Prescribing Flashcards
Drugs to stop before surgery
I LACK OP
Insulin
Lithium
Anticoagulants
COCP/HRT
K-sparing diuretics
Oral hypoglycaemics
Perindopril and other ACE-inhibitors
I LACK OP
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
Surgery for patients on long term corticosteroids
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
What does an enzyme inducer do?
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
What does an enzyme inhibitor do?
Decreases P450 enzyme activity, increasing the levels of other drugs, requiring reduced dosage
Cytochrome P450 enzyme system
Metabolises most drugs to inactive metabolites in the liver, preventing them from exerting infinite effects.
Enzyme inducers (decreased drug level)
Decreased drug concentration
PC BRAS
Phenytoin
Carbamazepine
Barbiturates
Rifampicin
Alcohol (chronic excess)
Sulphonylureas
Enzyme inhibitors
Increase drug concentration
AODEVICES
Allopurinol
Omeprazole
Disulfiram
Erythromycin
Valproate
Isoniazid
Ciprofloxacin
Ethanol (acute intoxication)
Sulphonamides
What should be stopped with any bleeding?
Antiplatelets/anticoagulants
eg Enoxaparin, aspirin, dalteparin
When should you be cautious with warfarin?
With an enzyme inhibitor- can greatly increase INR
Steroid side effects
STEROIDS
Stomach ulcers
Thin skin
oEdema
Right and left heart failure
Osteoporosis
Infection
Diabetes (commonly causes hyperglycaemia, uncommonly progresses to diabetes)
cushing’s Syndrome
Safety considerations for NSAIDs
NSAID
No urine
Systolic dysfunction (ie HF)
Asthma
Indigestion
Dyscrasia (clotting abnormality)
Antihypertensive side effects
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
Vomiting patient
GIVE MEDICINE NON ORAL ROUTE
Replacement fluid: which fluid for standard patient?
0.9 % saline
Replacement fluid: when not to give 0.9 % saline?
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
Replacement fluid: how fast if tachycardic or hypotensive?
500 ml bonus immediately (250 ml in Hx of HF)
Replacement fluid: how fast if only oliguric (not due to obstruction)?
1 L over 2-4 hours then reassess
Max infusion rate of IV potassium?
10 mmol/hour
Maintenance fluids: how much for adults/elderly in 24 hours?
Adults - 3 L
Elderly - 2 L
Maintenance fluid: which fluid should be prescribed?
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
Maintenance fluids: how fast to give each bag?
If giving 3 L per day = 8 hourly bags
If giving 2 L per day = 12 hourly bags
When not to prescribe anticoagulants
When not to prescribe compression stockings
RISK OF BLEEDING
Recent ischaemic stroke
PERIPHERAL ARTERIAL DISEASE - may cause acute limb ischaemia
When to avoid metoclopramide?
Dopamine antagonist
Parkinson’s patients - may exacerbate symptoms
Young women due to risk of dyskinesia
Antiemetic in nauseated patients
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
Antiemetic in not nauseated patients
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
When not to use cyclizine?
Cardiac cases as it can worsen fluid retention
Causes of microcytic anaemia
Iron deficiency anaemia
Thalassaemia
Sideroblastic anaemia
Causes of normocytic anaemia (4)
Anaemia of chronic disease
Acute blood loss
Haemolytic anaemia
Chronic renal failure
Causes of macrocytic anaemia
B12/folate deficiency (megaloblastic anaemia)
Excess alcohol
Liver disease (including non alcoholic causes)
Hypothyroidism
Haematological diseases starting with “M”: myeloproliferative, myelodysplastic, multiple myeloma
Causes of high neutrophils
Bacterial infection
Tissue damage (inflammation/infarct/malignancy)
Steroids
Causes of low neutrophils
Viral infection
Chemotherapy or radiotherapy
Clozapine (antipsychotic)
Carbimazole (antithyroid)
Causes of high lymphocytes
Viral infection
Lymphoma
CLL
Causes of thrombocytopenia
REDUCED PRODUCTION
Infection
Drugs (penicillamine)
Myelodysplasia, myelofibrosis, myeloma
INCREASED DESTRUCTION
Heparin
Hypersplenism
DIC
ITP
HUS
TTP
Causes of thrombocytosis
REACTIVE
Bleeding
Tissue damage (infection/inflammation/malignancy)
Postsplenectomy
PRIMARY
Myeloproliferative disorders
Causes of hypovolaemic hyponatraemia
Fluid loss (diarrhoea/vomiting)
Addison’s
Diuretics (any type)
Causes of euvolaemic hyponatraemia
SIADH
Psychogenic polydipsia
Hypothyroidism
Causes of hypervolaemic hyponatraemia
Heart failure
Renal failure
Liver failure (causing hypoalbuminaemia)
Nutritional failure (causing hypoalbuminaemia)
Thyroid failure (can also be euvolaemic)
Causes of SIADH
SIADH
Small cell lung tumours
Infection
Abscess
Drugs (carbemazepine and antipsychotics)
Head injury
Causes of hypercalcaemia (5)
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
Causes of hypokalaemia (DIRE)
DIRE
Drugs (loop and thiazide diuretics)
Inadequate intake or Intestinal loss (D&V)
Renal tubular acidosis
Endocrine (Cushing’s and Conn’s syndromes)
Causes of hyperkalaemia (DREAD)
DREAD
Drugs (K-sparing diuretics and ACE inhibitors)
Renal failure
Endocrine (Addison’s)
Artefact (very commonly due to clotted sample)
DKA
What is raised urea indicative of?
Kidney injury or upper GI haemorrhage
Raised creatinine for kidney injury, low Hb for GI bleed