Prescription Reviews Flashcards
Types of Heparin
Unfractionated heparin (UFH) - fondaparinux, argatroban, bivalirudin
Low molecular weight heparin (LMWH) - dalteparin sodium, enoxaparin sodium, tinzaparin sodium)
max dose of paracetamol
4g in 24 hours, 1g 6hrly
Essential areas to check on each prescription
PReSCRIBER
Patient details
reaction (allergies, and reactions to drugs)
Sign the front of the chart
Contraindications (for each drugs)
Route: check the route for each drug
Blood: Provide blood clot prophylaxis if needed
Emesis: provide an antiemetic if needed
Relief: Provide pain relief if needed
What should be included in patient details
new chart = 3 pieces of patient-identifying information on the front (name, dob, hospital number) or sticker
which common antibiotics have penicillin in
Tazocin and co-amoxiclav
contraindicated drugs for people who are bleeding, suspected of bleeding or at risk of bleeding
Drugs that increase bleeding: aspirin, heparin, warfarin
What can increase your risk of bleeding
Those with long prothrombin time due to long term liver disease
when is prophylactic heparin contraindicated
acute ischaemic stroke, due to the risk of bleeding into the stroke
which type of drugs do you need to be wary of when prescribing warfarin
enzyme inhibitors (e.g. Allopurinol, omeprazole, disulfiram, erythromycin, valproate, isoniazid, ciprofloxacin, ethanol, sulphonamides).
can increase warfarin effect and thus prothrombin time (PT) and INR.
Side effects of Steroids
STEROIDS
Stomach ulcers, Thin skin, oEdema, Right and left heart failure, Osteoporosis, Infection (including candida), Cushings Syndrome
Cautions and Contraindications of NSAIDs
NSAID
No urine (renal failure), Systolic dysfunction (heart failure), Asthma, Indigestion (any cause), and Dyscrasia (clotting abnormality)
Which NSAID is not contraindicated in renal or heart failure, or in asthma
Aspirin
ACE-inhibitor example and side effects
ramipril, lisinopril, enalapril
dry cough, electrolyte imbalance (hyperkalaemia), hypotension (which can lead to dizziness and headaches), fatigue, loss of taste
ARB (angiotensin receptor blockers) example and side effects
Candesartan, losartan
Headache, fainting, dizziness, fatigue, rest symptoms, vomiting and diarrhoea, back pain, leg swelling, effect blood flow to the kidneys
CCB types, examples and side effects
dihydropyridines - nifedipine, amlodipine
non-dihydropyridines - diltiazem, verapamil
oedema, fatigue, palpitations, flushing, hypotension, bradycardia
Diuretics examples and side effects
thiazide - indapemide
Loop - Bumetanide, furosemide
Potassium Sparing - Spironolactone, Eplerenone, Amiloride
Dehydration (increased urination), electrolyte imbalance (Na loss), muscle cramp, joint disorders, impotence, renal failure. Loop diuretics (e.g. furosemide) can cause gout. k-sparing diuretics (e.g. spironolactone) can cause gynaecomastia
BB example and side effects
Bisoprolol, atenolol, propanolol
tired, dizzy, light headed, cold peripheries, difficulty sleeping, avoid in asthma patients (wheeze, airway narrowing), bradycardia, worsening of acute heart failure (helps in chronic heart failure)
which routes should be considered if patient is vomiting and for which drugs
non oral (IV, IM, SC) for antiemetics
However if vomiting likely to last a short term, changing the route of other prescribed medicine is usually not necessary
Doses of common antiemetics
Same regardless of route
cyclizine - 50mg 8-hourly
metoclopramide - 10mg 8-hourly
what route should patients have their medication if they are nil by mouth
however they are prescribed, patients should still receive their oral meds, including prior to surgery (apart from those you should stop obviously)
when are IV fluids prescribed
replacement - dehydrated and acutely unwell
maintenance - if nil by mouth
Which fluid should you use as replacement?
