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PSA Revision > Prescription Review > Flashcards

Prescription Review Flashcards

1
Q

Risk of urinary incontinence?

A 
Urinary incontinence
Alpha-blockers
Diuretics
Acetylcholinesterase inhibitors 
Rivastigmine / donepezil
Clozapine

Bromocriptine

Benzodiazepines
Pregabalin
Anti-depressants (to varying degrees)
Certain anti-Parkinsonian drugs

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2
Q

Drugs that Inc. risk of falls?

A

Drugs that increase the overall risk of falls (and the baseline risk has many other factors)
Benzodiazepines, Z-drugs
Antidepressants (especially TCAs and SNRIs, less so SSRIs)
Monoamine oxidase inhibitors
Most antipychotics
Opiates
Most antihypertensives (especially alpha-blockers, diuretics, centrally acting antihypertensives)

Some anti-Parkinson’s medications (e.g. selegiline, ropinirole)
(Less commonly) some antiepileptics
In theory, those that cause hypoglycaemia

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3
Q

Risk of constipation?

A 
Constipation
Opioids
Oral iron
Some calcium channel blockers
Anti-psychotics
Some diuretics (if dehydration)
Anti-diarrhoeals
Some antacids (aluminium-containing)
Anti-muscarinics (even inhaled)
Ondansetron
Phosphate-binders
Exchange resins 
Some anti-Parkinson’s medications
Some anti-epileptics
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4
Q

Fetal drug exposure: what drugs?

A

1-Anti-convulsant: esp. sodium valproate = Fetal valporate syndrome & risk of miscarriage.

Exception: Lamotrigine & Levetiracetam.

2-Warfarin = Fetal warfarin syndrome & risk of miscarriage & labour bleeding.

Alternative: Heparin

Retinoids

Ace-I: Oligohydramnios

Opioids

Benzodiazepines

Methotrexate

Eplerenone (aldosterone antagonist)

Valsartan (Angiotensin-II receptor antagonist)

Finasteride (shouldnt handle in child bearing age)

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5
Q

Increased risk of hypertension?

A

NSAIDs
Glucocorticoids
Mineralocorticoids (but usually as treatment for hypotension/insufficiency)

Combined oral contraceptives
Mirabegron

Clozapine 
Venlafaxine / tricyclic antidepressants
Monoamine oxidase inhibtiors
Selegiline
Cyclosporine / tacrolimus / rapamycin
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6
Q

Risk of osteoporosis?

A

Steroids

PPIs at high doses can increase risk of fractures, especially in elderly over long courses

Long-term androgren suppression (e.g. LHRH agonists such as buserelin, goserelin for prostate cancer)

There are other rarer causes (including methotrexate)

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7
Q

Recognize chronic vs acute (or acute-on-chronic)
“Chronic” 🡪 main task is to ensure all medications are appropriately dosed based on renal function
“Acute” or “acute-on-chronic” 🡪 priority to stop potential nephrotoxics, AND to ensure all medications are appropriately dosed based on current renal function

Drugs to stop or adjust dose in renal impairment?

A

Analgesics: NSAIDs, Opiates, neuropathic pain meds e.g. gabapentin

Gastric acid secretion suppressants:
H2 antagonists e.g. ranitidine

Immunosupressants:
Most immunosuppressants such as methotrexate, aminosalicylates, azathioprine, sulfasalazine, ciclosporin, tacrolimus

Antiplatelets / anticoagulation:
LMWH, direct oral anticoagulants

Antibiotics
Most antibiotics, most antivirals, most antifungals: e.g. Aminoglycosides, vancomycin, penicillin, gentamycin, acyclovir

Renin-antgiotensin-aldosterone axis:
ACEi, ARBs, beta-blockers, mineralocorticoid antagonists

Other cardiovascular medications:
Digoxin, hydralazine, most statins, fibrates

Antidepressants: Most SNRIs

Antipsychotics / anti-mania: Amisulpride, Lithium

Sedatives: Benzodiazepines, z-drugs

Anti-epilepsy drugs:
Most (but not those for status epilepticus)

Anti-diabetic drugs
Metformin, DDP4 inhibitors (-gliptins), SGLT2 inhibitors (-flozins), GLP1 agonists (e.g. exenetide)

Hypo- / hyper-thyroid medications:
Propylthiouracil

Gout (acute / chronic):
NSAIDs, colchicine, allopurinol, febuxostat

Osteoporosis: Bisphosphonates

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8
Q

CI in acute gout?

A

Diuretics E.G. Furosemide & Indapamide

Pyrazinamide
Nicotinic acid
(Allopurinol and febuxosin in acute gout)

Many chemotherapy agents can result in hyperuricaemia, but this is not a contraindication, but need appropriate management

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9
Q

CI/Caution with Parkinson’s disease?

