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Phase 2B > Prescribing > Flashcards

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
Q

What are signs of community acquired pneumonia

A

Difficulty breathing

Oxygen saturation < 90%

Raised HR

Grunting, very severe chest indrawing

Inability to drink

Lethargy - reduced level of consciousness

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26
Q

What do you prescribe to CRB score = 0

A

1st choice oral amoxicillin 500 mg 3x a day for 5 days

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27
Q

What do you prescribe for CRB score 0 if the patient has a penicillin allergy

A

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

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28
Q

What is prescribed if CRB score is 1-2 (managed in the community)

A

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

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29
Q

What is prescribed to CRB score 1-2 (managed in the community) if the patient is allergic to penicillin

A

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

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30
Q

Name the safety advice for CAP

A

Seek medical advice if:

Symptoms worsen rapidly or significantly

Do not improve within 5 days

Become systemically very unwell

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31
Q

What are the explanation in CAP of when symptoms should improve

A

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

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32
Q

What are the treatment options for benign prostatic obstruction

A

Doxazosin and tamulosin

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33
Q

Describe doxazosin

A

Alpha-1 blocker, a1-adrenergic receptor antagonist.

Can also give hypertensive effects

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34
Q

Describe tamsulosin

A

Alpha-1 blocker

A subtype selective a1A- and a1D-adrenoceptor antagonist

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35
Q

What is point that someone needs to tell a patient if they are started on doxazosin or tamsulosin

A

Tell surgeon if having cataracts surgery

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36
Q

Name the side effects of alpha blockers used to treat benign prostatic obstruction

A

Postural hypotension

30% of men get retrograde ejaculation

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37
Q

Describe retrograde ejaculation

A

Occurs when seminal fluid preferentially flows into the bladder due to failure of the neck to close

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38
Q

Describe the key parts of a history of LUTS

A

Ask about possible underlying causes - sexual function, lifestyle habits, emotional and psychological factors

Review current medications

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39
Q

What are examination important in LUTS

A

Examine abdomen, external genitalia, digital rectal exam

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40
Q

What are investigations important for LUTS

A

Complete a urinary frequency-volume chart for at least 3 days

Dipstick test

Serum creatinine estimated
glomerular filtration rate

PSA - if appropriate

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41
Q

What is the order for prescribing caused by benign prostatic hyperplasia causing LUTS

A

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

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42
Q

What are the contraindications of alpha-blockers

A

Check history of syncope - postural hypotension micturition syncope (transient loss of consciousness due to cerebral hypoperfusion)

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43
Q

What are the drug interactions of alpha blockers

A

Any antihypertensives
CYP 34A inhibitors
Moxisylyte
Phosphodiesterase 5-inhibitors end-fil

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44
Q

What is the prescription of doxazosin

A

Doxazosin 4 mg oral modified release

Take one daily

Please supply 28 capsules

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45
Q

What is the prescription of tamsulosin

A

Tamsulosin hydrochloride 400 micrograms oral modified release

Take one daily

Please supply 28 capsules

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46
Q

What is first line for a UTI

A

Nitrofurantoin

100 mg modified release 2x a day for 3 days

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47
Q

Which UTI medication is avoided full term and why

A

Nitrofurantoin due to neonatal haemolysis

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48
Q

When is trimethoprim given in a UTI

A

In full term when nitrofurantoin cannot be given

If low risk of antimicrobial resistance

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49
Q

What medication for UTI cannot be given in 1st trimester

A

Trimethoprim - folate antagonist

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50
Q

How long do you given antibiotics for complicated UTI

A

Pregnant women
Men
Immunocompromised
Associated symptoms of complicated infections

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51
Q

Describe the prescription for nitrofurantoin

A

Nitrofurantoin

100 mg modified release 2x a day for 3 years

52
Q

Describe the prescription for trimethoprim

A

Trimethoprim

200 mg 2x a day for 3 days

53
Q

What is important to check before prescribing medication for UTI

A

Check renal and hepatic impairment and dose adjustment

54
Q

What advice should be included as part of constipation

A

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
Q

What is important information to know in the treatment of constipation

A

Intestinal obstruction
Ileus
Chron’s disease
Severe dehydration
History of hypersensivity to peanuts

56
Q

When should lactulose be avoided

A

Lactose intolerance may cause diarrhoea

57
Q

What are the first line for constipation

A

Bulk forming laxatives

e.g. Ispaghula husk

58
Q

Describe bulk forming laxatives

A

Contain soluble fibre

Act by retaining fluid within the stool and increasing faecal mass, stimulating peristalsis and also have stool-softening properties

59
Q

What is a name of an example of bulk-forming laxatives

A

Ispaghula husk

60
Q

What is second line in constipation

A

Osmotic laxatives

E.g.

