Prescribing Flashcards
1
Q
When can you give oestrogen only HRT and when can you give combined
A
No uterus = oestrogen only
Uterus = combined
Because of risk of endometrial hyperplasia/cancer on oestrogen only
2
Q
Rules on periods and HRT
A
<50 patients have to have been period free for 24 months to qualify for continuous therapy - if not cyclical
>50 12 months for continuous
3
Q
3 Alternative to hormone replacement therapy
A
1) Clonidine - Alpha blocker. Prevents vasomotor symptoms
2) Fluoxetine - SSRI
3) Venlafaxine - SNRI
4
Q
8 Contraindications of HRT
A
Undiagnosed abnormal bleeding Endometrial cancer/hyperplasia Breast cancer hx Raised BP Hx of VTE Liver disease Cardiovascular disease Pregnancy
5
Q
Example of oral oestrogen only medication
A
Estradiol - Estelle solo
6
Q
example of transdermal oestrogen only
A
Estradiol - Evorel
7
Q
Example of progesterone IUD
A
Levonorgestrol - Mirena
8
Q
Example of oral combined
A
Estelle duet
9
Q
Example of transdermal combined contraceptive
A
Evorel sequi = cyclical
Evorel conti = continuous
10
Q
Side effects of progesterone
A
Mood swings weight gain acne fluid retention bloating
11
Q
side effects of oestrogen
A
nausea/vom
breast tenderness
headaches
cramps
12
Q
Reason for choosing transdermal over oral
A
Lower risk of headache, CVD, VTE
13
Q
What drugs should be used to managed CKD caused by DM or hypertension
A
ACE-I
ARB
14
Q
What drugs should be stopped in AKI/renal impairment
A
diuretics
NSAIDs
Rifampicin
ACE-I/ARB - may have been prescribed in CKD
ciclosporin
Lithium - may need dose reduction. Don’t completely stop. Same for digoxin
Opioids - morphine and codeine avoid. Swap codeine for oxycodone where possible.
15
Q
Calcium channel blocker to be used in hypertension
A
Amlodipine (or nifedipine but don’t)
16
Q
Ca blocker to use in unstable angina
A
Don’t use one!
17
Q
Ca blocker to use in stable angina
A
Any. Amlodipine is safest choice.
18
Q
Cardio selective Ca blockers
A
non-dihydropyradines - verapamil and diltiazem
19
Q
Vascular selective Ca Blockers
A
dihydropyradine - amlodipine nifedipine
20
Q
What Ca blockers are CI with B blockers
A
non-dihydropyradines - verapamil and diltiazem
21
Q
Indications for Verapamil
A
Arrhythmias
SVT
22
Q
CI of Ca blockers
A
Avoid non-d in HF and in AV conduction delay/heart block.
Avoid non-d along side a b blocker
Avoid in unstable angina and aortic stenosis
23
Q
SSRI to prescribe in cardiac disease
A
Sertraline
24
Q
Treatment for lactational mastitis
A
Flucloxacillin
25
Monitoring for patients on digoxin
```
digoxin levels (toxic)
Potassium levels because digoxin raises potassium
```
26
Drugs that cause constipation
```
Opioids
Anti-cholenergic drugs
Iron supplements
Anti-emetics
Bisphosphonates
Ondansetron
```
27
1st 2nd and 3rd line mx of constipation
Bulk forming - ishaghula husk
Osmotic - lactulose or macrocell
Stimulant - senna
28
CI for laxatives
Bowel obstruction
| Faecal impaction
29
Antibiotics to prescribe in COPD exacerbation
Doxycycline
Amoxicillin
Clari
30
1) Drug to give in COPD exacerbations when patients who aren't getting better. + Dose
2) Another supportive measure that can be done in unwell patients
1) Aminophylline 5mg/kg max
| 2) NIV
31
1) First 3 drugs of management of asthma exacerbation
| 2) 2 specialist drug which may be given
1) Steroids (pred 40-50mg daily or IV hydrocortisone 100mg). Nebulised salbutamol 2.5mg. Nebulised ipratropium 500mcg
2) Mg 1.2-2g IV. Aminophylline
32
1) Rules on maintenance fluid prescribing in stroke patients - why?
2) How much, water, K+, Na+, Cl- needed per day.
3) How much glucose needing in stable patient
1) No glucose in first 24 hours due to risk of cerebral oedema
2) 25-30ml/kg of water. 1mmol/kg of electrolytes
3) 50-100g/day of glucose
33
1) How much glucose in a 5% dextrose bag 1L
| 2) How much K+ in 1L 0.3% and 0.15%
1) 50g
| 2) 40mmol and 20mmol
34
What rate do you prescribe fluids for:
1) Resus
2) Dehydration
3) Maintenance
1) < 15 min
2) 4-6 hours
3) 8-12 hours
35
1) When do you prescribe resuscitations fluids
2) What fluid, volume and rate?
