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pa30327: polypharmacy long answer question > polypharmacy > Flashcards

polypharmacy Flashcards

1
Q

The 7 steps

A
  1. Aims
  2. Essential?
  3. Unnecessary
  4. Effective?
  5. Safety
  6. Cost effectiveness
  7. Adherence/ patient centredness
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2
Q

Aims

A

What matters to the patient?
Objectives of drug therapy
Managing existing problems
Prevention of future problems

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3
Q

Essential?

A

Discuss with expert before stopping

Discuss with expert before altering

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4
Q

Unnecessary?

A

Expired indication
Valid indication?
Benefit vs risk

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5
Q

Effectiveness?

A

Intensifying existing drug therapy

Specified drug therapy

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6
Q

Safety

A

Cumulative toxicity
Anticholinergic burden
Frail
(Think about detail by therapeutic area)

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7
Q

Cost effectiveness

A

Dispersible
Specials?
Branded
More than 1 strength/ formulation of same drug

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8
Q

Adherence/ patient centredness

A

Cognitive self administration
Technical self admin
Tablet burden

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9
Q

PPIs

A

Clostridium difficile
Osteoporosis
Hypomagnesia
Try not to treat long term, keep at low doses

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10
Q

H2 blockers

A

Anticholinergic ADRs

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11
Q

Laxatives

A

Fluid loss> hypokalemia> constipation

If more than 1 do NOT stop abruptly

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12
Q

Antispasmodics

A

Rarely effective
Rarely indicated long term
Anticholinergic side effects

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13
Q

Anticoagulants

A

Bleeding risk - avoid use with antiplatelets and NSAIDs

Much more effective for stroke prevention in AF than antiplatelets

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14
Q

Antiplatelets

A

Bleeding risk - avoid use with anticoagulants and NSAIDs
Aspirin + clopidogrel only indicated for 12 months after ACS
Conisder PPI if GI risk factors

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15
Q

Diuretics

A

AKI risk

Electrolyte disturbance risk

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16
Q

Spironolactone

A

Hyperkalemia risk

Risk factors: CKD, high dose, co treatment with ACEIs/ ARBs, amiloride, triamteren, potassium supplements

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17
Q

Digoxin

A

Toxicity risk

Risk factors: CKD, high dose, poor adherence, hypokalemia, drug-drug interactions

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18
Q

Peripheral vasodilators

A

Rarely effective

Rarely indicated long term

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19
Q

Quinine

A

Risk of thrombocytopenia, blindness, deafness
Only short term if leg cramps
Review effectiveness regularly

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20
Q

Antianginals

A

Hypotension caution

If mobility has reduced, consider reducing dose

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21
Q

Antiarrhythmics

A

Overdosing risk

Thyroid complication risk

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22
Q

Statins

A

Rhabdomyolysis risk

Consider life expectancy

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23
Q

BP lowering drugs

A

Little evidence supporting tight BP control in older frail group
Individualise targets

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24
Q

Beta blockers

A

Risk of bradycardia (esp in combination with rate limiting CCBs)

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25
Q

ACEIs/ ARBs

A

Risk of AKI
Avoid using with NSAIDs
Stop when at risk of dehydration
Sick day rule guidance

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26
Q

CCBs

A

Risk of constipation and ankle oedema
If rate limiting, risk of bradycardia
If dihydropyridines, risk of reflex tachycardia

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27
Q

Spironolactone

A

Risk of hyperkalemia
Risk factors: CKD, ACEI/ARB
Risk of AKI
Do not combine with NSAIDs

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28
Q

Theophylline

A

Risk of toxicity (tachycardia, CNS excitability)
Monotherapy in COPD NOT appropriate
Avoid combining with macrolides/ quinolones

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29
Q

Steroids

A

Risk of osteoporotic fractures
If long term needed, give bone protection
Long term oral use rarely indicated
Withdraw gradually

