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PSA > Prescribing > Flashcards

Prescribing Flashcards

1
Q

Drugs to stop before surgery

A

I LACK OP

Insulin
Lithium
Anticoagulants
COCP/HRT
K-sparing diuretics
Oral hypoglycaemics
Perindopril and other ACE-inhibitors

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2
Q

I LACK OP

A

Insulin
Lithium - Day before
Anticoagulants
COCP/HRT - 4 weeks before
K-sparing diuretics - Day of
Oral hypoglycaemics
Perindopril and other ACE-inhibitors - Day of

Drugs to stop before surgery

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3
Q

Surgery for patients on long term corticosteroids

A

Commonly have adrenal atrophy so unable to mount an adequate physiological response to surgery => profound hypotension if steroids discontinued

Should be given IV steroids at induction of anaesthesia

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4
Q

What does an enzyme inducer do?

A

Increases P450 enzyme activity, hastening metabolism of other drugs and reducing their effect => patient requires more of some other drugs in the presence of an enzyme inducer

Increased enzyme activity => decreased drug concentration

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5
Q

What does an enzyme inhibitor do?

A

Decreases P450 enzyme activity, increasing the levels of other drugs, requiring reduced dosage

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6
Q

Cytochrome P450 enzyme system

A

Metabolises most drugs to inactive metabolites in the liver, preventing them from exerting infinite effects.

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7
Q

Enzyme inducers (decreased drug level)

A

Decreased drug concentration

PC BRAS

Phenytoin
Carbamazepine
Barbiturates
Rifampicin
Alcohol (chronic excess)
Sulphonylureas

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8
Q

Enzyme inhibitors

A

Increase drug concentration

AODEVICES

Allopurinol
Omeprazole
Disulfiram
Erythromycin
Valproate
Isoniazid
Ciprofloxacin
Ethanol (acute intoxication)
Sulphonamides

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9
Q

What should be stopped with any bleeding?

A

Antiplatelets/anticoagulants

eg Enoxaparin, aspirin, dalteparin

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10
Q

When should you be cautious with warfarin?

A

With an enzyme inhibitor- can greatly increase INR

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11
Q

Steroid side effects

A

STEROIDS

Stomach ulcers
Thin skin
oEdema
Right and left heart failure
Osteoporosis
Infection
Diabetes (commonly causes hyperglycaemia, uncommonly progresses to diabetes)
cushing’s Syndrome

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12
Q

Safety considerations for NSAIDs

A

NSAID

No urine
Systolic dysfunction (ie HF)
Asthma
Indigestion
Dyscrasia (clotting abnormality)

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13
Q

Antihypertensive side effects

A

Hypotension

Bradycardia with beta blockers and some CCBs
Electrolyte disturbance with ACEi and diuretics

ACEi - dry cough
Beta blockers => wheeze in asthmatics, worsen acute HF but can help chronic
CCBs => peripheral oedema and flushing
Diuretics => renal failure, thiazide diuretics can cause gout, K sparing can cause gynaecomastia

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14
Q

Vomiting patient

A

GIVE MEDICINE NON ORAL ROUTE

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15
Q

Replacement fluid: which fluid for standard patient?

A

0.9 % saline

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16
Q

Replacement fluid: when not to give 0.9 % saline?

A

Hypernatraemia or hypoglycaemia => 5 % dextrose instead

Has ascites => give human albumin solution (HAS) instead

Shocked from bleeding => give blood transfusion but crystalloid first if blood not available

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17
Q

Replacement fluid: how fast if tachycardic or hypotensive?

A

500 ml bonus immediately (250 ml in Hx of HF)

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18
Q

Replacement fluid: how fast if only oliguric (not due to obstruction)?

A

1 L over 2-4 hours then reassess

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19
Q

Max infusion rate of IV potassium?

A

10 mmol/hour

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20
Q

Maintenance fluids: how much for adults/elderly in 24 hours?

A

Adults - 3 L

Elderly - 2 L

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21
Q

Maintenance fluid: which fluid should be prescribed?

A

1 L of 0.9 % saline, 2 L of 5 % dextrose

Add KCl guided by U&Es
For normal potassium level, approx 40 mmol required each day - 20 mmol in each bag

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22
Q

Maintenance fluids: how fast to give each bag?

A

If giving 3 L per day = 8 hourly bags

If giving 2 L per day = 12 hourly bags

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23
Q

When not to prescribe anticoagulants

When not to prescribe compression stockings

A

RISK OF BLEEDING

Recent ischaemic stroke

PERIPHERAL ARTERIAL DISEASE - may cause acute limb ischaemia

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24
Q

When to avoid metoclopramide?

