Prescribing Flashcards
1
Q
What dose of statin is used for primary and secondary prevention of cardiovascular disease?
A
Primary: 20 mg atorvastatin
Secondary: 80 mg atorvastatin
NOTE: rosuvastatin is a potent statin that is more likely to cause statin-induced myopathy
2
Q
What dose of oral metronidazole is used to treat C. difficile infection?
A
400 mg every 8 hours for 10-14 days
Alternative: 500 mg every 8 hours
IMPORTANT: oral vancomycin should be used if it is a second episode of C. difficile colitis
3
Q
What dose of omeprazole is used for peptic ulcers, gastro-oesophageal reflux and the prevention of ulcers?
A
Omeprazole 20 mg OD (usually for 4-8 weeks)
4
Q
What is the first-line treatment option for cellulitis?
A
Oral flucloxacillin 250-500 mg QDS
2nd line: oral clarithromycin 250 mg BD for 7–14 days (up to 500 mg BD for severe infections)
5
Q
Which dose of cyclizine is used in nauseated patients?
A
Cyclizine 50 mg 8-hourly IM/IV/oral
WARNING: can cause fluid retention so avoid in heart failure
6
Q
What is the maximum dose of PRN paracetamol?
A
Paracetamol 1 g every 6 hours (maximum 4 g/day)
7
Q
Which PRN pain relief should be given for patients with mild pain?
A
Codeine 30 mg up to 6-hourly
8
Q
Which regular medication should be prescribed for patients with severe pain?
A
Co-codamol 30/500, 2 tablets every 6-hours
WARNING: pay attention to how much paracetamol a patient is taking if they are taking PRN co-codamol and regular paracetamol
9
Q
Which PRN medication should be prescribed for severe pain?
A
Morphine sulphate 10 mg up to 6-hourly
10
Q
Which medications are used first-line in neuropathic pain?
A
Amitriptyline 10 mg oral nightly
Pregabalin 75 mg oral 12-hourly
11
Q
What dose of ibuprofen should be used for pain?
A
Ibuprofen 400 mg 8-hourly
12
Q
What is the dividing factor for dosing when switching patients from oral codeine to oral morphine?
A
Divide by 10
Same with oral tramadol to oral morphine
13
Q
For patients with advanced and progressive disease who are in pain, what should be prescribed provided there are no comorbidities?
A
20-30 mg modified-release oral morphine (or immediate-release based on patient preference) - e.g. 15 mg BD
With 5 mg immediate-release oral morphine for breakthrough pain
14
Q
If a patient on 30 mg morphine sulphate BD is switched onto a syringe driver, what dose of subcutaneous morphine should be given?
A
30 mg in 24 hours
NOTE: if changing to SC morphine from oral morphine, the dose should be divided by 2 or 3
NOTE: if changing to SC diamorphine, it should be divided by 3
15
Q
What should be coprescribed in patients who develop pneumonia after influenza?
A
Flucloxacillin (cover S. aureus)
16
Q
What does 1% mean with regards to weight/volume calculations? (e.g. 1% lidocaine)
A
1 g in 100 mL (i.e. 10 mg in 1 mL)
17
Q
What does PReSCRIBER stand for?
A
Patient details (name, DOB and hospital number) Reaction (e.g. allergy) Sign the front of the chart Contraindications to each drug Route IV fluids necessary? Blood clotting prophylaxis necessary? Anti-Emetic necessary? Pain Relief necessary?
18
Q
What is the starting dose of ramipril and lisinopril in heart failure?
A
Ramipril: 1.25 mg OD
Lisinopril/Enalapril: 2.5 mg OD
19
Q
When should ACE inhibitors be taken?
A
In the evening/night as it can cause postural hypotension
20
Q
What dose of verapamil is used for rate control in atrial fibrillation?
A
40 mg 8-hourly
21
Q
What is the usual daily starting dose of levothyroxine in hypothyroidism?
A
50-100 mcg
NOTE: in elderly patients and patients with comorbidities, a starting dose of 25 mcg OD may be used
22
Q
What is the usual dose of amlodipine used for hypertension?
A
5 mg OD
Maximum of 10 mg OD
NOTE: it does not need to be taken at night
23
Q
Which medications are usually taken at night?