0.9% saline unless:
hypernatraemic (high sodium) or hypoglycaemic - then give 5% dextrose
Ascites - give human-albumin solution (HAS), sodium in saline will worsen ascites
in shock with systolic BP <90mmHg, give gelofusin
is shocked from bleeding: give blood transfusion
for replacement fluids: How much fluid should you give and how fast
if tachycardia or hypotensive, give 500ml bolus immediately (250ml if heart failure), then reassess HR, BP and urine output
if oliguric (urinary output less than 400ml per day or less than 20ml per hour) and not due to urinary obstruction, then give 1l over 2-4hrs then reassess
how can observations roughly predict how fluid depleted an adult is?
reduced urine output = 500ml fluid depletion
+ tachycardia = 1l fluid depletion
+shocked = >2l of fluid depletion
what is the max amount of fluid you should prescribe for a sick patient
2l , should review effect of fluids regularly
how should you indicate on a prescription the length of time over which the fluid is to be given
e.g. 2 hours, 2-hourly or 2-hrly
how much do adults need for maintenance fluids
adults 3l over 24hrs
elderly 2l
for maintenance, which combination of fluids are used to proved the right elecrolytes
1l 0.9 saline and 2l of 5% dextrose (1 salty 2 sweet)
how to provide k in fluids
bags of 5% dextrose or 0.9% saline containing potassium chloride (KCL) can be used but should be guided by urea and electrolyte results; with a normal potassium level
how many K required for a normal K level
40mmol KCl in 24hrs
what speed should you give IV K
Should not be given at more than 10 mmol/hour
how fast should you give maintenance fluids
if giving 3l per day = 8hrly 1L bags (24/3)
if giving 2l per day = 12hrly bags (24/2)
how should you assess the patient when you prescribe fluids
check the U&Es to confirm what to give them
check that the patient is not fluid overloaded (eg increased jugular venous pressure, peripheral and pulmonary oedema), ensure the patients bladder is not palpable (which signifies urinary obstruction), if prescribing for reduced urinary output
prophylaxis for blood clots, and who gets/doesnt get this
majority of patients admitted to hospital will receive prophylactic LMWH (e.g. dalteparin 5000 units daily s/c) and compression stockings for prevention of venous thromboembolism.
criteria for this, but this is given on almost every drug chart so don’t need to learn
if patient bleeding/at risk of bleeding (e.g. recent ischaemic stroke) they should be be prescribed warfarin or heparin.
Patients with peripheral arterial disease should not be prescribed compression stockings (they may cause acute limb ischaemia)
prescription for nausea
ciclizine 50mg (up to) 8hrly IM/IV/oral
metoclopramide 10mg (up to) 8hrly IM/IV if heart failure
which antiemetic should you avoid in heart failure patients and why
Cyclizine significantly increased systemic and pulmonary arterial pressures, and right and left ventricular filling pressures, and negated the venodilatory effects of diamorphine. The use of cyclizine in patients with heart failure should, therefore, be avoided.
which patients should you avoid metoclopramide?
Parkinsons, dopamine antagonist so risk of exacerbating symptoms
young women - risk of dyskinesia (unwanted movements, especially acute dystonia (sudden muscle contraction))
If a patient is in no pain what should you prescribe regularly, and what should you prescribe ‘as required’
nothing regularly, paracetamol 1g up to 6hrly oral as recquired. can add an NSAID if not contraindicated
If a patient is in mild pain what should you prescribe regularly, and what should you prescribe ‘as required’
regular paracetamol 1g 6hrly oral, codeine 30mg up to 6hrly oral as required. can add an NSAID if not contraindicated
If a patient is in severe pain what should you prescribe regularly, and what should you prescribe ‘as required’
co-codamol 30/500 2 tablets 6hrly regular, morphine sulphate 10mg put to 6hrly oral as required. can add an NSAID if not contraindicated
what should be prescribed in neuropathic pain
first line amitriptyline 10mg oral nightly or pregabalin 75mg oral 12-hrly.
