Prescribing Flashcards
Name the reasons why accurate drug history is important
High risk prescribing error during transitions between care settings
Avoid omission
Optimise medical management
Avoid prescribing interacting medicines
Identify ADRs
Medications may mask clinical signs and alter investigations
When taking drug history what information is needed?
Current and accurate list of medications - drug names, dose, formulation, frequency, duration
Indication if known
Non-adherence (reason, duration)
Recent changes
Drug interactions/intolerances (document)
What medications are needed to complete an accurate list of medications a patient is currently taking
Prescribed - regular, when required, acute
OTC
Internet, herbal, borrowed, illicit
How do you gain sources of information for drug history of a patient
2 sources needed
Patient/representative
Patients own meds
Summary care records
Repeat FP10 prescriptions
MAR charts
When checking drug history what information is important to check
Name
Drug
Dose
Route
Formulation
Indication
Side effects
Date (does the person take it?)
Why are FP10s not always reliable
Not always up to date
What must you check on the summary care records
Date
What medications are not on summary care records
Any specialist medications
Describe the prescription of methadone
Supervised = watched
Unsupervised = Unwatched, may have a few days
Call recovery steps to find out about
Call pharmacy - any missed methadone? How much is taken (if missed risk of withdrawal and/or overdose, make sure amount if correct - risk of overdose)
Ask if buy any benzo - ask risk of withdrawal
What is the tray called which medications are put in
Nomad tray
What medications can be gained from a pharmacy without a prescription
Oral contraceptives
Pain relief
Sumatriptan
Herbal meds
Recreational substances - possible referral to drug and alcohol team
Pre-workout, supplement, dietary supplements
What do you ask about pre-workout as part of drug history
Can be seen in cardiac arrythmias due to licensing
In notes what colour are allergies and sensitivities
Sensitivity = orange
Allergies = red
What medication is very important with timings
Parkinson’s meds
What drugs are important to know smoking status
Clozapine, olanzapine
Theophylline
Warfarin
Gefitinib, Osimertinib
Describe what would need to be tested in a patient who is on clozapine for schizophrenia
Red on the traffic light system
Bloods needed - due to side effects
Dose conformation
How can clozapine be taken
For schizophrenia
Daily or IM depot injections 3 monthly (would need to call mental health team to check not missed)
What is clozapine used to treat
Schizophrenia
What is important to ask about salbutamol or GTN spray
How often do you use it?
Will give a good idea about how well controlled the condition is
Name the checklist for prescribing
Do you manage your own tablets or does someone help you?
Have you brought your tablets in?
Do you take any:
- Tablets/liquids?
- inhalers/sprays?
- Insulin or injections?
- Patches?
- Eye drops/ear drops?
- Creams?
- Anything from hospital e.g. chemotherapy, depot injections?
- OTC or herbal medications?
- Illicit substances?
Allergy status
Have you recently started or stopped any medications? or changed doses? Do you ever miss any doses?
Describe medicine recollection
Completed by pharmacy within 24 hours with what medications the patient is on
What is the scoring tool for a respiratory tract infection
CRB-65
Describe the scoring of CRB-65 and what each score correlates to
3+ = urgent hospital admission
1-2 = hospital assessment should be considered
0 = treatment at home should be considered
What are important questions when obtaining a respiratory tract infection history
Onset of duration of symptoms
The type of cough (dry or productive)
Additional symptoms - breathlessness, wheeze, pleuritic pain and fever
Smoking status
Fever
Tachycardia
Travel history
Weight loss
What are signs of community acquired pneumonia
Difficulty breathing
Oxygen saturation < 90%
Raised HR
Grunting, very severe chest indrawing
Inability to drink
Lethargy - reduced level of consciousness
What do you prescribe to CRB score = 0
1st choice oral amoxicillin 500 mg 3x a day for 5 days
What do you prescribe for CRB score 0 if the patient has a penicillin allergy
Oral doxycycline 200mg on 1st day then 100 mg once a day for total of 5 days
OR
Oral clarithromycin (erythromycin in pregnancy) 500 mg twice a day for 5 days
What is prescribed if CRB score is 1-2 (managed in the community)
Oral amoxicillin 500 mg three times a day for 5 days + (if atypical pathogens suspected) oral clarithromycin (erythromycin in pregnancy) 500 mg 2x a day for 5 days
What is prescribed to CRB score 1-2 (managed in the community) if the patient is allergic to penicillin
Oral doxycycline 200 mg on 1st day and 100 mg once a day for 4 days (5 days total)
OR
Oral clarithromycin twice a day for 5 days
Name the safety advice for CAP
Seek medical advice if:
Symptoms worsen rapidly or significantly
Do not improve within 5 days
Become systemically very unwell
What are the explanation in CAP of when symptoms should improve
1 week - fever resolved
4 weeks - chest pain and sputum reduced
6 weeks - cough and breathlessness reduced
3 months - most symptoms resolved by fatigue may be present
6 months - symptoms resolved
What are the treatment options for benign prostatic obstruction
Doxazosin and tamulosin
Describe doxazosin
Alpha-1 blocker, a1-adrenergic receptor antagonist.
