer - effectiveness of warfarin / COCP reduced

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109
Q

What drug monitoring is required for statins?

A

LFTs - baseline, 3 months, 12 months

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110
Q

What drug monitoring is required for amiodarone?

A

TFT, LFT, U&Es CXR at baseline
TFT & LFT every 6 months

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111
Q

What drug monitoring is required for methotrexate?

A

FBC, LFT, U&Es before treatment then weekly until stabilised, then every 2-3 months

112
Q

What is the recommended monitoring for azathioprine?

A

FBC and LFT before treatment; FBC weekly for first 4 weeks; then FBC and LFT every 3 months

113
Q

What is the recommended monitoring for lithium?

A

TFT and U&E before starting
Lithium level weekly until stabilised then every 3 months
TFT and U&E every 6 months

114
Q

What is the recommended monitoring for sodium valproate?

A

LFT and FBC before starting treatment then LFT periodically during the first 6 months

115
Q

What is the recommended monitoring for glitazones?

A

LFT before treatment, then regularly during treatment

116
Q

What is the advice for switching between types of COCP with different progesterones?

A

BNF suggests omitting pill free period (FSRH advice contradicts)

117
Q

What are 5 types of cytotoxic agents?

A
  1. Alkylating agents
  2. Cytotoxic antibiotics
  3. Antimetabolites
  4. Acts on microtubules
  5. Topoisomerase inhibitors
    + other
118
Q

What is the mechanism of action of cyclophosphamide?

A

Alkylating agent - causes cross-linking in DNA

119
Q

What is an example of an alkylating cytotoxic agent?

A

Cyclophosphamide

120
Q

What are 3 side effects of cyclophosphamide?

A
  1. Haemorrhagic cystitis
  2. Myelosuppression
  3. Transitional cell carcinoma
121
Q

What are 2 examples of cytotoxic antibiotics?

A
  1. Bleomycin
  2. Anthracyclines e.g. doxorubicin
122
Q

What is the mechanism of action if bleomycin?

A

Degrades preformed DNA

123
Q

What is a key side effect of bleomycin?

A

Pulmonary fibrosis

124
Q

What is the mechanism of action of anthracyclines e.g. doxorubicin?

A

Stabilises DNA-topoisomerase II complex, inhibits DNA and RNA synthesis

125
Q

What is a key adverse effect of anthracyclines e.g doxorubicin?

A

Cardiomyopathy

126
Q

What are 4 examples of antimetabolite cytotoxic drugs?

A
  1. Methotrexate
  2. Fluorouracil
  3. 6-mercaptopurine
  4. Cytarabine
127
Q

What are 4 adverse effects of methotrexate?

A
  1. Myelosuppression
  2. Pulmonary fibrosis
  3. Liver fibrosis
  4. Mucositis
128
Q

What are 3 side effects of fluorouracil?

A
  1. Myelosuppression
  2. Mucositis
  3. Dermatitis
129
Q

What are 3 side effects of 5 fluorouracil?

A
  1. Myelosuppression
  2. Mucositis
  3. Dermatitis
130
Q

What is a key side effect of 6-mercaptopurine?

A

myelosuppression

131
Q

What are 2 key side effects of cytarabine?

A

myelosuppression, ataxia

132
Q

What are 2 examples of cytotoxic drugs that act on microtubules?

A
  1. vincristine/vinblastine
  2. docetaxel
133
Q

What are 2 key side effects of vincristine?

A
  1. peripheral neuropathy
  2. paralytic ileus
134
Q

What is a key side effect of vinblastine?

A

myelosuppression

135
Q

What is a key side effect of docetaxel?

A

neutropenia

136
Q

What is a key example of a topoisomerase inhibitor-type cytotoxic drug?

A

irinotecan

137
Q

What is a key side effect of irinotecan?

A

myelosuppression

138
Q

What are 3 key side effects of cisplatin?

A
  1. ototoxicity
  2. peripheral neuropathy
  3. hypomagnesaemia
139
Q

What is a key side effect of hydroxyurea?