Risks for acute dystonic disease?

A

1-Antipsychotic drugs (especially haloperidol), Chlorpromazine
2-Metoclopramide

Also risks for acute dystonic reactions

  • Antipsychotic drugs (especially haloperidol)
  • Metoclopramide
  • Domperidone
  • Cyclizine
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10
Q

Case presentation
A 53-year-old woman is admitted to hospital with a non-infective exacerbation of her chronic obstructive pulmonary disease. PMH. Alcohol dependence (up to 60 units/day), atrial fibrillation, chronic obstructive pulmonary disease, rheumatoid arthritis, type II diabetes. DH. In addition apixaban 5 mg orally 12hrly, her medications are listed right.

Question A
Select the TWO prescriptions that are least likely be efficacious at the current prescribed dose.
(mark them with a tick in column A)

Question B
Select the ONE prescriptions that should not be prescribed together with her apixaban
(mark them with a tick in column B)

CURRENT PRESCRIPTIONS

Drug name
Dose
Route
Freq.

Azathioprine
100 mg
ORAL
Daily

Chlordiazepoxide
10 mg
ORAL
Daily

Dalteparin
5000 units
S.C.
Daily

Ipratropium bromide
250 micrograms
NEBS
6-hrly

Metformin MR
1 gram
ORAL
Twice daily

Prednisolone
40 mg
ORAL
Daily

Salbutamol
200 micrograms
NEBS
6-hrly

Symbicort® 100/6
Two puffs
INH.
12-hrly

A

Answer box
Question A
Marks per correct tick
1
Chlordiazepoxide at 10mg orally daily is unlikely to be sufficient for the degree of alcohol dependence.
Salbutamol nebulisers are typically prescribed at 2.5mg (or occasionally 5mg) for each nebulizer – whereas the 200micrograms dose is typical for inhalers

Question B
Marks per correct tick
1
LWMH for DVT prophylaxis should not be used together with anticoagulation (be it DOAC or warfarin)

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11
Q

Risk of HYPOmagnesaemia?

A

Loop diuretics
Thiazide/ Thiazide-like diuretics

Proton pump inhibitors (usually within 1st year of treatment)
Exchange resins (e.g. calcium resonium)
Ciclosporin
IV bisphosphonates (e.g. during treatment of hypercalcaemia)
IV Antifungals
IV Aminoglycoside

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12
Q

Case presentation
A 66-year-old man attends his annual diabetic review. He has been well and asymptomatic since his last review.

PMH. Type II diabetes mellitus, gout, hypercholestrolaemia, hypertension.
He provides a hand-written list of medications he believe he is taking (see right).

Question A
Select the TWO prescriptions that is most likely contribute to hypoglycaemia.
(mark them with a tick in column A)

Question B
Select the ONE prescription that has a dosing error.
(mark it with a tick in column B)
CURRENT PRESCRIPTIONS

Drug name
Dose
Route
Freq.

Allopurinol
100 mg
ORAL
Daily

Amlodipine
10 mg
ORAL
Daily

Bezafibrate
400 mg
ORAL
At night

Canagliflozin
200 mg
ORAL
Daily

Glibenclamide
5 mg
ORAL
Daily

Metformin
1 mg
ORAL
Lunch and evening meal

Pioglitazone
45 mg
ORAL
Daily

Simvastatin
40 mg
ORAL
At night

Spironolactone
25 mg
ORAL
Daily

A

Answer box
Question A
Marks per correct tick
1
Insulin, sulfonylureas and SGLT2 inhibitors all carry a risk of hypoglycaemia
Thiazolidinediones (pioglitazone) also carries this risk, but is lower than the other two listed here.

(Canagliflozin, Glibenclamide)

Question B
Marks per correct tick
2
Metformin is prescribed between 500mg and 2g

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13
Q

Risk of HYPOkalaemia?

A

Hypokalaemia:

Diuretics
IV Antifungals (esp. amphotericin)
Cisplatin
Glucocorticoids / mineralocorticoids (typically only if excess)
Beta2-agonists

(Rarely) aminoglycosides such as gentamicin and amikacin

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14
Q

Drugs that can exacerbate Psoriasis?

A

Caution (none contraindicated) as may exacerbate condition:

Beta-blockers
Lithium salts
Chloroquine
NSAIDs
ACE-I
Infliximab 
withdrawal of systemic steroids
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15
Q

Risk of HYPERkalaemia?

A

Hyperkalaemia
ACEi, ARB, spiro/eplerenone/amiloride
Heparin and LMWH
Tolvaptam

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16
Q

Case presentation
A 63-year-old man returns to his General Practitioner to review his medications prior to a repeat prescription. PMH. Gout, H. pylori-associated gastritis three months ago, ischaemic heart disease, Type II diabetes mellitus. DH. Listed on table.

