Prescribing

Question 1

dosing of isosorbide nitrate

Answer 1

needs a nitrate free interval so give both doses in the day (morning?)

Question 2

drugs to stop before surgery

Answer 2

STOP NOW or I LACKOP
Insulin- go onto VRII
Lithium (the day before)
Anticoagulants/antiplatelets variable (day of)
COCP/HRT
K sparing diuretics
Oral hypoglycaemics
Perindopril and other ACE-I

Patients with a planned short starvation period (no more than one missed meal in total) should be managed by modification of their usual diabetes medication, avoiding VRIII wherever possible (although VRIII may be necessary if emergency surgery or in people with poorly controlled diabetes (HbA1c >69mmol/mol)). Patients expected to miss more than one meal should have VRIII if they develop hyperglycaemia (CBG >12mmol/L).

Question 3

When prescribing replacement fluids also prescribe maintenance fluids….

Answer 3

Worked example: fluid replacement
A child who weighs 12kg is 5% dehydrated. Calculate their total fluid requirement over 24 hours:

Fluid deficit = 5% dehydration x 12 x 10 = 600 mL
Maintenance = 1000mL (100 mL/kg for first 10 kg) + 100mL (50 mL/kg for last 2kg) = 1100 mL
Total fluid requirement = 1100 mL + 600 mL = 1700 mL/24 hours » 71 mL/hour

Question 4

if someone is oligouric how much mL do they need resus?

Answer 4

generally 500mL
if oligouric + tachycardia = 1L
If oligouric + tachy + shocked = >2L

Question 5

Glucose-free balanced crystalloids (e.g. Hartmann’s solution) are recommended as initial …. fluids.

Answer 5

resus not replacement.
replacement as in the case of dehydration not acute a-e
for replacement Use isotonic crystalloid that contains sodium with added glucose (e.g. 0.9% sodium chloride + 5% glucose).

Question 6

resus rate for kids

Answer 6

10 mL/kg over <10 minutes.

Question 7

how to work how much replacement to give in kids. note replacement not resus.

Answer 7

work out how dehydrated they are using usual/recent actual weight vs what they are now.

generally if they are shocked we already assume 10% dehydration

we then use this formula to calcuate how much Fluid deficit (mL) they are in and how much we need to replace them by = 10% dehydration x weight (kg) x 10

Question 8

how do you work out replacement and maintenance needs in kids

Answer 8

Replacement is used if you think theyre losing fluid
Maintenace is your bog standard
Using the replacement formula: ((well weight - current weight) / well weight )) x 100 , you find out the percentage dehydration they’re in. Shocked children are generally 10% dehydrated. Then you use this to work out how much fluid you have to give them. So if they’re 10% dehydrated, you do 10 x weight in kg x 10, and this is the total amount they need for that day (maintenace and replacement together as this formulae has accounted for their weight, ie. if they were 20kg it would come out as 2000mL , vs using the holliday segar maintenance formula which gives you 1000 + 500 = 1500mL)

If a patient is given resus boluses you dont need to subtract that from the total 24-hour fluid requirements.

Question 9

Recognising ongoing abnormal fluid or electrolyte losses can allow you to tailor your fluid prescription to prevent later complications (e.g. hypokalaemia).

Consider the following sources of ongoing fluid or electrolyte loss:

Vomiting/NG tube loss
Diarrhoea
Stoma output loss (colostomy, ileostomy)
Biliary drainage loss
Sweating/fever/dehydration (reduced or absent oral intake)
Urinary loss (e.g. diabetes insipidus/post-AKI polyuria)

Answer 9

Vomiting/NG tube loss- Give more potassium and chloride

Diarrhoea- Give more potassium and sodium and bicarb (hartmanns with extra potassium??)