Can also give hypertensive effects
Describe tamsulosin
Alpha-1 blocker
A subtype selective a1A- and a1D-adrenoceptor antagonist
What is point that someone needs to tell a patient if they are started on doxazosin or tamsulosin
Tell surgeon if having cataracts surgery
Name the side effects of alpha blockers used to treat benign prostatic obstruction
Postural hypotension
30% of men get retrograde ejaculation
Describe retrograde ejaculation
Occurs when seminal fluid preferentially flows into the bladder due to failure of the neck to close
Describe the key parts of a history of LUTS
Ask about possible underlying causes - sexual function, lifestyle habits, emotional and psychological factors
Review current medications
What are examination important in LUTS
Examine abdomen, external genitalia, digital rectal exam
What are investigations important for LUTS
Complete a urinary frequency-volume chart for at least 3 days
Dipstick test
Serum creatinine estimated
glomerular filtration rate
PSA - if appropriate
What is the order for prescribing caused by benign prostatic hyperplasia causing LUTS
Alpha blocker in men with moderate/severe LUTS
5-alpha reductase inhibitor for men with LUTS who have prostate estimated to be larger than 30g or a PSA level > 1.4 ng/ml and considered high risk of progression
Antimuscarinic for men with symptoms of overactive bladder
Loop diuretic or oral desmopressin for men with nocturnal polyuria
What are the contraindications of alpha-blockers
Check history of syncope - postural hypotension micturition syncope (transient loss of consciousness due to cerebral hypoperfusion)
What are the drug interactions of alpha blockers
Any antihypertensives
CYP 34A inhibitors
Moxisylyte
Phosphodiesterase 5-inhibitors end-fil
What is the prescription of doxazosin
Doxazosin 4 mg oral modified release
Take one daily
Please supply 28 capsules
What is the prescription of tamsulosin
Tamsulosin hydrochloride 400 micrograms oral modified release
Take one daily
Please supply 28 capsules
What is first line for a UTI
Nitrofurantoin
100 mg modified release 2x a day for 3 days
Which UTI medication is avoided full term and why
Nitrofurantoin due to neonatal haemolysis
When is trimethoprim given in a UTI
In full term when nitrofurantoin cannot be given
If low risk of antimicrobial resistance
What medication for UTI cannot be given in 1st trimester
Trimethoprim - folate antagonist
How long do you given antibiotics for complicated UTI
Pregnant women
Men
Immunocompromised
Associated symptoms of complicated infections
Describe the prescription for nitrofurantoin
Nitrofurantoin
100 mg modified release 2x a day for 3 years
Describe the prescription for trimethoprim
Trimethoprim
200 mg 2x a day for 3 days
What is important to check before prescribing medication for UTI
Check renal and hepatic impairment and dose adjustment
What advice should be included as part of constipation
Fibre intake - 30 g of fibre
Increased exercise levels
Helpful toileting routines - advice on regular, unhurried toilet routines, advice on responding immediately to the sensation of needing to defecate
What is important information to know in the treatment of constipation
Intestinal obstruction
Ileus
Chron’s disease
Severe dehydration
History of hypersensivity to peanuts
When should lactulose be avoided
Lactose intolerance may cause diarrhoea
What are the first line for constipation
Bulk forming laxatives
e.g. Ispaghula husk
Describe bulk forming laxatives
Contain soluble fibre
Act by retaining fluid within the stool and increasing faecal mass, stimulating peristalsis and also have stool-softening properties
What is a name of an example of bulk-forming laxatives
Ispaghula husk
What is second line in constipation
Osmotic laxatives
E.g.