A

myelosuppression

140
Q

What is the mechanism of action of quinolone antibiotics?

A

inhibit DNA synthesis by inhibiting topoisomerase II (DNA gyrase) and topoisomerase IV - bactericidal

141
Q

What are 4 adverse effects of quinolones?

A
  1. lower seizure threshold in patients with epilepsy
  2. tendon damage (including rupture)
  3. cartilage damage
  4. lengthens QT interval
142
Q

What drug used in concurrence with quinolones increases the risk of tendon damage?

143
Q

What are 3 contraindications to quinolones?

A
  1. pregnancy
  2. breastfeeding
  3. G6PD
144
Q

What is the mechanism of organophosphate (e.g. pesticide) poisoning?

A

inhibition of acetylcholinesterase leading to upregulation of nicotinic + muscarinic cholinergic neurotransmission

sarin gas = used in warfare, similar

145
Q

What are 7 features of organophosphate insecticide poisoning?

A
  1. salivation
  2. lacrimation
  3. urination
  4. defecation/diarrhoea
  5. cardiovascular: hypotension, bradycardia
  6. small pupils
  7. muscle fasciculation
146
Q

What are 2 aspects of the management of organophosphate poisoning?

A
  1. atropine
  2. pralidoxime - unclear role
147
Q

What is the mechanism of action of metformin?

A
  • activation of AMP-activated protein kinase (AMPK)
  • increases insulin sensitivity
  • reduces hepatic gluconeogenesis
  • reduce GI absorption of carbohydrates
148
Q

What are 3 key side effects of metformin?

A
  1. GI upset - nausea, anorexia, diarrhoea
  2. reduced B12 absorption
  3. lactic acidosis with severe liver disease or renal failure
149
Q

What are 4 contraindications to metformin?

A
  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
Q

What are the rules regarding metformin use in chronic kidney disease?

A
  • review if creatinine >130 umol/L (eGFR <45)
  • stop if creatinine >150 (eGFR <30)
151
Q

What should happen to a patient’s metformin if they are having imaging involving iodine-containing contrast?

A

stop on day of procedure and for 48h afterwards

152
Q

What is the mechanism of action of macrolides?

A
  • inhibit bacterial protein synthesis by blocking translocation
  • bacteriostatic
153
Q

What are 5 adverse effects of macrolides?

A
  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
Q

What is a key drug interaction of macrolides?

A

statins - macrolides inhibit cythochrome P450 isoenzyme CYP3A4 that metabolises statins; concurrent use significantly increases risk of myopathy / rhabdomyolysis

155
Q

What is the difference in P450 enzyme inhibitors and inducers in terms of speed of onset?

A

inhibitors have rapid effects, whereas induction usually requires prolonged exposure to the inducing drug

156
Q

What are the options for migraine prophylaxis and when should specific ones be avoided?

A
  1. propranolol
  2. topiramate - avoid in women of childbearing age
  3. amitriptyline
157
Q

Which anti-TB drug causes a peripheral neuropathy and how?

A

isoniazid - vitamin B6 deficiency

158
Q

What is another name for vitamin B6?

A

pyridoxine

159
Q

How can vitamin B6 deficiency caused by isoniazid be prevented?

A

prophylactic pyridoxine should be prescribed at the same time as isoniazid

160
Q

What are 2 consequences of vitamin B6 deficiency?

A
  1. peripheral neuropathy
  2. sideroblastic anaemia
161
Q

What is the mechanism of action of tamoxifen?

A

selective oestrogen receptor modulator (SERM) - acts as oestrogen receptor antagonist + partial agonist

162
Q

What are 4 side effects of tamoxifen?

A
  1. hot flushes (commonest)
  2. menstrual disturbance - vaginal bleeding, amenorrhoea
  3. VTE
  4. endometrial cancer
163
Q

How long is tamoxifen used for?

A

5 years following removal of tumour

164
Q

What is an alternative SERM to tamoxifen and how does its side effect profile differ?