Stoma output loss (colostomy, ileostomy)- Give more sodium and chloride (hartmanns)

Biliary drainage loss- Give more sodium, bicarb and chloride

Sweating/fever/dehydration (reduced or absent oral intake)- Need more water usually pure water loss

Urinary loss (e.g. diabetes insipidus/post-AKI polyuria)- variable

Question 10

cyclizine dose

Answer 10

50mg im/iv/po but contradincated in heart failure

Question 11

metaclopramide dose

Answer 11

10mg im/iv/po but?parkinsons or young people (risk of dyskinesia espeically if over 5 days)

Question 12

is it better to prescribe more opioid types or less?

Answer 12

less - prescribijng lots of different increases suscpetibility ot side effects so just do one brand/type

Question 13

typical concentration of morphine used is

Answer 13

oral tablets 5-10mg smallest dose (5mg if MST, 10mg if sevredol or zomorph (most commonly used in Wales))
oral solution is 10 mg/5 mL so go to the nearest 5mg because if you do it by 2.5mg thats really difficult to dose (like 1.25mL)

Question 14

gent vs vanc vs teico, When to measure and when to give.

Answer 14

TAKE U+E for everyone before starting.

GENT- trough levels 18-24hr after last (Given usually every 24hr, no need to monitor peak). If not possible and taken 6-14hr after the last and then use the nomogram to interpret. If patients are >65 years old, have abnormal renal function or poor urine output then you need to check levels before giving. If patients are normal then give dose before levels coming back. Check dosing twice weekly for normal patients, before every dose for abnormal renal function. Needs micro advice if given for >7 days.

VANC- trough levels- 1hr before dose (11hr post dose usually as you give it every 12hr). Usually they are around 10-15mg/L. First dose is taken after 3rd or 4th dose. Give before the results come back. Monitor every 2-3 days.

TEICO- 3-5 loading doses then reduce from BD to OD but you don’t have to wait for results to come back you just give. Trough levels are taken when the loading dose is complete (day 3,4, 5- depending on how many doses are given) and are only required if you plan to give treatment for >7 days.

Question 15

what drug to give for diarrhoea non infectious

Answer 15

loperamide 2mg orally up to 3hrly or coedien 30mg oral up to 6hrly

Question 16

insomnia

Answer 16

zopiclone max 3-7 days 7.5mg adults and 3.75mg in elderly

hospital initiated only= For people over 55 years of age with persistent insomnia, treatment with a prolonged-release melatonin may be considered.
The recommended duration of treatment is a maximum of 13 weeks.

Non-pharmacological CBTi, sleepio app, sleep diary.

Question 17

cramping vs secretion

Answer 17

hyoscine Butylbromide for Bowels/Buscopan
Hyoscine Hydrobromide for Hydro- water drowning in secretions

Question 18

brain vessel vasospasm drug

Answer 18

nimo
nimodipine

Question 19

statins after stroke

Answer 19

yes for ischameeic regardless of level of cholesterol
no for haemorrhagic
can start as soon as safe swallow in ischaemic

Question 20

stockings and LMWH post stroke ?

Answer 20

no!- intermattic penumatic compression if they’re going to be immobile.

Question 21

blood pressure management after stroke?

Answer 21

Only if low low risk patinets, i..e, none of your a-e patients (if GCS<6, they’re about to go for surgery/haematoma evacuation, or who have an underlying structural cause, or who have a very large haematoma with a poor expected prognosis. DONT)

Question 22

What antiemetic is contraindicated in long term palliative care and why

Answer 22

ondansetron - constipation causing

Question 23

domperidone parkinsons?

Answer 23

allowed used in substitute for metaclopramide in partial bowel obstruciton, migraines, Nausea where vomitting does help (nausea that impairs gastric motility)

Question 24

do you prescribe all inhalers by brand? and where do you write the concentration and device?

Answer 24

BNF
the brand and inhaler device should be specified when prescribing. The strength of inhaler device should also be considered and the one that uses the least amount of puffs to deliver the required dose is favourable.
The best inhaler nowadays according to All wales guidelines is DPI Symbicort Turbohaler 200/6 as you don’t need to change inhaler as you go up the asthma ladder of severity.

