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Phase 3 > Prescribing And Pharmacology > Flashcards

Prescribing And Pharmacology Flashcards

1
Q

What is the usual loading dose of digoxin for atrial fibrillation?

A

For rapid digitalisation: 0.75-1.5mg PO over 24h in divided doses

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2
Q

What is the usual maintenance dose of digoxin for atrial fibrillation?

A

According to renal function and initial loading dose

Usual range 125-250 micrograms once daily PO

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3
Q

What is the dose of digoxin for heart failure for patients in sinus rhythm?

A

65-125 micrograms PO once daily

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4
Q

What investigations should be done for a patient with suspected digitalis toxicity? And what are you looking for with each?

A

Serum digoxin level: therapeutic level 0.6-2.6ng/mL
U and Es: acute - hyperkalaemia, chronic - hypokalaemia, hypomagnesaemia
ECG: dysrhythmia, sinus bradycardia, AV conduction block, ventricular ectopy

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5
Q

What is the management for acute digitalis toxicity?

A 
Hydration with IV fluids
Oxygenation and support of ventilatory function
Discontinuation of drug
Correction of electrolyte imbalances
Activated charcoal
Binding resin: cholestyramine 
Digoxin immune Fab (fragment antigen binding)
Management of dysthymias
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6
Q

What blood tests need regular monitoring in patients prescribed IV vancomycin?

A

Renal function

Vancomycin levels

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7
Q

Which class of medication is first line for panic disorder? Give examples

A 
SSRI 
Fluoxetine 
Paroxetine
Sertraline
Citalopram
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8
Q

What are typical side effects of statins?

A 
Myalgia 
Headaches
Nausea
Hepatitis 
Myositis/rhabdomyolysis
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9
Q

What is the appropriate treatment for c diff?

A

Oral metronidazole or oral vancomycin

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10
Q

What drug is used to manage hyperthyroidism?

A

Carbimazole

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11
Q

By what mechanisms is metoclopramide an anti emetic?

A

Increased GI motility
Increases sphincter tone
Centrally: dopaminergic antagonist

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12
Q

A 44 year old man is diagnosed with TB. He has a history of mitral stenosis and AF. He is commenced on therapy. 3 weeks later his INR increased to 5.6. Which medication is likely to have caused this and why?

A

Isoniazid inhibits P450 system of liver enzymes so therefore inhibit warfarin metabolism and will therefore increase INR

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13
Q

What is the difference between unfractionated and low molecular weight heparin?

A

Unfractionated forms a complex which activates antithrombin III to inhibits thrombin, Xa, IXa, XIa and XIIa. IV, short duration of action. Monitor with APTT. Useful where high risk of bleeding as can be terminated rapidly
LMWH only increases action of antithrombin III on Xa. Subcutaneous, long duration of action

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14
Q

What is heparin induced thrombocytopenia?

A

Antibodies form against complexes of platelet factor 4 and heparin
Induce platelet activation by cross linking
Features include greater than 50% reduction in platelets, thrombosis and skin allergy

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15
Q

How do you reverse heparin overdose?

A

Protamine sulphate

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16
Q

What is the mechanism of action of clopidogrel?

A

Antagonist of P2Y12 ADP receptor inhibiting activation of platelets

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17
Q

What is bioavailability? What impact does this have on IV drugs?

A

Proportion of administered drug that reaches the systemic circulation
Therefore always 100% for IV drugs

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18
Q

Why do angina sufferers use a sub lingual spray rather than swallow a tablet?

A

Absorption is rapid and bioavailability is high as it goes straight into the circulation

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19
Q

Which is the most important of the cytochrome P450 enzymes?

A

CYP2D6

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20
Q

What is phase 1 metabolism?

A

Modification
Introduces reactive groups
Oxidation, reduction, hydrolysis
Enzyme catalysed by p450 system

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21
Q

What is phase 2 metabolism?

A

Conjugation
Mostly in the liver
Addition of glucuronide, sulphate and other charged groups

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22
Q

Give examples of p450 inducers

A 
Barbiturates
Carbamazepine
Alcohol 
Griseofulvin 
Phenytoin
Primidone
Rifampicin 
CRAPGPS
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23
Q

Give examples of p450 inhibitors

A 
Omeprazole
Disulfiram
Erythromycin
Valproate
Isoniazid 
Ciprofloxacin
Ethanol (acute)
Sulphonamides 
ODEVICES
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24
Q

Which fruit is an enzyme inhibitor?

A

Grapefruit

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25
Q

Give examples of drugs that are affected by enzyme induction/inhibition

A 
Ciclosporin 
Citalopram
Oral contraceptive
Warfarin
Phenytoin
Protease inhibitors
Acetylcholinesterase inhibitors 
Theophylline 
Statins 
COWPATS
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26
Q

What proportion of the population lack the enzyme to metabolise codeine?

A

8%

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27
Q

What percent of the population are rapid metabolisers of codeine?

A

1%

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28
Q

Why does diazepam have such a short length of activity when it has a long half life of 36 hours?

A

Distribution - it is highly lipid soluble so lots of it is distributed into fat
Has a high volume distribution

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29
Q

After how many half lives is the plasma concentration of an administered drug effectively zero?

A

5 half lives

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30
Q

What is clearance?

A

Volume of plasma cleared of drug per unit time

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31
Q

What drugs have zero order kinetics?

