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Prescribing Flashcards

1
Q

Name the reasons why accurate drug history is important

A

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

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2
Q

When taking drug history what information is needed?

A

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)

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3
Q

What medications are needed to complete an accurate list of medications a patient is currently taking

A

Prescribed - regular, when required, acute

OTC

Internet, herbal, borrowed, illicit

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4
Q

How do you gain sources of information for drug history of a patient

A

2 sources needed

Patient/representative
Patients own meds
Summary care records
Repeat FP10 prescriptions
MAR charts

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5
Q

When checking drug history what information is important to check

A

Name
Drug
Dose
Route
Formulation
Indication
Side effects
Date (does the person take it?)

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6
Q

Why are FP10s not always reliable

A

Not always up to date

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7
Q

What must you check on the summary care records

A

Date

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8
Q

What medications are not on summary care records

A

Any specialist medications

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9
Q

Describe the prescription of methadone

A

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

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10
Q

What is the tray called which medications are put in

A

Nomad tray

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11
Q

What medications can be gained from a pharmacy without a prescription

A

Oral contraceptives
Pain relief
Sumatriptan
Herbal meds
Recreational substances - possible referral to drug and alcohol team
Pre-workout, supplement, dietary supplements

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12
Q

What do you ask about pre-workout as part of drug history

A

Can be seen in cardiac arrythmias due to licensing

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13
Q

In notes what colour are allergies and sensitivities

A

Sensitivity = orange

Allergies = red

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14
Q

What medication is very important with timings

A

Parkinson’s meds

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15
Q

What drugs are important to know smoking status

A

Clozapine, olanzapine
Theophylline
Warfarin
Gefitinib, Osimertinib

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16
Q

Describe what would need to be tested in a patient who is on clozapine for schizophrenia

A

Red on the traffic light system

Bloods needed - due to side effects

Dose conformation

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17
Q

How can clozapine be taken

A

For schizophrenia

Daily or IM depot injections 3 monthly (would need to call mental health team to check not missed)

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18
Q

What is clozapine used to treat

A

Schizophrenia

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19
Q

What is important to ask about salbutamol or GTN spray

A

How often do you use it?

Will give a good idea about how well controlled the condition is

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20
Q

Name the checklist for prescribing

A

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?

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21
Q

Describe medicine recollection

A

Completed by pharmacy within 24 hours with what medications the patient is on

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22
Q

What is the scoring tool for a respiratory tract infection

A

CRB-65

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23
Q

Describe the scoring of CRB-65 and what each score correlates to

A

3+ = urgent hospital admission

1-2 = hospital assessment should be considered

0 = treatment at home should be considered

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24
Q

What are important questions when obtaining a respiratory tract infection history

