Prescribing Flashcards
What are the patient factors that affect prescribing?
Objective: allergies, co-morbidites, drug interactions
Subjective: preferences/influences
What are the DAMN drugs?
D - diuretics
A - ACE inhibitors/ARBs
M - metformin
N - NSAIDs
If someone comes in with acute pulmonary oedema secondary to heart failure do you give furosemide oral or IV?
IV, oral would take to long to have an effect
What would you give someone with a hypo and GCS of 10/15?
Glucose 20% up to 200mL - at an infusion rate of under 20 minutes
What is an adverse effect of tetracycline?
It discolours teeth so you have to be wary giving it to children
What can patients with a fentanyl patch use for breakthrough pain?
Fentanyl nasal spray
What should you use treat a UTI in a 79 year old man with eGFR of 41?
Trimethoprim 200mg PO BD for 7 days
What is the first line treatment for alcohol withdrawal?
Chlordiazepoxide hydrochloride 20mg PO 6-hrly
A lady has come in for surgery. She has AF, she’s on warfarin but stopped taking it 5 days ago in preparation for surgery. Her INR is 1.6 (target 2.5), what are you going to give her?
Vitamin K 2mg PO
What is special about how you take rivaroxaban?
Take it with food
Which of these drugs is most likely to interact with dabigatran? Amlodipine Bisoprolol Citalopram Digoxin Metformin
Citalopram - increases the risk of GI bleed, especially in over 65s
If there is a small increase in creatinine after starting an ACE inhibitor, what do you do?
Continue with it and measure U&Es in a week. A small creatinine rise (<20%) is expected when starting an ACE inhibitor
Someone shows up to their GP with a sore throat after starting carbimazole, what bloods do you do?
FBC to look for neutropaenia
What should you monitor after 2 weeks of ciclosporins?
Serum creatinine to look for hypertension and nephrotoxicity. Blood pressure should also be routinely monitored
How much should you increase biphasic insulin with an exacerbation of asthma?
By about 10%
How high can serum transaminases be before you should stop giving statins?
30%
If a patient is not bleeding but has an INR between 5 and 8 what should you do?
Stop the warfarin for 1-2 days and reduce maintenance dose
If a patient is not bleeding and has an INR above 8 what should you do
Stop warfarin until INR is below 5 and give oral vitamin K (phytomenadione)
How long does oral vitamin K take to have an effect?
16-24 hours
If the patient has a minor bleed and INR over 5, what are you going to do?
Omit warfarin and give IV vitamin K (phytomenadione)
What is a patient has a minor bleed and has an INR less than 5?
Omit warfarin for 1-2 days and consider oral Vitamin K
What if a patient on warfarin is having a major bleed?
Stop the warfarin and give IV prothrombin concentrate (beriplex) and IV vitamin K
What is a side effect of Bleomycin?
Lung fibrosis
What drugs are measured in micrograms?
Tamsulosin, fludrocortisone, levothyroxine, digoxin, naloxone, inhalers, ipratropium nebs
What drugs are measured in 100s mg-grams?
Some antibiotics, metformin, some anti-epileptics?
What drugs are measured in grams?
Paracetamol, calcium carbonate, N-acetylcysteine
What are some medications that are relating to activity/daytime?
Parkinson’s disease
Anticholinesterases for myaseathenia graves
Diuretics
What are some medications that are related to night time?
Night sedation
Statins
What are some medications that are related to other medications/an empty stomach?
Bisphosphonates
Antacids
What are some medications related to mealtimes?
Hypoglycaemics
Pancreatic enzymes
What are some medications related to days of the week?
Patches
Bisphosphonates
Methotrexate/folic acid
What are some drugs that are contraindicated/cautioned with a PMH of heart failure?
NSAIDs and COX2 inhibitors Midodrine Pioglitazone Moxonidine Verapamil Several immunosuppressive monoclonal antibodies
What are some medications that should be used with caution with a PMH of gout?
Diuretics
Pyrazinamide
Allopurinol and febuxosin in aute gout
What should you search in the BNF if looking for a side effect of a drug that could cause a long QT?
QT prolongation
What are some medications that you should use with caution with a PMH of psoriasis?
Beta blockers
Lithium salts
Chloroquine
What are some medications that you should use with caution with a PMH of myasthenia graves?
Tetracyclines
Macrolides
Quinolones
Sedating medications (Z-drugs, benzodiazepines, antipsychotics, opiates)
Local anaesthetics (particularly nerve blocks)
Beta Blockers
What are some drugs that can cause hypokalaemia?
Diuretics IV antifungals Cisplatin Steroids Beta-2-agonists Rarely Gentamicin
What are the drugs that can cause hyperkalaemia?
ACEi, ARB Spiro/eplerenone/amiloride Heparin and LMWH Tolvaptam Co-trimoxazole
What are some drugs that can cause hypomagnesaemia?
Thiazide and loop diuretics PPIs Calcium resonium Ciclosporin IV bisphosponates IV antifungals IV aminoglycosides
What are some drugs that can cause hypoglycaemia?
Insulin
Sulphonylureas
Other anti-diabetic drugs still have the risk but lower apart from metformin
What are some drugs that can cause hyperglycaemia?