A

Phenytoin
Thiopentone
Fluoxetine
Ethanol

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32
Q

What is zero order kinetics?

A

Enzymes catalysing elimination are in short supply
Can be fully saturated if drug given in high dose
Plasma concentration - time profile during elimination phase is linear

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33
Q

What is Emax?

A

Maximum possible effect produced by activation of a receptor

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34
Q

What is a partial agonist?

A

Ligand that binds to the same receptor but produces less than a maximal response - has lower intrinsic activity

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35
Q

Give examples of partial agonists

A

Buprenorphine

Salmeterol

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36
Q

What drug combination treats bronchospasm?

A

Beta 2 agonist - salbutamol

Muscarinic antagonist - ipratropium

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37
Q

Give an example of a non competitive antagonist

A

Phenoxybenzamine - used in management of Phaeochromocytoma

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38
Q

What makes warfarin, lithium, vancomycin, gentamycin and theophylline dangerous?

A

Narrow therapeutic index

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39
Q

What is telbivudine?

A

Antiviral drug used in treatment of hep B

Synthetic thymidine nucleoside analogue so impairs DNA virus replication by leading to chain termination

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40
Q

What is truvada?

A

Emtricitabine and tenofovir

Used for HIV pre exposure prophylaxis and treatment

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41
Q

Which drugs can cause SIADH?

A 
Carbamazepine
Sulfonylureas
SSRIs
Tricyclic antidepressants 
Vincristine
Cyclophosphamide
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42
Q

What are common adverse effects of thiazide diuretics?

A 
Dehydration
Postural hypotension
Hyponatraemia
Hypokalaemia
Hypercalcaemia 
Gout
Impaired glucose tolerance
Impotence
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43
Q

What are examples of low dose inhaled corticosteroids and their doses?

A

Beclometasone dipropionate: 50/100 mcg 2 puffs BD

Fluticasone propionate: 50 mcg two puffs BD

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44
Q

What are examples of medium dose inhaled corticosteroids and their doses?

A

Beclometasone dipropionate: 100/200 mcg 2 puffs BD

Fluticasone propionate: 125 mcg 2 puffs BD

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45
Q

What are examples of high dose inhaled corticosteroids and their doses?

A

Beclometasone dipropionate: 100/250 mcg 4 puffs BD

Fluticasone propionate: 250 mcg 2 puffs BD

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46
Q

At what level of GFR should metformin be reviewed/stopped?

A

If GFR below 45, review dose

If GFR below 30, stop

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47
Q

A 69 year old HIV negative man has lamivudine resistant chronic hep B. What is the treatment of choice?

A

Tenofovir plus entecavir

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48
Q

A 42 year old IV drug user is hep C PCR positive. What is the best treatment option?

A

PEG interferon alpha with ribavirin

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49
Q

What type of drug are carbimazole and propylthiouracil?

A

Thyroid peroxidase inhibitors used in thyrotoxicosis

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50
Q

What are indications for warfarin and target INRs for these conditions?

A

VTE: target 2.5 unless recurrent then 3.5
AF: target 2.5
Mechanical heart valve: target INR depends on type of valve and location

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51
Q

What factors may potentiate warfarin?

A

Liver disease
P450 inhibitors: amiodarone, ciprofloxacin
Cranberry juice
Drugs which displace warfarin from plasma albumin: NSAIDs
Drugs which inhibit platelet function: NSAIDs

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52
Q

What are side effects of warfarin?

A

Haemorrhage
Teratogenic
Skin necrosis: protein c reduced when first starting. Temporary pro coagulant state, avoided by concurrent heparin
Purple toes

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53
Q

What are major side effects of colchicine?

A 
Bleeding
Burning in stomach throat or skin
Convulsions
Diarrhoea 
Fast shallow breathing
Muscle weakness
Nausea and vomiting
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54
Q

What are complications of statins?

A

Myalgia
Myositis
Myopathy

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55
Q

What is the difference in statin prescription between primary and secondary prevention?

A

Primary prevention: atorvastatin 20mg OD. If non HDL has not fallen by at least 40% consider titration up to 80mg
Secondary: atorvastatin 80mg OD

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56
Q

Which drugs make complications of statins more likely?

A

Fibrate

Immunosuppressants

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57
Q

Why can renal failure occur with statins?

A

Rhabdomyolysis which leads to acute renal failure secondary to myoglobinuria

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58
Q

What effect can lithium have on your kidneys that would cause polyuria, polydipsia and high-normal sodium?

A

Can cause nephrogenic diabetes insipidus

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59
Q

What does ergometrine cause and what are possible complications?

A

Uterine contraction
Can cause shock from anaphylactoid reactions
HTN
MI

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60
Q

What is febuxostat and how does it work?

A

Drug used second line in prevention of gout

Xanthine oxidase inhibitor, reduces uric acid levels in the body

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61
Q

Name some drugs which may cause problems in asthmatics

A

Adenosine: wheeze, bronchospasm
Diclofenac
Beta blockers
Morphine: can cause histamine release

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62
Q

Why is unfractioned heparin less frequently used than low molecular weight?

A

Low molecular weight act specifically on factor Xa and do not require monitoring of APTT
Effective for prophylaxis and treatment of VTE and can be used in pregnancy
Can be given in once daily doses rather than needing a continuous infusion which is required in unfractioned due to short half life

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63
Q

What is the dose of enoxaparine used in STEMI?