Question A
Select the THREE prescriptions that should be prescribed for a short duration.
(mark them with a tick in column A)

Question B
Select the ONE prescription that has a dosing error.
(mark it with a tick in column B)
CURRENT PRESCRIPTIONS

Drug name
Dose
Route
Freq.

Allopurinol
200 mg
ORAL
daily

Amoxicillin
1 g
ORAL
12-hrly

Aspirin
75 mg
ORAL
daily

Bisoprolol
10 mg
ORAL
daily

Clarithromycin
500 mg
ORAL
12-hrly

Gliclazide
4 mg
ORAL
12-hrly

Metformin M/R
2 g
ORAL
evening

Omeprazole
20 mg
ORAL
12-hrly

Ramipril
10 mg
ORAL
daily

A

Answer box

Question A
Marks per correct tick
1
H. Pylori eradication therapy should be reviewed to consider whether it is appropriate to stop

(Amoxicillin, Clarithromycin, Omeprazole)

Question B
Marks per correct tick
1
Gliclazide 4mg 12-hrly is typically a sub-therapeutic dose, and usually prescribed between 40mg and 160mg

17
Q

Risk of medications that if aren’t controlled well can cause HYPERglycaemia?

A

Steroids
Antipsychotic drugs

Thiazide and thiazide-like diuretics 
(Loop diuretics less likely)
Beta-blockers
Tacrolimus
Olanzapine
18
Q

Drugs CI in breastfeeding:

A

MAAAACCCCCC

BREAST

Methotrexate
Aspirin
ACE-I
ATenolol
Amphetamine
Cannabis
Cocaine
Ciprofloxacin
Chloramphenicol
Carbimazole 
Cytotoxic drugs
BZ, Bromocriptine
Radioactive drugs e.g. radioiodine
Ergot
Amiodarone 
Sulfonamides, Sulfonyureas
Tetracycline

Lithium

19
Q

A-What medications are in micrograms?
B-What medications are in the 100’s of mg up to gram?
C-What medications are in the grams?
D-Different dosings?

A

A-Micrograms:

Tamsulosin 
Fludrocortisone (not hydrocortisone) Levothyroxine 
Digoxin
Naloxone 
Inhalers
Ipratropium nebs

B-100’smg-grams:

Some antibiotics
Metformin
Some anti-epileptics

C- Grams:

Paracetamol
Calcium carbonate
N-acetylcysteine

D-Different dozing:
Heparin is S/C
Salbutamol is inhaler

Tip: the majority of medications are in mg, so when you see any of the above meds check if in the right dose, or when you see the dose isn’t matching the known medications e.g. medication that are in g, mcg, or 100’s of mg then try to figure out if it matches the list of meds you know.

20
Q

Hepatic impairment affect on drugs:

A

A-Drug concentration in body:

Phenytoin- if cant bind to albumin = toxicity

Cannot undergo first-pass metabolism: 1-Most beta-blockers, 2-Benzodiazepines, 3-Morphine, Pethidine opioids

B-Drug effects:
People with liver disease are prone to:

1-Bleeding (anticoagulants/NSAIDs)

2-Renal failure (Nephrotoxic drugs)

3-Hepatic encephalopathy (so drugs that cause sedation (BZ, Opioids, TCAs, Sedating antihistamins e.g. chlorphenamine). can increase confusion/HE, as well as constipation (antimuscarinics, opioids, CCB) because ammonia is reasbrobed into the body, & hypokalamia drugs like loop/thiazide diuretics).

C- Further Hepatotoxicity:

1-Atrovastatin
2-Azithromycin
3-Methotrexate

*reduce paracetamol to 3g/day.

21
Q

A-Drugs that accumulate in renal impairment which can cause toxicity esp. if narrow therapeutic index?

C-Drugs that become ineffective in renal impairment?

D-Drugs that cause rhabdomyolysis?

A 
Aciclovir
Gentamicin
Digoxin
Gabapentin 
Morphine

C-Thiazides
Nitrofurantoin

D-Statins, alcohol, drugs of abuse (cocaine, heroin, methadone, methamphetamines)

22
Q

Effect of a P450 inhibitor?

Examples of P450 inhibitors?

A

Reduced metabolism of P450, therefore drug exerts more of an effect.

AODEVICES

  • Allopurinol
  • Omeprazole
  • Disulfiram
  • Erythromycin
  • Valproate
  • Isoniazid
  • Ciprofloxacin
  • Ethanol (acute intoxication)
  • Sulphonamides
23
Q

Case presentation
A 79-year-old woman presents to the emergency room after a fall. X-ray of her left hip confirms a fractured neck of femur. On examination you notice she has broken skin from scratch marks along both her arms (which appear quite thin compared to the rest of her rotund body). Even her face appears round. When asked why she fell, she tells you she felt dizzy two hours after taking her tablets. PMH. Hypertension, type 2 diabetes mellitus, giant cell arteritis. DH. Her current regular medicines are listed (right).

