psa Flashcards
Donepezil (anticholinesterase inhb)
Bradycardia
Co-beneldopa (bensarazide hydrochloride and levodopa)
Hallucinations
Anxiety
(Rare- leucopenia)
Monitoring for Pramipexole
BP - risk of postural hypotension
Serious SE of Lamotrigine
Stevens Johnson syndrome - rash within 8 weeks of treatment
Risk factor drugs for SJS
Anti-epileptics - Carbamazepine
Allopurinol
Sulfonamides
Anti-fungals- Terbinafine
SE of PPIs
- Low Mg
- Low Na+
- Osteoprosis, #risk
- Microscopic colitis
- C. diff infections (proliferation of C.diff spores due to reduced gastric acid production)
Digoxin toxicity
Can be precipitated by hypokalaemia (doesn’t compete with potassium for ATP-ase pump), but what other factors?
Why does this happen - related to MOA?
* Symptoms/ adverse effects
* Sign on ECG of digoxin induced changes (not necessarily toxicity)?
* Mx
- Digoxin toxicity triggers: electrolyte imbalance, renal failure, age, drugs (amiodarone and ones causing hypokalaemia eg chlortalidone - thiazide like diuretic)
- MOI: inhibitsNa+/K+ ATPase pump by competing with potassium so lower levels of potassium increase its effect
- High potassium reduces its efficacy/risk of treatment failure
- N&V, confusion, yellow-green vision (xanthopsia), drowsiness, diarrhoea
- Arrythmias - Bradycardia, AV block
- ECG: backwards tick - ST segment
- Mx: Digiband, monitor K+, correct arrythmias
Most likely SSRI to cause QT prolongation and torsades de pointes
Citalopram
drugs prolonging QT interval (risk of torsades de pointes - polymorphic VT)
- Methadone
- Odansetron
- Digoxin
- Antipsychotics - Haloperidol/Risperidone
- SSRIs - Fluoexeteine
Mirtazepine:
Class
MOA
Benefit over other antidepressants
NaSSA
Noradrenaline and specific serotinergic antidepressant
Increases levels of NA and serotonin in the brain
Helps with insomina, poor appetite, reduced sexual side effects (libido)
Ticagrelor SE
Dyspnoea
Dyspepsia
Dizziness
Diarrhoea
Gout
Monitoring:
IV Iron Dextran
Blood pressure
Monitoring:
Ethambutol
(eye-thambutol)
- Visual acuity
Monitoring for beneficial effects:
Furosemide
Weight
(overall loss of potassium with furosemide but not most accurate way to assess diuretic effect/volume loss)
Monitoring for beneficial effects:
Factor XA inhibitors (apixaban)
patient reports of bruising
Converting digoxin from IV to oral (via feeding tube)
Increase dose by 20-33% due to oral bioavailability
Monitoring requirements for bisphosphonates?
What has to be corrected before starting treatment?
- serum calcium
- calcium or vitamin d deficiency
treatment of PE: considerations for patients with cancer
Dalteparin sodium / Tinzaparin
CANCER - find in “Fragmin single dose syringe” –>
- “in patients with solid tumours”
- by weight categories
Also pregnant patients
note these extra considerations in the question stem!
Hypercalcaemia management
Aggressive fluid therapy
if hypotensive - fluid challenge
if not hypotensive:
4-6litres of 0.9 % NaCl over 24 hour period
E.g. 500ml over 2 hours
CYP450 Enzymes
Typical substrates
Warfarin
OCP
Statins
SSRI
Amitryptiline, codeine
CYP 450
Inhibitors (risk of toxicity) - SICK FACES
Sulfonamides
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alchohol, Amiodarone
Cipro
Erythro
Sodium valproate
CYP 450
Inducers (risk of treatment failure) - CRAP GPS drink grapefruit juice
Carbamazepine
Rifampicin
Alcohol (chronic)
Phenytoin
Griseofulvin
Phenobarbitol
St John’s wort, steroids
+ grapefruit juice!
Hydroxychloroquine (DMARD)
main AE
(bulls eye) retinopathy
risk of blindness
measure visual acuity/annual screening/need opthal review before
interaction between Azathioprine and what cause bone marrow suppression/agranulocytosis?
Allopurinol
Xanthine oxidase inhibitor
Reduces breakdown of 6-mercatopurine (active form of axathioprine) -. builds up in DNA of bone marrow cells
drugs causing hypercalcaemia (3)
common non-drug related causes (3)
- Thiazide diuretics (increase renal absorption of Ca)
- Lithium
- calcium containing antacids
- Primary hyperparathyroidism
- Malignancy - mets, PTHrP from SCLC
- granulomatous conditions - sarcoid
Other - dehydration, thyrotoxicosis etc
Drugs causing hypocalcaemia
- PPIs
- Phenytoin
- Bisphosphonates (prevent osteoclastic activity)
- Rifampicin
- Chemo
PALLIATIVE
- Regimens for starting pain treatment in palliative care
- Dose if no comorbidities
- What should be coprescribed?
