PSA Flashcards
Following medications may exacerbate heart failure [5]
- thiazolidinediones
pioglitazone is contraindicated as it causes fluid retention
- verapamil
negative inotropic effect
- NSAIDs/glucocorticoids
should be used with caution as they cause fluid retention
low-dose aspirin is an exception - many patients will have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks
- class I antiarrhythmics
flecainide (negative inotropic and proarrhythmic effect)
Following drugs may worsen seizure control in patients with epilepsy [DAPAN]
- alcohol, cocaine, amphetamines
- ciprofloxacin, levofloxacin
- aminophylline, theophylline
- bupropion
- methylphenidate (used in ADHD)
- mefenamic acid
drugs
abx
psych
asthma
NSAID
which antibiotics are contraindicated in pregnancy [5]
- tetracyclines
- aminoglycosides
e.g. gentamicin, amikacin, tobramycin, neomycin, and streptomycin - sulphonamides
- trimethoprim
- quinolones
which drugs are contraindicated in pregnancy (non Abx) [8]
- ACE inhibitors
- angiotensin II receptor antagonists
- statins
- warfarin
- sulfonylureas
- retinoids (including topical)
- cytotoxic agents
- antiepileptics (risk v benefits decision)
3 drugs to use with caution in asthmatics
NSAID
beta blockers
adenosine
what should be used as an alternative for adenosine in the treatment of SVT
verapamil
Exacerbating factors of psoriasis
drugs
alcohol
trauma
withdrawal of steroids
strep infection
Drugs that can exacerbate psoriasis
beta blockers
lithium
antimalarials (chloroquine and hydroxychloroquine)
NSAIDs
ACE inhibitors
infliximab
which anti-diabetic drug is contraindicated in heart failure?
why?
pioglitazone
causes fluid retention
which fluid should be avoided in stroke patients? why?
5% glucose as there is the risk of cerebral oedema
Maintenance water requirement
20-30ml/kg/day
maintenance electrolytes requirement
approximately 1 mmol/kg/day of potassium, sodium and chloride
maintenance glucose requirement
50-100g/day to limit starvation ketosis
what is the risk with overloading saline
hyperchloraemic metabolic acidosis
which patients should Hartmann’s not be given to?
hyperkalaemic patients
main adverse effect of carbimazole
agranulocytosis
what % is a HbA1c of 48
6.5
what % is a HbA1c of 53
7.0
what glucose parameter should determine change in diabetic medication
HbA1c
endocrine side effects of glucocorticoids [4]
impaired glucose regulation
increased appetite/weight gain
hirsutism
hyperlipidaemia
Features of Cushing’s syndrome (side effects of glucocorticoids) [3]
moon face
buffalo hump
striae
MSK side effects of glucocorticoids [3]
osteoporosis
proximal myopathy
avascular necrosis of the femoral head
immunosuppressive side effects of glucocorticoids [2]
increased susceptibility to severe infection
reactivation of tuberculosis
psychiatric side effects of glucocorticoids [4]
insomnia
mania
depression
psychosis
GI side effects of glucocorticoids [2]
peptic ulceration
acute pancreatitis
ophthalmic side effects of glucocorticoids [2]
glaucoma
cataracts
3 other side effects of glucocorticoids
suppression of growth in children
intracranial hypertension
neutrophilia
side effects of mineralocorticoids [2]
fluid retention
hypertension
why can taking long term steroids precipitate an Addisonian crisis
taking exogenous steroids suppresses the production of our own endogenous steroids therefore abrupt withdrawal can lead to Addisonian crisis
BNF suggests gradual withdrawal of systemic corticosteroids if patients have
1) received more than 40mg prednisolone daily for more than one week
2) received more than 3 weeks of treatment
3) recently received repeated courses
How should a patient be counselled for taking bisphosphonate
1) Take 30 minutes before breakfast i.e. on an empty stomach with plenty of water
2) remain standing or upright for 30 minutes after
main adverse reactions with oral bisphosphonates [5]
- oesophageal issues e.g. ulcer, oesophagi’s
- osteonecrosis of the jaw
- hypocalcaemia
- acute phase response
- atypical stress fractures
what should be corrected before starting bisphosphonates
low calcium/Vitamin D
what should be done 90 minutes after thrombolysis in STEMI?
