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Year 6 > Prescribing Safety > Flashcards

Prescribing Safety Flashcards

1
Q

What information is important to include on the drug chart if a drug is being used ‘as required’? (2)

A
  1. The maximum dose or the maximum frequency

2. The indication

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2
Q

What information is important to include on the drug chart if an antibiotic is prescribed? (2)

A
  1. The indication

2. The stop/review date

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3
Q

When is it important to include duration on the drug chart?

A

If the drug is not long term e.g. antibiotic

If the drug is prescribed in the GP setting

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4
Q

The general rule is don’t use the trade name of drugs, however which drug is an exception to the rule?

A

Tacrolimus - it is important to use the brand name because switching between brands can cause toxicity

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5
Q

What are the enzyme inducer drugs (use the pneumonic)?

A

PC BRAS

P - Penytoin 
C - Carbamezapine 
B - Barbiturates 
R - Rifampicin 
A - Alcohol (chronic excess) 
S - Sulphonylureas
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6
Q

Whats are the enzyme inhibitor drugs? (use the pneumonic)

A

AO DEVICES

A - Allopurinol
O - Omeprazole 
D - Disulfiram 
E - Erythromycin 
V - Valporate 
I - Isoniazid 
C - Ciprofloxacin 
E - Ethanol (acute intoxication) 
S - Sulphonamides
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7
Q

What is an example of an enzyme inibitor interaction?

A

Warfarin and Erythromycin
Erythromycin as an enzyme inhibitor can increase the drug concentration of Warfarin therefore causing the INR to dangerously increase, if the Warfarin is not reduced

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8
Q

Why are patients on long-term steroids unable to mount an adequate sick response?

A

They have adrenal atrophy

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9
Q

What should a patient on long-term steroids receive before surgery and why?

A

IV steroids at induction of anaesthesia
This is because they are unable to mount the stress response therefore would have profound hypotension otherwise

It is similar to patients taking double the dose of their steroids on sick days

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10
Q

Which drugs should be stopped before surgery? ( used the pneumonic)

A

I LACK OP

I - Insulin
L - Lithium 
A - Anticoagulants/antiplatelets 
C - COCP/HRT
K - K-sparing drugs

O - Oral hypoglycaemics
P - Perindopril and other ACE-inhibitors

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11
Q

When do you stop the COCP/HRT before surgery?

A

4 weeks before surgery

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12
Q

When do you stop Lithium before surgery?

A

Day before surgery

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13
Q

When do you stop potassium-sparing diuretics before surgery?

A

Day of surgery

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14
Q

When do you stop ACE inhibitors before surgery?

A

Day of surgery

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15
Q

When do you stop anticoagulants (inc prophylaxis dose) and antiplatelets?

A

Variable between hospitals and operations (some are even continued through the operation)

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16
Q

When should Oral hypoglycaemics be stopped before surgery?

A

Variable between hospitals and operations

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17
Q

Why should Oral hypoglycaemics be stopped before surgery? What should be done instead

A

Patients are nil by mouth before surgery therefore should not take metformin as it may cause lactic acidosis
A sliding scale should be used instead with hourly blood glucose monitoring and adjusting as appropriate (tighter control)

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18
Q

What is the pneumonic to help with prescribing?

A

PReSCRIBER

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19
Q

What does PReSCRIBER stand for?

A 
P - Patient details 
Re - Reaction (i.e. allergy plus the reaction) 
S - Sign the front of the chart 
C - Contraindications 
R - Route for each drug 
I - Intravenous fluids if needed 
B - Blood clot prophylaxis if needed 
E - antiEmetics if needed 
R - pain Relief if needed
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20
Q

How many pieces of patient identifying info needs to be on a drug chart and give examples of suitable ones?

A

3 are needed:
Patient name
DOB
Hospital number

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21
Q

Which two drugs contain penicillin, in a way which is not obvious?

A

Co-amoxiclav - amoxicillin and clavulanic acid

Tazocin - pipercillin and tazobactam

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22
Q

What are the 4 main groups of drugs, that i must know the contraindications for?

A
  1. Drugs that increase bleeding (anticoagulants, antiplatelets)
  2. Steroids
  3. NSAIDs/Aspirin
  4. Anti- hypertensives
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23
Q

In which patients are antiplatlets/anticoagulants contraindicated?

A

Bleeding
Suspected bleeding
At risk of bleeding

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24
Q

Give an example of why a patient might be at risk of bleeding

A

Prolonged prothrombin time due to liver disease

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25
Q

What pneumonic can be used for the side effects of steroids?

A

STEROIDS

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26
Q

What does the STEROIDS pnuemonic stand for?

A 
S - Stomach ulcers 
T - Thin skin 
E - oEdema 
R - Right and Left heart failure 
O - Osteoporosis 
I - Infection (inc Candida) 
D - Diabetes (commonly causes hyperglycaemia and uncommonly progresses to diabetes) 
S - cushing's Syndrome
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27
Q

What is the ‘safety considerations’ pneumonic for NSAIDs?

A

NSAID

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28
Q

What does the NSAID pneumonic stand for?

A 
N - No urine (i.e. renal failure) 
S - Systolic dysfunction (i.e. heart failure) 
A - Asthma 
I - Indigestion (any cause) 
D - Dyscrasia (clotting abnormality)
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29
Q

Why is Aspirin not subject to the same level of caution as NSAIDs used for pain management?

A

Because although it is an NSAID, it is not used at relatively low doses for the management of cardiovascular and cerebrovascular disease which is not necessary for those extra precautions

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30
Q

What are the 3 anti-hypertensive side effect categories you should always classify in?