3) When to escalate
1) BP < 90. HR > 90. CRT > 2
2) 500mL saline. < 15 min. (250 in frail)
3) after 2L
36
Fluids to prescribe in hypoglycaemia
20% glucose in 100mLs
37
Progesterone only pills:
1) What counts as a missed pill
2) How to manage a missed pill
3) When might they need emergency contraception
1) traditional pill >3hrs from due. Desogestrol >12 hrs
2) Take the pill asap, might involve taking 2 pills at once. Use condoms for next 48 hours
3) Unprotected sex within the 48 hours they will require emergency contraception
38
COCP:
1) What counts as a missed pill
2) When is emergency contraception required
1) 24 hours late (48 hours from last pill)
2) 1 missed pill, just take it and you're fine.
3) If 2 missed pills within the first 7 days of a pack
39
Management of gout.
| If allergic to first line
Naproxen
| Colchicine
40
Management of strep throat
| If allergic to first line
Phenoxymethylpenicillin
| Clarithromycin
41
1) First line emergency contraception option
2) Medical option
3) If the person if taking enzyme inducing drugs - what should be done
1) Copper coil
2) 1.5mg levonorgestrol.
3) Ideally copper coil. If not increase levo dose to 3mg
42
How to manage a patient on statins with raised LFTs
Raised = 3 times the upper limit in this case
| stop statin for 1 month. See if LFTs come down, then restart at a lower dose.
43
Name 10 drugs that legthen the Qtc
```
Antipsychotics
Type 1a anti-arrhythmics
Flacainide
Amiodarone
Anti-depressants
Macrolides
Hydroxychloroquine
```
44
1) What is the dose and volume of a VRII
2) What is considered a hypo on VRII
3) How is a hypo managed
4) When to manage a hyperglycaemic episode as DKA
5) Which diabetic drugs need to be stopped on VRII
6) When/how do you switch a patient back to their normal insulin regime
1) 50 units in 49.5mL (1U/mL)
2) < 4
3) Stop VRII for max 20 minutes. Give 20% glucose 100mL
4) When ketones >3
5) Oral hypoglycaemics. Fast acting insulins. Keep long acting insulins
6) At meal time. When they no longer have nausea or vomiting. Give food and dose of fast acting insulin. Turn VRII off after 30-60 minutes.
45
How to calculate insulin regime in insulin naive patients
1) By weight
2) For twice daily injections
3) For basal bolus
1) 0.5U x weight. in elderly 0.3U x weight
2) 60% in morning injection 40% in afternoon
3) 50% - long acting - 25% morning 25% eve
50 % derided into 3 doses of rapid acting for 3 meals
46
1) Indications for digoxin
2) mechanism of action
3) 4 side effects
4) contra-indications of digoxin
5) What to do with digoxin in renal failure
6) What can cause digoxin toxicity
7) symptoms of digoxin toxicity
1) AF. 3rd line mx of heart failure
2) increases intracellular Na, cells retain Ca and so have stronger contraction
3) bradycardia, visual disturbance, rash, dizziness
4) 2nd degree HB. Ventricular arrhythmias
5) Dose reduction
6) Renal impairment. Low K+, Low Mg, raised Ca. Thiazide and loop diuretics. Amiodarone
7) GI upset. Palpitations. Dyspnoea. Syncope
47
Side effect of ace-i more common in afro-caribean people.
Angio-oedema
48
indications for managing a PE with thrombolysis
Haemodynamically unstable
Cardiac arrest
Evidence of right heart strain
49
Management of stable patients with PE
DOAC treatment dose
| LMWH treatment dose
50
Contraindication for DOACs and the alternative
Pregnancy - LMWH
51
Cautions when prescribing LMWH
Renal impairment - low clearance so will accumulate - consider dose reduction
52
Serious adverse effect of heparin
HIT
Antibodies to heparin cause platelets to start coagulation cascade.
Platelets all used up
53
Severe adverse reaction of DOACs
severe cutaneous acute reaction
54
Other side effects of DOACs
constipation
| GI upset
55
Caution when prescribing DOACs
Teratogenic - don't give in pregnancy
56
Antidote for heparin overdose
protamine
57
1) Warfarin mechanism of action
2) 2 contraindication for warfarin use
3) effect of CYP450 enzymes on warfarin
1) vitamin K antagonist
2) liver disease. Pregnancy
3) Inducers increase warfarin breakdown - increased clotting risk. Inhibitors prevent warfarin breakdown - increased INR and bleeding risk
58
How to manage the following:
1) INR 5-8 no bleeding
2) INR > 8 bleeding
3) INR 5-8 bleeding
4) INR > 8 no bleeding
5) Major bleeding
1) Stop warfarin for 2-3 days. Remeasure INR
2) IV phytomenadione 1-5mg. Stop warfarin.