duloxetine 60mg oral daily is indicated in painful diabetic neuropathy
what should you check in a prescribing question regarding paracetamol
often a trap is to prescribe too much paracetamol, either too frequently (ie 4hrly not 6hrly) or in multiple preparations (co-codamol and paracetamol). they should only have 4g in one day. what you take away (paracetamol or co-codamol) depends on their pain
common side effects of thiazide like diuretics
Mainly tested: Hypokalemia
Alkalosis hypochloraemic; constipation; diarrhoea; dizziness; electrolyte imbalance (hypokalaemia); erectile dysfunction; fatigue; headache; hyperglycaemia; hyperuricaemia; nausea; postural hypotension; skin reactions; vomiting
common side effects of ACE-inhibitors
Mainly tested: cough/dry mouth/hyperkalaemia
Alopecia; angina pectoris; angioedema (can be delayed; more common in black patients); arrhythmias; asthenia; chest pain; constipation; cough; diarrhoea; dizziness; drowsiness; dry mouth; dyspnoea; electrolyte imbalance; gastrointestinal discomfort; headache; hypotension; myalgia; nausea; palpitations; paraesthesia; renal impairment; rhinitis; skin reactions; sleep disorder; syncope; taste altered; tinnitus; vertigo; vomiting
common side effects of steroids
Mainly tested - abdominal discomfort,
Anxiety; behaviour abnormal; cataract subcapsular; cognitive impairment; Cushing’s syndrome; electrolyte imbalance; fatigue; fluid retention; gastrointestinal discomfort; headache; healing impaired; hirsutism; hypertension; increased risk of infection; menstrual cycle irregularities; mood altered; nausea; osteoporosis; peptic ulcer; psychotic disorder; skin reactions; sleep disorders; weight increased
Common side effects of NSAIDs
Constipation (in adults); diarrhoea (in adults); dizziness (in adults); fatigue (in adults); gastrointestinal disorders (in adults); haemorrhage (in adults); headache (in adults); inflammatory bowel disease (in adults); insomnia (in adults); nausea (in adults); oral disorders (in adults); vertigo (in adults); vomiting (in adults)
side effects of opiates
constipation
resp depression
Arrhythmias; confusion; constipation; dizziness; drowsiness; dry mouth; euphoric mood; flushing; hallucination; headache; hyperhidrosis; miosis; nausea (more common on initiation); palpitations; respiratory depression (with high doses); skin reactions; urinary retention; vertigo; vomiting (more common on initiation); withdrawal syndrome
which pain killer should be avoided in asthmatics
NSAIDs - can cause broncho-constriction. so avoided if not closely monitored or strictly necessary
which antibiotic is contraindicated if taking methotrexate
trimethoprim - folate antagonist, as methotrexate is also a folate antagonist
when should a patient on methotrexate have it witheld
if they are septic, methotrexate is witheld pending the exclusion of neutropenic sepsis (if in doubt, withhold)
Aspirin secondary prevention dose
75mg or 150mg daily
Aspirin treatment dose
300mg daily for 14 days
Normal dose of bisoprolol
10mg daily
Route for insulin
s/c, except for sliding scales (act rapid or novorapid) which are given by IV infusion
which two cardiomedications should not be prescribed together?
Verapamil and beta blockers
Which drugs should be stopped before surgery
Anti-coagulants (warfarin, Heparin, rivaroxaban, dabigatran, apixaban,
edoxaban)
Anti-platelets (ticegrelor, prasugrel, clopidogrel, aspirin)
Combined oral contraceptive
which drugs should be ammended before surgery
Diabetic drugs.
Metformin stopped day before and considered for insulin
insulin regimes altered
which medications cause drowsiness
Anitidepressants, anti-histamines
Opiates
which medications must be stopped in AKI
ACEi
NSAIDs (but Aspirin okay!)
Metformin
Trimethoprim
K sparing diuretics
side effects of thiazide like diuretics
Exacerbate gout, diabetes and SLE
Hypokalaemia
Constipation, diarrhoea, dizziness, electrolyte imbalance, erectile dysfunction, postural hypotension, hyperglycaemia, hyperuricaemia, fatigue, headache, skin reaction, N&V
How much fluid should you have per day
3L
2L in elderly