A
  1. Hypotension
  2. Mechanism: Bradycardia or Electrolyte disturbance
  3. Individual drug
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31
Q

Which anti-HTNs can cause hypotension?

A

All of them

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32
Q

What is the earliest symptom of hypotension?

A

Postural hypotension

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33
Q

Which antihypertensives cause bradycardia?

A

Beta blockers (and some calcium channel blockers)

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34
Q

Which CCBs have a bradycardia effect and why?

A

The non-dihydropyridines - because they have inhibitory effects on the SAN and AVN

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35
Q

What are the non-dihydropyridines useful for treating?

A

Hypertension, reduces oxygen demand, and helps to control the rate in tachyarrhythmias

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36
Q

Give drug examples of non-dihyrdropyridine (2)

A

Diltiazem

Verapamil

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37
Q

What is the effect of the dihydropyridine CCBs?

A

Peripheral vasodilators + have very little effect on the myocardium

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38
Q

What are the dihydropyridine CCBs used for? (3)

A
  1. Hypertension

2. Post-intracranial haemorrhage associated vasospasm 3. Migraines

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39
Q

Which anti-HTNs cause electrolyte disturbance?

A
  1. ACE- inhibitors

2. Diuretics

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40
Q

4 individual anti-HTN drugs have their own side effects - name the 4 drugs

A
  1. ACE inhibitors
  2. Beta blockers
  3. CCBs
  4. Diuretics
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41
Q

Give an example of dihydropyridine drugs (3)

A
  1. Amlodipine
  2. Nifedipine
  3. Nicardapine
    These end in -pine
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42
Q

What is the individual side effect of ACE-Inhibtors?

A

Dry cough

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43
Q

What are the individual side effects of Beta blockers? (2)

A

Wheeze in asthmatics

Worsening of acute heart failure (but help in chronic heart failure)

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44
Q

What is the individual side effect of CCBs? (2)

A

Peripheral oedema and flushing

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45
Q

What is the individual side effect of Diuretics? (3)

A
  1. Renal failure
  2. Thiazide diuretics can cause gout
  3. Potassium-sparing diuretics can cause gynaecomastia
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46
Q

Name an example of a thiazide diuretic

A

Bendroflumethiazide

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47
Q

Name an example of a potssium-sparing diuretic

A

Spironolactone

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48
Q

If a patient is Nil by mouth, can they still recieve their oral medication before surgery?

A

Yes they can and should

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49
Q

If a patient is vomiting a lot how should you give the antiemetic?

A

non oral: i.e. IV, IM, SC

NOTE: cyclizine and metoclopramide doses dont change regardless of the route

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50
Q

IV fluid replacement - you always give 0.9% saline except in which 4 cases?

A
  1. Hypernatraemic
  2. Hypoglycaemic
  3. Ascites
  4. Shocked from bleeding
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51
Q

What replacement fluid do you give if someone is hypernatraemic?

A

5% dextrose

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52
Q

What replacement fluid do you give if someone is hypoglycaemic?

A

5% dextrose

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53
Q

What replacement fluid do you give if someone has ascites? and why?

A

Human-albumin solution (HAS) - the albumin maintains oncotic pressure (the higher sodium content in 0.9% saline will worsen ascites)

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54
Q

What replacement fluid do you give if someone is shocked from bleeding?

A

Blood transfusion (but give crystalloid first if no blood is available)

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55
Q

If someone is tachycardic or hypotensive how much /how fast do you give replacement fluids? (what about if they have heart failure?)

A

500ml bolus immediately

if HF then 250ml bolus immediately

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56
Q

How much/how fast do you give replacement fluid if they are only oliguric (and it is not due to urinary tract obstruction?)

A

1L over 2-4 hours

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57
Q

In the following scenarios state roughly how fluid depleted each individual is:

  1. reduced urine output (<30ml/h)
  2. reduced urine output + tachycardia
  3. reduced urine output + tachycardia + shocked
A
    • 500ml depleted
  2. 1L depleted
  3. > 2L fluid depleted
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58
Q

What is the max rate of infusion for IV potassium?

A

10 mmol/hr

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59
Q

How much maintenance fluids do adults vs elderly require as a general rule?

A

adults 3L IV fluids/ 24 hours

elderly 2L IV fluids/24 hours

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60
Q

What bags of fluid would you usually give for maintenance?

A

1 salty 2 sweet
(remember sweet tooth)
1 L of 0.9% saline
2 L of 5% dextrose

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61
Q

With a normal potassium level, how much potassium is needed per day in the maintenance fluids and how do you administer this?

A

adults need 40 mmol of K+ per day

Put 20 mmol KCl in 2 of the maintenance fluids bags

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62
Q

How fast do you give maintenance fluids in adults vs elderly?

A

adults 3L /24 hours - therefore 8 hourly

elderly 2L/12 hours - therefore 12 hourly

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63
Q

What do most pts coming into hospital receive for VTE prophylaxis? (2)

A

LMWH e.g. dalteparin 5000 units daily SC

and compression stockings

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64
Q

Which pts should not be prescribed compression stockings?

A

Those with peripheral arterial disease (indicated by abscent foot pulses)

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65
Q

What might happen if a patient with peripheral arterial disease is prescribed compression stockings?

A

Acute limb ischaemia

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66
Q

In which patients (2) should the antiemetic metoclopramide be avoided? why?

A
  1. Parkinson’s disease as it is a dopamine antagonst so can exacerbate symptoms
  2. Young women - due to risk of dyskinesia (esp acute dystonia)
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67
Q

Which antiemetics can you give if a patient is nauseated? (3) - include the dose and route

A

Cyclizine 50 mg 8 hourly IM/IV/oral
Metoclopramide 10mg 8 hourly IM/IV (if HF)
Ondansetron 4mg or 8mg 8 hourly IV/oral

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68
Q

When should Cyclizine be avoided and why?