A

Dopamine antagonist

Parkinson’s patients - may exacerbate symptoms

Young women due to risk of dyskinesia

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25
Q

Antiemetic in nauseated patients

A

Regular antiemetic

Cyclizine 50 mg 8-hourly IM/IV/oral for most cases but causes fluid retention

Metoclopramide 10 mg 8-hourly IM/IV if HF

Ondansetron 4 mg or 8 mg 8-hourly IV/oral

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26
Q

Antiemetic in not nauseated patients

A

As required antiemetic

Cyclizine 50 mg 8-hourly IM/IV/oral for most cases but causes fluid retention

Metoclopramide 10 mg up to 8-hourly IM/IV if HF

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27
Q

When not to use cyclizine?

A

Cardiac cases as it can worsen fluid retention

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28
Q

Causes of microcytic anaemia

A

Iron deficiency anaemia
Thalassaemia
Sideroblastic anaemia

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29
Q

Causes of normocytic anaemia (4)

A

Anaemia of chronic disease
Acute blood loss
Haemolytic anaemia
Chronic renal failure

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30
Q

Causes of macrocytic anaemia

A

B12/folate deficiency (megaloblastic anaemia)
Excess alcohol
Liver disease (including non alcoholic causes)
Hypothyroidism
Haematological diseases starting with “M”: myeloproliferative, myelodysplastic, multiple myeloma

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31
Q

Causes of high neutrophils

A

Bacterial infection
Tissue damage (inflammation/infarct/malignancy)
Steroids

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32
Q

Causes of low neutrophils

A

Viral infection
Chemotherapy or radiotherapy
Clozapine (antipsychotic)
Carbimazole (antithyroid)

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33
Q

Causes of high lymphocytes

A

Viral infection
Lymphoma
CLL

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34
Q

Causes of thrombocytopenia

A

REDUCED PRODUCTION
Infection
Drugs (penicillamine)
Myelodysplasia, myelofibrosis, myeloma

INCREASED DESTRUCTION
Heparin
Hypersplenism
DIC
ITP
HUS
TTP

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35
Q

Causes of thrombocytosis

A

REACTIVE
Bleeding
Tissue damage (infection/inflammation/malignancy)
Postsplenectomy

PRIMARY
Myeloproliferative disorders

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36
Q

Causes of hypovolaemic hyponatraemia

A

Fluid loss (diarrhoea/vomiting)
Addison’s
Diuretics (any type)

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37
Q

Causes of euvolaemic hyponatraemia

A

SIADH
Psychogenic polydipsia
Hypothyroidism

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38
Q

Causes of hypervolaemic hyponatraemia

A

Heart failure
Renal failure
Liver failure (causing hypoalbuminaemia)
Nutritional failure (causing hypoalbuminaemia)
Thyroid failure (can also be euvolaemic)

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39
Q

Causes of SIADH

A

SIADH

Small cell lung tumours
Infection
Abscess
Drugs (carbemazepine and antipsychotics)
Head injury

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40
Q

Causes of hypercalcaemia (5)

A

EXCESSIVE PTH PRODUCTION
Primary hyperparathyroidism (adenoma, hyperplasia)
Tertiary hyperparathyroidism (long-term stimulation of PTH secretion in renal insufficiency)

EXCESSIVE VITAMIN D PRODUCTION
Granulomatous diseases (sarcoidosis, TB)
Lymphomas
Vit D intoxication

HYPERCALCAEMIA OF MALIGNANCY
Tumour lysis syndrome
Bone metastasis

PRIMARY INCREASE IN BONE RESORPTION
Hyperthyroidism
Immobilisation

EXCESSIVE CALCIUM INTAKE
Milk-alkali syndrome
TPN

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41
Q

Causes of hypokalaemia (DIRE)

A

DIRE

Drugs (loop and thiazide diuretics)
Inadequate intake or Intestinal loss (D&V)
Renal tubular acidosis
Endocrine (Cushing’s and Conn’s syndromes)

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42
Q

Causes of hyperkalaemia (DREAD)

A

DREAD

Drugs (K-sparing diuretics and ACE inhibitors)
Renal failure
Endocrine (Addison’s)
Artefact (very commonly due to clotted sample)
DKA

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43
Q

What is raised urea indicative of?