- Morphine causes which transient side effects (2) and what persistent?
- By what percentage can opioids be increased by?
- Treatments for metastatic bone pain (3)?
- Treatments for nausea and vomiting?
- MR or IR Morphine + IR Breakthrough dose
- 20-30mg MR/day + 5mg PRN (2-4hrly)
- stimulant laxatives (senna or bisacodyl)
- transient - nausea and drowsiness, persistent - laxative
- Can increase opioids for next dose by 30-50%
- NSAIDs, Bisphosphonates, radiotherapy (+/- denosumab)
- Haloperidol, Cyclizine, Levomepromazine
SIGN Guidelines
* Breakthrough dose
* Choice of opiate in CKD (mild-moderate; severe)
- 1/6 of total daily dose of morphine
- Oxycodone (mild-mod renal impairment)
- Alfentanil/Fentanyl/Beprenorphine (severe)
PALLIATIVE
Opioid conversions
1. Between opioids
* Oral codeine –> oral morphine
* Oral tramadol –> oral morphine
* Oral moprhine –> oral oxycodone
2. From oral to subcut
* Oral morphine –> SC morphine
* Oral morphine –> SC diamorphine
* Oral oxycodone –> SC Diamorphine
- From oral to transdermal
BNF gives conversion factors but approx:
* 30mg oral morphine =? fentanyl (eg change every 7days)
* And 24mg oral morphine = ?buprenoprhine (OD, eg change every 3 days)
- Oral codeine/tramadol –> morphine: /10
- Oral morphine –> oral oxycodone: 1.5/2
- 30mg oral morphine = 12mcg fentanyl.
- And 24mg oral morphine = 10mcg buprenorphine
- Oral morphine –> SC morphine = /2
- Oral morphine –> SC diamorphine = /3
- Oral oxycodone –> SC Diamorphine /1.5
- 30mg oral morphine =12mcg fentanyl (eg change every 7days)
Syringe drivers:
Medications are mixed with what for injection (2 options)?
4 common symptoms:
1. Nausea and vomiting
2. Pain
3. Resp secretions and bowel colic
4. Agitation/restlessness
Which drug are there lots of incompatabilities for - e.g. to metoclopramide, sodium chloride 0.9%, hyoscine butylbromide?
Indications
- unsafe swallow
- intestinal obstruction
- dysphagia
- nausea
- weakness, coma
Infusion
- Water (majority)
- 0.9% NaCL e.g. for octreotide/odansetron
Commonly used drugs
1. Nausea and vomitng: Cyclizine, Levomepromazine, Haloperidol, Metoclopramide
2. Secretions: Hyoscine butylbromide, hyoscine hydrobromide, glycopyrronium bromide
3. Agitation: Midazolam, Haloperidol, Levomepromazine
4. PAin: diamorphine
NOTE - CYCLIZINE
Non-pharmacological approach for palliative care
- Pain
- N&V
- Low mood/distress
- TENS machine, physio, CBT
- regular mouth care, acupressure bands, meal alteration
- Complementary therapies, CBT, talking therapy
Advantage of using hyoscine butylbromide over hydrobromide for secretions?