A

In HF as it causes fluid retention

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69
Q

Which antiemetics can you give if a patient is NOT nauseated?

A

Cyclizine 50 mg UP TO 8 hourly (IV/IM/oral)
Metoclopramide 10mg UP TO 8 hourly (IM/IV) if HF
these are given PRN if not nauseated

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70
Q

Which analgesic do you give regularly if there is no pain?

A

NONE! if there is no pain, it shouldnt be regular, but PRn

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71
Q

Which analgesic do you give as required if there is no pain?

A

Paracetamol 1g up to 6 hourly oral

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72
Q

Which analgesic do you give regularly if there is mild pain?

A

Paracetamol 1g 6 hourly oral

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73
Q

Which analgesic do you give as required if there is mild pain?

A

Codeine 30 mg up to 6 hourly oral

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74
Q

Which analgesic do you give regularly if there is severe pain?

A

Co-codamol 30/500, 2 tablets 6 hourly oral

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75
Q

Which analgesic do you give as required if there is severe pain?

A

Morphine sulfate (10mg/5mL) 10 mg up to 6 hourly oral

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76
Q

Draw the table of analgesic choices

A

(see page 10 of PSA book)

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77
Q

How does oramorph come?

A

A a liquid

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78
Q

When are NSAIDs used in the analgesic choices?

A

At any stage they can be introduced regularly or PRN if not contraindicated

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79
Q

What is the first line analgesic for neuropathic pain?

A

Amitriptyline 10 mg oral nightly or pregabalin 75 mg oral 12 hourly

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80
Q

What is the maximum dose of paracetamol in patients >50kg vs <50kg?

A

> 50kg - max is 4g in 24 hours (this is 1g 6 hourly)

<50kg -max is 2g in 24 hours (this is 500mg 6 hourly)

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81
Q

What is a common mistake leading to overprescribing paracetamol?

A

Giving co-codamol and paracetamol

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82
Q

What are the 3 causes of a microcytic anaemia?

A
  1. Iron deficiency
  2. Thalassaemia
  3. Sideroblastic anaemia
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83
Q

What are the 4 causes of normocytic anaemia?

A
  1. Anaemia of chronic disease
  2. Acute blood loss
  3. Haemolytic anaemia
  4. Renal failure (chronic)
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84
Q

What are the 6 causes of megaloblastic anaemia

A
  1. B12 deficiency
  2. Folate deficiency
  3. Liver disease
  4. Excess alcohol
  5. Hypothyroidism
  6. Hamatological diseases beginning with M -myeloproliferative, myelodysplastic, multiple myeloma
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85
Q

Which type of anaemia is pernicious anaemia and why?

A

Macrocytic - becasue in pernicious anaemia there if a deficency of B12

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86
Q

What are the three causes of neutrophilia (high neutrohils)?

A
  1. Bacterial infection
  2. Tissue damage (inflammation, infarct, malifgnancy)
  3. Steroids
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87
Q

What are the 4 causes of neutropenia (low neutrophils)?

A
  1. Viral infection
  2. Clozapine (antipsychotic)
  3. Carbimazole (antithyroid)
  4. Chemotherapy or radiotherapy
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88
Q

Thrombocytopaenia can can be caused by reduced production or increased destruction - what are the 3 causes of reduced production?

A
  1. infection (viral)
  2. drugs e.g. penicillamine
  3. myelodysplasia, myelofibrosis, myeloma
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89
Q

Thrombocytopaenia can can be caused by reduced production or increased destruction - what are the 5 causes of increased destruction?

A
  1. Heparin
  2. Hypersplenism
  3. DIC (disseminated intravascular coagulation)
  4. Idiopathic Thrombocytopaenic purpura
  5. HUS (haemolytic uraemic syndrome)/TTP (thromboric thrombocytopaenic purpura)
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90
Q

What are the reactive causes of thrombocytosis (high platelets)? (3)

A
  1. Bleeding
  2. Tissue damage (infection/inflammation/malignancy)
  3. Post-splenectomy
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91
Q

What is the primary cause of thrombocytosis (high platelets)?

A

Myeloproliferative disorders

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92
Q

What types of hyponatraemia can hypothyroidism cause?

A

Euvalaemic and Hypervolaemic

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93
Q

Which drugs tend to cause SIADH?

A

Carbamezapine and antipsychotics

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94
Q

Hypernatraemia causes all begin with D - what are they? (4)

A
  1. Dehydration
  2. Drips (too much IV saline)
  3. Drugs
  4. Diabetes insipidus
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95
Q

What are the pneumonics for Hypokalaemia and Hyperkalaemia and what is a good way to remember which pneumonic goes with which?

A

Hypokalaemia: DIRE
Hyperkalaemia: DREAD
(I dread TOO MUCH work)

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96
Q

List the causes of Hypokalaemia

A

D - drugs (loop and thiazide diuretics)
I - inadequate intake or intestinal loss (diarrhoea/vomiting)
R - renal tubular acidosis
E - endocrine (Cushing’s and Conn’s syndromes)

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97
Q

List the causes of Hyperkalaemia

A

D - Drugs (potassium sparing diuretics and ACE-inhibitors)
R - Renal failure
E - Endocrine (Addisons’s disease)
A - Artefact (very common due to clotted sample)
D - DKA (but when insulin is given the K+ drops)

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98
Q

What two things can a raised urea indicate?

A

Kidney injury OR an upper GI bleed

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99
Q

Why does urea increase in an upper GI bleed?