A

Kidney injury or upper GI haemorrhage

Raised creatinine for kidney injury, low Hb for GI bleed

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44
Q

Types of AKI

A

Prerenal
Intrinsic renal
Postrenal

45
Q

Biochemical disturbance of prerenal AKI

A

Urea rise > creatinine rise

46
Q

Biochemical disturbance of intrinsic renal AKI

A

Urea rise < creatinine rise
Bladder or hydronephrosis not palpable

47
Q

Biochemical disturbance of postrenal AKI

A

Urea rise < creatinine rise
bladder or hydronephrosis may be palpable depending on level of obstruction

48
Q

Causes of prerenal AKI

A

Dehydration of any cause eg sepsis, blood loss

Renal artery stenosis (often triggered by drugs, ACEi or NSAIDs, effectively causing hypoperfusion of kidneys)

49
Q

Causes of intrinsic renal AKI

A

INTRINSIC

Ischaemia (due to prerenal AKI causing acute tubular necrosis)
Nephrotoxic antibiotics
Tablets (ACEi, NSAIDs)
Radiological contrast
Injury (rhabdomyolysis)
Negatively bifringent crystals (gout)
Syndromes (glomerulonephrodites)
Inflammation (vasculitis)
Cholesterol emboli

50
Q

Nephrotoxic antibiotics

A

Gentamicin
Vancomycin
Tetracyclines

51
Q

Causes of postrenal AKI

A

IN LUMEN
Stone or sloughed papilla

IN WALL
Tumour (renal cell, transitional cell)
Fibrosis

EXTERNAL PRESSURE
BPH
Prostate cancer
Lymphadenopathy
Aneurysm

52
Q

Markers of hepatocyte injury or cholestasis

A

Bilirubin
Alanine aminotransferase (ALT)
Aspartate aminotransferase (AST)
Alkaline phosphatase (ALP)

53
Q

Markers of synthetic liver function

A

Albumin
Vitamin K dependent clotting factors measured via PT/INR

54
Q

Vitamin K dependent clotting factors

55
Q

Causes of raised alk phos

A

Any fracture
Liver damage (post-hepatic)
Cancer
Paget’s disease of the bone
Pregnancy
Hyperparathyroidism
Osteomalacia
Surgery

56
Q

LFT derangement in prehepatic jaundice

A

Isolated raised bilirubin

57
Q

LFT derangement in intrahepatic jaundice

A

Raised bilirubin
Raised AST/ALT

58
Q

LFT derangement in posthepatic jaundice

A

Obstructive jaundice

Raised bilirubin
Raised ALP

59
Q

Causes of prehepatic jaundice

A

Haemolysis
Gilbert’s and Crigler-Najjar syndromes

60
Q

Causes of intrahepatic jaundice

A

Fatty liver
Hepatitis
Cirrhosis
Malignancy
Metabolic - Wilson’s disease/haemochromatosis
Heart failure causing hepatic congestion

61
Q

Causes of posthepatic jaundice

A

OBSTRUCTIVE

IN LUMEN
Gallstones
Drugs causing cholestasis

IN WALL
Tumour (cholangiocarcinoma)
Primary biliary cirrhosis
Sclerosing cholangitis

EXTRINSIC PRESSURE
Pancreatic or gastric cancer
Lymphadenopathy

62
Q

Causes of hepatitis and cirrhosis

A

Alcohol
Viruses (hepatitis A-E, CMV, EBV)
Drugs (paracetamol overdose, statins, rifampicin)
Autoimmune (primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis)

63
Q

Drugs causing cholestasis

A

Flucloxacillin
Co-amoxiclav
Nitrofurantoin
Steroids
Sulphonylureas

64
Q

TFTs in primary hypothyroidism

A

Decreased T4
Increased TSH

Decreased T4 from thyroid causing compensatory increased TSH

Hashimoto’s thyroiditis, drug induced hypothyroidism

65
Q

TFTs in secondary hypothyroidism

A

Decreased T4
Decreased TSH

Decreased TSH causing decreased T4

Pituitary tumour or damage

66
Q

TFTs in primary hyperthyroidism

A

Increased T4
Decreased TSH

Increased T4 causing decreased TSH through negative feedback

Grave’s disease, toxic nodular goitre, drug induced hyperthyroidism

67
Q

TFTs in secondary hyperthyroidism

A

Increased T4
Increased TSH

Increased TSH from pituitary causing increased T4

Pituitary tumour

68
Q

Type 1 respiratory failure

A

Low or normal PaCO2
Fast/normal breathing
Caused by anything that damages heart or lungs causing SOB

69
Q

Type 2 respiratory failure

A

High PaCO2
Slow/shallow breathing
COPD, neuromuscular failure or restrictive chest wall abnormalities

70
Q

Respiratory acidosis

A

Low pH
High PaCO2
Normal or raised HCO3 (compensation)

COPD, neuromuscular failure or restrictive chest wall abnormalities

71
Q

Respiratory alkalosis

A

High pH
Low PaCO2
Normal or reduced HCO3 (compensation)

Rapid breathing from disease or anxiety

72
Q

Metabolic acidosis

A

Low pH
Low HCO3
Normal or reduced PaCO2 (compensation)

Lactic acidosis, DKA, renal failure

73
Q

Metabolic alkalosis

A

High pH
High HCO3
Normal or raised PaCO2 (compensation)

Vomiting, diuretics, Conn’s syndrome

74
Q

How to manage over anticoagulation with an INR 5-8 and no bleeding?