ECG to check for at least 50% ST elevation resolution
main side effects of sulfonylureas e.g. gliclazide [2]
hypo and weight gain
rarer adverse effects of sulfonylureas [4]
hyponatraemia secondary to syndrome of inappropriate ADH secretion
bone marrow suppression
hepatotoxicity (typically cholestatic)
peripheral neuropathy
breastfeeding and pregnancy advice regarding sulfonylureas
AVOID
oxygen therapy for acute unwell COPD patient in hospital
Oxygen via a Venturi 24% mask at 2-3 l/min or Venturi 28% mask at a flow rate of 4 l/min or nasal cannula at a flow rate of 1-2 l/min (if a 24% mask is not available)
Aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia
two main side effects of insulin therapy
hypos and lipodystrophy
Levemir
insulin determir
long acting
Lantus
insulin glargine
long acting
Humalog
insulin lispro
rapid
Novarapid
insulin aspart
rapid
ECG sign of digoxin toxicity
reverse tick sign (downward sloping ST segment)
what is an FTU
amount of medication needed to squeeze a line from finger tip to first crease of an adult finger, provides enough to treat one side of both hands
Enzyme inducers: PC BRAS
P-phenytoin
C- Carbamazepine
B- Barbiturates
R- Rifampicin
A- Alcohol chronic
S- Sulphonylureas, St Johns Wort
Enzymes inhibitors: AODEVICES
A- Allopurinol, -azoles, amiodarone
O- Omeprazole
D- Disulfiram
E- Erythromycin
V- Valproate
I- Isoniazid
C- Ciprofloxacin, cimetidine
E- Ethanol acute
S- Sulphonamides, SSRIS
Drugs to stop before surgery: I LACK OP
I- Insulin
L- Lithium
A- Anticoagulants/antiplatelets
C- COCP/HRT
K- K-sparing diuretics
O- Oral hypoglycaemics
P- Perindopril and other ACEi and ARBs
how long before surgery must COCP be stopped
4 weeks before
how long before surgery must lithium be stopped
day before
how long before surgery must K+ sparing diuretics and ACEi be stopped
day before
Safe routine for prescribing: PReSCRIBER
P- Patient detials
Re- Reactions
S- Sign off the front of the chart
C- Contradications
R- Routes
I- IV fluids
B- Blood clot prophylaxis
E- anti Emetics
R- pain Relief
how many pieces of identifying detail must be written on the front of the chart
3
which groups of drugs should you know the contraindication of
anticoagulants/antiplatelets
steroids
antihypertensives
NSAIDs
contraindications of anticoagulants/antiplatelets
- active bleed
- suspected bleed
- risk of bleeding e.g. increased PT secondary to liver disease
- aware of enzyme inhibitors
contraindications of steroids: STEROIDS
S- Stomach Ulcers
T- Thin skin
E- oEdema
R- Right and left heart failure
O- Osteoporosis
I- Infection
D- Diabetes
S- Cushing’s syndrome
contraindications of NSAIDs: NSAID
N- No urine
S- Systolic dysfunction i.e. heart failure
A- Asthma
I- Indigestion (any cause)
D- Dyscrasia (clotting abnormality)
Contraindication to general antihypertensives
hypotension
two heart related contraindications of hypertensives
bradycardia –> beta blockers, CCB
electrolyte disturbances –> ACEi, diuretics
ACEi specific side effect
dry cough
Beta blocker specific side effects [2]
wheeze in asthmatics
worsening of HF
CCB specific side effects [2]
peripheral oedema
flushing
Thiazide specific side effect
gout
K+ sparing diuretic specific side effect
gynaecomastia
which organ system can diuretics negatively affect
renal
All patients should receive 0.9% saline for fluid replacement except which patients [4]
- hypernatraemic
- hypoglycaemic
- ascitic
- haemorrhaging
which replacement fluids should hypernatraemic patients receive
5% dextrose
which replacement fluids should hypoglycaemic patients receive
5% dextrose
which replacement fluids should ascitic patients receive
human albumin solution
(normal saline can worsen ascites)
which replacement fluids should haemorrhaging patients receive
blood transfusion
which factors should affect your decision on how much and over how long the replacement fluid should be given? [3]
HR
BP
urine output
how much fluid does someone tachycardia or hypotensive receive
what if they had heart failure:
500ml bolus
250ml if HF
how much and over how long should fluid be given for someone oliguric for causes other than post-renal
1L over 2-4 hours
roughly how fluid deplete is someone with reduced urine output
500ml
roughly how fluid deplete is someone with reduced urine output + tachycardia
~1L
roughly how fluid deplete is someone with reduced urine output + tachycardia + signs of shock
> 2L
what is the maximum fluid you should give to a sick patient
no more than 2L of IV fluid
what is the maximum rate IV potassium can be given
10mmol/hour
generally, how much fluid do adults require over 24 hours
3L
generally, how much fluid do the elderly require over 24 hour
2L
which fluids and how much of each provides enough electrolytes over a day
1L of 0.9% saline
2L of 5% dextrose
how much potassium replacement should be given for someone with normal potassium
40mmol per day
spread over two bags of 20
which fluids can be used to provide potassium
saline and dextrose
how often over 24 hours should 3L daily fluid be give
8 hourly bags
how often over 24 hours should 2L daily fluid be give
12 hourly bags
what three things must you do before prescribing fluids to the patient in terms of pre-assessment
1) check their U&Es
2) check for fluid overload
3) check if the bladder is palpable to indicate obstruction
what is contraindicated in those with peripheral arterial disease?
