Pharmacology and Therapeutics Flashcards

Question

What are the 3 pillars of the End TB strategy?

Answer 1

1. Integrated patient centred care + prevention 2. Bold policies + support systems 3. Intensified search + innovation

Answer 2

The involuntary nervous system made up of sympathetic and parasympathetic nervous system

Answer 3

pre-ganglionic system - cell body in CNS post-ganglionic - cell body in autonoic ganglion

Answer 4

- Interface between pre and post ganglionic neurones - ACh is primary transmitter

Answer 5

ACh, which acts on nicotinic receptors

Answer 6

Noradrenaline, which acts on adrenergic receptors

Answer 7

ACh, which acts on muscarinic receptors

Answer 8

Choline and acetyl CoA

Answer 9

- In the synapse, ACh is rapidly broken down by acetylecholinesterases - Choline is transported back into the axon terminal and used to make more ACh

Answer 10

- most post-synaptic sympathetic fibres release NA, acting on adrenoceptors - NA is synthesised, stored and released from sympathetic nerves - very sparse sympathetic innervation of airways - sympathetic control via circulating adrenaline

Answer 11

1 constrict most smooth muscle except in GI tract where it relaxes 2 presynaptic inhibition of neurotransmitter release sympathetic and parasympathetic neurones β1 increases heart rate and force of constriction β2 dilates/relaxes smooth muscle β3 thermogenesis in skeletal muscle

Answer 12

A chronic inflammatory disorder of the airways usually associated with - variable airflow obstruction - increase in airway response to a variety of stimuli

Answer 13

PEFR - peak expiratory flow rate FEV1 - forced expiratory volume in 1 second

Answer 14

1. increased smooth mucle contractility 2. increased excitatory nerve activity 3. decreased bronchodilator activity 4. inflammation

Answer 15

A SAMA - quaternary ammonium compound - poorly absorbed - lack of CNS effects

Answer 16

- b-adrenoceptor agonists - phosphodiesterase inhibitors

Answer 17

ACh (M3 receptors) eNANC

Answer 18

- adrenaline - iNANC - NO - ACh (M2 receptors)

Answer 19

Intrinsic - non-atopic - middle aged - hyperresponsive - severe airflow limit extrinsic - atopic (allergic) - young onset - hyperresponsive

Answer 20

- genetics - allergenic potential - physiochemical characteristics - 'dosing regimen' - allergic disease associated with an increase in the Th2:Th1 ratio

Answer 21

Interferon-gamma IL-12

Answer 22

IL-4 and IL-13 IL-5 IL-9

Answer 23

- older siblings - exposure at daycare - TB, measles, Hep A - rural environment

Answer 24

- widespread antibiotic use - western lifestyle - diet - sensitisation to dust mites etc

Answer 25

- relatively rare immunoglobulinin plasma - 'erythmatous' antibody - Fc region binds with high affinity to FcεR1on mast cell surface causes degranulation

Answer 26

- histamine - TNF and other cytokines - proteases - heparins

Answer 27

- leukotrienes - prostaglandins

Answer 28

- normally less than 1% of blood cells - rises to 5% in allergics - late phase response - IL-5 + chemokine induced migration - release basic proteins + ROS - produces cytokines, leukotrienes + prostaglandins

Answer 29

- chlorpheniramine, astemizole, cetrizine - effective in rhinitis, urticaria - little use for asthma

Answer 30

- disodium cromoglycate, nedocromil - mast cell stabilisers - inhibit mediator release from lung mast cell - effective in about half patients - mostly early + late phase - antigen, irritant and exercis related - prolonged prophylaxis required - well tolerated

Answer 31

anti-IgE antibody - monoclonal antibody - prevent IgE binding to mast cells

Answer 32

- escalating dose antigen - licensed for allergy - expensive - grass and tree pollen extracts - bee and wasp venom

Answer 33

smooth muscle - contraction - growth epithelium - damage - secretion bronchial venules increased - blood flow - permeability - leukocyte adhesion Leukocyte chemotaxis and activation - eosinophils, T-lymphocytes

Answer 34

- budesonide, inhalation - prednisolone, oral - reduce inflammation, swelling + mucus production - act mainly via regulating gene transcription - inhibit cytokine transcription - inhibit inflammatory leukocyte migration - indirectly inhibit phospholipase activity

Answer 35

- PDE IV in leukocytes - PDE inhibitors increase intracellular cAMP - inhibits. chemotaxis, granule release, respiratory burst - Roflumilast, PDE IV selective

Answer 36

- LTC4 + LTD4 - potent constrictor of airway smooth muscle - increase mucus production - LTB4 - no direct bronchoconstrictor - chemotactic for leukocytes - leukotriene receptor antagonist (montelukast) - leukotriene synthesis inhibitor (zileu)