A

Omit warfarin for 2 days then reduce dose

75
Q

How to manage over anticoagulation with an INR >8 and no bleeding?

A

Omit warfarin and give 1-5 mg PO vitamin K

76
Q

How to manage over anticoagulation with an INR 5-8 and minor bleeding?

A

Omit warfarin and give 1-5 mg IV vitamin K

77
Q

How to manage over anticoagulation with an INR >8 and minor bleeding?

A

Omit warfarin and give 1-5 mg IV vitamin K

78
Q

How to manage over anticoagulation with major bleeding?

A

ie causing hypotension or bleeding into confined space (brain/eye)

Stop warfarin
Give 5-10 mg IV vitamin K
Give prothrombin complex

79
Q

Gentamicin and vancomycin ADRs

A

Nephrotoxicity
Ototoxicity

80
Q

ADR of any antibiotic, but mainly broad spectrum

A

C. diff colitis

81
Q

ADRs of ACE inhibitors

A

Hypotension
Electrolyte abnormalities
AKI
Dry cough

82
Q

ADRs of beta blockers

A

Hypotension
Bradycardia
Wheeze in asthmatics
Worsens acute HF
Improves chronic HF

83
Q

ADRs of CCBs

A

Hypotension
Bradycardia
Peripheral oedema
Flushing

84
Q

ADRs of diuretics

A

Hypotension
Electrolyte abnormalities
AKI
Subclass dependent effects

85
Q

ADRs of heparins

A

Haemorrhage
Heparin-induced thrombocytopenia

86
Q

ADRs of warfarin

A

Haemorrhage

87
Q

ADRs of aspirin

A

Haemorrhage
Peptic ulcers
Gastritis
Tinnitus in large doses

88
Q

ADRs of digoxin

A

Nausea
D&V
Blurred vision
Confusion
Drowsiness
Xanthopsia

89
Q

Xanthopsia

A

Disturbed yellow/green visual perception including “halo” vision

90
Q

ADRs of amiodarone

A

Interstitial lung disease
Thyroid disease
Skin greying
Corneal deposits

91
Q

ADRs of lithium

A

EARLY
Tremor

INTERMEDIATE
Tiredness

LATE
Arrhythmias
Seizures
Coma
Renal failure
Diabetes insipidus

92
Q

ADRs of antipsychotics haloperidol and clozapine

A

Dyskinesias
Agranulocytosis

93
Q

ADRs of statins

A

Myalgia
Abdominal pain
Increased ALT/AST
Rhabdomyolysis

94
Q

Drugs with narrow therapeutic index

A

Warfarin
Digoxin
Phenytoin
Theophylline

95
Q

Drugs requiring careful dosage control

A

Antihypertensives
Antidiabetic drugs

96
Q

GI bleeding caused by

97
Q

Lactic acidosis caused by

98
Q

Hypertensive crisis caused by

99
Q

Sweating, flushing, nausea and vomiting caused by

A

Metronidazole
Disulfiram

100
Q

Sedation caused by

A

Barbiturates
Opioids
Benzodiazepines

101
Q

What drugs to avoid in peripheral vascular disease?

A

Beta blockers
ACEi cautioned in severe disease

102
Q

What drug should be continued through intercurrent illness?

A

Prednisolone (in case of chronic adrenal suppression)

103
Q

How many micrograms fentanyl/hour are equivalent to 60 mg oral morphine per day?

A

25 micrograms/hour

104
Q

Drugs causing hyperkalaemia

A

Potassium-sparing diuretics
Beta blockers
ACEi/ARBs
Digoxin at toxic levels
Heparin
Trimethoprim and co-trimoxazole
Ciclosporin
Tacrolimus
Non-steroidal anti-inflammatory drugs (NSAIDs)

105
Q

Drugs causing hypokalaemia

A

Laxatives (excessive use)
Thiazide and loop diuretics
High dose beta 2 agonists
Theophylline
High dose penicillins
Gentamicin
Amphotericin
Echinocandin antifungals
High dose insulin
Corticosteroids
Cisplatin
Sodium bicarbonate
Parecoxib

106
Q

Vitamin K BNF

A

Phytomenadione

107
Q

Drug induced extrapyramidal side effects/Parkinsonism treatment

A

Procyclidine hydrochloride

Not tardive dyskinesia

108
Q

Tardive dyskinesia treatment

A

Tetrabenazine

109
Q

How many mg of oral morphine/day are equivalent to 25 microgram fentanyl/hour?

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