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30
Q

Antihistamines

A

Risk of anticholinergic ADRs

Rarely indicated long term

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31
Q

Hypnotics and anxiolytics

A

Risk of falls, fractures, confusion, memory impairment

Risk of dependency

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32
Q

Antipsychotics

A

Risk of stroke and death in elderly patients with dementia
Anticholingeric ADR for chlorpromazine
Worsening of PD

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33
Q

Antidementia drugs

A

Only continue if functional/ behavioural symptoms improve

Use MMSE

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34
Q

TCAs

A

Confirm need
Risk of anticholinergic ADRs
Risk of GI bleeding
Avoid with MAOI because of risk of serotonin syndrome

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35
Q

Metoclopramidde

A

Only licensed for 5 days unless palliative

Worsening of PD (domperidone more suitabel)

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36
Q

Antihistamiens

A

Anticholiergic ADRs

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37
Q

Opioids

A 
Risk of constipation 
Risk of cognitive impairment
Risk pf respiratory depression
Risk of immunosuppression
Risk of sex hormone suppression
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38
Q

Paracetamol

A

Risk of overdosing

Dose reduction when low body weight/ renal/ hepatic impairment

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39
Q

AEDs

A

Risk of dizziness, blurred vision, sedation
Check renal function
Reduced dose in CKD
DN4/ LANSS to aid diagnosis

40
Q

Antibiotics

A

Review long term antibiotics for recurrent UTI

41
Q

Nitrofurantoin

A

Risk of pulmonary/ renal ADRs

Avoid in renal impairment

42
Q

Antidiabetics

A

Takes years for the microvascular benefit of tight HbA1c

43
Q

Metformin, sulfonylureas, glitazones

A

Risk of lactic acidosis
Avoid if eGFR, stop with dehydration
Risk of hypoglycaemia
Avoid in patients with HF

44
Q

Bisphosphonates

A

Check willingness to take

45
Q

Antimuscarinics e.g oxybutynin

A

Review continued need/ effectiveness after 3-6 months
Risk of anticholinergic ADRs
May decrease MMSE score in dementia

46
Q

Supplements

A

Review need

Monitor weight

47
Q

Potassium

A

Risk of hyperkalemia

Risk factors: CKD, ACEI/ARBs, spironolactone, amiloride, trimethoprim, triamterene

48
Q

NSAIDs

A

GI ADRs (consider GI protection with PPI)
CV ADRs
Renal ADRs

49
Q

Skeletal muscle relaxants

A

Rarely indicated long term

Anticholinergic ADRs

50
Q

DMARDs

A

Risk of Mtx overdosing

51
Q

Highest risk falls medication in elderly

A 
Antidepressants, esp TCAs e.g amitryptyline
Antipsychotics
Antimuscarinics
Benzodiazepines
Hypnotics
Dopaminergic drugs in PD
52
Q

Moderate falls risk medication in elderly

A 
Antiarrhythmics
AEDs
Opioids
Antihistamines
Alpha blockers
ACEIs/ARBs
Diuretics
Beta blockers
53
Q

Lower falls risk medication in eldelry

A

CCBs (incidence of dizziness low)
Nitrates (sit when taking GTN)
Oral antidiabetics: dizziness due to hypoglycaemia usually avoidable
AVOID long acting sulfonylureas e.g chlorpropamide

54
Q

People more susceptible to anticholinergic ADRs

A

Mental illness

Older

55
Q

Anticholinergic effects

A 
Mouth dryness
Urinary retention
Anhidrosis
Blurred vision
Mydriasis
Tachycardia
Palpitations
Restlessness
Fatigue
Headache
AtAXIA
Decreased gut motility
Delusions
Coma
Agitation
Delirium
56
Q

Antidepressants and anticholinergic burden

A

TCAS/ SSRIs/ mirtazapine > venlafaxine, trazodone, duloxetine

57
Q

Antipsychotics and anticholinergic burden

A

Clozapine/ chlorpromazine/ levopromazine/ olanzapine/ quetiapine/ risperidone/ haloperidol > aripiprazole

58
Q

Nausea and vertigo and anticholinergic burden

A

Prochlorperazine> metoclopramide (PD effects)/

Domperidone

59
Q

Urinary antispasmodics and anticholinergic burden

A

Oxybutynin > mirabegron

60
Q

Zolpidem and zopiclone

A

Sedatives
No anticholinergic activity
Falls risk

61
Q

Secondary CVD prevention

A

Aspirin + antiplatelets

62
Q

Abnormal ACR (>3) on 2 consecutive occaisions

A

Renal damage

63
Q

HbA1c target if managed on metformin and glicazide

A

53mmol/mol

64
Q

HbA1c target if just on metformin

A

48mmol/mol

65
Q

Why is the HbA1c target higher on glicazide?