A

IV 3000 units

Then 1mg/kg 12 hourly for up to 8 days

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64
Q

What is the dose of enoxaparine used in NSTEMI and unstable angina?

A

Subcut 1mg/kg 12 hourly for 2-8 days

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65
Q

In which patients should initial starting dose of levothyroxine be lower?

A

Elderly

Ischaemic heart disease

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66
Q

After a change in thyroxine dose, how soon should TFTs be performed?

A

8-12 weeks

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67
Q

What should happen to levothyroxine dose in pregnancy?

A

Increased by at least 25-50 micrograms due to increased demands of pregnancy
TSH monitored carefully, aiming for low normal value

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68
Q

What are side effects of levothyroxine therapy?

A

Hyperthyroidism due to over treatment
Reduced bone mineral density
Worsening of angina
Atrial fibrillation

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69
Q

What monitoring is required for statins and when?

A

LFT at baseline, 3 months and 12 months

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70
Q

What monitoring is required for ACE inhibitors and when?

A

U and Es prior to treatment, after increasing dose and at least annually

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71
Q

What monitoring is required for amiodarone and when?

A

TFT, LFT, U and Es, CXR prior to treatment

TFT, LFT every 6 months

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72
Q

What monitoring is required for methotrexate and when?

A

FBC, LFT, U and Es before starting treatment, weekly until stabilised, then every 2-3 months

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73
Q

What monitoring is required for azathioprine and when?

A

FBC, LFT before treatment
FBC weekly for first 4 weeks
FBC, LFT every 3 months

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74
Q

What monitoring is required for lithium and when?

A

Lithium levels weekly until stabilised then every 3 months

TFT and U and Es prior to treatment then every 6 months

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75
Q

What monitoring needs to be done for sodium valproate and when?

A

LFT and FBC before treatment

LFT periodically in first 6 months

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76
Q

Which drug causes red man syndrome?

A

Vancomycin if rapidly injected

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77
Q

Which TB drug can cause peripheral neuropathy? Which drug can be given concomitantly to prevent this?

A

Isoniazid

Give pyridoxine to prevent

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78
Q

What thyroid disorders can be caused by Amiodarone?

A

Hypothyroidism

Hyperthyroidism

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79
Q

Which anti diabetic medications can increase risk of DKA?

A

SGLT2 inhibitors: canagliflozin, dapagliflozin, empagliflozin

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80
Q

What is the most appropriate treatment for hyperthyroidism in pregnancy? What consequence is there in breast feeding?

A

Carbimazole
Propylthiouracil
Use at minimum dose as both cross placenta
Excreted in small amounts in breast milk, not absolutely contraindicated but not ideal while breastfeeding

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81
Q

Which antibiotic is contraindicated in pregnancy due to foetal dental staining?

A

Tetracyclines

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82
Q

What is the risk of giving fluoxetine alongside sulphonylureas?

A

Hypoglycaemia

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83
Q

Give some drug examples which can raise serum lipid concentrations

A

Beta blockers
Thiazide diuretics
Systemic retinoids

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84
Q

Which cardiology drugs can cause a photosensitive rash?

A

Amiodarone

Thiazide diuretics

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85
Q

How do you calculate a breakthrough dose of morphine?

A

1/6th dose of daily morphine intake

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86
Q

What is the preferred antithyroid drug in pregnancy?

A

Propylthiouracil - less likely to cross placenta

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87
Q

Ah what point should a statin be stopped if it is causing LFT derangement?

A

If serum transaminase concentrations rise to and persist at 3 times upper limit of reference range

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88
Q

What is nicorandil?

A

Potassium channel activator which has vasodilatory effects on coronary arteries

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89
Q

What are side effects of methylphenidate?

A

Abdominal pain
Nausea
Dyspepsia

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90
Q

How do you convert a dose or oral morphine to diamorphine?

A

Total daily morphine divided by 3

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91
Q

What can precipitate lithium toxicity?

A 
Dehydration 
Renal failure 
Diuretics (esp bendroflumethiazide)
ACE inhibitors
NSAIDs 
Metronidazole
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92
Q

Which drugs to treat UTI should be avoided in pregnancy?

A

Trimethoprim avoided in first trimester due to risk of neural tube teratogenicity
Nitrofurantoin avoided close to full time due to risk of neonatal haemolysis

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93
Q

What are precipitating factors for digoxin toxicity?

A 
Hypokalaemia 
Increasing age
Renal failure
MI
Hypomagnesaemia 
Hypercalcaemia 
Hypernatraemia 
Acidosis 
Hypoalbuminaemia 
Hypothermia 
Hypothyroidism
Drugs: amiodarone, verapamil, diltiazem, spironolactone
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94
Q

What is management for digoxin toxicity?

A

Digibind
Correct arrhythmias
Monitor potassium

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95
Q

Which antibiotics should be used with caution in patients with epilepsy?

A

Quinolones: ciprofloxacin, levofloxacin

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96
Q

Which anti malarial drugs are safe in pregnancy?

A

Chloroquine

Proguanil if folate supplement of 5mg OD taken

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97
Q

What are side effects of rifampicin?

A

Hepatitis
Orange secretions
Flu like symptoms

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98
Q

What are side effects of isoniazid?

A

Peripheral neuropathy (prevent with pyridoxine)
Hepatitis
Agranulocytosis
Liver enzyme inhibitor

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99
Q

What are side effects of pyrazinamide?