compression stockings as it may cause acute limb ischaemia
which two groups of patients should metoclopramide be avoided
Parkinsons’ –> worsening symptoms
Young women –> risk of dyskinesia
which antiemetic is good for most reasons except cardiac
what should be used instead
cyclizine
not good for cardiac cases as causes fluid retention
metoclopramide for cardiac cases
which drug is indicated in painful diabetic neuropathy
duloxetine
daily maximum dose of paracetamol
4g
important to check other sources of paracetamol including co-codamol
what is the maximum paracetamol dose in someone <50kg
500mg 6 hourly therefore 2g
diuretic drugs that cause hypokalaemia
thiazide diuretics
loop diuretics
why is metoclopramide bad for Parkinsons while domiperidone is okay to use?
metoclopramide is a dopamine agonist that cross the BBB
drugs that cause hyperkalaemia [6]
ACEi
ARBs
K sparing diuretics
Heparin and LMWH
Tolvaptam
Co-trimoxazole
two drugs that cause gastric ulceration
NSAIDs
steroids
signs of antimuscarinic toxicity [3]
pupillary dilation with loss of accomodation
dry mouth
tachycardia
what must be ensured to be written down when prescribing PRN Medication
the maximum dose/frequency
In an active ________ , methotrexate is contraindicated
In an active infection , methotrexate is contraindicated
first line thromboprophylaxis/secondary prevention for ischaemic stroke
clopidogrel
second line thromboprophylaxis/secondary prevention for ischaemic stroke
aspirin + MR dipyridamole
only if clopidogrel is contraindicated
what happens if CCBs are used with beta blockers
bradycardia
can become asystole
max dose bisoprolol daily
10mg
which insulins are given IV
novarapid (rapid) and actrapid (short) sliding scales
how is insulin usually always given
S/C
name three drugs contraindicated in asthma
beta blockers
NSAIDs
adenosine
4 causes of hypernatraemia
dehydration
drips
drugs
diabetes insipidus
3 haematological diseases that lead to microcytic anaemia
myeloproliferative
myelodysplastic
multiple myeloma
2 drugs that lead to neutropenia
carbimazole
clozapine
which rheumatoid arthritis treatment causes thrombocytopenia
penicillamine
which anticoagulant causes thrombocytopenia
heparin
3 hypovolaemic causes of hyponatraemia
fluid loss diarrhoea or vomiting
diuretics
Addisons’s disease
3 euvolaemic causes of hyponatraemia
SIADH
psychogenic polydipsia
hypothyroidism
3 hypervolaemic causes of hyponatraemia
heart failure
renal failure
liver failure
causes of SIADH: SIADH
S- Small cell lung cancers
I- Infection
A- Abscess
D- Drugs like carbamazepine and antipsychotics
H- Head injury
causes of hypokalaemia: DIRE
D- Drugs: loop and thiazide
I- Inadequate intake or intestinal loss
R- Renal tubular acidosis
E- Endocrine: Cushing’s and Conn’s
causes of hyperkalaemic: DREAD
D- Drugs: K+ sparing and ACEi
R- Renal failure
E- Endocrine: Addison’s
A- Artefact: clotted sample
D- DKA
what two things can raised urea indicate
1) AKI
2) Upper GI bleed
raised urea with normal creatinine and not dehydrated –> check Hb
urea rise and creatinine rise in the 3 types of AKI
- pre renal
- intrinsic
- post renal
- pre renal: urea»_space;creatinine
- intrinsic: urea «_space;creatinine
- post renal: urea «_space;creatinine
3 nephrotoxic antibiotics
gentamicin
vancomycin
tetracyclines
2 drugs that trigger renal artery stenosis
NSAIDs
ACEi
causes of raised ALP: ALKPHOS
A- Any fracture
L- Liver damage (post hepatic)
K- Kancer
P- Paget’s disease of the bone and pregnancy
H- Hyperparathyroidism
O- Osteomalacia
S- Surgery
5 drugs that cause cholestasis
flucloxacillin
co-amoxiclav
nitrofurantoin
steroids
sulfonylureas
what should guide your change in levothyroxine dose
TSH
How can you tell if someone is hypoxic despite being on oxygen and an above normal PaO2
FiO2-10 will give you a threshold of kPa for which they are considered, below this level, as hypoxic
3 causes of metabolic alkalosis
vomiting
diuretics
Conn’s
in terms of large squares, what is normal PR
less than one large square
no heart block
which drug causes ST segment depression in all leads
digoxin
name 6 drugs that require monitoring
digoxin
theophylline
lithium
phenytoin
gentamicin
vancomycin
when there is an adequate response to a drug, when should a change in drug dose be made?
