Prescribing safety assessment Flashcards
List drugs which can cause urinary retention
- Opioid analgesia, especially post-op
- Anticholinergics - antipsychotics, antidepressants, respiratory anti-muscarinics, detrusor relaxants
- General anaesthetics
- Alpha-adrenoreceptor agonists
- Benzodiazepines
- NSAIDs
- Calcium-channel blockers
- Antihistamines
- Alcohol
List drugs which can cause confusion
- Opioids, benzodiazepines, Z-drugs
- Anticholinergics - antipsychotics, antidepressants, respiratory anti-muscarinics, detrusor relaxants
- Anticonvulsants
- Histamine H2 receptor antagonists
- Digoxin
- Beta-blockers
- Steroids
- NSAIDs
- Antibiotics - fluoroquinolones
- Lithium
Monitoring required for statins
Liver enzymes measured pre-treatment, at 3 months and at 12 months
If transaminases raised but within 3x upper limit of normal no need to stop statin
If more than 3x upper limit of normal should discontinue
When should gentamicin concentration be measured?
Trough levels - just before next dose
If peak gentamicin concentration and trough gentamicin concentration are increased, how should the gentamicin prescription be adjusted?
Decrease dose, increase interval between doses
Drug of choice for symptoms of acute heart failure (oedema, SOB)
IV furosemide
Management for hypoglycaemia with reduced consciousness
IV glucose 20% - 50-100ml over 15 minutes
(10% if not available - 100-200ml over 15 minutes)
Oral antibiotic for moderate - severe acne
Lymecycline
Oxytetracycline
Tetracycline
List drugs which can cause hyperkalaemia
ACE inhibitors
ARBs
Potassium-sparing diuretics
Heparins
Beta-blockers
Digoxin
NSAIDs
Cyclosporin
Tacrolimus
List drugs which should be stopped prior to surgery and when they should be stopped
Antiplatelets - stop 7-10 days prior to surgery, use LMWH/UFH instead if high risk
Combined hormonal contraceptive - stop 4 weeks prior to surgery (major elective surgery, surgery involving immobilisation of lower limbs, surgery to pelvis) and use alternative contraceptive
HRT - stop 4-6 weeks prior to surgery (major surgery under general anaesthesia)
Oral anti-hyperglycaemics - sometimes omit doses?
List drugs which can cause hyperglycaemia
Steroids
Thiazide diuretics
Antipsychotics
Phenytoin
Protease inhibitors
Cyclosporin
Tacrolimus
List drugs which can cause hyponatraemia
SSRIs
Thiazide diuretics (+ other diuretics)
Antipsychotics
Carbamazepine
Others (less common) - opioids, ACEi, ARBs, PPIs, anticonvulsants, amiodarone, theophylline, dopamine antagonists, antidiabetics, NSAIDs, MDMA, desmopressin, oxytocin
Management of acute alcohol withdrawal
Long-acting benzodiazepine - chlordiazepoxide, diazepam
(+ lorazepam if seizures occur)
Prevention of Wernicke’s - IV pabrinex then oral thiamine
List drugs which can cause hypoglycaemia
Insulin
Sulphonylureas - highest risk of oral antihyperglycaemics
Other oral antihyperglycaemics (DDP-4 inhibitors, pioglitazone, metformin, SGLT2 inhibitors, GLP-1 mimetics) usually low risk but can contribute when combined
Others:
Beta-blockers
Fluoroquinolones
ACE inhibitors
How should contraception be managed in a woman taking the COCP and a liver enzyme-inducing drug concurrently?
Use alternative contraception for duration of treatment and until 4 weeks after enzyme-inducing drug stopped
How should contraception for a woman taking a teratogenic drug be managed?
Preferred method is copper or progestogen coil
List drugs which can precipitate/worsen heart failure
NSAIDs
Anaesthesia
Oral antihyperglycaemics - metformin, pioglitazone, DPP-4 inhibitors
Antiarrhythmics - flecainide, dronedarone
Alpha blockers - doxazosin
Calcium channel blockers - diltiazem, verapamil, nifedipine
Antifungals - intraconazole, amphotericin B
Chemotherapy - doxorubicin, cyclophosphomide, mitomycin
Biologics
Antiepileptics - carbamazepine
Citalopram
Antiparkinsons
Antipsychotics - clozapine
Lithium
Hydroxychloroquine
List drugs that can cause cough
ACE inhibitors
Beta-blockers
NSAIDs
Calcium channel blockers
List drugs that can cause oedema
Calcium channel blockers - amlodipine, nifedipine, felodipine
Insulin
Pioglitazone
NSAIDs
Steroids
Sex hormones e.g. COCP, HRT
Antipsychotics
Bisphosphonates
Chemotherapy
Anticonvulsants - gapapentin, pregabalin
MAOIs
List drugs which can cause hypokalaemia
Diuretics - thiazide + loop
Beta-agonists e.g. salbutamol, salmeterol
Insulin
Theophylline
Steroids
Laxatives
Antibiotics - penicillin, aminoglycosides
Antifungals - amphotericin B
Aciclovir
Verapamil overdose
List drugs that can cause myopathy
Statins (+ drugs which interact with and increase exposure to statins)
Steroids
Immunosuppressants
Antibiotics - ciprofloxacin, norfloxacin, ofloxacin
Chemotherapy agents - docetaxel, vincristine
Bisphosphonates
List drugs which commonly cause diarrhoea
PPIs
H2 receptor antagonists
SSRIs
Antibiotics
Metformin, sulphonylureas
Methotrexate
Iron
NSAIDs
Magnesium containing antacids