Answer 37

Production of IgE Eosinophil adhesion and migration Increase eotaxin Increase adhesion molecule expression Increase mucus secretion and influence remodelling Dupilumab anti-IL-4 receptor antibody used in severe asthma

Answer 38

High numbers of eosinophils in asthmatic lung Eosinophil products damaging to epithelium IL-5 promotes eosinophil production, survival and activation Anti-IL-5 and anti-IL-5 receptor antibodies: Possible indication in severe steroid resistant asthma Benralizumab, mepolizumab, reslizumab

Answer 39

- coughing, wheezing - chest tightness - shortness of breath - variable expiratory airflow limitation

Answer 40

- Personal or family history of atopic disease (eczema, allergic rhinitis, or allergic conjunctivitis) - Respiratory infections in infancy - Exposure (including prenatally) to tobacco smoke - Premature birth and associated low birth weight - Obesity - Social deprivation - Exposure to inhaled particulates

Answer 41

1. Allergens 2. Irritants 3. Respiratory infections 4. Exercise 5. Stress 6. Medications 7. Occupational hazards 8. Allergic reactions 9. Gord 10. Hormonal changes

Answer 42

History - Presence of typical symptoms and variable airflow obstruction - Personal/family history of asthma and/or other atopic conditions (eczema, dermatitis, allergic rhinitis) Tests - FeNO test of 40ppb ( or 35 in children) - Spirometry - FEV1/FVC usually >70% - FEV1 improvement of 12% or more + increased volume of ≥ 200mL in response to meds - Variable peak expiratory flow readings – over 20% variability at least BD for 2-4 weeks

Answer 43

- Avoid exertion and smoking > 1h - Do not eat nitrate-rich food (green leafy veg, beetroot) > 3h - Avoid hot drinks, caffeine and alcohol > 1h

Answer 44

- Insufficient expiratory effort - Effect of steroids (OCS and ICS) - Allergic rhinitis/rhinovirus infection

Answer 45

- Low dose ICS - + LTRA (montelukast) - + LABA (+ MART) +/- LTRA - switch to mod dose ICS - switch to high dose ICS

Answer 46

- SABA for all at diagnosis - always check adherance before making changes - LABA before increasing ICS - Use combination inhalers to ensure adherance

Answer 47

- Stop smoking - Inhaler technique - Monitoring - Pharmacotherapy - Lifestyle - Education

Answer 48

Triggers * Type and duration of Sx * Assess the severity of the exacerbation: * PEF (best of 3 recordings) to grade the severity of the attack against the person's best or predicted value: * Moderate: more than 50–75% * Acute severe: 33–50% * Life-threatening: < 33% O2 sats in room air using pulse oximetry FeNO (if available)

Answer 49

Difficult asthma (BTS/SIGN) - persistent symptoms and/or frequent asthma attacks despite treatment with: - high-dose ICS plus a LABA/LTRA or - continuous or frequent use of oral steroid

Answer 50

Severe asthma - asthma that is uncontrolled despite adherence with optimized high-dose ICS-LABA treatment with correct inhaler technique and management of contributory factors

Answer 51

Relatively safe in comparison to other biologics - Tertiary care only - Patients need to be adherent to max ICS therapy and still experience exacerbations

Answer 52

- Group of lung conditions that cause breathing difficulties - Characterised by progressive air flow limitation that is not fully reversible - Associated with an abnormal inflammatory response of the lungs to noxious particles or gases – primarily cigarette smoke

Answer 53

- Chronic bronchitis - Productive cough present over years - Excessive sputum production - Emphysema - Alveolar wall destruction - Irreversible enlargement of the terminal air spaces

Answer 54

- pollution - occupational hazards - smoking

Answer 55

Asthma has variable flow, while COPD has no varaibility. Asthma is related to hyperesponsiveness, COPD is not. Asthmatics have esinophilic-rich sputum, while COPDers have neutrophil-rich sputum

Answer 56

- Occlusion of airway by mucus - Thickened airway wall - Inflammatory cell infiltrate - Peribronchial fibrosis

Answer 57

- Mucous glands and goblet cells - Mucus production controlled by neuronal input and inflammatory mediators

Answer 58

- Leukocyte infiltration - macrophages and CD8+ T cells - neutrophils in infection - Leukocyte products - Elastase & other proteinases - Reactive oxidant species - Chemoattractants - IL-8, LTB4 - Recruit further leukocytes - Increased cytokines - increases mucin secretion from epithelium in vitro - induces elastase production - Macrophages and neutrophils release - proteases - break down connective tissue - stimulate mucus hypersecretion - Proteases are normally balanced by inhibitors - Reactive oxidant species - Damage epithelium - Activate inflammatory genes - Further damage - Macrophages and epithelial cells also release fibroblast growth factors - TGFb and EGF - implicated in fibrosis and mucus secretion - Cytotoxic T cells (CD8+) also implicated in the inflammatory cascade.