A

raloxifene - lower risk of endometrial cancer

165
Q

What is the main indication for digoxin?

A

rate control in management of AF; also has positive inotropic properties so sometimes used for improving symptoms (not mortality) in HF

166
Q

What is the mechanism of action of digoxin?

A
  • 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
Q

When is digoxin monitoring recommended and how?

A

if toxicity suspected only - concentration should be measured within 8-12h of last dose

168
Q

What are 7 features of digoxin toxicity?

A
  1. lethargy
  2. nausea + vomiting
  3. anorexia
  4. confusion
  5. yellow-green vision
  6. arrhythmias (AV block, bradycardia)
  7. gynaecomastia
169
Q

Which electrolyte abnormality classically precipitates digoxin toxicity?

A

hypokalaemia (digoxin binds to ATPase pump on same site as potassium; hypokalaemia means dig binds more easily, increasing its inhibitory effects)

170
Q

What are 8 drugs that can precipitate digoxin toxicity?

A
  1. amiodarone
  2. quinine
  3. verapamil
  4. diltiazem
  5. spironolactone
  6. ciclosporin
  7. thiazides
  8. loop diuretics
171
Q

What is the management of digoxin toxicity?

A

digibind, correct arrhythmias, monitorin K+

172
Q

What should be done in patients on long term oral prednisolone who develop intercurrent illness?

A

double steroid dose

173
Q

What are 2 key adverse effects of aminoglycosides e.g. gentamicin?

A
  1. ototoxicity - auditory/vestibular nerve damage
  2. nephrotoxicity - acute tubular necrosis
174
Q

Is ototoxicity due to aminoglycosides reversible?

A

no - irreversible

175
Q

What causes nephrotoxicity from gentamicin / aminoglycosides?

A

acute tubular necrosis

176
Q

Concomitant use of which drug with aminoglycosides increases the risk of acute tubular necrosis?

A

furosemide

177
Q

What is a contraindication to using aminoglycosides?

A

myasthenia gravis

178
Q

When should aminoglycoside levels be measured and how should doses be adjusted?

A
  • peak (1 hour after administration) - if too high, decrease dose
  • trough - if too high, increase interval
179
Q

What is the conversion from oral morphine to oral oxycodone?

A

divide by 1.5-2 to get oxycodone dose

180
Q

How does transdermal fentanyl equate to oral morphine?

A

fentanyl 12mcg patch = morphine 30mg PO

181
Q

Which opioid side effects tend to be transient vs persistent?

A
  • transient: nausea, sedation
  • persistent: constipation
182
Q

What is the guidance for statins and pregnancy?

A

contraindicated in pregnancy (IUGR, fetal death)

183
Q

What are 3 groups of adverse effects of statins?

A
  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
Q

What are 5 risk factors for myopathy in a patient taking statins?

A
  1. advanced age
  2. female sex
  3. low BMI
  4. multisystem disease e.g. DM
  5. lipophilic statins > hydrophilic
185
Q

What are 4 groups of patients who should take statins?

A
  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
Q

What is he mechanism of action of statins?

A

decrease intrinsic cholesterol synthesis via inhibiting enzyme HMG-CoA reductase (rate limiting

187
Q

Why does grapefruit juice have key drug interactions e.g. statins?

A

inhibits action of intestinal CYP3A4 which normally metabolises many drugs - increases their action

188
Q

What are 4 important side effects of ACE inhibitors?

A
  1. hyperkalaemia
  2. first-dose hypotension
  3. dry cough
  4. aniogoedema - may occur up to 1 year after starting
189
Q

What is the mechanism of action of benzodiazepines?

A

enhance effect of inhibitory neurotransmitter GABA by increasing frequency of chloride channels

190
Q

What is NICE guidance on withdrawing a benzo?

A
  • 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
Q

How long can it take to withdraw from benzodiazepines?

A

from 4 weeks to a year or more

192
Q

What are 9 features of benzodiazepine withdrawal syndrome?