List drugs that commonly cause dyspepsia
Aspirin
NSAIDs
Iron
Antibiotics
Alpha-blockers
Antimuscarinics
Benzodiazepines
Beta-blockers
Bisphosphonates
Calcium channel blockers
Steroids
Nitrates
Theophylline
Tricyclic antidepressants
List drugs that commonly cause bradycardia
Beta-blockers
Calcium channel blockers
Alpha-blockers
Digoxin
Phenytoin
Tricyclic antidepressants
Lithium
List drugs that can cause bleeding
Anticoagulants - heparin, warfarin, DOACs
Antiplatelets - aspirin, clopidogrel, dipyridamole, prasugrel, ticlopidine
NSAIDs
SSRIs/SNRIs
+ Drugs that interact with and increase exposure (e.g. warfarin and liver enzyme inhibitors)
List drugs that commonly cause constipation
Opiates
Anticholinergics
Antimuscarinics
Antimotility e.g. loperamide
Antipsychotics e.g. clozapine
Benzodiazepines
Iron
Tricyclic antidepressants
Antihistamines
List drugs which should be witheld/altered in AKI
Drugs which can cause renal toxicity:
Contrast media
ACEi
NSAIDs
Diuretics
ARBs
Bisphosphonates
Colchicine
Drugs which may accumulate due to reduced renal excretion and cause toxicity:
Opioids
Benzodiazepines
Antibiotics - aminoglycosides, penicillins, tetracyclines, trimethoprim, vancomycin
Antifungals - amphotericin, fluconazole
Antivirals - aciclovir, ganciclovir
Phenytoin
Pregabalin, gapapentin
Levetiracetam
Hypoglycaemis
Calcineurin inhibitors - ciclosporin, tacrolimus
Methotrexate
Allopurinol
Antihistamines
Antipsychotics
Digoxin
Statins, fibrates
Lithium
LMWH
Warfarin
Risk of hyperkalaemia:
Trimethoprim
ACEi/ARBs
Potassium-sparing diuretics
Calcineurin inhibitors - ciclosporin, tacrolimus
Digoxin
When is oxycodone used instead of morphine for pain management?
Morphine not tolerated e.g. nausea, anorexia, GI discomfort
Severe renal failure - GFR below 30
Describe a typical analgesia regimen for pain in palliative care
Initially titrate dose of regular immediate-release morphine
Breakthrough doses of immediate-release morphine given at one tenth to one sixth of regular 24-hour dose, repeated 2-4 hourly as required
Can also use nasal, buccal or sublingual fentanyl for breakthrough
Once pain controlled can be switched to equivalent modified- release morphine with 12-hourly or 24-hourly administration
Can give continuous subcutaneous infusion of morphine (or diamorphine) if patient becomes unable to swallow
Can give transdermal fentanyl or buprenorphine, not used for acute pain or rapidly changing analgesia requirements as long time to steady state, with immediate-release morphine or nasal/buccal/sublingual fentanyl given for breakthrough pain
Describe VTE prophylaxis for surgical patients
Pharmacological prophylaxis for patients undergoing general or orthopaedic surgery
LMWH suitable for all general/orthopaedic - dalteparin, enoxaparin (dose and regimen dependent on risk level)
UFH better if renal impairment
Specific regimens for elective knee and hip replacements
Describe VTE prophylaxis for medical patients
Acutely ill and high risk VTE - pharmacological prophylaxis with LMWH or fondaparinux for a minimum of 7 days
If renal impairment - LMWH or UFH
Describe VTE prophylaxis for pregnant patients
LMWH started 4-8 hours post-birth/miscarriage/termination, continued for minimum of 7 days if risk of VTE outweights risk of bleeding
Resuscitation fluids adult
500ml 0.9% saline in less than 15 minutes
250ml if heart/renal failure
Maintainance fluids adult
25-30ml/kg/day of fluid
1mmol/kg/day sodium, potassium, chloride
50-100g/day glucose
(need more if losses e.g. vomiting, diarrhoea, will need extra potassium if deplete)
e.g. 25-30ml/kg/day 0.18% sodium chloride in 4% glucose with potassium added
Which fluids should be given with a variable rate insulin infusion for diabetic patients undergoing surgery?
Potassium chloride with glucose and sodium chloride
Maintainence fluids for children
100ml/kg for 1st 10kg
50ml/kg for next 10kg
20ml/kg for further weight
Fluid of choice is usually 0.9% saline with 5% glucose, usually given with 20mmol of potassium (pre-mixed)
Resuscitation fluids for children
10ml/kg 0.9% saline
Rehydration fluids for children
Calculate deficit - weight x % dehydration x 10
Total requirement = maintenance + replacement of deficit + replacement of ongoing losses
Target INR for patients taking warfarin undergoing surgery
Less than 1.5 - give oral vitamin K if INR 1.5 or higher
Can give bridging LMWH if high risk for VTE
List common drugs which require therapeutic monitoring
Antiepileptics - carbamazepine, phenobarbitol, phenytoin, sodium valproate
Antibiotics - gentamicin, tobramycin, vancomycin
Lithium
Theophylline
Clozapine
List drugs which can cause urinary retention
Tricyclic antidepressants
Anticholinergics
Opioids
NSAIDs
Disopyramide
List drugs which can cause lung fibrosis
Amiodarone
Cytotoxics - bleomycin
Immunosuppressants - methotrexate, sulfasalazine
Nitrofurantoin
Dopamine receptor agonists - bromocriptine, cabergoline, pergolide