A

Because it is a breakdown product of amino acids e.g. globin chains in haemoglobin)
Or the haemoglobin in the blood can be broken down by gastric acid and then the urea absorbed into the bloodstream (this is what happens if someone has a bloody steak)

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100
Q

If a patient has a raised urea and is not dehydrated what should this prompt you to look at and why?

A

Their haemoglobin because if it has dropped the patient has probably had an upper GI bleed

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101
Q

What are the pre-renal causes of acute kidney injury? (4)

A
  1. dehydration
  2. sepsis
  3. blood loss
  4. renal artery stenosis
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102
Q

What are the intrinsic causes of acute kidney injury?

A 
INTRINSIC 
Ischaemia (due to pre-renal AKI causing acute tubular necrosis) 
N - nephrotoxic antibiotics 
Tablets (ACEi , NSAIDs)
Radiological contrast 
Injury (rhabdomyolysis) 
Negatively birefringent crystals (gout) 
Syndromes (glomerulonephritidies) 
Inflammation (vasculitis)
Cholesterol emboli
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103
Q

What are the nephrotoxic antibiotics?

A

Gentamycin
Vancomycin
Tetracyclines

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104
Q

Sometimes in severe pre-renal AKI, creatinine can also rise - if this happens how can you differntiate from non pre-renal causes?

A

urea x 10 - if it exceeds the creatinine then it means a relatively greater increase in urea compared to creatinine which suggests pre-renal aetiology

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105
Q

What are the 4 markers of hepatocyte injury or cholestasis?

A
  1. Bilirubin
  2. ALT
  3. AST
  4. ALP
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106
Q

What are the markers of synthetic function? (2)

A

Albumin

Vitamin K-dependent clotting factors

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107
Q

Which 2 investigations give an idea of the vitamin K-dependent clotting factors?

A

Prothrombin time

INR

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108
Q

How do you divide up the causes of post-renal causes of AKI?

A

In lumen
In wall
External pressure

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109
Q

What are the in lumen causes of a post-renal AKI? (2)

A
  1. Stone

2. Sloughed papilla

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110
Q

What are the In wall causes of a post renal AKI? (2)

A
  1. Tumours:
    Renal cell carcinoma
    Transitonal cell carcinoma
  2. Fibrosis
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111
Q

What are the External pressure causes of a post renal AKI? (4)

A

BPH
Prostate cancer
Lymphadenopathy
Aneurysm

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112
Q

What is the pattern of LFT derrangement in pre-hepatic jaundice?

A

Raised bilirubin on its own

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113
Q

What is the pattern of LFT derrangement in intrahepatic jaundice?

A

Raised bilirubin

raised ALT/AST

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114
Q

What is the pattern of LFT derrangement in post-hepatic jaundice?

A

Raised bilirubin

raised ALP

115
Q

What are the causes of pre-hepatic jaundice? (3)

A

Haemolysis
Gilberts syndrome
Crigler-Najjar syndrome

116
Q

What are the causes of intrahepatic jaundice? (6)

A

Fatty liver
Hepatitis
Cirrhosis
Malignancy (primary or secondary)
Metabolic: Wilson’s disease / Haemochromatosis
Heart Failure (causing hepatic congestion)

117
Q

In the intrahepatic causes of jaundice - what can be the causes of hepatitis and cirrhosis?

A

Alcohol
Viruses (Hep A-E, CMV, EBV)
Drugs (paracetamol overdose, statins, rifampicin)
Autoimmune causes: PBC, PSC, autoimmune hepatitis

118
Q

What are the causes of post-hepatic jaundice? (using the structure: In lumen, In wall, external pressure)

A

In lumen: stone (gallstone), drugs causing cholestasis
In wall: Tumour (cholangiocarcinoma), PBC, PSC
External pressure: Pancreatic or gastric cancer, lymph node

119
Q

Which drugs cause cholestasis? (5)

A
  1. Flucloxacillin
  2. Co-Amoxiclav
  3. Nitrofurantoin
  4. Steroids
  5. Sulphonylureas
120
Q

Using the pneumonic ALKPHOS, list the causes of raised ALP

A 
Any fracture 
Liver damage (post-hepatic)
K cancer 
Paget's disease of the bone / Pregnancy 
Hyperparathyroidism 
Osteomalacia 
Surgery
121
Q

Causes of primary hypothyroidism

A

Hashimotos thyroiditis

Drug induced hypothyroidim

122
Q

Causes of secondary hypothyroidism

A

Pituitary tumour

damage

123
Q

Primary hyperthyroidism causes

A

Grave’s disease
Toxic nodular goiter
drug induced hyperthyroidism

124
Q

Secondary causes of hyperthyroidism

A

Pituitary tumour

125
Q

On CXR how do you check for rotation?

A

The distance between the spinous processes and the clavicle should be equal

126
Q

How can you check for good inspiration on CXR?

A

The 7th anterior rib should transect the diaphragm

127
Q

white areas on CXR - diagnose the following:

  1. unilateral and solid
  2. unilateral and fluffy
  3. bilateral and fluffy
  4. bilateral and honeycomb
A
  1. pleural effusion
  2. pneumonia
  3. pulmonary oedema
  4. pulmonary fibrosis
128
Q

If you spot cardiomegaly, pleural effusion or pulmonary oedema on CXR what else should you check for?

A

ABCDE signs of HF
A - alveolar oedema (bats wings)
B - Kerley B lines (interstitial oedema)
C - cardiomegaly
D - upper lobe diversion (vessels in the upper zone are larger than the vessels in the lower zone)
E - Effusions

129
Q

What does air under the right hemi-diaphragm suggest?(2)

A

Bowel preforation

recent surgery

130
Q

What is sail sign and what does it suggest?