Answer 59

- Epithelial damage - Decrease ciliary cell function - Increase mucus secretion from goblet cells - Mucus cell hyperplasia – more cells - Increased bronchial permeability - Airway oedema and protein exudation - Stimulation of sensory nerves - Neurogenic inflammation - Cough

Answer 60

Motor reflex in response to sensing chemicals, particulates and excessive airway mucus Sensory nerves sensitised by inflammatory mediators

Answer 61

- Bronchoconstriction not major cause of airway obstruction so b2 agonists often limited effect - Muscarinic antagonists - ipratroprium bromide some improvement - tiotropium & aclidinium have pharmacokinetic advantages

Answer 62

- PDE III & IV in airway smooth muscle - Inhibition leads to bronchodilation - PDE IV in leukocytes - PDE inhibitors increase intracellular cAMP - Theophylline (weak, non-selective) - Roflumilast PDE IV selective

Answer 63

- Mucus hypersecretion associated with decline in FEV1 and hospitalisation - Therapy - mucolytics - N-acetyl cysteine, carbocisteine, acetylcisteine - Breaks disulphide bonds in mucin - Anti-oxidant activity - Muscarinic antagonists - Block parasympathetic stimulation of secretion - Experimental treatments: - Neurokinin antagonists - Agents inhibiting sensory fibre activation - Neutrophil elastase inhibitor - brensocatib

Answer 64

- Reduce inflammation - Inhaled for acute exacerbations - Small benefit from inhaled steroids for maintenance - Given in combination with muscarinic antagonists

Answer 65

- Destruction of alveolar walls - Permanent enlargement of airspace distal to the terminal bronchiole - Reduces surface area of lungs for gas exchange

Answer 66

- Strongly implicated in emphysema - Derived from neutrophils and macrophages include cathepsins, proteinase 3 and gelatinase - Degrade elastin, basement membrane and connective tissue - Increased after smoking - Serpins (serine protease inhibitors) inactivated by oxidant stress

Answer 67

- a1-antitrypsin augmentation therapy in patients with deficiency - Elastase inhibitors

Answer 68

- Vitamins C and E - N-acetyl cysteine - Limited evidence for efficacy

Answer 69

- Oxidative stress results in decreased steroid sensitivity - Impaired glucocorticoid receptor function? - Neutrophil apoptosis inhibited by glucocorticoids - Compare with asthma – eosinophil apoptosis promoted by glucocorticoids

Answer 70

- unpacks histones and allows RNA polymerase binding to DNA - Increased binding of transcription factors (NFkB, AP-1, CREB) - Increased inflammatory gene expression

Answer 71

- Wraps DNA tightly in the histone - Decreases transcription factor binding - Suppression of inflammatory gene expression

Answer 72

- glucocorticoids bind to glucocorticoid receptors - inhibits HAT and represses gene expression - cigarette smoke decreases glucocorticoid receptor binding - increases the activity of HAT - decreases the effect of HDAC

Answer 73

History: medical, family and social - Physical examination - Assessment tools and questionnaires - Post-bronchodilator spirometry (mandatory) - Other tests e.g., chest X-ray, (HR)CT, ECG, blood tests

Answer 74

- Diagnosis - Assessment of airflow obstruction severity (for prognosis) - Follow-up assessment - Therapeutic decisions - Identification of rapid decline

Answer 75

CAT Modified MRC Dyspnoea Scale GOLD

Answer 76

Ask - identify users Advise - urge to quit Assess - determine willingness Assist - help patient however you can Arrange - follow up visit

Answer 77

- oxygen therapy - learning about disease - clearance technoques - management of posture - taking respiratory medications - breathing exercises - managment of airway - exercise sessions - nutrition management

Answer 78

Type 1 (hypoxic) respiratory failure – inadequate provision of oxygen to the body, leading to hypoxaemia * Pulmonary oedema, pneumonia, PE, pulmonary fibrosis

Answer 79

Type 2 (hypercapnic) respiratory failure – insufficient removal of carbon dioxide from the body, leading to hypercapnia * Chest-wall deformities (e.g., kypho-scoliosis) or trauma, respiratory muscle weakness, COPD, severe obesity

Answer 80

Acute use in ECOPD hospitalised with acute respiratory failure * In stable patients with severe COPD with hypercapnic respiratory failure and obstructive sleep apnoea * Improves ventilatory pressure leading to better gas exchange * Reduces respiratory rate, work of breathing, severity of breathlessness and mortality