Butyl- less sedative
Amlodipine/dihydropyridines CCBs side effects
Ankle swelling
Gum swelling (gingival hyperplasia)
Flushing
Headache
Diclofenac - contraindications
IHD, PVD, stroke, heart failure
Drug monitoring once established on drug:
* Amiodarone - 6 monthly
* Methotrexate: every 3 months
* Azathioprine: every 3 months
* Lithium: every 6 monthg
* Sodium valproate: periodically in 6 months
Amiodarone - LFT, TFT (U&E and CXR prior to treatment)
Azathioprine - FBC, LFT
Methotrexate - FBC, LFT, U&E
Lithium - Lithium level, TFT, U7E
Valpriate - LFT
Amiodarone (class3 antiarrythmic)
K+ channel inhibitor (and Na+ channel)
SIDE EFFECTS
- Skin/eyes: slate/grey; photosensitivity, corenal deposits
- Vessels: thrombophlebitis
- Heart: prolongs QT, bradycardia
- Fibrosis: lung, liver
Lunf fibrosis can also cause fever and raised ESR - Thyroid dysfunction - hypo/hyper (amiodarone)
- Neuro: peripheral neuropathy, myopathy
note amiodaraone typically does NOT cause finger clubbing unlike other causes of pulmonary fibrosis
Neonaclex
Bendoflumethazide
Interractions:
Indapamide (diuretic) and colecalciferol (vitamin d)
risk of
hypercalcaemia
Metclopramide - dopamine antagonist
- rare adverse effect and treatment
- acute dystonias (EPS)
- seen in first 1-2 days of treatment
- Procyclidine (antimuscarinic)
Phenothiazine - side effect
dry mouth
–>primary polydipsia
Drug worsening ischemia in peripheral vascular disease
Beta blockers - beta adrenergic antagonist - cause peripheral vasoconstriction
e,g, atenolol
Drugs contributing to heart failure
corticosteroid - prednisolone
calcium channel blocker
Insulin
improving glycaemic control in the afternoon
e.g. on biphasic insulin
increase morning dose
(if you increased the evening dose it could cause hypoglycaemia in early morning)
interactions with simvastatins - higher risk of myopathy and rhabdomyolysis
gemfibrozil - a fibrate for hyper choleserolaemia (increases statin concentration); inhibits CYPP2C8
clarithromycin
if statin supsected to be cause of myopathy, CK elevated (5x upper limit of normal) or muscular symptoms are severe …
discontinue treatment and reintroduce statin at a lower dose if CK levels return to normal (e.g. from 80mg atorvastatin to 40mg PO nightly)
then - switch to other statij with lower risk of myalgia
Simvastatin ->Atorvastatin –> Prav –> Fluva; or a fibrate
Drugs causing hyponatreamia
Thiazide diuretics
SSRIs
SNRIs
anti-epileptics
Dopamine antagonists
Which is safe in Parkinson’s disease?
Haloperidol
Metoclopramide
Domperidone - safe in PD as doesn’t cross blood brain barrier
Hyperkalaemia
Typical drugs
- K+ sparing diuretics (Spironalactone, Eplerenone)
- ACE Inhb/ARB (inhibit aldosterone –> less potassium excretion_)
- Ciclosporin
What increases risk of digoxin toxicity?
Hypokalaemia
and hypercalcaemia
- because digoxin competes with potassium at the Na+/K+ATPase (removal of potassium increases effect of digoxin on receptor)
Aspirin ADRS
Haemorrhage
Peptic ulcers
Gastritis
Tinnitus (large doses)
Amiodarone ADRs
Grey skin
Corneal deposits
Pulmonary fibrosis
Hypo/hyperthyroid
Lithium ADRs
Early - tremor
Intemediate - fatigue
Late - arrythmias, coma, renal failure, diabetes insipidus
Haloperidol
Clozapine
EPSE: dyskinesias (acute dystonias, oculogyric crisis)
Agranulocytosis
Corticosteroids (Dexamethasone and Prednisolone) ADRs - STEROIDS
S: Stomach ulcers
T: Thin skin
E: Edema
R: R/L heart failure
O: Osteoporosis
I : Infection more likely eg candia
D: Diabetes/hyperglycaemia is commonn bt uncommon toprogress ton DM
S: Syndrome (Cushing’s)
Fludrocortisone
Sodium and water retention (acts like aldosterone)
Hypertension
STATIN adrs
- Myalgia
- Abdominal pain
- Increased ALT/AST (mild)
- Rhabdo (midly increased CK throughout or severe)
Trimethoprim
(e.g. cotrimoxazole contains trimethoprim)
Neutropenia
e.g. two antifolates (trimethoprim and methotrexate) ccan cause bone marrow suppression, pancytopenia and neutropenic sepsis
SURGERY RULES
STOP (4)
Diabetics -convert insulin regimens to what?
keep what drugs?
What might need to be supplemented?
- Hormonal treatments (OCP)
- Anticoagulants (heparin, DOAC)
- Antiplatelets (aspirin, ticagrelor)
- Metformin - stop day before
- Lithium - day before
DM - insulin infusion variable rate
Keep
antihypertensives - particularly beta blockers and calcium channel blockers, if BP lower consider stopping a diuretic instead
supplement iv steroids
can aspirin be continued in aki
yes
is an nsaid but not c/id
Lithium toxicity - if dose has not changed, what drugs could be increasing plasma levels?