when serum levels are high
which drug require a change in frequency rather than dose if serum levels are too high
gentamicin
4 signs of digoxin toxicity
confusion
nausea
visual haloes
arrhythmia
early sign of lithium toxicity
coarse tremor
intermediate sign of lithium toxicity
tiredness
late signs of lithium toxicity [5]
arrhythmias
comas
seizures
renal failure
diabetes insipidus
signs of phenytoin toxicity [5]
gum hypertrophy
ataxia
nystagmus
peripheral neuropathy
teratogenicity
signs of gentamicin and vancomycin toxicity [2]
ototoxicity and nephrotoxicity
3 things to do if there are signs of drug toxicity
1) stop the drug, give alternative if needed
2) supportive treatment e.g. fluids
3) give antidote is applicable
what two factors are used in calculating gentamicin dose
weight and renal function
which groups of conditions need altered gentamicin dosing [2]
renal failure and endocarditis
how do you determine if a patient needs 36 or 48 hour dosing of gentamicin instead of daily
serum levels fall above the 24 hour line on the normogram
normal INR target for those on warfarin
2.5
normal INR target for those on warfarin with recurrent VTE
3.5
treatment of someone with major bleed on warfarin
stop warfarin
give IV vitamin K 5-10mg
give prothrombin complex (Beriplex), if not available give FFP which is less effective
nb bleeding always needs IV vit K
if INR is between 5-8 and there is NO bleeding, what must be done with warfarin
omit warfarin for 2 days/Withhold 1 or 2 doses of warfarin
reduce subsequent maintenance dose
if INR is between 5-8 and there is bleeding, what must be done with warfarin
stop warfarin
give 1-5mg slow IV vit K
Restart warfarin when INR <5.0
if INR is >8 and there is NO bleeding, what must be done with warfarin
omit warfarin
give 1-5mg PO vit K
(Repeat dose of phytomenadione if INR still too high after 24 hours)
Restart warfarin when INR <5.0
if INR is >8 and there is bleeding, what must be done with warfarin
stop warfarin
give 1-5mg IV vit K
Repeat dose of phytomenadione if INR still too high after 24 hours)
Restart warfarin when INR <5.0
how many milligrams in a gram
1000
how many micrograms in a milligram
1000
how many micrograms in a gram
1,000,000
what is the relationship between dose volume and concentration
volume= dose/conc
conc= dose/vol
relationship between rate, dose per time and conc
rate= dose per time/conc
relationship between rate, dose and time
rate= dose/time
what does % w/v mean
x grams in 100ml
rhythm control: pharm cardioversion in those with NO structural heart diseasw
flecanide
rhythm control: pharm cardioversion in those with structural heart diseasw
amiodarone
CCB used in AF management
diltiazem
4 contraindications of beta blocker
bradycardia
asthma
acute heart failure
hypotension
3 contraindications of calcium channel blocker
hypotension
bradycardia
peripheral oedema
what is the next step in treating angina if failure to treat with 2 anti-anginals
urgent revascularisaltion e.g. PCI or CABG
4 steps of diabetes management
1) education: dietary and exercise advice
2) cardiovascular risk factor management- aspirin and statin
3) monitoring for complications: ACR
4) blood glucose lowering therapy
examples of levodopa combined with peripheral decarboxylase inhibitors
co-beneldopa and co-careldopa
male treatment for myoclonic seizure
valproate
female treatment for myoclonic seizure
levetiracetam
male treatment for tonic seizure
valproate
female treatment for tonic seizure
lamotrigine
male treatment for generalised TC seizure
valproate
female treatment for generalised TC seizure
lamotrigine
treatment for all other focal seizure
carbamazepine or lamotrigine
treatment for absence seizures [2]
ethosuximide or valproate
three licensed drugs for treatment of Alzheimers
donepezil
rivastigmine
galantamine
which enzyme must be tested for before starting azathioprine
what should be done if this enzyme is absent
thiopurine S-methyl transferase (TPMT)
use methotrexate for maintenance of Crohn’s remission
mild flare of Crohn’s treatment
prednisolone
severe flare of Crohn’s treatment
hydrocortisone
maintenance of remission in Crohn’s
azathioprine or 6-mercaptopurine
side effects of lamotrigine [2]
rash
SJS
side effects of carbamazepine [5]
rash
dysarthria
ataxia
nystagmus
hyponatraemia (secondary to SIADH)
side effects of phenytoin [4]
ataxia
peripheral neuropathy
gum hyperplasia
hepatotoxicity
side effects of sodium valproate [3]
tremor
teratogenicity
weight gain
side effects of levetiracetam [3]
fatigue
mood disorders
agitation
contraindication to bulking agents like isphagula husk
faecal impaction
contraindications to phosphate enema [2]
acute abdomen and IBD
example of osmotic laxatives [2]
phosphate enema
lactulose
example of stimulant laxatives [2]
Senna and bisacodyl
what is the treatment for rheumatoid arthritis if there is failure to respond to 2 DMARDS
TNF alpha inhibitors like infliximab
when should a laxative never be given
in obstruction
what is the most first line hypnotic to give for insomnia when all other methods are exhausted
zopiclone 7.5mg oral at night in adults
3.75mg in the elderly
interaction between tamoxifen and warfarin
tamoxifen increases warfarin’s anticoagulant effect
effet of calcium salts on bisphosphonates
reduces absorption
combined HRT or oestrogen only HRT: which has the higher risk of breast cancer
combined
do vaginal preparation of HRT with low dose oestrogen increase the risk of breast cancer
no
3 drugs that differ in formulation on salt factor
phenytoin
digoxin
sodium fusidate
information on dose equivalence and conversion section.