3) IV phytomenadione 1-5mg. Stop warfarin
4) Oral phytomenadione 1-5mg. Stop warfarin
5) Dried prothrombin complex 50U/kg. + IV phytomenadione 5mg
59
1) Drug used to manage focal seizures
2) Drug for most other seizures
3) Second line drug
1) Carbamazepine
2) Valproate
3) Carbamazepine or Lamotrigine
60
Best anti-epileptic for pregnant and breast feeding women
Lamotrigine
61
Side effects of Carbamazepine
```
Oedema
Hyponatraemia
GI upset
Leucopenia
Thrombocytopenia
```
62
Side effects of valproate
```
increased weight
raised LFTs
thrombocytopenia
hair loss
oedema
ataxia
tremor
```
63
Drugs that lower the seizure threshold
SSRIs
Tricyclics
Antipsychotics
Tramadol
64
Patient presents with lymphadenopathy, fever and a rash. PMH: epilepsy
1) likely diagnosis
2) causes
1) Anti-epileptic hypersensitivity syndrome
2) Aromatic epileptic drugs
Phenytoin. Phenobarbitol. Carbamazepine
65
Management of status epileptics
1) Outside of hospital
2) With IV access
3) After ? long
1) Buccal midazolam 10mg every 10 min
2) 4mg lorazepam
3) 25 min - ITU. Give phenytoin infusion. Then propafol if still no resolution.
66
Side Effects of lithium
```
L - Leukocytosis
I - increased weight
T - tremor
H - hypothyroidism
I - impaired renal function
U - increased during output
M - metalic taste
```
67
Signs of lithium toxicity
```
T - Tremor
O - oliguric AKI
X - Ataxia
I - increased reflexes
C - convulsions
```
68
Extra Pyramidal signs seen with anti-psychotics
Parkinsonism - bradykinesia, tremor, rigidity
Akethesia
Dystonia
tardive dyskinesia
69
Patient recently started on respiradone presents with stiff neck muscles, and eyes rolled upwards.
1) Name of symptoms
2) Diagnosis
3) Management
1) Rigidity of neck and jaw muscles + oculogyric crisis
2) Acute dystonic reaction
3) Procyclidine
70
1) Timing of neuroleptic malignant syndrome
| 2) Management
First 10 days of starting anti-psychotic
| Bromocriptine
71
Symptoms of neuroleptic malignant syndrome
```
Confusion
Pyrexia
increased HR
Fluctuating BP
Rigidity
Derranged LFTs
Leukocytosis
raised CK
```
72
1) Cause of serotonin syndrome
| 2) Timing of symptoms presenting
1) Increased serotonin
| 2) Within minutes of taking SSRI
73
Symptoms of Serotonin syndrome
```
Headache
agitation
Hypomania
Shivering
Sweating
Hyperthermia
Hypertension
Increased reflexes
Myoclonus
Tremor
```
74
Peri-operative management of:
1) Sex hormones
2) Anti-platelets (aspirin)
3) Warfarin
4) ace-i and why
1) Combined hormones (HRT and contraception) should be stopped 4 weeks prior to elective surgery. Contraception can be restarted 2 weeks post of. HRT once fully mobilised (VTE risk)
2) Anti-platelets should be stopped 7 days prior to elective surgery
3) Warfarin stopped 5 days prior to surgery. Measure INR on the day/day before. Give phytymenodione 1-5mg if INR still >1.5
4) Need stopping prior to surgery (24 hrs) because of risk of peri-operative hypotension
75
Emergency reversal drug for dabigantran
Idarucizumab
76
Emergency reversal of apixaban or rivaroxiban
Andexant alpha
77
Patient has pitting oedema up to thighs and bibasal crackles on auscultation.
Prescription and route, why?
IV furosemide
| Pulmonary oedema requires faster acting loop diuretic (not oral)
78
Mx of nausea in vomiting post op in a patient with schizophrenia
Cyclizine
Ondansetron would normally be first line but this patient is likely to be on an anti-psychotic which would further prolong the QTc.
79
1) Best anti-emetic for nausea caused by hepatomegaly, reduced gut motility.
2) Serious side effect of this drug, and the worse effected age group.