1st = macrogol
2nd = lactulose
Name 2 examples of osmotic laxatives
Act by increasing the amount of fluid in the large bowel producing distension, which leads to stimulation of peristalsis, lactulose and macrogols also have stool softening properties
Name 2 examples of osmotic laxatives
Macrogol
Lactulose
What is the 3rd line of constipation
Stimulant laxatives
E.g. senna, bisacodyl and sodium picosulfate, docusate
Describe stimulant laxatives
Causes peristalsis by stimulating colonic nerves (senna) or colonic and rectal nerves (bisacodyl, sodium picosulfate)
Describe senna
Hydrolysed to the active metabolite by bacterial enzymes in the large bowel
Describe bisacodyl and sodium picosulfate
Hydrolysed to the same active metabolite
Bisacodyl - hydrolysed by intestinal enzymes
Sodium picosulfate - relies on colonic bacteria
Describe docusate
A surface wetting agent which reduces the surface tension of the tool allowing water to penetrate and soften it
Also has a relatively weak stimulant effect
Name the 3 lines of constipation
- Bulk forming e.g. ispaghula
- osmotic e.g. macrogol, lactulose
- stimulant e.g. senna, docusate
What is the advice with use of laxatives in constipation
Gradually reduce and stop laxatives once the person is producing soft, formed stool without straining at least 3 times a week
What advice should be given with bulk forming laxatives
e.g. ispaghula
Make sure drink enough water
When should 3rd line laxatives be given
Stimulant effects e.g. senna, docusate
If stools are soft but difficult to pass or there is a sensation of inadequate emptying
Define diarrhoea
Passage 3 or more loose or liquid stools per day
Describe acute diarrhoea
< 14 days
Usually bacterial or viral infection, medication, anxiety, food allergy and acute appendicitis
Describe chronic diarrhoea
> 4 weeks
IBS, diet, IBD, coeliac disease and bowel cancer
What are key questions to ask in the history of diarrhoea
Determine onset, duration, frequency and severity of symptoms
Red flag symptoms
Underlying cause
Looking for complications
Blood or pus
Travel
Sexual history
What are the red flag symptoms of diarrhoea
Blood in stool
Recent hospital treatment or antibiotic treatment
Weight loss
Evidence of dehydration - nausea, light headedness, postural hypotension, tachycardia
Nocturnal symptoms - suggests organic cause
Faecal incontinence
What is the treatment for acute diarrhoea
Loperamide hydrochloride
4mg followed by 2 mg for up to 5 days
Dose to be taken after each loose stool
Usual dose 6-8 mg daily, max 16 mg per day
What is the treatment for chronic diarrhoea
Loperamide hydrochloride
Initially 4-8 mg daily divided doses, adjusted according to response, maintenance up to 16 mg daily in 2 divided doses
Name the symptoms of GORD
4 weeks or more
Upper abdominal pain or discomfort
Heartburn
Gastric reflux
N&V
What should you check when someone presents with GORD symptoms
Other causes - h. pylori, no issues with swallowing, travel, alcohol
What increases the risk of GORD
Triggered by fatty foods
Pregnancy
Hiatus hernia
Family history of GORD
Increased intragastric pressure from straining and coughing
Stress, anxiety
Obesity
Drug side-effects
Smoking and alcohol consumption
What are way in which GORD can be reduced without medical treatment
Healthy eating
Weight loss (if obese)
Avoid triggering foods, eating smaller meals, eating the evening meal 3-4 hours before going to bed
Raising the head of the bed
Smoking cessation and reducing alcohol consumption
Write a prescription for GORD
Omeprazole - 20 mg once daily for 4 to 8 weeks
OR
Lansoprazole - 30 mg once daily for 4 weeks, continued for a further 4 weeks if not fully healed, dose to be taken in the morning, maintenance 15-30 mg once daily, dose to be taken in the morning
What medication is used to treat angina
Glyceryl trinitrate (GTN)
Describe the treatment for stable/unstable angina
Subinguinal administration using subinguinal tablets or aerosol spray
Describe prescription for subinguinal administration using aerosol spray for treatment of angina
400-800 micrograms, to be administered under the tongue and then close the mouth
Dose may be repeated at 5 minute intervals if required
Seek urgent medical attention if symptoms have not resolved 5 minutes after the second dose, repeat earlier if pain is intensifying or the person is unwell
Describe the pain management ladder
- Non-opioid =/- adjuvant
- Opioid for mild or moderate pain (codeine, tramadol) +/- adjuvant
- Opioid for moderate or severe pain (morphine, oxycodone, methadone, buprenorphine, fentanyl) and non-opioid +/- adjuvants
What opioids are on step 2 of the pain management ladder
Codeine
Tramadol
What opioids are on the 3rd step of pain management ladder
Morphine
Oxycodone
Methadone
Buprenorphine
Fentanyl
What are the 2 bigger risk of paracetamol
High risk of overdose
< 50kg patient need lower as it can be toxic
Describe what happens in a paracetamol overdose
Can be seen in blood levels
Toxic (liver damage) overdose approx. 12 grams (24 tablets)
Give N-acetylcysteine
What are NSAIDs good for
Good for MSK (bone pain) and inflammatory pain
What are the negatives of NSAIDs
Risk of peptic ulcers (upper GI bleeding)
Need to check renal function
Nephrotoxic
Can cause wheezing in asthmatics - as if someone has already taken it before?