when are ACEi best taken and why?
in the evening as they can cause postural hypotension
what two drugs can be used in rate control of AF
Beta blocker or CCB e.g. diltiazem or verapamil
first line drug to decrease potassium in the body
short acting insulin with dextrose
10 units act rapid in 100ml of 20% dextrose over 30 minutes IV
second line drug to decrease potassium in the body
salbutamol
2.5-5mg nebs stat
side effect of levetiracetam
depression
ideally don’t give in depressed women
contraindications of metformin [4]
1) chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)
2) metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration
3) Iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter
4) alcohol abuse is a relative contraindication
first line anti diabetic drug in overweight people
metformin
supresses appetite
what creatinine level contraindicates the use of metformin
> 150
what needs to be checked before starting vancomycin
renal function
renally cleared drug
what should be measured before starting statins
hepatic function
cleared by liver
when should CK be checked when starting someone on a statin
if they have risk factors for developing myopathy
what blood test should be done before starting lithium
FBC
how does sodium affect lithium in management of mania
sodium depletion increases risk of lithium toxicity
FBC monitoring in MTX
monitor FBC at baseline and every 1-2 weeks until levels are stable, then monitor every 2-3 months
when is CXR done during MTX therapy
not at baseline
only when pulmonary toxicity is suspected
how is MTX excreted
predominantly renally
what should be measured before starting olanzapine [2]
fasting blood glucose
ECG if there is previous CVD or risk factors
what imaging is done at baseline before starting amiodarone
chest X-ray
patients with which electrolyte abnormality must be started with amiodarone with caution
hypokalaemia
how is gentamicin cleared
predominantly renally
what should be measured regularly with ACEi
U&Es
when should plasma digoxin levels be measured
if toxicity is suspected
what should be monitored during digoxin therapy
renal function as it is predominantly renally cleared
drugs with a narrow therapeutic window
warfarin
phenytoin
digoxin
theophylline
which drug causes a hypertensive crisis
MAO-I
what should be avoided whilst taking metronidazole
alcohol –> causes fulminant N&V
what co-prescription can worsening renal failure with NSAIDs
ACEi
what type of drug is amiloride
K+ sparing diuretic
how much potassium in KCl 0.3% 1L
over how long
40mmol
over 4 hours
how much potassium in KCl in 0.15% 1L
over how long
20mmol
2 hours
overhow long should a litre of saline be given if there are no losses/deficits
over 8 -12 hours
emergency resuscitation in children: fluid bolus given
saline 0.9% 10ml/kg over 15 minutes
what fluid is given in emergency hypoglycaemia
how much over how long
IV 20% glucose 100ml over 15 minutes
what fluid is given in emergency hypercalcaemia
how much over how long
IV sodium chloride 0.9% 1000ml over 4 hours
what fluid is given in emergency hypokalaemia
IV sodium chloride 0.9% with 0.3% KCL over 4 hours
what fluid is given in maintenance with losses/deficits?
replace minimum 30ml/kg/24 hours with required electrolytes over 4-6 hours
thromboprophylaxis in renally impaired
UFH
standard thromboprophylaxis
LMWH e.g. enoxaparin, tinzaparin
monitoring of UFH
aPTT
monitoring of LMWH
anti factor Xa
treatment for hypocalcaemia
calcium gluconate 10% IM
signs of hypocalcaemia
CATS go numb:
C- Convulsions
A- Arrhythmia
T- Tetany
S- signs: trousseau and chvostek
where do you find treatment for situations in primary care
medical emergencies in the community
treatment of migraine with no aura
ibuprofen
treatment of migraine with aura
triptan
localised neuropathic pain but can’t take tablets PO
lidocaine patch
treatment of trigeminal neuralgia
carbamazepine
anti-emetic: vestibular cause
cyclizine
anti-emetic: post-op
ondansetron
anti-emetic: palliative
cyclzine
haloperidol
levopromazine
anti-emetic: chemo (acute and delayed)
acute- ondansetron
delayed- metoclopramide
anti-emetic: Parkinson’s
domperidone
anti-emetic: hyperemesis gravidarum
promethazine
what BP is a UKMEC 4 for microgynon
above 160/100
drug for Bell’s Palsy
HIGH DOSE prednisolone (50-60mg OD)
how often should children with T1DM monitor their BMs
at least 5 times a day
when should dual therapy for diabetes start
when HbA1c hits above 58
ADVICE 1
when checking monitoring requirements, check for what use of the medication that monitoring requirement is for
TFT abnormalities whilst on levothyroxine med changes
usually not needed if there is poor compliance, which includes over taking and under taking
what three things should you check when checking for serious prescribing errors?