Investigations
Full blood count normal, U+E normal, capillary blood glucose 6.2 mmol/L.

Question A
Select the TWO medications that raised her likelihood of fracture.
(mark it with a tick in column A)

Question B
Select the TWO medications that are most likely to be contributing to the dizzy feeling which led to her fall.
(mark it with a tick in column B)

CURRENT PRESCRIPTIONS

Drug name
Dose
Route
Freq.

Aspirin
75 mg
ORAL
Daily

Empagliflozin
10 mg
ORAL
Daily

Gaviscon
10 ml
ORAL
PRN

Metformin
500 mg
ORAL
12-hrly

Omeprazole
40 mg
ORAL
Daily

Prednisolone
15 mg
ORAL
Daily

Ramipril
10 mg
ORAL
Daily

Senna
15 mg
ORAL
Nightly

Simvastatin
20 mg
ORAL
Daily

A

Question A:

Prednisolone in this dose is common for those with giant cell arteritis. However, steroids in high doses taken regularly without bone protection can make bones easier to fracture.

Omeprazole

Question B

Empagliflozin and ramipril-associated hypotension can make the patient feel dizzy and lead to falls.
Metformin would not be implicated as it will not cause a hypoglycaemic episode.
(GI bleed a possibility as on steroid and NSAID but urea and haemoglobin normal).o

24
Q

CI with HF?

A 
NSAIDs and COX2 inhibitors
Midodrine
Pioglitazone
Moxonidine
Verapamil (other CCBs also caution in acute heart failure)

Several immunosuppressive monoclonal antibodies

25
Q

Prescriptions with specific timing?

A

Relating to activity / daytime:
Medications for Parkinson’s disease
Anticholinesterases for myasthenia gravis
Diuretics

Relating to night time:
Night sedation
Less crucially, statins

Relating to other medications / empty stomach:
Bisphosphonates
Antacids

Relating to mealtimes:
Hypoglycaemics (know your insulin types!)
Pancreatic enzymes

Relating to days of the week:
Patches
Bisphosphonates
Methotrexate/folic acid

Medicines containing penicillin:
Tazocin & co-amoxiclav

26
Q

Effect of a P450 inducer?

Examples of P450 Inducers ?

A

Increase metabolism of P450, therefore drug exerts less of an effect

Increased enzyme activity, decreased drug concentration

  • PC BRAS
  • Phenytoin
  • Carbamazepine
  • Barbiturates
  • Rifampicin
  • Alcohol (chronic excess)
  • Sulphonylureas
27
Q

Drugs that worsen myasthenia gravis?

A

Caution (none contraindicated) as may exacerbate condition:

Tetracyclines, macrolides, quinolones (higher risk IV)
Sedating medications including Z-drugs, benzodiazepines, antipsychotics, opiates
Local anaethetics (particularly nerve blocks)
Beta-blockers

28
Q

Risk of diarrhoea?

A 
Diarrhoea
Laxatives
Antibiotics
Some antacids (magnesium-containing)
Alpha-glucosidase inhibitors (Acarbose)
Lipase inhibitors (orlistat)
Cholinesterase inhibitors (e.g. rivastigmine)
Colchicine

Many others!
Can also relate to lactose- or sorbitol-content of the medications

29
Q

Increased risk of high cholesterol?

A 
Systemic steroids
Diuretics (thiazide and loop)
Most antipsychotics
Cyclosporine (and less frequently tacrolimus)
Most HIV medications
SGLT2 inhibitors (-flozins)
30
Q

Risk of hypoglycaemia?

A
  • Insulin
  • Sulfonylureas

Other anti-diabetic drugs still have the risk, but lower:

1-GLP-1 activators (e.g. exenetide)

SGLT2 inhibitors (e.g. canagiflozin)

DPP4 inhibitors (e.g. sitaglitpin)

Pioglitazone
(Not metformin)

Other RARE causes

31
Q

Risk of urinary retention?

A 
Urinary retention
Anticholinergic drugs
Oxybutinin / tolterodine / glycopyronnium / atropine / procyclidine 
(less likely for eyedrops)
Opioids

Benzodiazepines
Inhalation anaesthesia
Antihistamines
chlorphenamine > Loratidine / fexofenadine

Cyclizine / domperidone / promethazine
Anti-depressants (to varying degrees)
Certain anti-Parkinsonian drugs

PSA Revision (9 decks)

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