A
Statins
Amitryptiline
NOTE: atorvastatin can be taken at any time of the day
24
Q
What is an appropriate starting regime of analgesia for palliative patients?
A
20-30 mg per day of modified-release morphine + 5 mg morphine for breakthrough pain
25
Outline the rules for converting doses of opioids.
Oral codeine --> oral morphine = divide by 10
Oral tramadol --> oral morphine = divide by 10
Oral morphine --> oral oxycodone = divide by 1.5-2
Oral morphine --> SC morphine = divide by 2
Oral morphine --> SC diamorphine = divide by 3
26
Which opioids are preferred in CKD?
Buprenorphine and alfentanil
NOTE: the same drug should be used for maintenance and break-through pain (e.g. fentanyl 50 mcg/actuation nasal spray in each nostril repeated after 10 mins if required)
27
Which analgesic should you prescribe to a patient with renal colic?
IM diclofenac 75 mg
28
How big should the breakthrough dose of morphine be?
1/6 of the daily dose
29
What is the starting dose of methotrexate for rheumatoid arthritis?
7.5 mg weekly
5 mg folic acid should be co-prescribed, to be taken more than 24 hours after the methotrexate dose
NOTE: methotrexate is available in 2.5 mg pills
30
List some p450 inducers.
```
Antiepileptics (phenytoin, carbamazepine)
Phenobarbitone
Rifampicin
St. John's wort
Chronic alcohol intake
Griseofulvin
Smoking
```
31
List some p450 inhibitors.
```
Antibiotics (ciprofloxacin, clarithromycine/erythromycin)
Isoniazid
Cimetidine, omeprazole
Amiodarone
Allopurinol
Imidazoles: ketoconazole, fluconazole
SSRIs: fluoxetine, sertraline
Ritonavir
Sodium valproate
Acute alcohol intake
```
32
What are some adverse drug reactions associated with gentamicin and vancomycin?
Nephrotoxicity
| Ototoxicity
33
Which antibiotics are particularly notorious for causing C. difficile colitis?
Cephalosporins
| Ciprofloxacin
34
List some adverse effects of ACE inhibitors.
Hypotension
Electrolyte abnormalities (hyperkalaemia)
AKI
Dry cough
35
List some adverse effects of beta-blockers.
Hypotension
Bradycardia
Wheeze in asthmatics
Worsens acute heart failure (drops CO)
36
List some adverse effects of CCBs.
Hypotension
Bradycardia
Peripheral oedema
Flushing
37
List some adverse effects of heparins.
Haemorrhage (especially if renal failure or < 50 kg)
| Heparin-induced thrombocytopaenia
38
List some adverse effects of aspirin.
Haemorrhage
Peptic ulcers
Tinnitus
39
List some adverse effects of digoxin.
```
Nausea and vomiting
Diarrhoea
Blurred vision
Confusion
Drowsiness
Xanthopsia (yellow-green visual perception)
```
40
List some adverse effects of amiodarone.
Interstitial lung disease
Thyroid disease
Grey skin
Corneal deposits
41
List some adverse effects of lithium.
Early - tremor
Intermediate - tiredness
Late - arrhythmias, seizures, coma, renal failure, diabetes insipidus
42
List some adverse effects of statins.
Myalgia
Abdominal pain
Increased ALT/AST
Rhabdomyolysis
43
List some common drugs that have a narrow therapeutic index.
Warfarin
Digoxin
Phenytoin
Theophylline
44
Which commonly used medications should be stopped before surgery?
Antiplatelets
Anticoagulants
COCP
Lithium (omit the day before surgery)
45
What is the usual daily dose of alendronic acid?
10 mg
NOTE: 70 mg can be given WEEKLY in patients with post-menopausal osteoporosis
46
List some commonly used classes of medication that cause indigestion.
NSAIDs
Steroids
Bisphosphonates
47
What is the usual treatment dose of enoxaparin?
1.5 mg/kg
NOTE: 40 mg is the prophylactic dose
48
Which medications can reduce renal excretion of lithium?