dose
frequency/timing
route
what drugs can be continued during intercurrent illness
steroids
what drugs must be stopped during intercurrent illness [3]
metformin
statins
gliflozins
which drugs can worsen Parkinsons [3]
antipsychotics
antiemetics like metoclopramide
antidepressants esp MAO-I
which drugs may worsen Myasthenia gravis [4]
antibiotics
beta blockers
local anaesthetic
sedating drugs
drugs that are usually in micrograms [6]
levothyroxine
digoxin
tiotropium,other inhalers
tamsulosin
naloxone
fludrocortisone
drugs usually given in the daytime
steroids
drugs usually given at night [2]
statin
sedating drugs
which type of insulin is given with meals
rapid acting Bolus – e.g. Actrapid or soluble / short-acting insulin
how can you check if the insulin type is long acting or rapid
scroll to the bottom of BNF
which drugs can cause oral thrush [3]
steroids
antibiotics
immunosuppressants
treated with nystatin
drugs that cause euglycaemic diabetic ketoacidosis
glifozins
therefore hold during illness
drugs that can increase risk of hypomagnesaemia [3 main ones]
Thiazide / thiazide-like diuretics
Loop diuretics
Proton pump inhibitors
Exchange resins (e.g. calcium resonium)
Ciclosporin
IV bisphosphonates (e.g. during treatment of hypercalcaemia)
IV Antifungals
IV Aminoglycosides
ADVICE 2
if you want to see if a drug should be stopped in CKD, AKI, poor creatinine etc. check renal impairment section
meds may require dose adjustments / cessation with existing reduced renal function
E.g. canagliflozin, metformin, spironolactone
May cause a reduction in renal function
E.g. ACE inhibitors/ARBs, diuretics
which drugs can cause acute dystonic reactions [4]
Antipsychotic drugs (especially haloperidol)
Metoclopramide
Domperidone
Cyclizine
drugs that cause hypokalaemia [5]
Diuretics
IV Antifungals (esp. amphotericin)
Cisplatin
Glucocorticoids / mineralocorticoids (typically only if excess)
Beta2-agonists
(Rarely) aminoglycosides such as gentamicin and amikacin
how often is a fentanyl patch replaced
every 72 hours
drugs that can elevate blood pressure [4]
- NSAIDs
- Glucocorticoids & Mineralocorticoids (but usually as treatment for hypotension/insufficiency)
- Venlafaxine / tricyclic antidepressants
- Combined oral contraceptives
Mirabegron
Clozapine
Monoamine oxidase inhibtiors
Selegiline
Cyclosporine / tacrolimus / rapamycin
drugs that can cause hypoglycaemia [2 main ones]
Insulin
Sulfonylureas
Other anti-diabetic drugs still have the risk, but lower
GLP-1 activators (e.g. exenetide)
SGLT2 inhibitors (e.g. canagiflozin)
DPP4 inhibitors (e.g. sitaglitpin)
Pioglitazone
drugs that increase risk of falls [6]
Benzodiazepines
Z-drugs
Antidepressants (especially TCAs and SNRIs, less so SSRIs)
Most antipsychotics
Opiates
Most anti-hypertensives (especially alpha-blockers, diuretics, centrally acting)
Some anti-Parkinson’s medications (e.g. selegiline, ropinirole)
(Less commonly) some anti-epileptics (excess dosing / levels)
In theory, those that cause hypoglycaemia
drugs that are given weekly [2]
methotrexate
bisphosphonates sometimes
ADVICE 3
if there is a specific brand of that drug, dosage may vary
how can you check if heart failure treatment is working
exercise tolerance
ADVICE 4
it is better to alter an existing insulin regime than to add to it
ADVICE 5
if a method of contraception affects the efficacy of another drug or vice versa, use an alternative method of contraception
How do I know if a drug / product needs a prescription or not?
BNF Drug of interest, e.g., ibuprofen Navigate to Section box: “Medicinal forms”
Many brands & strengths - But for each product listed, the “Legal category” line gives prescription status information
ADVICE 6
A lot of questions have answers where more than one, or all, options are “true”, You have to select “most important”
Ask yourself: “What happens if the patient does not know this?”
Self-reporting / clinician-monitoring of severe side effects (check safety info)
Sick day rules / peri-operative prescribing
Potential teratogenicity
Missed doses / interactions (i.e. things that make treatment less effective)
Risk of adverse effects if stopping medication suddenly?
important info about clozapine
Self-reporting
He should report symptoms of infection, especially influenza-like illnesses
He should report new onset (or worsening) constipation – may herald intestinal obstruction
Medications use
He should not stop the medication abruptly
what needs to be monitored with clozapine
Cholesterol and fasting blood glucose levels
FBC
Prolactin levels
At increased risk of cardiac disease and QTc prolongation
important side effects of anti psychotics
Blood dyscrasias / agranulocytosis
QT prolongation, arrythmias
Worsening diabetes
Worsening Parkinson’s disease
Neuroleptic malignant syndrome
important info about doxycycline
avoid exposure to sunlight due to severe photosensitivity reaction
visual side effects are also severe but rare
list drugs that cause photosensitivity [5]
Isotretinoin
Doxycycline (and other tetracyclines)
Amiodarone
Thiazide diuretics
Topical NSAIDs – on light-exposed skin
where can I find drug safety advice
cautions
medicincal forms
patient and carer advice
Important info regarding insulin
stop taking metformin if she develops diarrhoea or vomiting:
To prevent side effects (such as lactic acidosis) when dehydrated.
medications to stop on sick days
Metformin (not insulin!)
