Prescription Review Flashcards
Risk of urinary incontinence?
Urinary incontinence Alpha-blockers Diuretics Acetylcholinesterase inhibitors Rivastigmine / donepezil Clozapine
Bromocriptine
Benzodiazepines
Pregabalin
Anti-depressants (to varying degrees)
Certain anti-Parkinsonian drugs
Drugs that Inc. risk of falls?
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
Risk of constipation?
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
Fetal drug exposure: what drugs?
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)
Increased risk of hypertension?
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
Risk of osteoporosis?
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)
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?
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
CI in acute gout?
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
CI/Caution with Parkinson’s disease?
Risks for acute dystonic disease?
1-Antipsychotic drugs (especially haloperidol), Chlorpromazine
2-Metoclopramide
Also risks for acute dystonic reactions
- Antipsychotic drugs (especially haloperidol)
- Metoclopramide
- Domperidone
- Cyclizine
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
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)
Risk of HYPOmagnesaemia?
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
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
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
Risk of HYPOkalaemia?
Hypokalaemia:
Diuretics IV Antifungals (esp. amphotericin) Cisplatin Glucocorticoids / mineralocorticoids (typically only if excess) Beta2-agonists
(Rarely) aminoglycosides such as gentamicin and amikacin
Drugs that can exacerbate Psoriasis?
Caution (none contraindicated) as may exacerbate condition:
Beta-blockers Lithium salts Chloroquine NSAIDs ACE-I Infliximab withdrawal of systemic steroids
Risk of HYPERkalaemia?
Hyperkalaemia
ACEi, ARB, spiro/eplerenone/amiloride
Heparin and LMWH
Tolvaptam
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
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
Risk of medications that if aren’t controlled well can cause HYPERglycaemia?
Steroids
Antipsychotic drugs
Thiazide and thiazide-like diuretics (Loop diuretics less likely) Beta-blockers Tacrolimus Olanzapine
Drugs CI in breastfeeding:
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
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-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.
Hepatic impairment affect on drugs:
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.
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?
Aciclovir Gentamicin Digoxin Gabapentin Morphine
C-Thiazides
Nitrofurantoin
D-Statins, alcohol, drugs of abuse (cocaine, heroin, methadone, methamphetamines)
Effect of a P450 inhibitor?
Examples of P450 inhibitors?
Reduced metabolism of P450, therefore drug exerts more of an effect.
AODEVICES
- Allopurinol
- Omeprazole
- Disulfiram
- Erythromycin
- Valproate
- Isoniazid
- Ciprofloxacin
- Ethanol (acute intoxication)
- Sulphonamides
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
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
CI with HF?
NSAIDs and COX2 inhibitors Midodrine Pioglitazone Moxonidine Verapamil (other CCBs also caution in acute heart failure)
Several immunosuppressive monoclonal antibodies