A

Hyperuricaemia
Arthralgia
Myalgia
Hepatitis

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100
Q

What are side effects of ethambutol?

A

Optic neuritis

Dose adjust in renal impairment

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101
Q

What effects does metoclopramide have?

A

Increase GI motility
Increase sphincter tone
Central antiemetic actions through dopamine

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102
Q

Which drugs can cause gingival hyperplasia?

A

Phenytoin
Ciclosporin
Calcium channel blockers
AML

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103
Q

Why do PPIs increase risk of fractures?

A

Malabsorption of calcium and magnesium

104
Q

What is the mechanism of action of quinolones? (Ciprofloxacin)

A

Inhibit topoisomerase II (DNA gyrase) and topoisomerase IV to prevent DNA synthesis
Bactericidal

105
Q

What are adverse effects of ciprofloxacin?

A

Lower seizure threshold in patients with epilepsy
Tendon damage, including rupture
Cartilage damage - avoid in children
Lengthens QT interval

106
Q

What is the mechanism of action of mifepristone?

A

Partial agonist of progesterone receptors, blocks their action
Inhibits ovulation
Sensitises endometrium to action of prostaglandins

107
Q

What are the actions of misoprostol?

A

Induction of labour/uterine contractions
Dilation of cervix
Expulsion of products of conception

108
Q

Why is hyperkalaemia a side effect of co trimoxazole?

A

Inhibits sodium channels in the distal nephron similar to potassium sparing diuretic amiloride

109
Q

What are some adverse effects of finasteride?

A

Impotence
Decreased libido
Ejaculation disorders
Gynaecomastia and breast tenderness

110
Q

Which antibiotic is associated with aplastic anaemia?

A

Chloramphenicol

111
Q

Which antibiotic is associated with staining dental enamel?

A

Tetracyclines eg doxycycline

112
Q

Which antibiotics can cause cartilage erosion and reduce fit potential?

A

Quinolones and fluoroquinolones e.g. Ciprofloxacin

113
Q

Which antibiotic can cause a metallic taste in the mouth?

A

Metronidazole

114
Q

What is the mechanism of action of tacrolimus?

A

Calcineurin inhibitor - reduce activation of nuclear factor of activated T cells (NFAT) which promotes IL2 production

115
Q

What is the mechanism of action of mycophenolate mofetil?

A

Antimetabolite - interrupt DNA synthesis

Inhibits inosine monophosphate dehydrogenase so prevents purine synthesis

116
Q

What is the mechanism of action of azathioprine?

A

Antimetabolite - interrupt DNA synthesis
Pro drug metabolised to 6mercaptopurine which is inserted into DNA sequence instead of purine, recognised as mismatch and triggers apoptosis

117
Q

What are some associations of advanced maternal age?

A 
Miscarriage
Chromosomal abnormality
HTN
Diabetes 
Prolonged labour
Low birth weight
Pre term delivery 
Neonatal mortality
118
Q

What is the mechanism of action of demeclocycline? What is it used for?

A

Vasopressin antagonist
Induces free water excretion
Treatment for SIADH who fail to respond to fluid restriction

119
Q

What effect do macrolide antibiotics have on statins?

A

Inhibit metabolism by CYP3A4

Can lead to myopathy and rhabdomyolysis

120
Q

Why is ciprofloxacin contraindicated in patients under 16 years?

A

Associated with experimental arthropathy in growing animals

121
Q

Which drugs can cause gingival hyperplasia?

A

NCP
Nifedipine
Ciclosporin
Phenytoin

122
Q

How many days before surgery should warfarin be stopped?

A

5 days

INR needs to go below 1.5

123
Q

Which TB drug is associated with visual problems/colour blindness?

A

Ethambutol

124
Q

What is an equivalent dose of prednisolone if a patient is on 20mg hydrocortisone?

A

5mg prednisolone

4:1 ratio

125
Q

What may be side effects of sulfasalazine and therefore what monitoring is required?

A

Leucopenia
Thrombocytopenia
Oligospermia
Monitor FBC, U and Es, LFTs

126
Q

Why does co trimoxazole cause hyperkalaemia?

A

Inhibits sodium channels in distal nephron in a similar way to amiloride

127
Q

What are signs of procyclidine overdose?

A

Agitation
Confusion
Sleeplessness lasting up to 24 hours or more
Pupils dilated and unreactive to light

128
Q

Which drugs can interact warfarin and lead to an increase in INR?

A 
O DEVICES
Omeprazole
Disulfiram
Erythromycin 
Valproate
Isoniazid
Cimetidine and ciprofloxacin
Ethanol
Sulphonamides
129
Q

Which TB drug is associated with peripheral neuropathy? What is given to counteract this?

A

Isoniazid

Give pyridoxime

130
Q

Which TB drug used in resistant and atypical cases may cause vertigo?

A

Cycloserine

131
Q

Which TB drug is a potent hepatic enzyme inducer?

A

Rifampicin

132
Q

Which drug is useful for speeding up gastric motility in acute migraine?

A

Metoclopramide

133
Q

Why could bendroflumethiazide precipitate digoxin toxicity?

A

Could cause hypokalaemia

134
Q

How do you convert a morphine dose from oral to SC?

A

Divide by 2

135
Q

What are side effects of carbimazole?

A

Rash
Hair loss
Agranulocytosis

136
Q

What is the most serious adverse event associated with amiodarone?