1st = macrogol
2nd = lactulose

61
Q

Name 2 examples of osmotic laxatives

A

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
Q

Name 2 examples of osmotic laxatives

A

Macrogol
Lactulose

63
Q

What is the 3rd line of constipation

A

Stimulant laxatives

E.g. senna, bisacodyl and sodium picosulfate, docusate

64
Q

Describe stimulant laxatives

A

Causes peristalsis by stimulating colonic nerves (senna) or colonic and rectal nerves (bisacodyl, sodium picosulfate)

65
Q

Describe senna

A

Hydrolysed to the active metabolite by bacterial enzymes in the large bowel

66
Q

Describe bisacodyl and sodium picosulfate

A

Hydrolysed to the same active metabolite

Bisacodyl - hydrolysed by intestinal enzymes

Sodium picosulfate - relies on colonic bacteria

67
Q

Describe docusate

A

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
Q

Name the 3 lines of constipation

A
  1. Bulk forming e.g. ispaghula
  2. osmotic e.g. macrogol, lactulose
  3. stimulant e.g. senna, docusate
69
Q

What is the advice with use of laxatives in constipation

A

Gradually reduce and stop laxatives once the person is producing soft, formed stool without straining at least 3 times a week

70
Q

What advice should be given with bulk forming laxatives

A

e.g. ispaghula

Make sure drink enough water

71
Q

When should 3rd line laxatives be given

A

Stimulant effects e.g. senna, docusate

If stools are soft but difficult to pass or there is a sensation of inadequate emptying

72
Q

Define diarrhoea

A

Passage 3 or more loose or liquid stools per day

73
Q

Describe acute diarrhoea

A

< 14 days

Usually bacterial or viral infection, medication, anxiety, food allergy and acute appendicitis

74
Q

Describe chronic diarrhoea

A

> 4 weeks

IBS, diet, IBD, coeliac disease and bowel cancer

75
Q

What are key questions to ask in the history of diarrhoea

A

Determine onset, duration, frequency and severity of symptoms

Red flag symptoms

Underlying cause

Looking for complications

Blood or pus

Travel

Sexual history

76
Q

What are the red flag symptoms of diarrhoea

A

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
Q

What is the treatment for acute diarrhoea

A

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
Q

What is the treatment for chronic diarrhoea

A

Loperamide hydrochloride

Initially 4-8 mg daily divided doses, adjusted according to response, maintenance up to 16 mg daily in 2 divided doses

79
Q

Name the symptoms of GORD

A

4 weeks or more

Upper abdominal pain or discomfort

Heartburn

Gastric reflux

N&V

80
Q

What should you check when someone presents with GORD symptoms

A

Other causes - h. pylori, no issues with swallowing, travel, alcohol

81
Q

What increases the risk of GORD

A

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
Q

What are way in which GORD can be reduced without medical treatment

A

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
Q

Write a prescription for GORD

A

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
Q

What medication is used to treat angina

A

Glyceryl trinitrate (GTN)

85
Q

Describe the treatment for stable/unstable angina

A

Subinguinal administration using subinguinal tablets or aerosol spray

86
Q

Describe prescription for subinguinal administration using aerosol spray for treatment of angina

A

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
Q

Describe the pain management ladder

A
  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
Q

What opioids are on step 2 of the pain management ladder

A

Codeine
Tramadol

89
Q

What opioids are on the 3rd step of pain management ladder

A

Morphine
Oxycodone
Methadone
Buprenorphine
Fentanyl

90
Q

What are the 2 bigger risk of paracetamol

A

High risk of overdose

< 50kg patient need lower as it can be toxic

91
Q

Describe what happens in a paracetamol overdose

A

Can be seen in blood levels

Toxic (liver damage) overdose approx. 12 grams (24 tablets)