ACEi / ARBs / diuretics
NSAIDs
important information for steroids
Do not stop steroids abruptly (discuss: fine-tune this advice)
Usually taken in morning (reduce nocturnal side effects)
Take with or just after food
Should carry steroid card
ADVICE 7
use treatment cessation for advice on how to stop a drug
important information about azathioprine
Should be warned to report immediately any signs or symptoms of bone marrow suppression e.g. inexplicable bruising or bleeding, infection
There is a risk of hypersensitivity reactions, which calls for immediate withdrawal
important information about methotrexate
Weekly dosing
Requires folic acid also weekly on a separate day to methotrexate
Should be warned to report immediately any signs or symptoms of bone marrow suppression e.g. bruising or bleeding, infection
Should be warned to report if stomatitis develops (may be first sign of gastro-intestinal toxicity)
Should be warned to report to seek medical attention if dyspnoea, cough or fever (pneumonitis)
Contraception recommended for both women and men for at least 3 months after treatment
Patients should avoid self-medication with over-the-counter aspirin or ibuprofen / NSAIDs – renal toxicity from both; NSAID renal impairment reduced mtx excretion (mainly excreted unchanged, renally)
what can unexpected bruising be a sign off
bone marrow toxicity
important information about sodium valproate
Highly teratogenic - contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met
Advice on how to recognise signs of liver dysfunction or pancreatitis (e.g. persistent vomiting and abdominal pain, anorexia, jaundice) and advised to seek immediate medical attention
important information about carbamazepine
Advice on how to recognise signs of blood, liver, or skin disorders (e.g. fever, rash, mouth ulcers, bruising, or bleeding) - seek immediate medical attention; CYP enzyme inducer; Teratogenicity reported – specialist referral; Skin: SJ/TEN risk - HLA B*1502 testing before commencing
important information about phenytoin
Narrow therapeutic index – neurologic toxicity - nystagmus, ataxia, tremor; CYP enzyme inducer – initial dose needs increase to maintain therapeutic level; Teratogenicity reported – specialist referral; Skin toxicity SJS/ TEN
important information about lamotrigine
Advice to see doctor immediately if rash or symptoms of hypersensitivity (risk of Stevens-Johnson syndrome SJS / toxic epidermal necrolysis TEN); Advice on recognising signs of bone marrow suppression - anaemia, bruising, or infection.
important information about anti epileptics in general
Often require LFT ± FBC monitoring; Slow up-titration (carbamazepine, phenytoin induce own metabolising CYP enzymes; monitor levels until steady state dose reached); Don’t abruptly withdraw medications; Where appropriate, discuss teratogenic risk of non- valproate agents v epilepsy risks to foetus – specialist neurology;
how many nanograms in a microgram
1000
ADVICE 8
check body surface area in children under BNFC
what is the guidance around pre dose trough and post dose peaks and gentamicin administration
“If the pre-dose (‘trough’) concentration is high, the interval between doses must be increased i.e. made less frequent
If the post-dose (‘peak’) concentration is high, the dose must be decreased”
where can I see what do for bleeding whilst on warfarin
Oral anticoagulants treatment summary and go to haemorrhage section
VTE prophylaxis in the renally impaired
LMWH or UFH
what Creatine Kinase increases can be tolerated in statins
between 1 to 5 times the upper limit of CK can be tolerated, continue the statin but monitor CK., stop if there are muscle symptoms or CK continues to rise
above that , statin needs to be stopped
what LFT derangement warrants stopping statins
> 3 times the upper limit and recheck LFTs within 4–6weeks to ensure that values settle
in terms of non HDL changes with statins, when must you consider an increase in dose
when reduction in non-HDL is <=40 %
if more than 40, continue the dose
paediatrics dose of adrenaline in anaphylaxis
150-300 micrograms
depends on age
what bloods may impact choice of DOAC
Creatinine and eGFR
what duration do you put down for a repeat prescription
28/30 days
important monitoring requirement for children taking inhaled steroids
height and weight
what is used to monitor low molecular weight heparin
anti factor Xa activity
what needs to be monitored with azathioprine for adverse effects
FBC
what needs to be monitored with azathioprine for beneficial effects in the treatment of Crohns
stool frequency
typical BMs target whilst on insulin
4-10
what percentage adjustments are made with insulin dosages
10%
which type of insulin is given at night
Basal – e.g. Lantus, Levemir or insulin glargine