A

Pulmonary toxicity - pneumonitis

137
Q

Why should verapamil not be given in combination with beta blockers?

A

May cause complete heart block

138
Q

What is the mechanism of action of bupropion?

A

Noradrenaline and dopamine reuptake inhibitor and nicotinic antagonist

139
Q

What are contraindications to bupropion?

A

Epilepsy
Pregnancy
Breastfeeding
Eating disorder (relative)

140
Q

What is the mechanism of action of varenicline?

A

Nicotinic partial agonist

141
Q

What is the recommended course of treatment with varenicline?

A

12 weeks

142
Q

What are common side effects with varenicline?

A

Nausea
Headache
Insomnia
Abnormal dreams

143
Q

In which patients should varenicline be used with caution?

A

History of depression or self harm

Contraindicated in pregnancy and breast feeding

144
Q

What are side effects of amiodarone?

A 
Pneumonitis/lung fibrosis
Neutropenia
Hepatitis
Phototoxicity 
Slate grey skin discolouration
Hypothyroidism
Hyperthyroidism
Arrhythmias
Corneal deposits
Peripheral neuropathy 
Myopathy
145
Q

Which immunosuppressant drug used to prevent organ rejection can cause new onset diabetes after transplantation?

A

Tacrolimus - calcineurin inbibitor

146
Q

Which antibiotics can cause photosensitivity?

A

Doxycycline/tetracycline

147
Q

What is malarone?

A

Atovaquone/proguanil antimalarial

148
Q

Which opioids are preferred in patients with chronic kidney disease?

A

Alfentanil
Buprenorphine
Fentanyl

149
Q

What is the risk of concurrent prescription of methotrexate and trimethoprim?

A

Marrow aplasia

150
Q

What are problematic side effects of ciprofloxacin?

A

C diff infection

Enthesitis and tendon rupture

151
Q

Why are ACE inhibitors contraindicated in bilateral renal artery stenosis?

A

Glomerular filtration pressure dependent on vasoconstriction of the efferent arteriole because the resistance of the afferent blood vessels have been pathologically increased

152
Q

Which is the recommended anti malarial for sub Saharan Africa?

A

Mefloquine

153
Q

How long before travel does mefloquine need to be started?

A

2-3 weeks

154
Q

How long before travel does chloroquine/proguanil need to be started?

A

1 week

155
Q

What is the recommended antibiotic for prophylaxis of meningitis in those who have been exposed?

A

Ciprofloxacin

156
Q

Which antibiotic is used for prophylaxis of TB in those who are exposed?

A

Isoniazid for 6 months

Or combo isoniazid and rifampicin for 3 months

157
Q

Which drug can be given to pregnant HIV positive women who wish to reduce risk of transmission to their baby?

A

Zidovudine

158
Q

What is the mechanism of action of finasteride?

A

5 alpha reductase inhibitor: prevent conversion of testosterone to active DHT

159
Q

What are side effects of calcium channel blockers?

A

Headache
Flushing
Ankle oedema

160
Q

Which drugs may interact with clarithromycin?

A

Warfarin
Aminophylline
Statins

161
Q

What is the mechanism of action of varenicline?

A

Nicotinic receptor partial agonist - reduces cravings and pleasurable effects

162
Q

What is the mechanism of action of bupropion? What is the major risk?

A

Antidepressant
Risk of seizures
Noradrenaline dopamine reuptake inhibitor

163
Q

What are side effects of beta blockers?

A 
Fatigue
Orthostatic hypotension
Weakness
Blurred vision
Stuffy nose
Impotence
Rash
CHF
Bradycardia
Pulmonary oedema
164
Q

What are side effects of calcium channel blockers?

A 
Dizziness
Headache
Redness in the face
Fluid build up in the legs
Rapid heart rate
Slow heart rate
Constipation
Gingival overgrowth
165
Q

What is the mechanism of action of ivabradine?

A

Acts at funny channels - reduce cardiac pacemaker activity

166
Q

What is advice regarding statins in pregnancy?

A

Stop them due to congenital abnormality risk

167
Q

What is the mechanism of action of Azathioprine?

A

Purine analogue

Interrupts DNA synthesis and drives rapidly dividing cells into apoptosis

168
Q

What is the mechanism of action of sirolimus?

A

Inhibitor of mTOR, mammalian target of rapamycin (protein kinase acting downstream of IL2 signalling to promote proliferation and survival of T cells)

169
Q

What is the mechanism of action of tacrolimus?

A

Calcineurin inhibitor

Reduces activation of nuclear factor of activated T cells which is a transcription factor that promotes IL2 production

170
Q

What is the interaction between iron and thyroxine?

A

Iron reduces the absorption of thyroxine

171
Q

What are side effects of sodium valproate?

A 
Weight gain
Nausea 
Vomiting
Hair loss
Easy bruising
Tremor
Hepatic failure
Pancreatitis
172
Q

Which beta blocker is safe to use in liver failure?

A

Propranolol 40mg BD

173
Q

In which patients should caution be used when prescribing sulfasalazine?

A

G6PD deficiency

Allergy to aspirin or sulphonamides

174
Q

What are adverse effects of sulfasalazine?

A 
Oligospermia
SJS
Pneumonitis
Myelosuppresion
Heinz body anaemia 
Megaloblastic anaemia
Coloured tears/stained contact lenses
175
Q

What is the conversion factor between oral codeine and oral morphine?