A

Sail sign = a triangle behind the heart

suggests left lower lobe collapse

131
Q

If the apices are not clear, what DDx should you consider (2)?

A 
TB 
apical tumour (pancoast)
132
Q

What type of breathing do you get in type 1 resp failure vs type two resp failure?

A

Type 1 = fast / normal breathing

Type 2 = slow/shallow breathing

133
Q

What causes type I resp failure?

A

Anything that damages the heart of lungs causing SOB

134
Q

What causes type 2 resp failure?

A

‘blue-bloaters’ of COPD
neuromuscular failure
restrictive chest wall abnormalities

135
Q

What causes respiratory alkalosis?

A

rapid breathing - either from disease or anxiety

136
Q

What causes respiratory acidosis?

A

The same causes as type I resp failure

137
Q

What causes metabolic alkalosis?

A

Vomiting
Diuretics
Conn’s syndrome

138
Q

What causes metabolic acidosis?

A

anion gap high: lactic acidosis, DKA, ethanol/methanol/ethylene glycol poisoning), renal failure (due to uraemia)

139
Q

How big does that PR interval need to be for first degree heart block?

A

> 1 large square (>5 small squares)

140
Q

If QRS >3 small squares what does this suggest?

A

Bundle branch block

141
Q

How can you detect LVH on ECG?

A

Add the largest deflection in V1 to the largest deflection in V6 - if the sum is >3.5 large squares then LVH

142
Q

Other than ischaemia/infarction, what else can cause ST depression?

A

Digoxin - ST segment down-sloping in all leads

143
Q

How can you detect hyperkalaemia by T waves on ECG

A

If the height f the T waves is >2/3 the QRS height throughout the ECG then hyperkalaemia present

144
Q

T wave inversion in which leads suggests old infarction/LVH?

A

leads aVR and lead I (top middle two leads)

145
Q

Which are the drugs which commonly need monitoring?

A 
Lithium 
Digoxin 
Theophylline 
Phenytoin 
Gentamicin 
Vancomycin
146
Q

If there is an adequate response to the drug, but the serum level is high what should you do? However which drug is an exception to this and what do you do instead?

A

Decrease the dose
Gentamicin is an exception - instead of omitting the drug, you decrease the frequency by 12 hours rather than reducing the dose e.g. changing from every 24 hours to every 36 hours

147
Q

If there serum drug level is very high and there is toxicity, what might you consider doing?

A

Omitting the drug for a few days

148
Q

If toxicity is evident- what are the 3 options?

A
  1. stop drug
  2. supportive measures (usually IV fluids)
  3. give antidote (if available)
149
Q

What are toxicity features of digoxin? (4)

A
  1. confusion
  2. nausea
  3. visual halos
  4. arrhythmias
150
Q

What are the toxicity features of lithium? (early (1) , intermediate (1), late(5)

A

Early: tremor
Intermediate: tiredness
Late: Arrhythmias, seizures, coma, renal failure, diabetes insipidus

151
Q

What are the toxicity features of phenytoin?

A 
Gum hypertrophy
Ataxia 
Nystagmus 
Peripheral neuropathy 
Teratogenicity
152
Q

What are the toxicity features of gentamicin?

A

Ototoxicity and nephrotoxicity

153
Q

What are the toxicity features of vancomycin?

A

Ototoxicity and nephrotoxicity

154
Q

If there is a patient on Warfarin and there is a major bleed causing hypotension of bleeding into a confined space e.g. brain or eye - what 3 things should be done?

A
  1. Stop warfarin
  2. Give IV Vit K (5-10 mg)
  3. Give prothrombinase complex
155
Q

If INR is 5-8 and there is No bleeding - what do you do?

A

Omit warfarin for 2 days then reduce dose

156
Q

If INR is >8 and there is no bleeding what do you do?

A

Omit warfarin and give 1-5mg PO Vit K

157
Q

If INR is 5-8 and there is minor bleeding what do you do?

A

Omit warfarin and give 1-5mg IV vitamin K

158
Q

If INR >8 and there is minor bleeding what do you do?.

A

Omit warfarin and give 1-5mg IV vitamin K

159
Q

What is the triad of symptoms that means opioid overdose until proven otherwise?

A
  1. reduced GCS
  2. Pinpoint pupils
  3. Respiratory depression
160
Q

What is the triad which points to anticholinergic overdose?

A

DDD
Dry
Dilated
Delirious

161
Q

What is the fun rhyme for anticholinergic overdose?

A 
Mad as a hatter (confused and agitated) 
Hot as hell (hyperpyrexia) 
Blind as a bat (dilated pupils) 
Dry as a bone (dry mouth, eyes and retention) 
Red as a beet (flushing)
162
Q

What is the most common cause of anticholinergic overdose?

A

Tricyclic antidepressants

163
Q

Which medications can cause serotonin syndrome?

A 
SSRIs 
Tricyclic antidepressants 
Monoamine oxidase inhibitors 
Opioids 
Amphetamines 
MDMA 
Cocaine 
Ondansetron
164
Q

What medication can help in Serotonin syndrome?

A

Benzodiazepines - helps the agitation and muscle rigidity

165
Q

What should be avoided in serotonin syndrome and why?

A

IV fluids due to risk of hyponatraemia

if you do need to use fluids use hypertonic saline

166
Q

What time of day should ACE inhibitors be taken and why?

A

Night time because they can cause postural hypotension

167
Q

Write the insulin prescription for hyperkalaemia

A

Actrapid 10 Units in 100ml of 20% dextrose, over 30 mins

168
Q

What do you need to be careful of when starting a patient on Carbamezapine?

169
Q

When would Metformin not be used first line in T2DM??