Answer 81

Oxygen (and any other medical gas) is a medication and needs to be prescribed - For critically ill patients high concentration O2 should be administered immediately - O2 saturation should be checked by pulse oximetry in all breathless and acutely ill patients

Answer 82

- concentration - rate - device/route - target saturation level

Answer 83

Increases survival in those with severe chronic resting arterial hypoxaemia * No benefit if no chronic hypoxaemia * Must NOT SMOKE (including e-cig) * Used minimum 15 hours daily * Risks: respiratory depression, falls from tripping over equipment, burns & fires

Answer 84

- Discussions with patients and their families about their views on resuscitation, advance directives and other relevant arrangements - Opioids, oxygen and fans blowing air onto the face can relieve breathlessness - Nutritional supplementation should be considered to improve respiratory muscle strength and overall health status - Fatigue common – can be improved by PR, nutritional support, self- management education and mind-body interventions

Answer 85

- An event characterised by dyspnoea and/or cough and sputum that worsen over < 14 days. - Often associated with increased local and systemic inflammation caused by airway infection, pollution or other insults to the lungs - >80% managed w/o hospital admission

Answer 86

- SABA/SAMA initially and review and escalate maintenance Tx - OCS (5/7) can improve FEV1, oxygenation and shorten recovery time - Abx (5/7), when indicated, can shorten recovery time and reduce the risk of early relapse, treatment failure and hospitalisation duration - Methylxanthines NOT recommended - NIV – first mode of ventilation in acute respiratory failure - Up to 4-6 weeks to recover, some don’t reach the baseline function - Tx goal: minimise negative impact of current ECOPD and prevent subsequent events

Answer 87

e.g. aldosterone – affect water and electrolyte balance

Answer 88

e.g. hydrocortisone and corticosterone - affect carbohydrate and protein metabolism - anti inflammatory and immunosuppressive effects

Answer 89

Osteoporosis - (dec – collagen synthesis, osteoblast func, Ca absorption by inhibition of vitD action ) (Parathyroid hormone then increases Ca resorption from bone) Diabetogenic due to dec in glucose uptake and utilisation and inc in gluconeogenesis plus increased appetite – obesity Mineralocortocoid effects –Na/ H2O retention, hypertension, oedema and CV events

Answer 90

Glucocorticoids enter cells and bind to cytoplasmic receptors. Complex translocates to the nucleus to act as transcription factor Can bind to response elements and activate anti inflammatory gene transcription Can bind and repress pro-inflammatory gene activation (eg COX-2, PLA2) Can interact and inhibit binding of other transcription factors (AP-1 and NFkB)

Answer 91

- Inhibit both early and late stages of inflammatory response - Decrease vasodilation and extravasation - Inhibit cell activation- TH (inhibit IL-2 and clonal expansion) - Decrease production of inflammatory mediators (ROS, prostanoids and leukotrienes, complement and histamine) - Endogenously prevent ‘overshoot’ of immune response

Answer 92

- Many unwanted side-effects associated with GC actions Generally associated with high doses, systemic long-term admin - Immunosuppression can increase risk of infections - Impaired leucocyte traffic can delay wound healing - Suppress HPA axis through feedback inhibition

Answer 93

- Ask about possible trigger factors, such as a recent upper respiratory tract infection. - Ask about the type and duration of symptoms, what treatment has been started (if any), and whether treatment has improved symptoms. - Assess the severity of the exacerbation: signs of exhaustion and cyanosis, record the respiratory rate, pulse, and blood pressure. - Record the peak expiratory flow rate and use the best of three recordings to grade the severity of the attack on the basis of the person's best or predicted value: Moderate: more than 50–75%. Acute severe: 33–50%. Life-threatening: < 33%. - Measure a person's oxygen saturation in room air using pulse oximetry - Ask about social hx

Answer 94

- Infection - Bacterial infection with Staphylococcus aureus, which may present as typical impetigo or as worsening of eczema with increased redness, oozing, and crusting - Risk of herpes simplex and fungal infections - Psychosocial - Distress, missed school days, self image, sleep disturbances - Erythroderma - Erythroderma (a generalised redness of the skin) is a severe skin condition that can result in complications such as dehydration, heart failure, infection, and death - Eye abnormalities - Irritation of the conjunctivia

Answer 95

Take a history and examine the rash Assess severity Mild: areas of dry skin, infrequent itching Moderate: areas of dry skin, frequent itching and redness Severe: widespread areas of dry skin, incessant itching and redness Infected: if eczema is weeping, crusted, or there are pustules with fever and malaise Consider using validated tools to assess severity - Visual analogue scales (0–10) of the individual's assessment of severity, itch, and sleep loss over the last 3 days and nights - Patient-Oriented Eczema Measure - Ask about the effect of eczema on daily activities (school, work, and social life), sleep, and mood. None: no impact on quality of life. Mild: little impact on everyday activities, sleep, and psychosocial well-being. Moderate: moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep. Severe: severe limitation of everyday activities and psychosocial functioning, and loss of sleep every night.