A

Divide by 10

176
Q

What is the generic name for herceptin?

A

Trastuzumab

177
Q

What are adverse effects of interferon alpha?

A

Flu like symptoms

Depression

178
Q

Which drugs can cause pancreatitis?

A 
Azathioprine 
Mesalazine 
Didanosine 
Bendroflumethiazide
Furosemide
Pentamidine 
Steroids
Sodium valproate
179
Q

Which antihypertensive is associated with rebound HTN following acute withdrawal?

A

Clonidine

180
Q

Which drug when combined with beta blockers can cause complete heart block?

A

Verapamil

181
Q

Which drugs are associated with drug induced lupus?

A 
Antibodies to tumor necrosis factor-a
Anticonvulsants: phenytoin
Chlorpromazine
D-penicillamine
Hydralazine
Interferon alfa
Isoniazid
Methyldopa
Minocycline
Procainamide
182
Q

What is a side effect of minoxidil which is used for benefit in another condition?

A

Hirsutism - used in regaine topical minoxidil solution for treatment of baldness

183
Q

Which antihypertensive can precipitate haemolysis?

A

alpha methyldopa

184
Q

Concurrent use of what drug may make clopidogrel less effective?

A

PPI

185
Q

Which antidiabetic drugs can cause cholestasis?

A

Sulphonylureas

186
Q

What should be the first line agent in diabetic neuropathic pain?

A

Duloxetine

187
Q

What is the mechanism of action of adenosine?

A

Transient heart block in AV node
Agonist of A1 receptor which inhibits adenylyl cyclase so reduces cAMP causing hyperpolarisation by increasing outward potassium flux
Adenosine has short half life of 8-10secs

188
Q

What are side effects of verapamil?

A 
Heart failure
Constipation
Hypotension
Bradycardia
Flushing
189
Q

What are side effects of nifedipine and amlodipine?

A

Flushing
Headache
Ankle swelling

190
Q

In which patient group should mefloquine not be prescribed?

A

Hx of anxiety, depression, schizophrenia or other psychiatric disorders

191
Q

Which drugs are associated with causing IIH?

A 
Oral contraceptive 
Tetracyclines 
Nalixidic acid
Nitrofurantoin 
Growth hormone
192
Q

What are side effects of cyclosporin?

A 
Everything increased
Fluid
BP
Hair
Potassium 
Gums
Glucose
193
Q

Which acetylcholinesterase inhibitors are recommended by nice for mild to moderate AD?

A

Donepezil
Galantamine
Rivastigmine

194
Q

Which drug is used for moderate to severe AD?

A

Memantine (NMDA antagonist)

195
Q

What are side effects of EPO?

A 
Accelerated HTN leading to encephalopathy and seizures
Bone aches
Flu like symptoms 
Skin rash
Urticaria 
Pure red cell aplasia 
Raised PCV increases risk of thrombosis 
Iron deficiency
196
Q

What is the most common cause of drug induced angioedema?

A

ACE inhibitors

197
Q

What change in eGFR and creatinine is acceptable when starting an ACE inhibitor?

A

Decrease in eGFR up to 25%

Rise in creatinine up to 30%

198
Q

How does a dose of Azathioprine change if a patient is on allopurinol?

A

2mg/kg starting dose - but if on allopurinol - give 25% dose

199
Q

What monitoring and counselling should be given to a patient before starting them on Azathioprine?

A

TPMT (thiopurine methyltransferase): if no activity, can’t break down AZA
Blood tests - weekly for 4/52, then 3/12
Myelosuppression signs and symptoms: sore throat, unexplained bruising / bleeding
Immunosuppressant hence recommend to avoid any live vaccines, but recommend annual flu vaccine
Sun exposure – limited or high factor sunscreen

200
Q

What are prescribing options for IBD?

A 
Mesalazine (5ASA) suppository/enema 
Steroids 
Azathioprine 
6 mercaptopurine 
Methotrexate (crohns only)
Infliximab 
Surgery
201
Q

Why are aminosalicylate drugs best given as local preparations for UC?

A

Absorbed very quickly in small bowel so need mechanism to get it to large bowel

202
Q

Why is sulfasalazine useful for treating UC?

A

Anti inflammatory
5-ASA attached to Sulphapyridine with a diazo bond
Bacteria hydrolyse the diazo bond
Means that it isnt broken down so quickly in small bowel so can get to site of action

203
Q

What 2 forms of mesalazine are available?

A

Coated with Eudragit-S, pH dependent release: Asacol acts from TI onwards
Microparticles coated with ethylcellulose: Pentasa acts from duodenum onwards

204
Q

What is the mechanism of action of mesalazine?

A

Inhibits both cyclo-oxygenase and 5- lipo-oxygenase pathways of arachidonic acid metabolism
Reduces inflammatory prostaglandin production and the formation of other chemotactic substances

205
Q

What cautions should be applied when prescribing mesalazine?

A

Renal impairment
Pregnancy and breast feeding
Blood disorders can occur: Patients must be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever or
malaise during treatment
Elderly- risk of serious renal toxicity with oral preparations, test renal function initially and every 3 months for first year, then every 6 months for next 4 years and annually thereafter

206
Q

What are contraindications to mesalazine prescription?

A

Avoid in salicylate hypersensitivity

Severe hepatic impairment

207
Q

Which drugs may interact with mesalazine?