Steroids Antipsychotics Thiazide diuretics Beta blockers Tacrolimus
What are some drugs that can cause hypercholesterolaemia?
Systemic steroids Diuretics (thiazide and loop) Antipsychotics Ciclosporin Most HIV meds SGLT2 inhibitors (-flozins)
What are some drugs that can cause hypertension?
NSAIDs Glucocorticoids Mineralocorticoids COCP Mirabegron Clozapine Venlafaxine/triyclic antidepressants Monoamine oxidase inhibitors Selegeline Ciclosporin and Tacrolimus
What are some drugs that increase the risk of falls?
Benzodiazepines, Z-drugs Antidepressants MAO inhibitors Antipsychotics Opiates Most antihypertensives (especially alpha blockers, diuretics) Anti-parkinsons meds
What are some drugs that can increase the risk of osteoporosis?
Steroids
PPIs at high doses especially in elderly over long courses
Long-term androgen suppression
What are some drugs that can increase the risk of urinary retention?
Oxybutinin Atropine Procyclidine Glycopyrroinium Opioids Benzodiazepines Inhalation anaesthesia Antihistamines Antidepressants
What are some drugs that can increase the risk of urinary incontinence?
Alpha blockers Diuretics ACEi Clozapine Bromocriptine Benzodiazepines Pregabalin
What are some drugs that can cause constipation?
Opioids Oral iron Some calcium channel blockers Anti-psychotics Some diuretics Antacids Anti-muscarinics Ondansetron Some anti-parkinsons and some anti-epileptics
What are some drugs that can cause diarrhoea?
Laxatives Antibiotics Some antacids Orlistat Cholinesterase inhibitors (rivastigmine) Colchicine
What are some IMPORTANT side effects of anti-psychotics?
Blood dyscrasias / agranulocytosis QT prolongation, arrythmias Worsening diabetes Worsening Parkinson’s disease Neuroleptic malignant syndrome
What are some COMMON side effects of anti-psychotics?
Drowsiness, constipation, urinary retention, dry mouth, hypotension
Weight gain
Galactorrhoea, gynaecomastia, sexual dysfunction
What are some general things that need to be monitored with anti-psychotics?
FBCs, U+Es, LFTs, lipids, blood glucose, blood pressure
Prolactin
Physical health (and cardiovascular risk) monitoring, QTc monitoring
What are some common drugs that can cause photosensitivity?
Isotretinoin
Doxycycline (and other tetracyclines)
Amiodarone
If unwell with diarrhoea, vomiting, fever or sweats which drugs would you consider stopping?
Metformin (not insulin!) ACEi / ARBs / diuretics NSAIDs (“DAMN” medications) Restart when you are well (after 24-48 hours of eating and drinking normally)
What are the sick day rules for T1DM?
Never omit insulin (may need increased – local guidance usually provided) Maintain adequate (sugar-free) fluid intake Maintain regular carbohydrate intake – if unable to take solids, in liquid carbohydrate format
Consider anti-emetic if nauseated
Consider oral electrolyte replacement in diarrhoea
If prolonged inability to keep down fluids (e.g. >4hrs), then likely needs hospital admission
Increased blood glucose monitoring (e.g. 4hr-ly, and even more frequently if >moderate ketones)
Ketone testing 2-4 hrly
If persistently elevated, or elevated while low blood glucose – may need hospital admission
Diabetic specialist nurse should provide individualised plan
What are the sick day rules in T2DM in patients NOT taking sulphonylureas?
Continue with medication as normal (except metformin if prolonged D/V)
Encourage adequate fluid and diet intake
Consider providing an oral electrolyte replacement
What are the sick day rules in T2DM in patients taking sulphonylureas?
Minimum of daily self-blood glucose monitoring
Advice should be provided regarding the increased risk of hypoglycaemia and reinforce the importance of taking some form of regular carbohydrate
Seek advice if blood glucose persistently elevated (e.g. > 17)
What are the important things about the method of us with long term steroids?
Do not stop steroids abruptly
Usually taken in morning (reduce nocturnal side effects)
Taken with or just after food
Should carry steroid card
How do you find which drugs need to be stopped peri-operatively on the BNF?
Under treatment summary surgery and long term medication
more specific ‘diabetes, surgery and medical illness’ and ‘contraceptives, hormonal’
What are some absolute contraindications to HRT?
Undiagnosed vaginal bleeding Severe liver disease Pregnancy Coronary artery disease Endometrial cancer Recent DVT or stroke
What are some relative contraindications to HRT?
Migraine headaches
Personal history of breast cancer
Personal history of ovarian cancer
Venous thrombosis
History of uterine fibroids
Atypical ductal hyperplasia of the breast
Active gallbladder disease (cholangitis, cholecystitis)
What is an example of a COCP name in the BNF?
Ethinylestradiol with desogestrel
What is an example of a progestogen only pill in the BNF?
Levonorgestrel
Which drugs need contraception advice for men?
Methotrexate
Cyclophosphamide and many other strong immunosuppressants
Some chemotherapy
(Some antifungals and some antivirals)
What are the important communication things about insulin?