Answer 96

- Diet: ask about itch or redness after certain foods (immediately or hours later), diarrhoea, vomiting, and poor weight gain - Consider asking the person to keep a food diary over 4–6 weeks. - Irritants: ask about changes in soaps, detergents, and clothing, especially in previously well controlled eczema. - Inhalants: ask about symptoms around pets and pollen,

Answer 97

Advice - avoid scratching - house dust mite - irritants - stress - diet Prescribe generous amounts of emollients (liberal and frequent use) Step up and consider a mild corticosteroid cream or ointment (and for 48hrs after flare has been controlled) - Regular corticosteroid use should not be needed - Review annually emollient use and symptom control

Answer 98

Advice – avoid scratching, house dust mite, irritants, stress, diet Prescribe generous amounts of emollients (liberal and frequent use) Moderately potent topical corticosteroid (betamethasone valerate 0.025% or clobetasone butyrate 0.05%) and continued for 48hrs For delicate areas of skin (face and flexures) consider starting with a mild potency topical corticosteroid (hydrocortisone 1%) and increase to a moderate potency corticosteroid if needed (maximum of 5 days use) Occlusive bandages or dry bandages might be considered Topical antibiotics if infected (max 2 weeks) – fusidic acid or mupirocin ointment if small areas or oral flucloxacillin If there is severe itch of urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine) Avoid triggers Frequent and liberal emollient use Topical corticosteroids – for flare prone areas Either Step down approach Intermittent treatment Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option (prescribed by a specialist, including GPs with a specialist interest in dermatology) Identifying a flare early is considered to be important, as early treatment can reduce the severity of the flare and allow for more conservative treatment measures (such as emollients alone and reduced use of topical corticosteroids)

Answer 99

Advice – avoid scratching, house dust mite, irritants, stress, diet Prescribe intensive treatment until the flare is controlled Prescribe a generous amount of emollients and advise frequent and liberal use Prescribe a potent topical corticosteroid for inflamed areas (betamethasone valerate 0.1%) For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid (betamethasone valerate 0.025%, clobetasone butyrate 0.05%). Aim for a maximum of 5 days use If itching is severe and affecting sleep, consider prescribing a sedating antihistamine (such as chlorphenamine) for adults and children aged 6 months or over (maximum two-week course) or non sedating if only daytime itching Occlusive dressings or dry bandages may be of benefit If there is severe, extensive eczema causing psychological distress, consider prescribing a short course of oral corticosteroids (> 16 years) (30 mg prednisolone in the morning for 1 week should be sufficient If there are signs of infection, consider prescribing an oral antibiotic

Answer 100

Immunomodulating drugs Inhibit calcineurin production which is responsible for inflammation in the skin (causing redness and itching) Calcineurin is responsible for activation of T-lymphocytes, hence initiation of immune inflammation Can be applied topically due to their low MW, hence has the ability to penetrate the striatum corneum Does not have the same problems with long term use as steroids, so useful for use on the face and flexures

Answer 101

Tacrolimus may be considered to treat moderate or severe atopic eczema for adults, or children aged 2 years or older, if the maximum strength and potency of topical corticosteroid that is appropriate for the patient's age and the area being treated has been adequately tried and hasn't worked, where there is serious risk of important side effects from further use of topical corticosteroids (particularly permanent damage to the skin)

Answer 102

Pimecrolimus may be considered to treat moderate atopic eczema on the face and neck for children aged between 2 and 16 years if the maximum strength and potency of topical corticosteroid that is appropriate for the patient's age and the area being treated has been adequately tried and hasn't worked, where there is serious risk of important side effects from further use of topical corticosteroids (particularly permanent damage to the skin)

Answer 103

Alitretinoin is recommended, as a treatment option for adults with severe chronic hand eczema that has not responded to potent topical corticosteroids Alitretinoin treatment should be stopped: as soon as an adequate response (hands clear or almost clear) or if the eczema remains severe at 12 weeks or if an adequate response (hands clear or almost clear) has not been achieved by 24 weeks. Alitretinoin is a first generation member of the retinoid family, which also includes isotretinoin and acitretin (all related to Vitamin A) Orally administered, the exact mechanism of action for hand eczema is unknown

Answer 104

Streptococcal infection — strongly associated with guttate psoriasis, especially if the throat is infected Some drugs – lithium, NSAIDs, beta-blockers Sunlight Trauma Stress Alcohol Smoking Climate changes Hormone changes HIV/AIDs