A

Possible increased risk of leucopenia when aminosalicylates are given with azathioprine or mercaptopurine
Preparations that lower stool pH (e.g. lactulose) may prevent release of mesalazine

208
Q

What are some side effects of aminosalicylates?

A 
Nausea
Diarrhoea
Abdominal pain
Headache
Hepatitis 
Agranulocytosis
Interstitial nephritis
Asthma in the salicylate sensitive
209
Q

What is the first line immunosuppressant in UC and crohns?

A

Azathioprine

210
Q

What is the mechanism of action of Azathioprine?

A

Cytotoxic, antiproliferative immunosuppressant
Metabolised to 6-Mercaptopurine (6MP
Works by inhibiting purine production (decrease leucocytes)

211
Q

What are side effects of Azathioprine?

A

Hypersensitivity reactions (including malaise, dizziness, vomiting, diarrhoea, fever, rigors, myalgia, arthralgia, rash, hypotension and interstitial nephrosis) require immediate
withdrawal
Other main SE seen in 2-3% = hepatitis, pancreatitis, pneumonitis

212
Q

What cautions should be used when prescribing Azathioprine?

A

Hepatic impairment: may need to reduce dose
Renal impairment: may need to reduce dose
Reduce dose in elderly
Pregnancy: treatment should not be started during pregnancy, but safe to continue treatment during pregnancy if already on it

213
Q

What are contraindications to Azathioprine prescription?

A

Hypersensitivity to azathioprine or mercaptopurine

Breast feeding

214
Q

Which drugs does Azathioprine interact with?

A

Allopurinol: enhances effect and toxicity of azathioprine, Reduce dose of AZA when allopurinol is given concurrently
Aminosalicylates: possible increased risk of leucopenia
Anticoagulants: reduces anticoagulant effects of coumarins
Antibacterials: risk of toxicity of azathioprine is enhanced with
rifampicin, co- trimoxazole and trimethoprim

215
Q

What are long term risks with use of 6 mercaptopurine?

A

Lymphoma

Non melanotic skin cancers- Use of suncreams

216
Q

What is the mechanism of action of methotrexate?

A

Anti-metabolite folic acid inhibitor
Prevents DNA synthesis and cell division by preventing synthesis of purines and thymydilate. As rapidly dividing cells require thymydilate to synthesise DNA, MTX halts division
Suppression of immune system, improving disease
Immunosuppressant and anti-inflammatory activity

217
Q

What are side effects of methotrexate?

A 
Nausea
Diarrhoea
Stomatitis 
Leucopenia
Pneumonitis 
Hepatitis
Liver fibrosis
218
Q

What monitoring needs doing when on methotrexate?

A

Monitor FBC, U+E’s and LFT’s at baseline and every 2-4 weeks until treatment stabilised

219
Q

What are some cautions and contraindications for methotrexate use?

A 
liver and renal disease 
alcohol
obesity 
diabetes
infections 
pregnancy  
breast feeding
220
Q

Who is eligible for biologic drugs according to nice guidelines?

A 
Severe active Crohn’s disease / UC
AND 
Refractory to immunomodulatory drugs / can nottolerate side effects / experienced toxicity
AND
Surgery inappropriate (UC)
Very good drugs for fistulising disease
221
Q

What is TNF alpha?

A

Pro-inflammatory cytokine
Binds to TNF-alpha receptors on target cells inducing variety of local and systemic effects
TNF Causes local Inflammation in GI tract: diarrhoea, malabsorption
Presumed to be CD4 subset of T cells mediating disease

222
Q

What are side effects of infliximab infusion?

A

Human anti-chimeric Ab formation can develop
Acute hypersensitivity reactions can occur
Symptoms – fever, chills, pruritus, urticaria, chest pain, hypo/hypertension, dyspnoea
Each infusion requires P & BP every 30 mins and access to resuscitation equipment
If mild reaction – slow down / temporarily stop infusion, If severe – stop and give IV hydrocortisone
Delayed hypersensitivity reactions can occur: Fever, rash, myalgia, arthralgia, Up to 2 weeks post infusion
More likely if >12 weeks between infusions
Antibody formation can lead to reduced response to infliximab

223
Q

Why is adalimumab usually better tolerated by younger patients than infliximab?

A

Can be given subcut rather than infusion

224
Q

What are possible complications of biologic drugs for IBD?

A

Possible risk of lymphoma and malignancy: Increased if pt on other immunosuppressants
Infectious complications (VZV, candida): Serious in 3%
TB reactivation (PPD (purified protein derivative) and CXR required prior to treatment)
Interactions tacrolimus / live vaccines

225
Q

What are contraindications to biologic therapy?

A 
Sepsis 
Significantly raised LFTs (x3)
Hypersensitivity to infliximab
Active TB
Pregnancy, avoid for 6 months after
Breast Feeding, stopping treatment
226
Q

What cautions should be applied in prescribing biologic therapy?

A 
Previous TB
Hepatic Impairment
Renal Impairment
Heart Failure
Mouse allergies
> 14 weeks since last infusion
227
Q

Which drugs can cause SIADH?

A

Carbamazepine
Sulphonylureas
SSRIs
TCAs

228
Q

When should calcichew be prescribed if being used as a phosphate binder?

A

With meals

229
Q

How should EPO be prescribed?

A

By brand

230
Q

What is a key pharmacodynamic parameter in dosing of aminoglycosides?

