Prescribing and Theraputics

Question 1

Important points to cover when discussing a new medication with a patient?

Answer 1

1. Aim of the treatment 2. How they work (SIMPLE TERMS/LAY LANGUAGE) 3. Specifically how to take the medication (what time? With food? Etc.) 4. How long to take the medication for (?lifelong or short course – be specific) 5. Potential side effects 6. Potential serious adverse events 7. How the medication will be monitored

Question 2

Ramipril - aim of treatment

Answer 2

The aim is to lower your blood pressure and so reduce your risk of heart disease

Question 3

Ramipril - how they work

Answer 3

They work through your kidneys to make your blood vessels wider (dilate), this lowers the pressure inside them and so bringing your blood pressure down.

Question 4

Ramipril - how to take it

Answer 4

Take it once a day, usually in the morning but that doesn’t matter too much. It is a lifelong medication (or at least until we decide to stop)

Question 5

Ramipril - side effect

Answer 5

cough; it lowers blood pressure so you may feel dizzy, if anything significant please speak to your GP

Question 6

Ramipril - monitoring

Answer 6

• For most people this medication helps keep their kidneys healthy but for a small number it has the opposite effect. - For this reason we need to check your kidney blood test 1-2 weeks after you start the prescription and after every time we increase the dose. - We will need to see you back for a blood pressure check in X weeks to ensure it is helping otherwise we may need to adjust your treatment.

Question 7

Metformin - AIM

Answer 7

The aim is to lower your blood sugars and so reduce your risk of diabetic complications such as kidney, eye and sensation problems. It has also been shown to have a positive impact in lowering your risk of developing heart disease

Question 8

Metformin - mechanism

Answer 8

It works by stopping your liver making sugar, reducing the amount of sugar you absorb from you food, and makes your own body’s insulin work better.

Question 9

Metformin - how to take it

Answer 9

Usually metformin will be taken twice a day but that can vary depending on your response to it. Take it until told to stop.

Question 10

Metformin - side effects

Answer 10

The most common side effects are changes in your bowel habit; it can make you very loose and pass more wind that way.

Question 11

Metformin - adverse effects

Answer 11

Whilst it doesn’t affect your kidney directly metformin does need your kidney to be working well for it to be taken safely. We may need to adjust the dose of the medication based on how well your kidney is working, and during times your kidney is under strain (such as when dehydrated, or unwell with an infection) we will stop metformin to let your kidney recover. Otherwise it can make the strain on your kidneys worse.

Question 12

Metformin - monitoring

Answer 12

The main way we will check metformin is helping is through a blood test called HBA1c; we will do one to check 3 months after starting or changing the dose.

Question 13

Atorvastatin - aim

Answer 13

Lowers your cholesterol and so we hope reduces your risk of developing heart disease and stroke

Question 14

Artovastatin - mechanism

Answer 14

It works by blocking part of the process the body does to actually make the cholesterol in the liver. (Note: this is very simplified and you may want to have a quick refresher on how statins work? They also seem to help by having a direct effect on reducing atheroma in addition to the lipid lowering one)

Question 15

Artovastatin - how to take it

Answer 15

Take it once a day at night (physiological studies have shown most cholesterol is made when dietary intake is low in the day - HMG CoA reductase seemingly works better at night and this is what is blocked) lifelong or until we decide to stop it

Question 16

Artovastatin - side effects

Answer 16

Side effects noted from statins seem to be general increase in aches and pains, and headaches. For a number of people it can trigger Diabetes

Question 17

Artovastatin - adverse reactions

Answer 17

A very serious condition where your muscles become very inflamed and broken down, this will make you feel very unwell and can cause your kidney to fail. The risk of this is very very low (around 1 in 250,000) but as it is so serious please seek medical advice straight away if you are concerned

Question 18

Artovastatin - monitoring

Answer 18

Due to the way it works through the liver we check your liver blood tests at 3 and 12 months. We will usually check your cholesterol at 3 months too and look for a positive change (40% reduction LDL for primary prevention)

Question 19

GLICLAZIDE - Aim

Answer 19

Reduces your blood sugar so hopefully lowering risk of kidney, eye and sensation problems that can be caused by high sugar readings in diabetes

Question 20

GLICLAZIDE - mechanism

Answer 20

It works by helping to release more of your body’s own natural insulin

Question 21

GLICLAZIDE - how to take it

Answer 21

Usually taken twice a day but depends on response too, take lifelong or until decided otherwise.

