PSA Flashcards
What is 1st line management for thromboprophylaxis ?
- A low molecular weight heparin administered for 10 days followed by a low dose aspirin for a further 28 days
- LMWH for 28 days in combination with anti-embolism stockings
- Or rivaroxaban
IV management of hypoglycaemia
- Glucose 10 % or 20%
- 200ml if 10% or 100ml if 20%
- Over less than 10 mins
What medication should be held in a patient who is unwell and/or has reduced oral intake ?
- ACEi e.g. ramipril
What medications should be withheld until renal function recovers ?
-Candesartan cilexetil(ARBs) and ramipril (ACEi) - Allopurinol
Name medications that can contribute to confusion
- Co-codamol
- Diazepam
- Prednisolone
In what causes should nitrofurantoin be avoided ?
- eGFR is less than 45
In which case use trimethoprim or doxycycline
When should patients stop taking warfarin before surgery ?
- 5 days
In what circumstance should patients be given vitamin K before surgery ?
- Having stopped warfarin but INR is still above 1.5
What can be expected with starting lisinopril ?
- A small rise in creatinine (<20%) that does not require investigation or change in prescription
- Repeat urea and electrolyte measurement after 1 week
What is a potentially dangerous presentation of a patient with a sore throat whom has just started carbimazole ?
Agranulocytosis
What should be monitored 3 months after initiating COCP and then annually ?
- Blood pressure
- Weight
What are serious side effects of ciclosporin ?
- Nephrotoxicity
- HTN
- BP and serum ciclosporin should be monitored every 2 weeks
What change in cholesterol should be seen after initiating a statin ?
- > 40% reduction in non-HDL after 3 months
Which drugs should be avoided in renal failure ?
- Antibiotics: tetracycline, nitrofurantoin
- NSAIDs
- Lithium
- Metformin
What medications accumulate in chronic kidney disease and need dose adjustments ?
- Most ABxs including penicillin’s, cephalosporins, vancomycin, gentamicin and streptomycin
- Digoxin + atenolol
- Methotrexate
- Sulphonylureas
- Furosemide
- Opioids
What opioid is useful in palliative care ?
Oxycodone
Which drugs are relatively safe in kidney failure ?
- ABxs e.g. erythromycin and rifampicin
- Diazepam
- Warfarin
What ABx can lower seizure threshold ?
- Ciprofloxacin
Which medicines are P450 inducers ?
- Antiepileptics: phenytoin and carbamazepine
- Barbiturates: phenobarbitone
- Rifampicin
- St John’s Wort
- Chronic Alcohol Intake
- Griseofulvin
- Smoking
Which medications are inhibitors of P450 systems ?
- ABx: ciprofloxacin or erythromycin
- Isoniazid
- Cimetidine and omeprazole
- Amiodarone
- Allopurinol
- Imidazoles: fluconazole
- SSRIs
- Ritonavir
- Sodium valproate
- Acute alcohol intake
- Quinupristin
The side effect most commonly associated with metformin
- Diarrhoea or nausea
- Lactic acidosis
The side effect most commonly associated with Glitazones (Pioglitazone)
- Worsening heart failure
- Weight gain
- Fluid retention
- Liver dysfunction
- Fractures
The side effect most commonly associated with sulfonylureas (gliclazide)
- Hypoglycemia
- Increased appetite and weight gain
- SiADH
- Cholestatic liver dysfunction
Features of salicylate overdose
- Hyperventilation
- Tinnitus
- Lethargy
- Sweating/pyrexia
- Nausea/vomiting
- Hyperglycemia and hypoglycemia
- Seizures
- Coma
Treatment of salicylate overdose
- ABC + charcoal (if within 1 hour)
- IV sodium bicarbonate
- Hemodialysis
Indications for hemodialysis in salicylate overdose
- Serum concentration > 700mg/L
- Metabolic acidosis resistant to treatment
- AKI
- Pulmonary oedema
- Seizures
- Coma
Rifampicin side effects
- Potent liver enzyme inducer
- Hepatitis
- Orange secretions
- Flu-like symptoms
Isoniazid side effects
- Peripheral neuropathy (can be prevented with pyridoxine Vit B6)
- Hepatitis
- Agranulocytosis
- Liver enzyme inhibitor
Pyrazinamide side effects
- Hyperuricemia causing gout
- Arthralgia
- Myalgia
- Hepatitis
Ethambutol side effects
- Optic neuritis (check visual activity before and during treatment)
- Dose needs adjusting in patients with renal impairment
If suspecting digoxin toxicity when should serum concentration be measured ?