A

If Creatinine is >150 as it can cause lactic acidosis

170
Q

Why should Metformin be used first line in overweight patients?

A

It causes appetite suppression

171
Q

Give 4 examples of sulphonylureas for diabetes?

A
  1. Gliclazide
  2. Tolbutamide
  3. Glipizide
  4. Glipenclamide
172
Q

What is the mechanism of action of Metformin?

A

Helps increased sensitivity to insulin (encourages cells to respond better to insulin and take up more glucose from the blood stream)

173
Q

What is the mechanism of action of sulphonylureas?

A

Stimulate production of insulin from the pancreas

174
Q

Why is Glibenclamide a less appropriate starting drug for T2DM?

A

It is a longer-acting sulphonylurea

175
Q

What time of day/when should gliclazide be taken?

A

With the first meal

176
Q

What is the mechanism of NSAIDs causing stomach ulcers?

A

They inhibit prostaglandin synthesis which is needed for gastric mucosal protection from acid- hence inflammation and ulceration

177
Q

What is the mechanism of streroids causing stomach ulcers?

A

They inhibit gastric epithelial renewal

178
Q

What are the symptoms of mild vs moderate vs severe lithium toxicity?

A

mild - tremor
moderate - lethargy
severe - seizures, renal failure, coma, arrhythmia

179
Q

If the dose of Lithium has not been changed why might the plasma levels increase? (2)

A

Reduced breakdown

Reduced excretion

180
Q

What can cause reduced breakdown of Lithium?

A

Cytochrome P450 enzyme inhibitors

- check for AO DEVICES

181
Q

Which drugs can cause reduced excretion of Lithium? (4)

A

ACE- inhibitors
Diurectics (in particular thiazide diuretics e.g. bendroflumethiazide)
NSAIDs

182
Q

If a diuretic must be given whilst a patient is on Lithium, which one should be given?

A

Loop diuretics e.g. furosemide

183
Q

What dose of adrenaline is give IV during cardiac arrest?

A

1mg or 1 : 10,000 adrenaline

184
Q

In pulmonary oedema, when should patients be considered for NIV?

A

If they remain hypoxic on 100% oxygen vis a non-rebreathe mask

185
Q

Over what time frame does angio-oedema caused by ACE-inhibitors typically occur?

A

Over months - it takes time before it appears as the bradykinin needs time to build up first

186
Q

What two things are important to monitor with ACE-inhibitors and when do you do the bloods?

A

K+ and renal function

Blood test 1-2 weeks after starting

187
Q

Why shouldnt’ statins be used in patients with active liver disease?

A

The metabolism of the statin may be affected

188
Q

What is a side effect of statins?

A

Myositis - patients can get muscle cramps - unusual aches and pains

189
Q

What time of day are statins taken?

A

Night time

190
Q

What is the dietary restriction for patients taking a statin and why?

A

Grape fruit should be avoided because it contained polyphenolic compounds that can be an enzyme inhibitor (of CYP3A4) and so increases statin toxicity

191
Q

Which antibiotic, would make you with-hold statins during the time of antibiotic treatment and why?

A

Clarithromycin as it is a CYP3A4 inhibitor and so increases the toxicity and associated side effects of statins

192
Q

Why should patients on long courses of steroid never have the steroid stopped suddenly?

A

Risk of Addisonian crisis

193
Q

What card should those on long term steroids carry with them?

A

A steroid therapy card

194
Q

Patients on steroids are at risk of hypertension or hypotension?

A

Hypertension

195
Q

What should be checked before starting methotrexate?

A

FBC
Liver function
Renal function

196
Q

Describe the monitoring of methotrexate once started

A

FBC, LFTs and renal function tests should be carried out every 1-2 weeks until the therapy is stabilised
Then they should be checked ever 2-3 months

197
Q

What safety net is important to give to patients on methotrexate?

A

Be cautious of sore throat

- because they can get neutropaenia

198
Q

How often is methotrexate taken?

A

once a week

199
Q

What is a potential side effect of methotrexate?

A

Pulmonary toxicity (breathlessness, dry cough, fatigue)

200
Q

What group of medications shouldn’t be used at the same time as methotrexate and why? Give 2 examples of such drugs

A

Folate antagonists - they will increase the folate antagonism (as methotrexate is also one) - this can put the patient at risk of bone marrow suppression and subsequent neutropaenic sepsis

Examples: Trimethoprim and Co-trimoxazole

201
Q

What needs to be monitored for patients on Olanzapine?

A

Lipids and wieght

202
Q

Describe the monitoring of Olaanzapine and explain how this is different to other anti-psychotics?

A 
Weight and Lipids 
Olanzapine: 
Measure weight and lipids at: 
1. Baseline  
2. Every 3 months for the 1 year 
3. Annually 
Other antipsychotics: measure at base line, then at 3 months and then annually 
Fasting Glucose 
Olanzapine: 
Measure fasting blood glucose at: 
1. Baseline 
2. at 1 month 
3. Every 4-6 months

Other antispychotics: measure at baseline, at 4-6 months and then annually

203
Q

Why is an ECG sometimes needed in patients taking Olanzapine?

A

Because Olanzapine can cause a prolonged QTc interval

204
Q

In which patients would you consider doing an ECG in if they are started on Olazapine?

A

Those with cardiovascular risk factors or a personal history of cardiovascular disease

205
Q

If Olanzapine is stopped in the first ____ there is a considerable risk of relapse

206
Q

How do you decide between codeine and tramadol as the weak opioid to use in the WHO ladder?