ACE inhibitors
Diuretics (particularly thiazides)
NSAIDs
NOTE: if diuretics must be used in a patient on lithium, use loop diuretics
49
What is the target range for TSH in a patient with hyperthyroidism?
0.5-5.0 microU/L
50
When might you expect fluid input to be greater than fluid output in a patient?
Correction of dehydration
| Renal failure
51
What are the daily maintenance requirements of fluid and potassium when NBM?
Fluid: 3 L (i.e. 1 L per 8 hours)
K+: 40-60 mmol
So, 1 L 0.9% saline with 20 mmol KCl over 8 hours
52
Which type of fluid should be used for maintenance in adults who are NBM?
Provided biochemistry is normal, they should have:
1 L of 0.9% saline
2 L 5% dextrose
Every 24 hours with 40-60 mmol KCl per day
53
What is the first-line diabetic medication in patients with CKD?
Gliclazide
Metformin cannot be used if GFR < 30 ml/min
54
What is the normal starting dose of amitryptyline?
10 mg
55
Which antibiotic commonly interacts with statins and how should you deal with it?
Clarithromycin
It is a CYP3A4 inhibitor and it increases the toxicity of statins. So, statins should be stopped during the course of clarithromycin.
56
Which medication can give immediate relief for patients with dyspepsia?
Magnesium carbonate 10 mL TDS
57
What is a major contraindication for using lactulose?
Bloating
58
What are some major contraindications for using Senna?
Colitis and cramps
59
What is the main difference between the side-effects of codeine and tramadol?
Codeine - constipation
Tramadol - agitation/hallucinations
NOTE: both of them cause typical opioid side-effects (respiratory depression, reduced consciousness, pinpoint pupils)
60
What dose of codeine is typically used for the management of pain?
30 mg 6-hourly
NOTE: maximum daily dose is 240 mg
61
What is the best way of measuring the therapeutic effect of an aminophyline infusion?
Oxygen saturations will improve
62
What is the best way of measuring tacrolimus levels in transplant patients?
Trough level before the morning or evening dose (aim for 6-10 ng/mL)
63
What is the target pre-dose trough concentration for vancomycin?
10-15 mg/L
64
List some common side-effects of calcium channel blockers.
```
Abdominal pain
Dizziness
Drowsiness
Flushing
Headache
Nausea
Palpitations
peripheral oedema
Skin reactions
Tachycardia
Vomiting
```
65
Outline the management of high INR in patients on warfarin.
MAJOR BLEEDING: Stop warfarin + IV 5 mg vit K + PCC (or FFP)
INR > 8.0 + minor bleeding: stop warfarin + IV 1-3 mg vit K + restart warfarin when INR < 5
INR > 8 + no bleeding: stop warfarin + 1-5 mg oral vit K + restart warfarin when INR < 5
INR 5-8 + minor bleeding: stop warfarin + IV 1-3 mg vit K + restart warfarin when INR < 5
INR 5-8 + no bleeding: withhold 1 or 2 doses of warfarin + reduce subsequent maintenance dose
66
When should diuretics be taken and why?
Any time except the evening because they will be up all night peeing
67
Which commonly used NSAID is NOT nephrotoxic?
Aspirin
NOTE: it also rarely worsens asthma
68
Which type of bladder stabilising drugs should be avoided in myasthenia gravis?
Anti-cholinergic (e.g. oxybutynin, solifenacin)
Use mirabegron instead
69
Which medication can be given as a one-off for acute anxiety?
2 mg diazepam PO
70
Which parameter is important to monitor in patients on digoxin?
Serum creatinine
It is mainly excreted renally, so patients with renal dysfunction are at risk of digoxin toxicity
71
Which parameter is important to check at baseline and monitor in patients receiving sodium valproate?
LFTs (ALT)
Valproate is associated with hepatotoxicity
72
What should you keen an eye on when giving a patient IV aminophylline?
ECG - it can precipitate cardiac arrhythmias
73
What should be checked to identify theophylline toxicity?
Serum theophylline level (18 hours after commencing treatment)
Target: 10-20 mg/L
NOTE: aminophylline is a stable mixture of combined theophylline and ethylenediamine
74
When does enoxaparin require dose-adjustment?
eGFR < 30 mL/min
| Weight < 50 kg
75
Which commonly used diabetes drugs can cause hypoglycaemia?