- 8-12 hours after last dose
Features of digoxin toxicity
- Lethargy, nausea and vomiting
- Anorexia
- Confusion
- Yellow-green vision
- Arrhythmias
- Gynecomastia
Precipitating Factors for digoxin toxicity
- Hypokalemia
- Increasing age
- Renal failure
- Myocardial ischemia
- Hypomagnesaemia, hypoalbuminemia, hypothermia, hypothyroidism
- Hypercalcemia, hypernatremia, acidosis
- Many medications e.g. Amiodarone, quinidine, verapamil
- Any medication that causes hypokalemia
What drugs can cause digoxin toxicity
- Amiodarone, quinidine, verapamil, diltiazem, spironolactone, ciclosporin
- Drugs which cause hypokalemia
- Thiazides e.g. Indapamide or Chlorothiazide
- Loop diuretics e.g. furosemide
Management of digoxin toxicity
- Digibind
- Correct arrhythmias
- Monitor potassium
What should be used to treat DVT in a patient with reduced renal function ?
- Unfractionated heparin
- Normally it would be a DOAC
What 2 key medications does St John’s Wort Interact with
- Warfarin
- Ciclosporin
- St John’s Wort is an inducer !
Drugs which cause lung fibrosis
- Amiodarone
- Cytotoxic agents: busulphan, bleomycin
- Anti-RA drugs: methotrexate, sulfasalazine
- Nitrofurantoin
- Ergot-derived dopamine receptor agonists: bromocriptine, cabergoline and pergolide
What medications can be given during breastfeeding ?
- ABxs: Penicillin, cephalosporins, trimethoprim
- Endocrine: glucocorticoids (low dose), levothyroxine
- Sodium valproate, carbamazepine
- Asthma: salbutamol, theophyllines
- Psych drugs: TCA and APs apart from clozapine
- BBs
- Warfarin/heparin
- Digoxin
What drugs should be avoided during breastfeeding ?
- ABxs: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
- Lithium, benzos
- Aspirin
- Carbimazole
- Methotrexate
- Sulfonylureas
- Cytotoxic drugs
- Amiodarone
Which medications should be avoided in HF ?
- Thiazolidinediones e.g. pioglitazone
- Verapamil
- NSAIDs/glucocorticoids
- Class I antiarrhythmics – flecainide
What type of monitoring do statins require ?
- LFTs at baseline, 3 months and 12 months
- A rise of under 3 times the upper limit of normal is acceptable
What medications can be given during breastfeeding ?
- ABxs: Penicillin, cephalosporins, trimethoprim
- Endocrine: glucocorticoids (low dose), levothyroxine
- Sodium valproate, carbamazepine
- Asthma: salbutamol, theophyllines
- Psych drugs: TCA and APs apart from clozapine
- BBs
- Warfarin/heparin
- Digoxin
What drugs should be avoided during breastfeeding ?
- ABxs: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
- Lithium, benzos
- Aspirin
- Carbimazole
- Methotrexate
- Sulfonylureas
- Cytotoxic drugs
- Amiodarone
Which medications should be avoided in HF ?
- Thiazolidinediones e.g. pioglitazone
- Verapamil
- NSAIDs/glucocorticoids
- Class I antiarrhythmics – flecainide
What type of monitoring do statins require ?
- LFTs at baseline, 3 months and 12 months
What type of monitoring do ACEi require ?
- U&E prior to treatment, after increasing dose and at least annually
What type of monitoring does amiodarone require ?
- TFT, LFT, U&E and CXR prior to treatment
- TFT, LFT every 6 months
What type of monitoring does methotrexate require ?
- FBC, renal and LFTs before staring treatment and then repeat weekly until therapy stabilized
- Thereafter every 2-3 months
What type of monitoring does azathioprine require ?
- FBC, LFT before treatment
- FBC weekly for the first 4 weeks
- FBC, LFT every 3 months
What type of monitoring does lithium require ?