Answer 105

Psychological and social Physical Erythrodermic psoriasis substantially affects the body's ability to regulate temperature and also affects haemodynamics, intestinal absorption, and protein and water metabolism Generalized pustular psoriasis can cause fever, malaise, tachycardia, weight loss, and hypothermia, and has a significant mortality rate Less severe psoriasis can also cause physical discomfort, including itch Pregnancy

Answer 106

Nature of psoriasis, treatment aims and fact it is a chronic relapsing remitting condition that might not be fully treatable Reassurance it is not an infectious condition Referral to support groups/websites Lifestyle advice to reduce flares – think triggers! Referral for mental health support if needed Range of information leaflets available. See CKS for the links

Answer 107

An emollient to reduce scale and help with other symptoms including itch (always apply often and first) Potent topical corticosteroid applied once daily (review after 4 weeks, no longer than 8 weeks without a break) plus a vitamin D analogue applied once daily (Calcitriol or tacalcitol) If response is poor after 8 weeks, continue Vit D analogue twice daily alone for up to 12 weeks. 2nd or 3rd line options are via a specialist – phototherapy or systemic therapy

Answer 108

Treat with a potent topical corticosteroid (applied once a day max of 8 weeks – 4 week break as needed) For people who cannot use corticosteroids on their scalp or who have scalp psoriasis that has not responded, consider treatment with a vitamin D preparation alone (applied once a day) or in combination with a potent corticosteroid scalp application Coal tar preparations might be considered if treatment failure still occurs 2nd or 3rd line options are via a specialist – phototherapy or systemic therapy

Answer 109

An emollient and short-term mild or moderate topical corticosteroid preparation (applied once or twice daily) for up to 2 weeks, only being used for 1-2 weeks each month 4 week treatment break as needed between corticosteroid courses Do not use potent or very potent corticosteroids on the face, flexures or genitals 2nd or 3rd line options are via a specialist – phototherapy or systemic therapy

Answer 110

Generalized pustular psoriasis — refer for same-day specialist assessment and treatment It is a medical emergency that requires urgent hospital referral Pustular psoriasis localized to the hands or feet — refer to a dermatologist. This is often difficult to control and usually requires systemic treatment

Answer 111

Must be seen immediately, associated with life-threatening complications

Answer 112

Keep their nails short Avoid manicure of the cuticle — this may provoke infection Avoid fake nails If nail disease is mild and is not causing discomfort or distress, no treatment is required. Nail varnish can be used to disguise pitting, but abrasive acetone removers should be avoided. If severe, refer to a dermatologist.

Answer 113

Topical corticosteroids are associated with adverse effects, as well as rebound psoriasis on discontinuation Risk of serious adverse effects is low if used correctly Greater risk if treatments are used for long periods of time on large areas, or potent or very potent steroids used incorrectly Maximum of 8 weeks treatment, with 4 week breaks between use

Answer 114

Vitamin D preparations bind to vitamin D receptors, which inhibits keratinocyte proliferation and enhances keratinocyte differentiation 6-8 week treatment is needed for best results Topical vitamin D preparations should be avoided in people with Calcium metabolism disorders (can cause hypercalcemia), severe liver and kidney disease Max 100g per week for creams and 60ml scalp solution Side effects include skin irritation and photosensitivity

Answer 115

Coal tar is a distillation product of coal and has anti-inflammatory and anti-scaling properties Newer products tend to be easier to apply Can be applied long term Not used with broken, infected & inflamed skin, genitals, rectum, pregnancy Caution with face, flexures, late pregnancy and breastfeeding

Answer 116

Dithranol is thought to prevent T-lymphocyte activation and normalize keratinocyte differentiation Dithranol should not be used in people with acute or pustular psoriasis, or inflamed psoriasis or used dithranol on the face Short contact essential (0.1 to 2% creams and 30-60 minute contact time) increased weekly till lesion is palpably flat (then discontinue) If skins becomes inflamed during treatment stop, and restart at a lower % when settled

Answer 117

Ultraviolet light reduces inflammation in the skin, which is why it can be effective for psoriasis Narrowband (311-313nm) UVB is often used to treat guttate or chronic plaque psoriasis The other type of therapy is known as PUVA, and is a combination of the UVA part of the spectrum and psoralen Might be used if UVB has not worked, or if hands or feet are affected BAD offers support leaflets on this therapy

Answer 118

Are drugs activated by long wave UV light (320-400nm) They interfere with DNA synthesis hence reduce epidermal cell turnover, enhancing the effect of irradiation Not licensed so prescribed under a named-patient basis Either taken orally 2hrs before UVA, or applied topically immediately before exposure If taken orally sunglasses are needed and nausea is a common side effect Exposure depends on patient initially and increased, normally twice weekly for up to six weeks. Unless severe and relapsing repeat treatments should be avoided