A

Dependent on the side effect profile

  • Codeine - has more constipation side effect
  • Tramadol has more hallucinogenic and agitation side effect (particularly in the elderly so you want to avoid in the elderly )
207
Q

Some people with penicillin allergy may have cross reactivity and therefore also be allergic to which other antibiotic groups?

A

Cephalosporins

Carbapenems

208
Q

What is first line treatment for hospital acquired pneumonia?

A

Piperacillin and Tazobactam (Tazosin- but dont write tazosin on a drug chart)

209
Q

Why can’t you use CURB-65 score with Hopsital acquired pneumonia?

A

It is only for community acquired pneumonia - remember the purpose of the score is to determine if they are admitted to hospital so if they have a HAP, they are already in hospital

210
Q

In terms of reviewing IV antibiotic therapy - what is the rule of thumb?

A

Review NO MORE than 3 days after initiating as most patient will then be able to step down to oral antibiotics

211
Q

How do stimulant laxatives work?

A

Promote peristalsis

212
Q

Name 2 examples of stimulant laxatives

A

Senna and Bisacodyl

213
Q

What is the difference in the MOA of senna and bisacodyl?

A

Senna stimulates colonic nerves to cause peristalsis

Bisacodyl stimulates both colonic and rectal nerves to cause peristalsis

214
Q

Give an example of a stool softner laxative

215
Q

What is the MOA of Docuate?

A

It is a surface-wetting agent - reduces the surface tension of the stool allowing water to more easily penetrate the stool and soften it

216
Q

List the 4 types of laxative

A

Bulk forming
Stool softeners
Stimulant
Osmotic

217
Q

Give 2 examples of osmotic laxatives

A

Lactulose

Macrogol

218
Q

What is the MOA of osmotic laxatives?

A

Increases fluid in the large bowel which produces distention leading to stimulation of peristalsis

219
Q

What is important to note regarding the administration of macrogol

A

They require a large volume of fluid to drink and if not enough fluid is drunk it can lead to dehydration

220
Q

What might lead you to avoid osmotic laxatives?

A

If the patient is already bloated

221
Q

When might you avoid stimulant laxatives?

A

If the patient is in bowel obstruction

222
Q

Give an example of a bulk forming laxative

A

Isphagula Husk

223
Q

What is the MOA of bulk forming laxatives?

A

Retain fluid within the stool and increases faecal mass which stimulates peristalsis (they also have stool softening effects)

224
Q

State the time it take to have effect for each of the 4 groups of laxative

A

Bulk forming laxatives - 2-3 days
Stool softeners - 12-72 hours
Stimulant - 6- 12 hours
Osmotic 2-3 days

225
Q

How do you know whether to put an analgesic in the ‘as required’ section or the regular section?

A

If they are in constant pain then make it regular, if the pain is sometimes there then ‘as required’

226
Q

If a patient wants immediate relief of indigestion what would you prescribe?

A

Antacid

Note:PPIs (e.g. omeprazole) and H2 antagonists e.g. Ranitidine improve dyspepsia but are not immediate

227
Q

Which medication has gum hypertrophy as a side effect?

A

Ciclosporin

228
Q

What electrolyte disturbance can SSRIs cause?

A

Hyponatraemia

229
Q

Why should COPD patients who are chronic CO2 retainers have reduced O2?

A

Normally there are two drivers for increased respiration - hypoxia and hypercapnoea
In chronic retainers they have lost their hypercapnic drive
and so rely on hypoxia to keep them breathing - hence you don’t want to give them too much oxygen

230
Q

What o2 sats should you aim for in a COPD chronic retainer?

A

88-92%

>95% can lead to a reduction in resp rate

231
Q

If a patient is conscious and hypoglycaemic, what should be the first treatment option?

A

10-20g of glucose by mouth e.g. orange juice or biscuits

232
Q

How do you treat hypoglycaemia if the patient is unconscious?

A

IM glucagon injection

233
Q

When would you use IV glucose and what %?

A

If the IM glucagon doesnt work, 10% IV glucose can be used

234
Q

What is the effect of NSAIDs on the kidneys?

A

NSAIDs Inhibit prostaglandins but prostaglandins normally dilate the afferent vessels promoting flow into the kidney but inhibiting prostaglandin through NSAIDs causes reduces renal perfusion

235
Q

What is the effect of ACE-inhibitors on the kidneys?

A

ACE-i causes the efferent blood vessels to dilate - this reduces the hydraulic pressure in the glomerulus and therefore reduces glomerular filtration

236
Q

Why should NSAIDs and ACEi never be prescribed together?

A

NSAIDs constrict the afferent vessels, ACEi dilate the efferent vessels - both occuring together reduces the pressure in the kidney too much and GFR tails off + the kidney is under perfused

237
Q

Why can’t oxybutynin be used in myasthenia gravis?

A

Because in myasthenia gravis they produce anti-acetylcholine receptor blockers and so the medication (which is an anti-muscarinic) wouldn’t work

238
Q

In the WHO ladder, what are you options for weak opiates?

A

Codeine

Tramadol

239
Q

Compare and contrast codeine and tramadol and when to use each

A

Codeine - side effects are resp depression, reduced consciousness and pinpoint pupils + is more constipating than tramadol
Tramadol - agitation and hallucinations (particularly in the elderly)
If a patient has diarrhoea you may be more inclined towards codeine

240
Q

When should you put the stop/review for antibiotics date if unsure?

A

oral antibiotics - after 5 days

iv antibiotics - after 3 days

241
Q

Is St John’s wort an enzyme inducer or inhibitor?

A

Enzyme inducer

242
Q

What is the first line drug for GAD?

A

Sertraline 25mg
(although it is not licensed on the BNF for GAD, NICE recommends it as first line as it more cost effective than citalopram and escitalopram)

243
Q

In which trimester of pregnancy are NSAIDs the most dangerous?