Insulin
Sulphonylureas (e.g. gliclazide)
Thiazolidinediones (e.g. pioglitazone)
76
List some drugs that cause urinary retention?
```
Opioids
Anticholinergics
General anaesthetics,
Alpha-adrenoceptor agonists,
Benzodiazepines (e.g. diazepam),
Non-steroidal anti-inflammatory drugs (e.g. ibuprofen),
Calcium-channel blockers,
Antihistamines,
Alcohol.
```
77
List drugs classes that can cause confusion.
```
Opioids (e.g. morphine)
Metoclopramide
Anticholinergics (e.g. oxybutynin, tiotropium)
Glucocorticoids (e.g. prednisolone)
Antibiotics (e.g. co-amoxiclav)
Diazepam
Antipsychotics
Antidepressants
Anticonvulsants
Beta-blockers
```
78
How should the dosing of gentamicin be changed if the peak and trough concentrations are too high?
Peak too high --> reduce the dose
| Trough too high --> increase interval between doses (giving more time for clearance)
79
Name two different LMWHs and their prophylactic and treatment doses.
Tinzaparin: 4500 U (prophylactic), 175 U/kg (treatment)
Enoxaparin: 40 mg (prophylactic), 1.5 mg/kg (treatment)
NOTE: enoxaparin 40 mg = 4000 U
80
List some drugs that contribute to hyperkalaemia.
```
ACE inhibitors/ARB
Heparins (inhibit aldosterone synthesis)
Tacrolimus
Spironolactone/amiloride
NSAIDs
```
81
When should aspirin be stopped before surgery?
7 days
82
How should patients on warfarin be advised ahead of elective surgery?
Stop warfarin 5 days before surgery
| If INR > 1.5 on the day before surgery, give 1-5 mg vitamin K PO
83
Which monitoring parameter may rise slightly in patients started on ACE inhibitors?
Creatinine - but a rise < 20% is no cause for concern and treatment should continue (repeat U&E after 1 week)
84
What is the best gauge of whether chronic heart failure treatment (i.e. ACE inhibitors, beta-blockers) are working?
Exercise tolerance
85
How should the usual dose of insulin in a type 1 diabetic be changed if their blood glucose is being deranged due to the use of steroids?
Increase insulin dose by 10%
86
When should patients be reviewed after starting a statin?
Measure total cholesterol, LDL and HDL 3 months after starting treatment
Aim for > 40% reduction in non-HDL cholesterol
If failed to achieved --> discuss adherence, consider increasing dose
87
What medication should you prescribe for a mild CAP?
Amoxicillin 500 mg TDS for 5 days
Penicillin allergy: clarithromycin 500 mg BD for 5 days
88
What medication should you prescribe for a HAP?
Piperacillin with tazobactam (tazocin) 4.5 g TDS IV
89
How should acute dystonic reactions be treated?
Procyclidine
90
Which steroid should be given to patients with an acute exacerbation of COPD?
30 mg prednisolone OD for 5 days
91
Describe the interaction between warfarin and clarithromycin.
Clarithromycin increases the effect of warfarin (thereby leading to a rise in INR)
92
How should patients be advised after missing one pill?
Take the missed pill and continue as per usual
| They will be protected anywhere in the cycle
93
Which diabetes drug does simvastatin interact with leading to myotoxicity?
Gemfibrozil
94
What should be checked and corrected before starting amiodarone?
Serum potassium
Because amiodarone can cause hypokalaemia
95
How is phenytoin monitored?
Trough level
| Therapeutic at 10-20 mg/L
96
What are the main risks of using metoclopramide?
Cardiac conduction disorders as it causes QTc prolongation (e.g. electrolyte disturbances)
Extra-pyramidal side-effects (avoid if already on an antipsychotic)
97
What dose of aciclovir should be used to treat shingles in adults?
800 mg 5 times daily for 7 days
98
List some common drugs that can cause ankle oedema.
CCBs (e.g. amlodipine)
| Naproxen
99
What should you do with a patient's normal long- and short-acting insulin regimes when you start treating them for DKA?