- TFT, U&E prior to treatment
- Lithium levels weekly until stabilized and then every 3 months
- TFT, U&E every 6 months
What type of monitoring does sodium valproate require ?
- LFT, FBC before treatment
- LFT periodically during first 6 months
What type of monitoring does Glitazones require ?
- LFT before treatment
- LFT regularly during treatment
Medications that can cause SIADH
- Sulfonylureas
- SSRIs, Tricyclics
- Carbamazepine
- Vincristine
- Cyclophosphamide
In which condition should HRT be avoided ?
- IHD
What are maintenance fluids ?
- 25-30 ml/kg/day of water and
- Aprox 1 mmol/kg/day of K+, Na+ and Cl+
- Aprox 50-100 g/day of glucose to limit starvation ketosis
How much fluid, K+ and glucose would a 80kg man need ?
- 2L water
- 80 mmol of K+
- 50-100g of glucose
How would you manage a patient on warfarin with a high INR and an acute haemorrhage ?
- Stop warfarin
- Give IV vitamin K (IV phytomenadione)
- Dried prothrombin complex factors (2, 7, 9 and 10)
What eGFR level would prompt reduction of a ACE-I dose ?
- 25% or more
What are the peak and trough levels of gentamicin ?
- 5-10 peak – change the dose
- 0-2 trough – change the dose timings
How are absence seizures managed in children ?
- Ethosuximide or valproate
What is the amount of fluid bolus given for a child ?
- 0.9% NaCl stat (<10 mins)
- 10ml/kg
What are maintenance fluids given for a child ?
- 0.9% NaCl + 5% glucose (over 24 hours)
- First 10kg 100ml/kg/day
- Second 10kg = 50ml/kg/day
- Anything after = 20ml/kg/day
In a patient on anti-psychotics with a prolonged QT interval what would be the first line antiemetic of choice ? and what medication should be avoided ?
- 1st line Cyclizine
- Prochlorperazine – extra-pyramidal side effects
How is DKA managed according to BNF treatment summery ?
- IV fluid replacement followed by IV insulin
- Pts who normally take long acting insulin should continue with their usual dose but should omit sort acting
When should loperamide be taken ?
- After each loose stool
What is the best way to monitor the beneficial effects of perindopril erbumine when treating HF associated breathlessness ?
- Exercise tolerance
How should apixaban be monitored for side effects ?
- Presence of bleeding
What would be a good medication option for acute pain with renal failure ?
- Oxycodone
How is severe warfarin associated haemorrhage managed ?
- Phytomenadione (Vit K) and dried prothrombin complex
What are maintenance fluids ?
- 25-30ml/kg/day
- Approx 1mmol/kg of K+, Na+ and Cl-
- Approach 50-100/day glucose
How would you prescribe maintenance fluids in a 58kg patient ?
- 1st bag 1000ml NaCl 0.18% (containing 30mmol NaCl) + glucose 4% + potassium 40mmol over 8-12 hours
- Then a 500ml bag of NaCl 0.18% and 4% glucose and 20mmol of K+ over 6 hours
Digoxin is available as a 0.025% preparation. What does this mean ?
- 0.025g in 100ml
What fluids should be prescribed in severe hypoglycaemia ?
- Glucose 20% - 100mls – <10 mins
- Glucose 10% - 150-200mls – <10 mins
What is a common side effect of ticagrelor ?
- Dyspnoea
First line management of migraines ?
- Aspirin or ibuprofen
What conditions should triptans be avoided in ?
- Hypertension
- CAD
- History of seizures
What is first line for oral thrush treatment ?
- Nystatin oral suspension
What fluids should be given in paeds with low BP and in need of rapid rehydration ?
- 10ml/kg
- Hartmann’s
- <10 mins
What should be first given when treating emergency hypercalcaemia ?
- Sodium chloride 0.9% IV over 4 hours
How do SGLT-2 inhibitors work ?
- Increase glucose excretion in the urine
- Thus a common side effect is increased risk of UTI
A new prescription of atorvastatin causes a rise in serum transaminases. How would you proceed depending on serum transaminase level ?
- Continue with current dose if serum transaminase level is less than 3 times the upper limit of normal
What is measured in response to finasteride prescription for BPH ?