Question 25

Do you prescribe medical devices like TED stockings? and where do you find information about where to prescribe them?

Answer 25

Yes - Nia showed us you write T then arrow from morning to night to mornign like a cycle to show you want them on all day

find information on NICE–>BNF–>Medical devices
or
NICE–>BNF–>Medicines guidance–> Guidance on prescribing

https://bnf.nice.org.uk/medicines-guidance/guidance-on-prescribing/

generally
1. narrow index
2. modified release
3. specific devices theyve been taught on (insulin, inhalers, epipens)
4. biologics
5. combination drugs i.e., pancreatic enzymes.
6. ENOXAPARIN SHOULD BE PRESCRIBED BY BRAND!!! AND OTHER BIOLOGIC LMWH BUT I DONT THINK UFH.
7. class 1 antiepileptics (carbamezapine, phenytoin? phenybarbitol)

https://www.sps.nhs.uk/articles/prescribing-by-generic-or-brand-name-in-primary-care/

Question 26

VRII and long acting vs intermedaite/mixed insulin rules

Answer 26

long acting- continue at 80% of normal with VRII

mixed- stop! and start as you would short acting (give at normal time around/ before eating then stop the VRII 30 minutes after eating)

Question 27

when would u not offer a DOAC for confirmed PE?

Answer 27

1. Extremes of body weight >120kg (LWMH)
2. <15ml creatinine clearance (LMWH)
3. Triple positive antiphospholipid syndrome (LMWH and then warfarin)
4. PE with haemodynamic instability (Give UFH while considering thrombolysis as it is short acting)

Question 28

what time should u give ACE-i?

Answer 28

For hypertension the first dose should preferably be given at bedtime.

due to hypotension risk

Question 29

which drugs do you have to taper/ shouldn’t you stop immeditely

Answer 29

steroids long term - adrenal suppression
beta blockers in the case of iscahemic heart disease as it can cause rebound MI!!!!!!!
Clonidine - rebound HTN
Benzos - seizures
SSRI - withdrawal side effects
Lithium salts (BNF says - not sure why though)

Question 30

HTN and ?chronic heart failure in an over 55 year old first line drug.

Answer 30

ace-i or BB
even though >55 and realistically amlodipine would eb best for HTN, ACE-I work for HTN and also reduce mortality in CHF so are first line

Question 31

calcium gluconate brings down potassium

Answer 31

no, it just stabilises cardiac membrane therefore it is IMPERATIVE YOU GIVE ACTRAPID (R) 10 UNITS IN 100ML OF 20% DEXTROSE OVER 30 MINUTES IV.

BNF SAYS IDEALLY 25G GLUCOSE SO THAT WOULD BE 10% 250mL as 20% 125mL sounds a bit obscure adn you dont give 50% cause this is too irritating!

it does bring down magnesium though

Question 32

Do you prescribe levetiracetam by brand?

Answer 32

no - No, it’s not always necessary to prescribe levetiracetam by brand as it is a category 3 antiepileptic- The Medicines and Healthcare products Regulatory Agency (MHRA) has issued guidance on prescribing anti-seizure medications. They say that certain ASMs must be prescribed with the same version, and that for other ASMs this is less important.

Category 1 Phenytoin, carbamazepine, phenobarbital and primidone MUST BE PRESCRIBED BY BRAND

Category 2 Sodium valproate, lamotrigine, perampanel, retigabine, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine acetate, topiramate and zonisamide ARE UP TO DOCTOR’S DECISION

Category 3 Levetiracetam, lacosamide, tiagabine, gabapentin, pregabalin, ethosuximide, brivaracetam and vigabatrin DON’T NEED TO BE PRESCRIBED BY BRAND.

Question 33

Which antibiotics can only be given IV and why?