Risk of hypoglycaemia
Rotate sites of injection
Not to massage sites of injection
What are the important communication things about metformin?
Should be stopped if continued diarrhoea or vomiting
GI side-effects are common and diarrhoea is usually transient
Seek immediate medical attention if symptoms such as dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia occur (lactic acidosis)
GI side-effects can be helped by taking with or just after food
What are the important communication things about sulphonylureas?
Risk of hypoglycaemia
Can encourage weight gain
What are the important communication things about SGLT2 inhibitors (-flozins)?
Advised to report symptoms of volume depletion including postural hypotension and dizziness
Patients should be informed of the signs and symptoms of diabetic ketoacidosis
Should be stopped if hospitalised for major surgery or acute serious illnesses
Hypoglycaemia risk especially if co-prescribed with sulfonylurea of insulin)
What are the important communication things about carbamazepine?
Advice on how to recognise signs of blood, liver, or skin disorders (e.g. fever, rash, mouth ulcers, bruising, or bleeding) and advised to seek immediate medical attention
What are the important communication things about valproate?
Highly teratogenic - contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met
Advice on how to recognise signs of liver dysfunction or pancreatitis (e.g. persistent vomiting and abdominal pain, anorexia, jaundice) and advised to seek immediate medical attention
What are the important communication things about lamotrigine?
Advice to see their doctor immediately if rash or symptoms of hypersensitivity (risk of Stevens-Johnson syndrome / toxic epidermal necrolysis)
Advice on how to recognise signs of bone marrow suppression - anaemia, bruising, or infection.
Where can you find the info on the BNF about paracetamol overdose?
Treatment summaries Poisoning, emergency treatment
Where can you find info on warfarin and INR on the BNF?
Treatment summaries Oral anticoagulant
Where can you find info on lithium toxicity on the BNF?
Treatment summaries Poisoning, emergency treatment
What do you do to statins after 3 month non-HDL result for primary prevention?
> 40% reduction - continue dose
<40% reduction - consider increasing dose (discuss adherence/lifestyle)
What do you do to the statin dose in secondary prevention?
Start high-intensity statin (e.g. atorvastatin 80mg on) and continue as tolerated
How does creatinine kinase level affect statin treatment?
If between 1x and 5x upper limit of normal - Continue statin, but regular CK monitoring - stop statin if muscle symptoms OR rising CK levels
If >5x upper limit of normal - stop statin
How do LFTs affect statin treatment?
If between 1x and 3x upper limit of normal - Continue the statin but recheck LFTs within 4–6weeks to exclude further increases in transaminase levels - no extra monitoring is required if values are stable.
If >3x upper limit of normal - Stop the statin and recheck LFTs within 4–6weeks to ensure that values settle (consider re-introducing the statin cautiously at a later date),OR reduce the statin dose (if the person is taking a high dose) and recheck LFTs within 4–6weeks,OR change to a statin in a lowerintensity group(for example change to a medium-intensity statin if the person is taking a high-intensity statin) and recheck LFTs within 4–6weeks.
If transaminase levels continue to be three times the upper limit of normal or more, stop the statin and seek specialist advice (for example from a lipid clinic).
How would you decide how much to change an insulin dose by?
Typically adjustments by 10% of dose (varies with experience), e.g.
Reducing from 24 units new dose 22 units
Increasing from 16 units new dose 18 units
How can you measure the effect of warfarin?
INR
How can you measure the effect of LMWH?
Anti-Factor Xa activity.
Not routine
But may be necessary in patients at increased risk of bleeding / difficult dosing (e.g. in renal impairment and those who are underweight or overweight, pregnancy)
NOTE: will need to monitor platelets (for heparin-induced thrombocytopenia)
How can you measure the effect of unfractionated heparin infusion?
aPTT (activated partial thromboplastin time) monitored regularly during infusion
What fluids do you give in emergency resuscitation?
0.9% Sodium chloride, 500 ml in 10 minutes
NO potassium
What fluids do you give in emergency hypoglycaemia?
20% Glucose, 50 ml in less than 5 minutes
NO potassium
What fluids do you give in severe symptomatic hypercalcaemia?
0.9% Sodium chloride, 1000 ml in 2-4 hours
NO potassium
What fluids do you prescribe for general maintenance?
0.9% sodium chloride with 20 mmol KCl, 1000ml over 8-12 hours
5% glucose with 20 mmol KCl, 1000ml over 8-12 hours
If there’s multiple options of what you could prescribe what are the questions you should ask yourself?
Are there any contraindications in the PMH?
Does the DH result in any interactions?
Are there any patient preferences in the scenario?
Are there any investigation results that influences the selection/dosing?
Does patient characteristics (e.g. age, weight) influence your choice?
What questions should go through your mind when deciding antibiotics from an MC&S?
Which antibiotic is the organism sensitive to?
Is there an antibiotic allergy?
Choose oral vs intravenous
Renal (and liver) function
Check past medical history – any other contraindications
When choosing between oral and IV what should you think about?
Is there indication for intravenous route (e.g. severe infection)?
Can/will the patient take oral medications?
Is there vomiting or severe confusion declining oral medications?