Answer 119

Folic acid antagonist used for severe psoriasis affecting high impact sites, and when phototherapy has failed, is contraindicated or has relapsed within three months Can cause bone marrow suppression and should be taken once weekly at low dose

Answer 120

- Iris smooth muscle dilator + sphincter to regulate pupil size - Ciliary muscle changes refractive index of lens

Answer 121

Pupil dilation

Answer 122

Pupil constriction

Answer 123

Pupil constriction

Answer 124

Pupil dilation

Answer 125

block constrictor muscle - leads to pupillary dilation

Answer 126

paralyse ciliary muscle - block accommodation

Answer 127

- Ocular examination: tropicamide - Anterior uveitis – inflammation - Amblyopia (lazy eye): atropine

Answer 128

Is a group of eye diseases that damage the optic nerve It is associated with high pressure within the eye. Classify in: Primary, secondary, developmental. Glaucoma in one eye/both eyes

Answer 129

- Older - High blood pressure - African-carribean ethnicity - Family history of glaucoma - Diabetes

Answer 130

By rate of formation and rate of drainage of Aqueous Humour AH produced continuously by ciliary body epithelium Maintains intraocular pressure Provides nutrients to cornea, lens etc Released into posterior chamber

Answer 131

AH produced by ciliary body AH flows from the posterior chamber through the iris into the anterior chamber Trabecular meshwork (90%) Canal of Schlemm & into vein Uveoscleral outflow (10%)

Answer 132

Ultrafiltration of plasma Produces nearly protein-free liquid The high level of lactate is due to anaerobic glycolysis The high level of ascorbic acid protects against UV-radiation that can cause the formation of free radicals

Answer 133

a1 agonists - vasoconstrictors - decreased blood supply to ciliary body a2 agonists decreased cAMP, directly inhibits AH formation, decreased NA release from sympathetic fibres

Answer 134

Eye drops: The different drops fall into five main categories, which work in slightly different ways: Alpha agonist, Beta blockers, Carbonic anhydrase inhibitors, Cholinergic inhibitors and Prostaglandin analogues. Laser: Laser treatment is used in glaucoma to decrease the amount of fluid in the eye Trabeculectomy surgery: A trabeculectomy is an eye operation that improves drainage of fluid out of the eye. Our trabeculectomy page explains how it works, what the surgery involves and what to expect after surgery Aqueous Shunt Implantation: An aqueous shunt is a device which drains aqueous humour out of the eye to a small blister

Answer 135

More common in East Asian & Inuit populations Angle between iris and cornea narrowed Blocks flow of aqueous humour from posterior to anterior chamber Onset can be sudden and result in rapid irreversible damage

Answer 136

Obstruction of drainage through trabecular meshwork and canal of Schlemm Intra-ocular pressure rises

Answer 137

Macula is an oval-shaped pigmented region of the retina essential for ‘sharp’ vision High density of cones (photoreceptors)

Answer 138

Blurry spots in center of vision Blank or dark spots in center of vision Difficulty reading Loss of clear color vision Objects appear distorted Straight lines that appear crooked or wavy

Answer 139

Most patients Slow insidious onset No successful treatments

Answer 140

Rapid onset Choroidal neovascularization (abnormal blood vessels underneath the macula) Excessive growth of leaky blood vessels under retina Stopped with photodynamic therapy (PDT): Verteporfin i.v. followed by laser photoactivation (red laser) Occlusion of leaky blood vessels Blood vessel growth & leak stimulated by vascular endothelial cell growth factor (VEGF) Anti-VEGF antibodies or VEGF receptor constructs arrest progression Other VEGF binding molecules – pegaptanib

Answer 141

Dry eye syndrome (keratoconjunctivitis sicca) occurs when there is a problem with the tear film that normally keeps the eye moist and lubricated Caused by a lack of tear production or increased evaporation of the tears More common in women (50%) than men

Answer 142

conjunctivitis and keratitis

Answer 143

Dryness, grittiness, or soreness in both eyes Vision might be affected Watering of the eyes, particularly when exposed to wind

Answer 144

Conjunctivitis Sjogren’s syndrome Filamentary keratitis Infectious diseases Corneal damage

Answer 145

Eyelid hygiene Limiting the use of contact lenses Stopping medication that exacerbates dry eyes Using a humidifier to moisten ambient air Stopping smoking If using a computer for long periods, ensuring that the monitor is at or below eye level, avoiding staring at the screen, and taking frequent breaks

Answer 146

Hypromellose (30 minute intervals initially then reduce as symptoms improve) Carbomer or polyvinyl alcohol (used less frequently but less well tolerated)