Answer 33

only IV due to poor oral bioavailability, instability in the gastrointestinal (GI) tract, or because achieving therapeutic concentrations orally is challenging.

Vancomycin - oral form for treating C.diff but systemic infections (e.g., MRSA bacteraemia, endocarditis) require IV vancomycin because oral absorption is negligible.

Ertapenem, Meropenem, Doripenem - Like imipenem, other carbapenems are only administered IV due to poor oral bioavailability and the need for high serum concentrations to treat serious infections.

Ceftriaxone and Cefepime - only available for IV or IM use, especially for severe infections.

Piperacillin-tazobactam (Zosyn) - Used for broad-spectrum coverage, including Pseudomonas, this combination is also restricted to IV administration.

Question 34

which antibiotics are ci if penicillin allergy

Answer 34

1. all the ceftriaxones and meropenem, aztreonam ertapenem imipenem plus cilastatin are contraindicated if severe penicillin allergy

Question 35

when prescribing vanco, gent, teico how do you tell nurses you want levels and they need to be given at a specific time?

Answer 35

when nurses give gent they need to write the time given so we can know when to check the trough levels. write this under or next to where they sign to say they’ve given it

Question 36

When prescribing a new drug on a chart of a patient that’s already been in 5 days, what do you need to make sure you do?

Answer 36

cross off the first 5 days so people dont get confused and give duplicates due to it being recorded on the wrong day (see morphine sulfate)

Question 37

what can you write in PRN section ‘max dose’ for oramorph?

Answer 37

either their total daily dose of morphine or write when taking ≥2 daily breakthroughs. (NICE)

Question 38

prescribe paracetamol for a 10 year old child

Answer 38

NOTE, SOME CONCENTRATIONS ARE NOT ALLOWED IN CERTAIN AGES I.E., 500mg/5mL under 12 or 16?

Question 39

10kg girl.

if a question says 30–60 mg every 8 hours as required, maximum daily dose to be given in divided doses; maximum 60 mg/kg per day.

Do you give 60mg or do you give 600mg per dose?

Answer 39

60mg or 100-150mg per dose (every 4 or every 6 hours)
600mg is for the whole 24hr not for the single dose.

Question 40

prescribe codeine for pain for a 10 year old child

Answer 40

first of all, you should find out that it is CONTRAINDICATED <12 YEARS.

Second of all you should make sure it is only being given for 3 DAYS MAXIMUM

But we have done this prescription assuming it is a 12 year old child so you can see how it would be prescribed.

Question 41

Give me an exmaple of how to prescribe max dosing for an opioid

Answer 41

either 6 doses (as breakthrough is 1/6 total) or after 2 doses seek doctor review (as if theyre using that much it is an indication to go up)

Question 42

whats wrong with each of these and correct them

Answer 42

Question 43

what drugs do you have to check LFTs before precribing?

Answer 43

antifungals
statins
antibiotics - clarithromycin, erythromycin
Warfarin
Direct Oral Anticoagulants- apixaban, rivaroxaban

Question 44

When do you prescribe apixiban?

Answer 44

BD - 12 hours apart. 6 hour leway. If miss during this time skip dose.

Question 45

Do you need to give PPI with DOACS?

Answer 45

mixed evidence. If clopidogrel DON’T GIVE OMEPRAZOLE OR ESOMEPRAZOLE. Should be lansoprazole.

However only take if high risk of bleeding (ORBIT >3), GIB in past

Question 46

Where do you find information on pregnancy dosing for VTE?

Answer 46

Scroll down on drugs - it will eventually show, but for knowledge optimal answers:

tinzaparin
dalteparin
enoxaparin

based off weight and renal function
can be twice daily or once daily always s/c for lmwh

Question 47

Answer 47

Question 48

Why would you change to morphine?

Answer 48

Question 49

why is this answer wrong?

Answer 49

the 24ml is not specific to the concentration
it is the FINAL volume so you need to minus 3mL from it!