A
  1. insomnia
  2. irritability
  3. anxiety
  4. tremor
  5. loss of appetite
  6. tinnitus
  7. perspiration
  8. perceptual disturbances
  9. seizures
193
Q

For how long can benzodiazepine withdrawal symptosm occur after withdrawal?

A

up to 3 weeks after stopping long-acting drug

194
Q

What advice should be given when commencing patients on mefloquine for malaria prophylaxis?

A
  • 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
Q

Which patients is mefloquine contraindicated in?

A

anxiety, depression, schizophrenia, other psychiatric disorders

196
Q

What is the most important counselling to give to a patient taking carbimazole?

A

attend for urgent medical review if develops symptoms of infection e.g. sore throat or fever

197
Q

What is a key adverse effect of carbimazole?

A
  • agranulocytosis
198
Q

How is carbimazole usually used to treat thyrotoxicosis?

A

given in high doses for 6 weeks until patient becomes euthyroid before being reduced

199
Q

What is the mechanism of action of carbimazole?

A

blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin, reducing thyroid hormone production

200
Q

What is the mechanism of action of propylthiouracil?

A
  • 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
Q

What is the guidance about carbimazole in pregnancy?

A

crosses placenta but may be used in low doses during pregnancy

202
Q

What are 2 first line options to treat hiccups in palliative care?

A
  1. chlorpromazine
  2. haloperidol

gabapentin and dexamethasone also work

203
Q

What is the treatment of local anaesthetic toxicity?

A

IV lipid emulsion

204
Q

What is the maximum dose of lidocaine if given a) alone and b) with adrenaline?

A

a) 3mg / kg
b) 7 mg / kg

205
Q

What are 2 things that increase the risk of lidocaine toxicity?

A
  1. liver dysfunction
  2. low protein states
206
Q

What are 3 lidocaine drug interactions?

A
  1. beta blockers
  2. ciprofloxacin
  3. phenytoin
207
Q

What are the features of lidocaine toxicity?

A

Initial CNS over activity then depression as lidocaine initially blocks inhibitory pathways then blocks both inhibitory and activating pathways. Cardiac arrhythmias.

208
Q

How does the action of bupivacaine differ from lidocaine?

A

much longer duration of action - may be used for topical wound infiltration at end of surgery with long duration of analgesic effect

209
Q

What local anaesthetic is used for IV regional anaesthesia e.g. Biers block?

A

prilocaine

210
Q

What are 2 situations when adding adrenaline to local anaesthetic is contraindicated?

A
  1. patients taking MAOIs
  2. Tricyclic antidepressants
211
Q

Which LA can’t be given in higher doses with adrenaline?

A

bupivacaine

212
Q

What are 2 teratogenic effects of ACE inhibitors?

A
  1. renal dysgenesis
  2. craniofacial abnormalities
213
Q

What is the teratogenic effect of alcohol?

A

craniofacial abnormalities

214
Q

What is the teratogenic effect of aminoglycosides?

A

ototoxicity

215
Q

What are 2 teratogenic effects of carbamazpine?

A
  1. neural tube defects
  2. craniofacial abnormalities
216
Q

What are 2 teratogenic effects of cocaine?

A
  1. intrauterine growth retardation
  2. preterm labour
217
Q

What are 2 teratogenic effects of smoking?

A
  1. intrauterine growth retardation
  2. preterm labour
218
Q

What are 2 teratogenic effects of valproate?

A
  1. neural tube defects
  2. craniofacial abnormalities
219
Q

What are 5 teratogenic effects of maternal diabetes mellitus?

A
  1. macrosomia
  2. neural tube defects
  3. polyhydramnios
  4. preterm labour
  5. caudal regression syndrome
220
Q

What is a teratogenic effect of chloramphenicol?

A

grey baby sydrome

221
Q

What is a teratogenic effect of diethylstilbesterol?

A

vaginal clear cell adenocarcinoma

222
Q

What is a teratogenic effect of tetracyclines?