A

Cmax: minimum inhibitory concentration ratio

Therefore once daily dosing is appropriate as it keeps this ratio high enough for longer than multiple lower doses

231
Q

What is the key pharmacodynamic parameter in dosing beta lactam antibiotics?

A

Time antibiotic concentration remains above the MIC of organism expressed as T > MIC
So aim is to maximise duration of exposure

232
Q

Where are bugs located that aminoglycosides are good at killing?

A

Circulating microorganisms

233
Q

Where are bugs located that beta lactams are good at killing?

A

Soft tissue
Bone and joints
Lungs
CSF

234
Q

Which graph is used to look at gentamicin levels?

A

Hartford Nomogram

235
Q

When should gentamicin levels be checked? What level is required for further dose to be given?

A

24 hours post dose

Pre dose level 1mg/L or less

236
Q

Why might a patient’s gent levels be high?

A

Blood collected too early
Patient not clearing Gentamicin
Blood collected from lumen used to infuse Gentamicin earlier on

237
Q

Which bugs are targeted by vancomycin?

A

Gram-positive bacteria including MRSA

238
Q

What vancomycin levels are required for monitoring?

A

Collect serum specimen 30 minutes or less before next dose
Frequency of collection: First level at steady state (3rd - 5th dose)– Subsequent levels once or twice/week
More frequently if renal function changing or concurrent nephrotoxic drugs

239
Q

Which are the safest drugs in renal and liver failure?

A

Beta lactams

240
Q

Which antibiotic drugs are cell wall synthesis inhibitors?

A

Beta Lactam agents: Penicillins, Cephalosporins, Carbapenems, Beta-lactamase inhibitors
Glycopeptides

241
Q

What is a minimum inhibitory concentration?

A

Lowest concentration of antimicrobial required to prevent visible growth after overnight incubation

242
Q

What is the minimum bactericidal concentration?

A

Lowest concentration of antimicrobial required to kill bacteria

243
Q

Which antibiotic drugs are protein synthesis inhibitors?

A

Aminoglycoside: Blocks binding of amino acid charged t-RNA to acceptor site; Miss reading of m-RNA
Tetracycline: Blocks binding of amino acid charged t-RNA to acceptor site
Chloramphenicol: Block growth of peptide chain by interfering with peptidyl transferase
Macrolides: Interfere with translocation of t-RNA on bacterial ribosome preventing further peptide elongation

244
Q

What are aminoglycosides mainly used for? (Gent, streptomycin)

A

Used primarily to treat infections with Gram negative bacilli or in synergic combination with cell wall active antimicrobial agents against some resistant Gram positive bacteria

245
Q

What are features of aminoglycoside antibiotics?

A

Bactericidal
Poorly absorbed orally, so only parenteral (and topical)
Penetrates poorly into CSF, bone, eye, prostate, lung, biliary tract even in inflammation
Toxicity to VIII nerve (irreversible, occur even after discontinuation, cumulative with repeated courses) Gentamicin mainly vestibular, Amikacin mainly auditory and kidney (reversible)

246
Q

How can bugs become resistant to antibiotics?

A

Enzymatic inactivation /destruction of drug: beta lactamase, Penicillinase, Carbapenemase
Modification/bypass of target site
Drug efflux

247
Q

What is the mechanism of action of mirtazapine?

A

Blocks alpha 2 adrenergic receptors which increases release of neurotransmitters - noradrenaline and serotonin

248
Q

What are 2 important side effects of mirtazepine that can be used for benefit?

A

Sedation

Increased appetite

249
Q

In a patient on aspirin/nsaid, what else needs adding if they are to be started on an SSRI?

A

Add PPI to reduce GI bleed risk

250
Q

How does amiodarone cause hyper and hypothyroidism?

A

Hypothyroidism: interferes with conversion of T4 to T3
Hyperthyroidism: thyroiditis, donation of iodine

251
Q

What does highly active anti retroviral therapy involve?

A 
Combination of at least 3 drugs
Usually 2 nucleoside reverse transcriptase inhibitors and either a protease inhibitor or a non nucleoside reverse transcriptase inhibitor 
NRTI: zidovudine, lamivudine 
NNRTI: nevirapine, efavirenz 
Protease inhibitor: ritonavir, indinavir
252
Q

What are side effects of NRTIs?

A

Peripheral neuropathy
Zidovudine: anaemia, myopathy, black nails
Didanosine: pancreatitis

253
Q

What are side effects of NNRTIs?

A

P450 enzyme interaction - inducer

Rash

254
Q

What are side effects of protease inhibitors?

A 
Diabetes
Hyperlipidaemia
Buffalo hump
Central obesity
P450 enzyme inhibition
255
Q

Who should receive statins?

A

All people with established CV disease (stroke, TIA, IHD, peripheral arterial disease)
10 year CV risk 10% or more including type 2 diabetics
Type 1 diabetics diagnosed more than 10 years ago or aged over 40 or have established nephropathy

256
Q

What are major side effects of anti malarial medications?

A

Atovaquone and proguanil (malarone): GI upset
Chloroquine: headache, contraindicated in epilepsy
Doxycycline: photosensitivity, oesophagitis
Mefloquine: dizziness, neuropsychiatric disturbance, contraindicated in epilepsy

257
Q

What are pharmacological management options for postural hypotension?

A

Fludrocortisone

Midodrine

Phase 3 (23 decks)

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