A

More likely to cause a hypo

66
Q

Empagliflozin

A

More likely to cause weight loss

67
Q

eGFR cut off for metformin

A

30

68
Q

Ipratropium

A

SAMA

69
Q

ICS issues

A

Weight gain
Increased risk of infection
Cautioned in COPD

70
Q

Umeclidium

A

LAMA

71
Q

High blood pressure and COPD

A

High BP is NOT a symptom of COPD

72
Q

MMRC

A

Modified medical research questionnaire used to assess the severity of COPD

73
Q

Mucolytics

A

Evidence poor

Tiring

74
Q

RPS competency framework for rxers(July 2016)

A 
Consultation + rxing governance
Assess the patient
Conisder the options
Reach a shared decision
Prescribe
Provide info
Prescribe safely
Prescibe professionally
Improve prescribing practice
Prescribe as part of a team
75
Q

Symptoms of hyperkalemia

A

Tingling and numbness in fingers

Palpitations

76
Q

AEDs with low teratogenic potential

A

Lamotrigine

Levetiracetam

77
Q

K+ targets ACEI

A

Less than 5mmol/L

78
Q

When to stop, monitor and refer for ACEIs

A

If K+ >5mmol/L

If Cr >20% increase or eGFR >15% decrease

79
Q

Creatinine normal levels

A

45-90 micromol/L

80
Q

eGFR normal level

A

Greater than 90

81
Q

eGFR normal level

A

Greater than 90

82
Q

T2DM 1st line for HTN

A

CCB regardless of age

83
Q

Category A

A

1 or less non serious exacerbations
MMRC 0-1
CAT <10
Bronchodilator only

84
Q

Category B

A

1 or less non serious exacerbations
MMRC of 2 or more
CAT 10 or more
LAMA/ LABA > LABA + LAMA

85
Q

Category C

A 
at least 1 serious exacerbation
MMRC 0-1
CAT of 10 or less
LAMA
LAMA + LABA 
OR
LABA + ICS
86
Q

Category D

A 
At least 1 serious exacerbation
MMRC 2 or more
CAT 10 or more
LAMA
LABA + LAMA
LAMA + ICS
Consider rofluminast if FEV1 less than 50%
prednisolone
macrolide IN FORMER SMOKERS
87
Q

SOCRATES

A 
Site
Onset
Character
Radiation
Associations
Timing
Exacerbating/ relieving factors
Severity
88
Q

5 underlying principles of ethical decision making

A 
Benificence
Non malificence
Respect for autonomy
Justice
Respect for patient
89
Q

2006 study

A

50% of ADRs resulting in hospital admission caused by 4 types of drugs:

  1. NSAIDs
  2. Diuretics
  3. Antiplatelets
  4. Anticoagulants
90
Q

Falls in older people

A

4 or more meds

91
Q

NICE screening tools to identify potential medicines related to patient safety issues

A

Explicit criterion based tools

Implicit judgment based approach

92
Q

Explicit crierion based tools

A

BEERs criteria

STOPP/START

93
Q

Implicit judgement based apporach

A

NO TEARS

MAI

94
Q

T2DM patients with severe frailty

A

Avoid hypoglycaemia
Decrease risk of infection
Avoid hospital admission
Control symptoms

95
Q

Statin monitoring

A

LFTs and cholesterol

96
Q

Empagliflozin

A

SGLT2 inhibitor

Causes weight loss

97
Q

Metformin

A

Doesn’t cause hypos when given alone

pa30327: polypharmacy long answer question (1 decks)

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