A

discoloured teeth

223
Q

What is a teratogenic effect of thalidomide?

A

limb reduction defects

224
Q

What is a teratogenic effect of warfarin?

A

craniofacial abnormalities

225
Q

What is the mechanism of action of clopidogrel?

A

antagonist of the P2Y12 adenosine diphosphate (ADP) receptor, inhibiting the activation of platelets

226
Q

The concurrent advice of which drug with clopidogrel make it less effective?

A

PPIs (lansoprazole and pantoprazol OK - avoid omeprazole)

227
Q

What is a key investigation in an unwell person taking aminosalicylates?

A

FBC - agranulocytosis is a key side effect

228
Q

What are 6 side effects of sulfasalazine?

A
  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
Q

What are 5 side effects of mesalazine?

A
  1. GI upset
  2. headache
  3. agranulocytosis
  4. pancreatitis
  5. interstitial nephritis
230
Q

What are the neurological features of ecstasy poisoning?

A
  • agitation
  • anxiety
  • confusion
  • ataxia
231
Q

What are the cardiovascular effects of ecstasy poisoning?

A

tachycardia, hypertension

232
Q

What is the key electrolyte seen in ecstasy poisoning and why?

A

hyponatraemia - SIADH or excessive water consumption whilst taking MDMA

233
Q

What are 5 effects of ecstasy poisoning?

A
  1. neurological
  2. cardiovascular - tachycardia, hypertension
  3. hyponatraemia
  4. hyperthermia
  5. rhabdomyolysis
234
Q

What is the management of ecstasy poisoning?

A
  • supportive
  • dantrolene for hyperthermia if simple measures fail
235
Q

Which antiepileptic can cause weight gain?

A

sodium valproate

236
Q

What effect does sodium valproate have on the P450 system?

237
Q

What are 8 side effects of sodium valproate?

A
  1. nausea
  2. increased appetite + weight gain
  3. alopecia - curly regrowth
  4. ataxia
  5. tremor
  6. hepatotoxicity
  7. pancreatitis
  8. hyperammonemic encephalopathy
238
Q

What are 3 abnormalities that may be seen on blood tests with sodium valproate?

A
  1. thrombocytopenia
  2. hyponatraemia
  3. hyperammonemic encephalopathy
239
Q

What treatment may be used if hyperammonemic encephalopathy develops secondary to sodium valproate?

A

L-carnitine

240
Q

What is the first line choice for palliative patients with confusion and agitation in whom reversible causes have been ruled out?

A

haloperidol (other options: chlorpromazine, levomepromazine)

241
Q

What can terminal agitation / restlessness be treated with?

242
Q

What is the mechanism of sulphonylureas?

A
  • 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
Q

What are 6 adverse effects of sulphonylureas?

A
  1. hypoglycaemic episodes
  2. weight gain
  3. hyponatraemia - SIADH
  4. bone marrow suppression
  5. hepatotoxicity (cholestatic)
  6. peripheral neuropathy
244
Q

What is the treatment of benzodiazepine overdose?

A
  • flumazenil
  • many cases managed with supportive care only - flumazenil has risk of seizures
245
Q

What is the management of tricyclic antidepressant poisonoing?

A
  • IV bicarbonate - reduce risk of seizures and arrhythmias
  • lots of antiarrhythmics and dialysis unsafe / ineffective
246
Q

What is the antidote to heparin poisoning?

A

protamine sulphate

247
Q

What is the management of beta blocker overdose?

A
  • atropine if bradycardic
  • glucagon in resistant cases
248
Q

What is the treatment for ethylene glycol poisoning?

A
  • fomepizole - first line
  • ethanol
  • haemodialysis - refractory cases
249
Q

What is the treatment of methanol poisoning?

A

fomepizole or ethanol
haemodialysis

250
Q

What is the management of organophosphate insecticide poisoning?

251
Q

What is the management of iron overdose?

A

desferrioxamine

252
Q

What is the management of lead overdose?