Answer 147

Preservative free preparations should be used Ocular ointment at night If there are visible strands of mucus – specialist only Consider prescribing acetylcysteine drops (mucolytic drug) If there is inflammation – specialist only Consider prescribing a topical steroid or topical ciclosporin Punctal occlusion

Answer 148

The use of liposomal sprays results in a clinically and significant increase in lipid layer thickness and tear film stability following application They mimic what happens naturally when lipids are secreted from the meibomian glands The sprayed-on phospholipid liposomes reach the lid margins via the same effect and mix with the endogenous lipids to help repair the tear film lipid layer

Answer 149

The key benefit is that liposomal sprays aim to specifically address the disrupted lipid layer in evaporative dry eye (rather than simply bathing the eye in a short lasting tear replacement) Stabilise the outer lipid layer Last for up to 4 hrs Can be used by contact lenses wearers Easy to use – dexterity Long expiry date after opening

Answer 150

Not mentioned in guidelines Expensive Not allowed on prescription

Answer 151

Direct observation of optic nerve (ophthalmoscopy) Visual field examination (perimetry) Assessment of intraocular pressure (tonometry) Determine if open or closed angle (gonioscopy) Measure of thickness of cornea (pachymetry)

Answer 152

Medical treatment Laser treatment Surgical treatment

Answer 153

Prostaglandin analogues Beta-blockers Carbonic anhydrase inhibitors Sympathomimetics Miotics

Answer 154

Increase uvoscleral outflow Most effective of all management options Efficacy; bimatoprost > travoprost > latanoprost Side effects; latanoprost > travoprost > bimatoprost Eye colour / eyelid change

Answer 155

Reduces aqueous humour production Betaxolol; shown to be neuroprotective by increasing blood flow Effects of systemic absorption seen Interactions Systemic beta-blockers, anaesthesia, verapamil Side effects Breathlessness, bradycardia, dry eyes, masking hypoglycaemia

Answer 156

Decrease production of intraocular fluid Increase perfusion to eye, neuro-protective for ocular nerve head Dose differs in monotherapy versus combination Cross-reactivity with sulphonamides Weak diuretic effect Contraindicated in renal failure (CrCl <30mL/min)

Answer 157

Very effective at reducing intraocular pressure Decrease aqueous humour production, increase outflow Cautions Severe cardiovascular disease, cerebral/coronary insufficiency Contraindicated with MAOIs Side effects; blurred vision, discomfort, headache, nausea, hyperaemia

Answer 158

Pull iris away from trabecular meshwork; improve outflow Generally less well-tolerated than other agents Cautions due to parasympathomimetic effects Peptic ulcer, cardiac disease, asthma, epilepsy, Parkinson’s disease, hyperthyroidism, urinary tract obstruction

Answer 159

Surgery to improve aqueous humour outflow Trabeculectomy/trabeculotomy – remove part of eye drainage tubes Viscocanalostomy – remove part of the sclera Deep sclerectomy – widen the drainage tubes in eye Trabecular stent bypass – trabeculoplasty to meshwork Laser iridotomy; creates holes in iris Surgery to reduce aqueous humour production Cyclodiode laser; destroys tissue in eye responsible for aqueous formation

Answer 160

Trabeculoplasty, laser; trabeculectomy, surgery Small hole in eye to improve outflow of fluid May be more cost effective in advanced disease More effective at reducing IOP, no difference in change in vision or QOL at 24 months First-line by NICE but some resistance

Answer 161

Scarring during the healing process can cause the outflow channel to close and the operation to fail with a rise in pressure Use antimetabolites to prevent scarring by inhibiting the multiplication of cells which produce scar tissue. Intraoperative mitomycin-C or 5-fluorouracil

Answer 162

Assess compliance with existing drops regimen Goldman tonometry for IOP Reassess for visual field defects

Answer 163

Poor compliance; device, elderly population, side effects (drug/preservative) Travoprost electronic aid study #Knowyourdrops campaign Check eye drop installation technique Combination therapies; different dosing regimen Local formulary choices Brand versus generic prescribing Preservatives Contact lenses

Answer 164

Diuretics; mannitol, acetazolamide IV/oral to increase drainage Pilocarpine to induce miosis PGAs, beta-blockers, sympathomimetics Surgery; cataract replacement, peripheral iridotomy

Answer 165

Raised intraocular pressure > 21 mmHg Genetic mutation of trabecular meshwork / anterior chamber angle Surgical management often required Topical beta-blockers first line Carbonic anhydrase inhibitors if contraindicated PGAs preferred if juvenile-onset, less effective in young children Adrenergic agonists CI in under 2s Consider licensing and practical administration issues Timolol LA reduced frequency but unlicensed