3) Similar drug with fewer side effects
4) drugs that commonly cause nausea through reduced gut motility
1) Metoclopramide
2) Acute dystonia
3) Domperidone
4) Opioids
80
1) Drugs used to manage nausea in palliative care
| 2) Side effect - when to avoid
1) Haloperidol
| 2) Extra-pyramidal signs. Avoid in Parkinson's
81
1) Best anti-emetic to use in patients with vertigo.
2) Mechanism of action
3) 2 side effects
4) 2 contraindications
1) Cyclizine
2) H1 receptor antagonist
3) anti-cholinergic. Anti-histaminic
4) Hepatic encephalopathy. Prostate hyperplasia
82
1) Best anti-emetic to use in peri-operative nausea
2) Side effect
3) Second line anti-emetic in post surgical nausea
1) Ondansetron
2) Prolongation of QTc
3) cyclizine
83
Drug licensed for management of N/V in migraines
Metochlopramide
84
important side effects of amiodarone
Hyperthyroidism
bradycardia
AV block
Hepatitis
85
Important contraindications of adenosine
Coronary ischemia
Heart failure
asthma and COPD
86
1st and second line management of oral candida
1 - Nystatin
2 - Miconazole
3 - PO fluconazole when the above topical treatments don't work
87
Monitoring required before starting patient on COCP
BP
88
Patient presents to A&E feeling unwell.
ABG shows Low C02. Low pH. Low Bicarb.
What drug is likely to have caused this
Metabolic acidosis
| Metformin
89
Monitoring to do for patients on ACE-I
Renal function
| Esp K and Na
90
1) 4 drugs for managing pseudonomal infection
| 2) Only oral option
1) Ceftazidime. Aminoglycosides. Gentamycin. Tobramycin. Ciprofloxacin
2) Ciprofloxacin
91
Adverse effects of statins
Headache. GI upset. Myopathy/rhabdo. Increased liver enzymes, hepatitis
92
When prescribing what drugs would you have to suspend statins? Why?
CYP450 inducers.
| Amiodarone. Diltiazem. Itraconazole. **Macrolides**
93
1) Side effects of glucocorticoids
| 2) Serious adverse effects
```
1)Diabetes/glucose intolerance
Osteoporosis
Increased R of infection
Fluid retention
Hypokalaemia
Mood changes
Muscle atrophy/breakdown
2) Peptic ulcers - warn about abdo pain. Addisonian crisis when stopped.
```
94
Drugs that should be avoided with glucocorticoids
B agonists - increase hypokalaemia
| NSAIDs increase R of peptic ulcers
95
1) action of ACE-I
2) Side effects
3) CI/interactions
1) decreases angiotensin 2 and aldosterone through RAAS. Efferent arteriole dilation (protective in CKD). Reduced Na absorption and water through distal tubule
2) Low BP after first dose. Dry cough (switch to ARB). Angioedema
3) Pregnancy, AKI, Renal artery stenosis.
NSAIDs increase renal damage. Potassium elevating drugs
96
1) Action of spiro
2) Side effects
3) CI
1) aldosterone antagonist in distal tubule. Na and water excretion. K retention
2) Hyperkalaemia. Titties.
3) Renal impairement (K+) Addisons (hypo-aldosteronism)
97
1) Action of furosemide
2) side effects
3) CI
1) Blocks Na/K/Cl channel in loop. All electrolytes and water quickly excreted
2) Ototoxic - hearing loss, tinnitus. Worsens gout.
3) Avoid in hepatic encephalopathy.
98
1) Action of thiazide
| 2) side effects
1) Blocks Na/Cl channel in distal tubule. Stops Na reabsorption, therefore water.
2) impotence, gout.
99
Stepwise management of acne vulgarisms
1 - Benzoyl peroxide
2 - Add topic retinoid (adapalene)
3 - Topic retinoid + topic abx (clindamycin)
4 - Benzoyl peroxide + clindamycin
5 - Add oral abx, tetracyclines first eg doxy
6 - If above not working/CI/tolerated. Erythro or trimethoprim
7 - Oral isotrenin
100
Adverse effect of isotrenin
dry skin/lips
photosensitivity
depression
steven - Johnson's syndrome
101
Important patient communication thing for isotrenin
Highly teratogenic
| Female patients must be on contraception
102
Mx of hirsutism due to hyperandrogegism
Co-cyprindiol
103
Management of a patient with pmh of gout, during a current attack
Continue allopurinol if already taking. Short term mx with NSAID (if tolerated) or colchicine.
104
When to advice a pt to call an during chest pain ambulance if prescribed GTN.
Chest pain > GTN > 5 min > next dose of GTN > 5 min > if pain not subsided - call ambulance.
105
Management of DKA
0.1U/kg/hr fixed rate insulin - actrapid.
106
Management of hyperglycaemia hyper osmotic state
0.05U/kg/hr fixed rate infusion - actrapid