A

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

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25
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
26
What do you prescribe to CRB score = 0
1st choice oral amoxicillin 500 mg 3x a day for 5 days
27
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
28
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
29
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
30
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
31
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
32
What are the treatment options for benign prostatic obstruction
Doxazosin and tamulosin
33
Describe doxazosin
Alpha-1 blocker, a1-adrenergic receptor antagonist. Can also give hypertensive effects
34
Describe tamsulosin
Alpha-1 blocker A subtype selective a1A- and a1D-adrenoceptor antagonist
35
What is point that someone needs to tell a patient if they are started on doxazosin or tamsulosin
Tell surgeon if having cataracts surgery
36
Name the side effects of alpha blockers used to treat benign prostatic obstruction
Postural hypotension 30% of men get retrograde ejaculation
37
Describe retrograde ejaculation
Occurs when seminal fluid preferentially flows into the bladder due to failure of the neck to close
38
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
39
What are examination important in LUTS
Examine abdomen, external genitalia, digital rectal exam
40
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
41
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
42
What are the contraindications of alpha-blockers
Check history of syncope - postural hypotension micturition syncope (transient loss of consciousness due to cerebral hypoperfusion)
43
What are the drug interactions of alpha blockers
Any antihypertensives CYP 34A inhibitors Moxisylyte Phosphodiesterase 5-inhibitors end-fil
44
What is the prescription of doxazosin
Doxazosin 4 mg oral modified release Take one daily Please supply 28 capsules
45
What is the prescription of tamsulosin
Tamsulosin hydrochloride 400 micrograms oral modified release Take one daily Please supply 28 capsules
46
What is first line for a UTI
Nitrofurantoin 100 mg modified release 2x a day for 3 days
47
Which UTI medication is avoided full term and why
Nitrofurantoin due to neonatal haemolysis
48
When is trimethoprim given in a UTI
In full term when nitrofurantoin cannot be given If low risk of antimicrobial resistance
49
What medication for UTI cannot be given in 1st trimester
Trimethoprim - folate antagonist
50
How long do you given antibiotics for complicated UTI
Pregnant women Men Immunocompromised Associated symptoms of complicated infections
51
Describe the prescription for nitrofurantoin
Nitrofurantoin 100 mg modified release 2x a day for 3 years
52
Describe the prescription for trimethoprim
Trimethoprim 200 mg 2x a day for 3 days
53
What is important to check before prescribing medication for UTI
Check renal and hepatic impairment and dose adjustment
54
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
55
What is important information to know in the treatment of constipation
Intestinal obstruction Ileus Chron's disease Severe dehydration History of hypersensivity to peanuts
56
When should lactulose be avoided
Lactose intolerance may cause diarrhoea
57
What are the first line for constipation
Bulk forming laxatives e.g. Ispaghula husk
58
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
59
What is a name of an example of bulk-forming laxatives
Ispaghula husk
60
What is second line in constipation
Osmotic laxatives E.g. 1st = macrogol 2nd = lactulose
61
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
62
Name 2 examples of osmotic laxatives
Macrogol Lactulose
63
What is the 3rd line of constipation
Stimulant laxatives E.g. senna, bisacodyl and sodium picosulfate, docusate
64
Describe stimulant laxatives
Causes peristalsis by stimulating colonic nerves (senna) or colonic and rectal nerves (bisacodyl, sodium picosulfate)
65
Describe senna
Hydrolysed to the active metabolite by bacterial enzymes in the large bowel
66
Describe bisacodyl and sodium picosulfate
Hydrolysed to the same active metabolite Bisacodyl - hydrolysed by intestinal enzymes Sodium picosulfate - relies on colonic bacteria
67
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
68
Name the 3 lines of constipation
1. Bulk forming e.g. ispaghula 2. osmotic e.g. macrogol, lactulose 3. stimulant e.g. senna, docusate
69
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
70
What advice should be given with bulk forming laxatives
e.g. ispaghula Make sure drink enough water
71
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
72
Define diarrhoea
Passage 3 or more loose or liquid stools per day
73
Describe acute diarrhoea
< 14 days Usually bacterial or viral infection, medication, anxiety, food allergy and acute appendicitis
74
Describe chronic diarrhoea
> 4 weeks IBS, diet, IBD, coeliac disease and bowel cancer
75
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
76
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
77
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
78
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
79
Name the symptoms of GORD
4 weeks or more Upper abdominal pain or discomfort Heartburn Gastric reflux N&V
80
What should you check when someone presents with GORD symptoms
Other causes - h. pylori, no issues with swallowing, travel, alcohol
81
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
82
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
83
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
84
What medication is used to treat angina
Glyceryl trinitrate (GTN)
85
Describe the treatment for stable/unstable angina
Subinguinal administration using subinguinal tablets or aerosol spray
86
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
87
Describe the pain management ladder
1. Non-opioid =/- adjuvant 2. Opioid for mild or moderate pain (codeine, tramadol) +/- adjuvant 3. Opioid for moderate or severe pain (morphine, oxycodone, methadone, buprenorphine, fentanyl) and non-opioid +/- adjuvants
88
What opioids are on step 2 of the pain management ladder
Codeine Tramadol
89
What opioids are on the 3rd step of pain management ladder
Morphine Oxycodone Methadone Buprenorphine Fentanyl
90
What are the 2 bigger risk of paracetamol
High risk of overdose < 50kg patient need lower as it can be toxic
91
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
92
What are NSAIDs good for
Good for MSK (bone pain) and inflammatory pain
93
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?
94
When should NSAIDs be co-prescribed
With PPI if over 50 or history of upper GI bleeding/gastritis
95
Name step 2 of pain management ladder
Codeine (co-codamol) and tramadol
96
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
97
How do you convert codeine to morphine
divide by 10 240 mg of codeine is 24 mg of morphine
98
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
99
What is one negative of tramadol
Very addictive
100
Name the opioids that are on the 3rd level of pain management
Morphine, oxycodone, fentanyl, buprenorphine
101
What are the types of morphine
Oral Oramorph - liquid - immediate release - does not last very long Zomorph - tablet - modified release IV Subcut
102
What must you check when you prescribe morphine
Renal impairment as it cam build up in the system
103
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
104
Describe the role of fentanyl
Patch (common) Very strong Provides constant release Less side effects - metabolised slightly differently
105
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
106
Name 2 adjuvants
Amitriptyline Gabapentin/pregabalin
107
Describe amitriptyline as a adjuvant in pain management
Tricyclic antidepressants 10/20 mg at night Helps with neuropathic pain and sedation
108
Why is amitriptyline not used as an antidepressant
Tricyclic antidepressant Cardiotoxic in overdose
109
What are the side effects of amitriptyline
Dry mouth Blurred vision Dry eyes Constipation Urinary retention Postural hypotension
110
Describe the role of gabapentin/pregabalin
Anticonvulsants/neuropathic pain Useful in sciatica and diabetic neuropathy
111
What are the negatives of gabapentin/pregabalin
Very addictive, popular in the drug community Dose should be reduced in patients with renal impairment
112
What are the side effects of gabapentin/pregabalin
Usually improve within first few weeks of treatment Drowsiness Dizziness Ataxia
113
What are yellow flag symptoms in pain management
Obesity Low exercise Low mood (psychosocial pain)
114
What is the clinical toxidrome of opioid overdose
Triad Reduced consciousness Respiratory depression Constricted pupils (miosis)
115
When is trimethoprim avoided
1st trimester - folate antagonist
116
When is nitrofurantoin avoided
At term due to neonatal haemolysis
117
What is the formulation of amoxicillin
Capsules
118
What is the formulation of clarithromycin
Tablet
119
What is the formulation of flucloxacillin
Capsule
120
What type of medication is salbutamol
Beta-2 adrenoreceptor agonist
121
What type of medication is Montelukast
Leukotriene receptor antagonist
122
What type of medication is hydrogen peroxide
Topical anti-infective
123
What type of medication is flucloxacillin
Penicillin antibiotic
124
What type of medication is clarithromycin
Macrolide antibiotic
125
What type of medication is amoxicillin
Penicillin antibiotic
126
What is the action of nitrofurantoin
Interferes with production of bacterial proteins, DNA and cells walls
127

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