Stop short-acting
Continue long-acting
Place on fixed-rate insulin infusion
100
How should you advise patients to take loperamide?
4 mg followed by 2 mg after each loose stool up to a maximum of 16 mg/24 h
101
What monitoring is required in patients taking ciclosporin?
Liver and kidney function
NOTE: it is not myelotoxic
102
Which opioid is safe to use in renal impairment?
Oxycodone - it is mainly metabolised by the liver
103
In a patient with DKA, what range of serum K+ warrants giving fluids with KCl?
3.5-5.5 mmol/l - use 0.9% saline + 40 mmol/L of potassium replacement
104
Name a commonly used NSAID that can cause hepatitis.
Diclofenac
105
What is the maximum rate at which fluids containing potassium can be given through a peripheral cannula?
10 mmol/hour
NOTE: rates above 20 mmol/hour needs cardiac monitoring
106
How many mmol of KCl are in 1 L of 0.3% potassium?
40 mmol
107
How should long-term prednisolone dose be changed in patients who are acutely unwell?
Double it
108
What is the dose of nebulised adrenaline that should be given in severe croup?
400 micrograms/kg
109
Why shouldn't diltiazem and verapamil be used in heart failure?
Worsens fluid retention
NOTE: if AF in heart failure, digoxin should be used
110
Which anti-epileptic is safest to use in pregnancy?
Lamotrigine
111
Which are the best anti-epileptics for focal epilepsy?
Lamotrigine
| Carbamazepine
112
In which patients with newly diagnosed T2DM should you avoid using metformin?
Underweight (as it causes appetite suppression)
Creatinine > 150 umol/L (risk of lactic acidosis)
In these scenarios, use gliclazide instead
113
What should be checked before starting treatment with atypical antipsychotic drugs?
Fasting blood glucose
114
How do you manage a Parkinson's disease patient who is nil by mouth?
Get an urgent SALT assessment
Consider inserting NG tube
Consider prescribing rotigotine patch
115
Which medications can be used to reduce secretions in palliative care?
Glycopyrronium
Hyoscine
NOTE: these are usually SC injections
116
List some medications that exacerbate heart failure.
```
NSAIDs (fluid retention)
Verapamil and diltiazem (negative inotrope and fluid retention)
Pioglitazone (fluid retention)
Flecainide
Cyclizine (fall in cardiac output)
```
117
How do you convert from morphine to alfentanil and fetanyl?
Morphine --> Alfentanil (divide by 30)
Alfentanil --> Fentanyl (divide by 5)
Breakthrough fentanyl = 1/8th of daily dose
118
Which medications should be stopped before surgery?
```
Insulin
Lithium
Anticoagulants/antiplatelets
COCP/HRT
K+ sparing diuretics and ACE inhibitors
Oral hypoglycaemics (metformin)
Perindopril and other ACE inhibitors
```
119
Which commonly used drugs should be avoided in peripheral vascular disease?
Beta-blockers
| ACE inhibitors
120
Which medication can be used as an alternative to LMWH in patients with VTE and a phobia of needles?
Apixaban 10 mg BD for 7 days
121
Which medication is used for agitation in palliative care?
Midazolam
NOTE: haloperidol should be used for patients with hallucinations
122
Which types of seizures can be treated with sodium valproate?
Generalised
Absence (also ethosuximide)
Myoclonic
Tonic
123
Describe the equivalent doses between prednisolone and hydrocortisone.
5 mg prednisolone = 20 mg hydrocortisone
124
What is the maximum dose of lidocaine that can be administered as local anaesthetic?
3 mg/kg without adrenaline
7 mg/kg with adrenaline
125
In which patients should 5% dextrose be avoided?
Stroke - increased risk of cerebral oedema
126
Which courses of steroids require weaning?
More than 40 mg prednisolone daily for 1 week
More than 3 weeks treatment
Repeated courses
127
Which antibiotic is usually used for surgical prophylaxis?
Ceftriaxone 2 g IV stat
128
How should a patient be switched from an insulin infusion to SC insulin?
VRIII should be stopped at breakfast or evening meal only (not at midday meal)
Administer usual dose of mixed insulin.
Allow patient to eat meal as normal.
Stop intravenous insulin infusion 30 minutes later.