A

dimercaprol, calcium edetate

253
Q

What is the management of cyanide poisoning?

A
  • hydroxocobalamin
  • combination of amyl nitrite, sodium nitrite, sodium thiosulfate
254
Q

What are 2 key side effects of metronidazole?

A
  • disulfiram like reaction with alcohol
  • increases anticoagulant effect of warfarin
255
Q

What are 2 cardiovascular side effects of admiodarone?

A
  1. prolonged QT interval
  2. bradycardia
256
Q

What are 3 dermatological side effects of admiodarone?

A
  1. photosensitivity
  2. ‘slate-grey’ appearance
  3. thrombophlebitis and injection site reactions
257
Q

What is the effect of amiodarone on warfarin / INR?

A

decreases warfarin metabolism leading to raised INR

258
Q

Is sulfasalazine safe in pregnancy / breastfeeding?

A

yes - safe in both

259
Q

What are 4 side effects of PPIs?

A
  1. hyponatraemia, hypomagnesaemia
  2. osteoporosis + fragility fractures
  3. microscopic colitis
  4. increased risk of C diff infections
260
Q

What drugs can worsen symptoms of stress incontinence?

A

alpha blockers e.g. doxazosin - worsen stress incontinence by relaxing bladder outlet and urethra

261
Q

What are 7 drug causes of thrombocytopenia?

A
  1. Quinine
  2. Loop diuretics - furosemide
  3. NSAIDS
  4. Antibiotics: penicillins, sulphonamides, rifampicin
  5. Anticonvulsants: valproate, carbamazepine
  6. Heparin
  7. Abciximab
262
Q

What are 7 drugs associated with lichenoid ruptions?

A
  1. ACE inhibitors
  2. NSAIDs
  3. methyldopa
  4. chloroquine
  5. oral antidiabetics
  6. thiazide diuretics
  7. gold
263
Q

What are 3 types of vaccinations which people with egg allergy should avoid?

A
  1. influenza
  2. MMR
  3. yellow fever
264
Q

Which antihypertensive limits the maixmum dose of simvastatin to 20mg OD and why?

A

amlodipine - weak inhibitor of CYP3A4 therefore concurrent use results in raised blood levels of simvastatin - doubles its effect

265
Q

What are 5 examples of drugs which colchicine shouldn’t be co-prescribed with?

A
  1. clarithromycin
  2. erythromycin
  3. ritonavir
  4. verapamil
  5. itraconazole / ketoconazole
266
Q

What are 6 contraindications to colchicine?

A
  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
Q

What are 5 side effects of cholestyramine?

A
  1. constipation
  2. tooth discolortion
  3. tooth enamel erosion
  4. premature tooth decay
  5. increased riks of gallstones
268
Q

What type of cholesterol are statins vs. fibrates effective at lowering?

A
  • statins: LDL
  • fibrates: triglyceride
269
Q

What is a key side effect of nicotinic acid to treat raised cholesterol?

A

vasodilatation - facial flushing

270
Q

What are 8 drug interactions of azathioprine?

A
  1. allopurinol
  2. febuxostat
  3. co-trimoxazole / trimoethoprim - haem toxicity
  4. warfarin
  5. clozapine
  6. ACE inhibitors
  7. aminosalicylates
  8. methotrexate
271
Q

What are 8 drugs which can cause erectile dysfunction?

A
  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
Q

What are 2 types of antihypertensives which can worsen glycaemic control in diabetics?

A

thiazides, beta blockers

273
Q

What are 2 cautions for prescribing sulfasalazine?

A
  1. G6PD deficiency
  2. aspirin allergy or sulphonamide allergy
274
Q

What is the hepatitis B vaccination made of?

A

HBsAg absorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology

275
Q

What are 7 SSRI discontinuation symptoms?

A
  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
Q

What is the maximum daily dose of citalopram?

A
  • 40mg for adults
  • 20mg for patients >65 years
  • 20mg if hepatic impairment

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