A

3rd trimester - as prostaglandins keep open the ductus arteriosus and NSAIDs inhibit prostaglandin synthesis meaning it could prematurely close

244
Q

If a patient has impaired renal function, what should happen to their metformin?

A

Stop the metformin (it is largely cleared by the kidneys and you dont want it to accumulate due to risk of lactic acidosis)

245
Q

If a patient has impaired renal function, what should happen to their digoxin?

A

Reduce the dose - it is renally cleared and you don’t want it to accumulate which can lead to digoxin toxicity

246
Q

What information shouldbe communicated with patients regarding bisphosphonates

A

Take on empty stomach -at least 30 minutes before breakfast (or any other oral tablet)

Stand/sit upright for 30 minutes after taking the tablets

247
Q

What must patients be warned about before taking adenosine?

A

Chest tightness - it may feel like they are about to die

248
Q

How long do the effects of adenosine last?

A

1-2 minutes

249
Q

What effect does adenosine have on BP?

A

Lowering effect

250
Q

Why does furosemide increase the risk of lithium toxicity?

A

Furosemide decreases GFR and lithium is cleared renally (Lithium does not involve the CYP 450 enzymes)

251
Q

What drug should be prescribed to stabilise the myocardium in hyperkalaemia?

A

Calcium gluconate

(not calcium carbonate)

252
Q

In ACS, why do you give metoclopramide in addition to morphine?

A

Due to Opioid-induced nausea

253
Q

In maintenance fluids what is the daily intake of water?

A

20-25mL/kg

254
Q

In maintenance fluids, what is the daily intake of potassium?

255
Q

In maintenance fluids, what is the daily intake of sodium?

256
Q

In maintenance fluids, what is the daily intake of chloride?

257
Q

In maintenance fluids, what is the daily intake of glucose?

A

50-100g (to limit starvation ketosis)

258
Q

Which diuretic causes dyslipidaemia?

A

Bendroflumethiazide

259
Q

How does clopidogrel work?

A

Blocks the ADP-mediated activation of the glycoprotein GPIIb/IIIa complex which normally causes platelets to aggregate

260
Q

What is the safest prescription of analgesia for a patient with chronic alcoholic liver disease?

A

Paracetamol 500mg PO four times a day (notice it is not 1g 4 times a day - the dose is reduced to avoid hepatotoxicity)

261
Q

Why are NSAIDs not safe to use in patients with alcoholic liver disease?

A

Patients with alcoholic liver disease may have clotting abnormalities and NSAIDs would further increase the risk of bleeding

262
Q

Why are opioids not safe in patients with alcoholic liver disease?

A

They may precipitate hepatic encephalopathy

263
Q

Which group of medications exacerbate psoriasis?

A

Beta blockers

264
Q

Which anti-emetics are preferred in pregnancy for hyperemesis gravidarum?

A

antihistamines e.g. cyclizine

265
Q

Which statins should not be prescribed with warfarin?

A

Fluvastatin

Rosuvastatin

266
Q

Why should patients taking metronidazole avoid alcohol?

A

They may develop a disulfiram-like reaction

267
Q

What is the definition cut off values for gestational diabetes?

A

Fasting plasma glucose > or = 5.6mmol/L
OR
Two hour plasma glucose > or = 7.8

268
Q

Does Gliclazide cause constipation or diarrhoea?

269
Q

VTE prophylaxis (orthopaedic surgery) - what are the options?

A
  1. RIvaroxaban - 5 weeks (hip surgery), 2 weeks (knee surgery)
  2. LMWH for 10 days followed by aspirin for 28 days
  3. LMWH for 28 days with anti-embolism stockings (until discharge)
270
Q

How do heparins contribute to hyperkalaemia?

A

They inhibit aldosterone synthesis

271
Q

How does Tacrolimus cause hyperkalaemia?

A 
Reduced excretion 
Note ciclosporin (another calcineurin inhibitor also causes hyperkalaemia)
272
Q

Antiplatelets such as aspirin are stopped up to how many days before surgery?

273
Q

What is the exception for witholding antiplatelets before surgery?

A

If they have recently had PCI/vascular stent - the risk of thrombosis is still high

274
Q

Why should allopurinol be stopped if a patient develops AKI?

A

It can accumulate as it is renally cleared

275
Q

Why do SSRIs cause hyponatraemia?

276
Q

At what eGFR should nitrofurantoin be avoided?

277
Q

If INR is >1.5 on the day before surgery, what prescription is recommended to bring INR down quickly?

A

Phytomenadione (Vitamin ) 1-5mg PO

note: IV can also be used

278
Q

How should the rivaroxaban be taken - i.e. the instructions to the patient?

A

Take it with food

279
Q

What should happened to the contraception if a woman is on POP or COCP and needs to take topiramate (for migraine)? and why/.

A

Switch to an alternative form of contraception (until at least 4 weeks after stopping the topiramate) because topiramate is an enzyme inducing drug

280
Q

What side effect can commonly occur with co-amoxiclav treatment?

A

jaundice due to cholestasis

281
Q

What % rise in creatinine is to be expected when starting an ACE inhibitor?

A

<20% - this would not require a change in prescription

282
Q

What should be monitored to check that an ACE inhibitor is having beneficial effect in heart failure treatment?

A

Exercise tolerance

283
Q

What are the most serious adverse effects of ciclosporin? (2)

A

Nephrotoxicity

Hypertension

284
Q

How do you know if the atorvastatin dose needs to be changed after commencing due to QRISK score?

A

No dose change if after 3 months of treatment a >40% reduction in non-HDL cholesterol has occurred

Year 6 (18 decks)

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