Question 22

GLICLAZIDE - side effect

Answer 22

Common side effects include weight gain, and some change in bowel habit. Unlike metformin they can lower your blood sugar levels too much and cause a HYPOglycaemic episode – you may feel shivery, tremble, drowsy, and worse case may pass out.

Question 23

GLICLAZIDE - adverse effect

Answer 23

Rarely they can cause a serious irritation of your liver, or lead to a reduced number of blood cells that fight an infection, or stop bleeding, or cause a significant anaemia. These are very rare but if you notice any changes in your skin colour, or easy bruising see doctor straight away.

Question 24

GLICLAZIDE - monitoring

Answer 24

Effect is monitored by checking your blood sugar levels usually 3 months after starting or changing the dose (HBA1c) and we will probably check your liver blood tests and full blood count then too

Question 25

OMEPRAZOLE - aim

Answer 25

The aim is to reduce your natural stomach acid and so get rid of your heartburn/indigestion or allow your stomach ulcer to heal.

Question 26

OMEPRAZOLE - mechanism

Answer 26

They block the final stage of releasing the acid into the stomach

Question 27

OMEPRAZOLE - how to take it

Answer 27

Usually you would take them once a day (at least at the start) but sometimes it can be twice a day, especially if treating Helicobacter infection. The course is usually short term, and for most cases can be reassessed at about 4 weeks but longer courses may be required.

Question 28

OMEPRAZOLE - side effects

Answer 28

Usually well tolerated but like all medications can cause some side effects such as abdominal bloating, abdominal pain, and bowel changes. Long term use can lead to low blood magnesium and sodium levels, worth checking these if patients at high risk (on diuretics or digoxin – bnf), and can increase risk of CDT infection alongside certain antibiotics (and risk of pneumonias)

Question 29

OMEPRAZOLE - adverse effects

Answer 29

Longterm use MAY be associated with increased risk of dementia and heart disease but that causality has not yet been fully established but worth stating at initiation re the short term nature of the prescription, and being mindful for future reviews to trial stopping therapy (may cause rebound acid secretion when stopped so consider h2 receptor antagonist ie ranitidine as shorterm replacement)

Question 30

OMEPRAZOLE - monitoring

Answer 30

So monitoring for longterm use is targeting high risk groups for yearly renal, and magnesium blood checks and obviously checking clinical need for ongoing treatment

Question 31

BECLOMETASONE INHALER - aim & mechanism

Answer 31

Asthma attacks are caused by inflammation and swelling in the airways. This leads to narrowing of the passages and the subsequent difficulty breathing/wheeze/cough etc. Inhaled corticosteroids work to reduce this inflammation by reducing the type of blood cells and proteins involved with this process. So should cause a reduction in your asthma symptoms

Question 32

BECLOMETASONE INAHLER - how to take it

Answer 32

Inhaled – usually 2 puffs twice a day (obviously depending on dose of inhaler and age etc). One puff at a time (worth going in to inhaler technique here?). Use of a spacer is recommended especially for those with poorer technique and to help prevent local side effects of the inhaler

Question 33

Beclometasone inhaler - TX plan

Answer 33

ICS are a mainstay of treatment of asthma but current guidance disagree on their positioning. The BTS guidance list them now as first line (2016) whilst NICE (2018) continue to recommend SABA as first line but BTS argue this is on basis of cost effectiveness and not effectiveness. So depending on whose advice you take patients with asthma would either stay on forever (BTS) or be reviewed once symptoms controlled for 3 months (NICE)

Question 34

Beclometasone inhaler - Side effects

Answer 34

Side effects are relatively limited – sore throat, poral thrush., hoarse voice can happen. They can be reduced/avoided by use of spacer and swilling mouth out after taking dose. Some evidence that usage is associated with increased risk of pneumonias

Question 35

Beclometasone inhaler - monitoring

Answer 35

Effectiveness is main monitoring requirement – use of SABA 3 x a week should lead to consideration of increasing treatment