Management for mild-moderate
and severe
Drugs that reduce renal excretion:
ACE-Inhibitors
Diuretics - thiazides
Nsaids
e.g. stop lithium and the offending drugs causing the toxicity
Mx
Mild/moderate; volume resus with normal saline
Severe: haemodialysis
Fluid balance charts
- fluid inputs should equal fluid outputs
- if hypernatremic 5% glucose solution is a better choice
- potassium can be corrected with KCl (40mmol/day) and can never exceed 20mmol/hour
- eg if fluid negative - work out at what rate the patient is losing fluids and prescribe fluids at a rate that matches this
- eg loss of 6 litres / 24 hours = 1 litre every 4 hours so replace with fluids over 4 hours
maintenance fluids
adults req
ederly req
assuming the blood results are normal the maintenance fluids should include (3) in 24hrs
generally = 3 L per day (in 8hrly bags)
elderly = 2L (12hrly bags)
regime
2 salty, 1 sweet
2L 0.9% NaCl
1L 5% glucose
1st line antidiabetic in ckd
gliclazide
who requires an ecg for olanzapine
if cardiovascular risk factors
eg long term smoker
steroid conversion charts
search “glucocorticoid therapy”
remember doubek dose during infection/sepsis
Laxatives - when to use/avoid
Bulk-forming (isphagula husk)
Stimulant (senna, bisacodyl)
Stimulant and faecal softener (docusate sodium)
Faecal softeners (arachis oil enemea, docusate sodium enema)
Osmotic laxative (lactulose, macrogol 3350)
- bulk forming: short term constipation; avoid in obstruction, colitis and cframps, takes 72 hours to have affect, avoid in opioid-induced consipation
- stimulant: stools soft but difficult to pass, second line for short-duration constipation
- faecal softener: can be used in constipation in palliative care
- osmotic laxative: causes bloating, first line hepatic encephalopathy, use in constipation in palliative care
marker of improvement:
aminophylline
antibiotic treatment for pneumonia
o2 sats
RR, ABG, O2 sats
pre-dose (trough) concentrations for vancomycin
1-15mg/l
Cause of dyspepsia
Steroids- prednisolone
Alendronic acid -
Ibuprofen
Cause of peripheral oedema (ankle swelling)
Amlodipine / CCBs
Naproxen
management for haloperidol-associated parkinsonism (Drug induced epse)
procyclidine hydrochloride (anticholinergic)
Constipation - treatment options
Bulking agents (isphagula husk)
Stimulant (senna, bisacodyl)
Osmotics (lactulose, phosphate enema, polytethylene glycol “Movicol”)
Stool softener (docusate sodium - also a stimulant at higher doses; arachis oil)
- Bulking agents- contraindicated in fecal impaction/reduced gut motility; can take 72 hours to take effect
- Stimulants: CId in acute abdomen, may make abdominal cramps worse
- Osmotics: CId in IBD (enema), may cause bloating
- Stool softener: good for faecal impaction/ reduced gut motility
Constipation first line for children
(no fecal impaction)
Osmotic laxatives:
Search “Movicol -
polyethylene glycol 3350 plus electrolytes
1 sachet oral once daily 28 days
or Lactulose - liquid firm
second line is senna
Asthma adults
- Salbutamol
- Fluticasone
- Montelukast
AKI - drugs to stop
DAMN - PCL
also codeine (reduced excretion in AKI so more likely to have AEs)
Risks of ACE/I/ARBs in Afro-Carribean
higher risk angioedema
can happen in CCBs - but less common
Drugs causing urinary retention
Opiods
TCA - Imipramine
anticholinergics
general anaesthetics
alpha agonists
diazepam
nsaids
ccbs
antihistamines
alcohol
drugs causing weight gain
antidiabeitcs - pioglitazones, gliclazides
mirtazepine
depot provera injection
drugs causing cold peripheries
beta blockers
methylphenidate
diabetes treatment targets
- diet and lifestyle alone / metformin or one antidiabetic alone
- on a drug associated with hypoglycaemia
if blood sugars aren’t controlled on one and rise to above 58 –> drug treatment should be intesified or add a second
- on two antidiabetics
Hba1c <48mmol
<53 mmol
<53 mmol
Drugs to stop before surgery
ILACKOP
Insulin - INSTEAD variable rate insulin with long acting, omit short acting
Lithiuim
Anticoagulatns/antiplatelets (except aspirin, generally)
COCP/HRT
K+ sparing diuretics
Oral hypoglycaemics - EG nbm
Perindopril/ACE-Inhbs
Fluids
Adults
Elderly
Electrolytes - sweet/salty
Potassium
Adults: 3L per day (3 x 8hrly bags)
Elderly: 2l (2 x12 hr bags)
Electrolytes: 1 salty, 2 sweet
K+ = 1mmol/kg/day
Anti-emetics
- general
-nausea but cardiac failure/risk of cardiac failure
Cyclizine 50mg 8hrly
Metoclopramide 10mg 8hrly - avoid in parkison’s disease and young women due to dyskenesia risk
Post-op vomiting - Odansetron
never prescribe beta blockers with verapamil due to
life threatening bradycardias