Give N-acetylcysteine

92
Q

What are NSAIDs good for

A

Good for MSK (bone pain) and inflammatory pain

93
Q

What are the negatives of NSAIDs

A

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
Q

When should NSAIDs be co-prescribed

A

With PPI if over 50 or history of upper GI bleeding/gastritis

95
Q

Name step 2 of pain management ladder

A

Codeine (co-codamol) and tramadol

96
Q

Describe the options of co-codamol doses

A

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
Q

How do you convert codeine to morphine

A

divide by 10

240 mg of codeine is 24 mg of morphine

98
Q

What is one think you must check when giving opioids

A

Do you drive or operate machinery.

Check whether it affects you or not before doing either of these

99
Q

What is one negative of tramadol

A

Very addictive

100
Q

Name the opioids that are on the 3rd level of pain management

A

Morphine, oxycodone, fentanyl, buprenorphine

101
Q

What are the types of morphine

A

Oral

Oramorph
- liquid
- immediate release
- does not last very long

Zomorph
- tablet
- modified release

IV
Subcut

102
Q

What must you check when you prescribe morphine

A

Renal impairment as it cam build up in the system

103
Q

Describe the benefits of oxycodone compared to morphine

A

Synthetic opioid - more potent than morphine

Does not affect renal function the same as morphine - better for those with reduced renal function

104
Q

Describe the role of fentanyl

A

Patch (common)

Very strong

Provides constant release

Less side effects - metabolised slightly differently

105
Q

Compare fentanyl compared to buprenorphine

A

Patch (stronger than fentanyl)

Safter than fentanyl - as contains agonist and antagonist = has a celling

Takes 48 hours to build up in system

106
Q

Name 2 adjuvants

A

Amitriptyline

Gabapentin/pregabalin

107
Q

Describe amitriptyline as a adjuvant in pain management

A

Tricyclic antidepressants

10/20 mg at night

Helps with neuropathic pain and sedation

108
Q

Why is amitriptyline not used as an antidepressant

A

Tricyclic antidepressant

Cardiotoxic in overdose

109
Q

What are the side effects of amitriptyline

A

Dry mouth
Blurred vision
Dry eyes
Constipation
Urinary retention
Postural hypotension

110
Q

Describe the role of gabapentin/pregabalin

A

Anticonvulsants/neuropathic pain

Useful in sciatica and diabetic neuropathy

111
Q

What are the negatives of gabapentin/pregabalin

A

Very addictive, popular in the drug community

Dose should be reduced in patients with renal impairment

112
Q

What are the side effects of gabapentin/pregabalin

A

Usually improve within first few weeks of treatment

Drowsiness
Dizziness
Ataxia

113
Q

What are yellow flag symptoms in pain management

A

Obesity
Low exercise
Low mood (psychosocial pain)

114
Q

What is the clinical toxidrome of opioid overdose

A

Triad

Reduced consciousness
Respiratory depression
Constricted pupils (miosis)

115
Q

When is trimethoprim avoided

A

1st trimester - folate antagonist

116
Q

When is nitrofurantoin avoided

A

At term due to neonatal haemolysis

117
Q

What is the formulation of amoxicillin

A

Capsules

118
Q

What is the formulation of clarithromycin

A

Tablet

119
Q

What is the formulation of flucloxacillin

A

Capsule

120
Q

What type of medication is salbutamol

A

Beta-2 adrenoreceptor agonist

121
Q

What type of medication is Montelukast

A

Leukotriene receptor antagonist

122
Q

What type of medication is hydrogen peroxide

A

Topical anti-infective

123
Q

What type of medication is flucloxacillin

A

Penicillin antibiotic

124
Q

What type of medication is clarithromycin

A

Macrolide antibiotic

125
Q

What type of medication is amoxicillin

A

Penicillin antibiotic

126
Q

What is the action of nitrofurantoin

A

Interferes with production of bacterial proteins, DNA and cells walls

127
Q
A

Phase 2B (15 decks)

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