when are biphasic insulins dosed
Typically dosed at breakfast and evening meal
what is used to monitor UFH
aPTT
which anticoagulants are monitored clincially
DOACs and fondaparinux
how often must ketones be measured during sick days
2-4 hourly
which contraception can be continued preoperatively
POP
HRT and oestrogen containing contraceptives need to be stopped before major surgery
ADVICE 9: checking Abx suitability, check their PMH
E.g. Quinolones with long QT, G6PD
E.g. Nitrofurantoin with G6PD, folate deficient (or predisposition)
E.g. Trimethoprim with folate deficiency (or predisposition)
Also, for female, childbearing age, check ask/check re pregnant / breastfeeding
where do you find the paracetamol nomogram
poisoning treatment
when is folate given relative to MTX
never on the same day
MTX Mondays Folate Fridays
two emergency contraceptive pills
levonorgestrel (<72h) and ulipristal acetate (<120h)
emergency contraception: extra info for levonorgestrel [4]
can be taken straight away if vomiting occurs within 3 hours
double dose if >70kg or BMI >26
double dose if taking an enzyme inducer
can start COCP straightaway
emergency contraception: extra info for ulipristal actetate
contraindicated in asthma
can start COCP after 5 days
COCP cancer risk
increases risk of cervical and breast cancer
decreases risk of ovarian and endometrial
main side effect of cocp
increased risk of VTE
main side effect of POP
irregular bleeding
MoA of COCP
inhibits ovulation
MoA of POP
thickens mucus
what drug is cerazette
desogestrel
what drug is microgynon
ethinylestradiol with levonorgestrel
perioperative insulin
give insulin the day before surgery as normal except is once a day long acting, reduce the dose by 20%
metformin and sulfonylureas on the day of surgery
continue metformin
hold sulfonylurea
threshold for diabetes in pregnancy
5678
ADVICE 10
“antibacterials, use for prophylaxis” for example pre pacemaker insertion
examples of triple inhalers for COPD
beclometasone with formoterol and glycopyrronium
fluticasone with umeclidinium and vilanterol
mometasone furoate with glycopyrronium bromide and indacaterol
ADVICE 11
if there is severe hyperkalaemia with no ECG changes, don’t prescribe calcium gluconate yet as there is no benefit if there is no cardiac membrane instability
give insulin (e.g., Actrapid) 10-20units in 50mL of 50% glucose IV over 5-15min would
ADVICE 12
replacing potassium needs to be done at 10mmol/hr so even if they are hypotensive, no stat dose can’t be given
500ml 0.9% NaCl with 0.15% K+ (10mmol K+ in 500mL) over 1h; or 1L over 2h would be reasonable
not 15 min! and don’t use dextrose as glucose pushes K+ into cell
ADVICE 13
Diabetes, surgery and medical illness to check for example fluids during surgery
Needs Na / K/ Glu fluid, 1L over 12h ok; 500ml over 6h ok
treatment for headlice
malathion
treatment for threadworm
mebendazole
croup management
Dexamethasone
GP may give oral
in ED, IV maybe given depending on how severe
ADVICE 14
HRT advice found under “sex hormones”
for someone who doesnt want withdrawal bleeds continuous oestrogen and progestogen is indicated e.g. patch Evorel Conti
treatment of scarlet fever
phenoxymethylpenicillin
if antibiotics and warfarin are interacting, what is changed?
warfarin
advice regarding methotrexate and conception
use effective contraception whilst on MTX and for at least 6 months after stopping
treatment of Group B strep in pregnancy
benzylpenicillin
Group B is agalactiae
loading dose vs prophylaxis in MI
300mg v 75mg
one is before PCI
fluid deficit formula
% dehydration x weight (kg) x 10
VTE prophylaxis in a needle phobic pt
oral rivaroxaban, apixaban, dabigatran
NOT edoxaban
standard VTE thromboprophylaxis
LMWH
dalteparin, tinzaparin, enoxaparin
what is used for anticoagulation in pregnancy
LWMH
DOACS and warfarin are contraindicated
Long-term treatment with heparins in pregnancy require monitoring :
anti-Factor Xa activity (for dosing)
platelets (for heparin-induced thrombocytopenia)
fluid to give in someone hypokalaemic (maintenance)
1L NaCL 0.9% + 0.3% KCL over 4 hours
fluid to give in severe hypercalcaemia
1L NaCL 0.9% over 4 hours
at what GFR should metformin be stopped and why
<30
risk of lactic acidosis
treatment of chronic heart failure
BASH:
Beta blocker
ACEi
Spirinolactone
Hydralazine + nitrate
when should IV insulin be stopped
30 minutes after SC infusion
drugs that alter the absorption of other drugs
antacids, PPIs and H2RAs
how long should metoclopramide be prescribed for
5 days (short term)
contraindications of pioglitazone
heart failure
bladder cancer
macroscopic haematuria
two anti diabetic drugs that cause weight gain
sulfonylureas and GLP-1
what does cabergoline need monitoring for
fibrotic disease eg. the heart so needs echo