When should NSAIDs be co-prescribed
With PPI if over 50 or history of upper GI bleeding/gastritis
Name step 2 of pain management ladder
Codeine (co-codamol) and tramadol
Describe the options of co-codamol doses
8/500 - buy over counter
Prescription 15.500, 30/500
Be careful as 30/500 x2 tablets x4 times a day = 240 mg of codeine. = 24mg of morphine
How do you convert codeine to morphine
divide by 10
240 mg of codeine is 24 mg of morphine
What is one think you must check when giving opioids
Do you drive or operate machinery.
Check whether it affects you or not before doing either of these
What is one negative of tramadol
Very addictive
Name the opioids that are on the 3rd level of pain management
Morphine, oxycodone, fentanyl, buprenorphine
What are the types of morphine
Oral
Oramorph
- liquid
- immediate release
- does not last very long
Zomorph
- tablet
- modified release
IV
Subcut
What must you check when you prescribe morphine
Renal impairment as it cam build up in the system
Describe the benefits of oxycodone compared to morphine
Synthetic opioid - more potent than morphine
Does not affect renal function the same as morphine - better for those with reduced renal function
Describe the role of fentanyl
Patch (common)
Very strong
Provides constant release
Less side effects - metabolised slightly differently
Compare fentanyl compared to buprenorphine
Patch (stronger than fentanyl)
Safter than fentanyl - as contains agonist and antagonist = has a celling
Takes 48 hours to build up in system
Name 2 adjuvants
Amitriptyline
Gabapentin/pregabalin
Describe amitriptyline as a adjuvant in pain management
Tricyclic antidepressants
10/20 mg at night
Helps with neuropathic pain and sedation
Why is amitriptyline not used as an antidepressant
Tricyclic antidepressant
Cardiotoxic in overdose
What are the side effects of amitriptyline
Dry mouth
Blurred vision
Dry eyes
Constipation
Urinary retention
Postural hypotension
Describe the role of gabapentin/pregabalin
Anticonvulsants/neuropathic pain
Useful in sciatica and diabetic neuropathy
What are the negatives of gabapentin/pregabalin
Very addictive, popular in the drug community
Dose should be reduced in patients with renal impairment
What are the side effects of gabapentin/pregabalin
Usually improve within first few weeks of treatment
Drowsiness
Dizziness
Ataxia
What are yellow flag symptoms in pain management
Obesity
Low exercise
Low mood (psychosocial pain)
What is the clinical toxidrome of opioid overdose
Triad
Reduced consciousness
Respiratory depression
Constricted pupils (miosis)
When is trimethoprim avoided
1st trimester - folate antagonist
When is nitrofurantoin avoided
At term due to neonatal haemolysis
What is the formulation of amoxicillin
Capsules
What is the formulation of clarithromycin
Tablet
What is the formulation of flucloxacillin
Capsule
What type of medication is salbutamol
Beta-2 adrenoreceptor agonist
What type of medication is Montelukast
Leukotriene receptor antagonist
What type of medication is hydrogen peroxide
Topical anti-infective
What type of medication is flucloxacillin
Penicillin antibiotic
What type of medication is clarithromycin
Macrolide antibiotic
What type of medication is amoxicillin
Penicillin antibiotic
What is the action of nitrofurantoin
Interferes with production of bacterial proteins, DNA and cells walls