- Patient symptom score
- Examinations/investigations are not necessary
What should be monitored in LMWH prescription ?
- Platelet count (before and during)
- Hyperkalemia (in those at risk)
- Anti-factor Xa (in renal damage or low BMI)
How should a postprandial insulin be measured in order to enable titration of dose ?
- Intention is to achieve euglycemia in fasting state not postprandial hyperglycemia
- Thus the best time and measurement to measure should be a pre-breakfast capillary blood glucose
What is the best measurement of response to steroid treatments ?
- Symptom severity
What are the oestrogens used in HRT ?
- Estradiol
- Estrone
What are the progesterones used in HRT ?
- Medroxyprogesterone
- Norethisterone
- Levonorgestrel
- Dropirenone
Which medications can increase the risk of fractures ?
- Omeprazole (All PPIs)
- Prednisolone (All PO steroids)
- GnRH agonists (busereline, goserelin etc.)
Medication that can increase the risk of falls
- Amitriptyline (anticholinergic syndrome, drowsiness and hypotension)
- Ramipril (dizziness, drowsiness and hypotension)
Medications that increase risk of falls (types)
- Benzodiazepines
- Antidepressants (particularly TCAs and SNRI and MAO-i)
- Antipsychotics
- Opiates
- Most antihypertensives (particularly diuretics and alpha blockers)
Medications likely to increase risk of pancreatitis ?
- Exenatide (GLP-1 receptor agonist)
- Sitagliptin (DPP-4-ihibitor)
Medications to be stopped during an AKI
- Candesartan
- Metformin
Medications to stop during an AKI
- Diuretics
- ACEi/ARB
- Metformin
- NSAIDs
- Many antibiotics e.g. amoxicillin
- Chemo
- Iodine based contrasts
- Opioids (not nephrotoxic but can accumulate)
What oxygenation device and setting should be used in a patient with low oxygen stats and COPD (and other conditions that would lead to chronically low sats) ?
- 24 or 28% venturi mask and titrate towards 88-92% or level specific to patient
Medications that can cause hypokalemia ?
- Loop (furosemide) or thiazide diuretics (indapamide)
Medications that can cause hyperkalaemia
- K+ sparing diuretics e.g. spironolactone
- ACE-I e.g. ramipril
- ARB e.g. candesartan
- NSAIDs e.g. ibuprofen
- BBs e.g. bisoprolol
Treatment of hypokalemia
- 0.3% potassium chloride 1000ml over 4h
Treatment of hyperkalaemia (short term)
- Initially calcium gluconate 10% 30ml over 10m
- Then insulin + glucose and salbutamol
When should long acting insulin that is taken at night be monitored ?
- Pre-breakfast capillary glucose
If a trough or pre-dose medication level is too high what would one do ?
- Increase the duration between doses
If a trough or pre-dose medication level is too low what would one do ?
- Decrease the time between doses
With what PMHx would NSAIDs be considered sub-optimal in prescribing ?
- NASIDs can cause fluid retention and raise blood pressure and therefore may not be appropriate in conditions such as HTN, CVD or Stroke/TIA
What would be an indication for IV antibiotics in cellulitis
- Peripheral vascular disease
- Severe infection
What are guidelines for insulin before surgery ?
- On the day before surgery the patients usual insulin should be given as normal other than once daily long acting insulin analogues which should have a dose reduction of 20%
How should modified release morphine tablets be taken ?
- Swallowed whole
- Chewing or crushing could lead to overdose
What should be given in transfusion-associated circulatory overload (TACO) ?
- IV diuretics e.g. furosemide
In the BNF how should a complicated UTI be treated ?
- With medications under pyelonephritis
- E.g. cefalexin
Give some examples of a complicated UTI
- Anatomical variation
- Renal disease or failure
- Atypical organism
- Immunocompromised
- Pregnancy
What laxatives are useful in opioid induced constipation ?
- Osmotic laxatives e.g. lactulose
- Stimulant laxatives e.g. senna
- Docusate sodium can be used as an adjunct stool softener
Under what criteria would you make a dose adjustment in apixaban ?
- 2 of the following
- Age over 80
- Weight < 60 kg
- Serum creatinine > 133
- Also if CrCl 15-29 mL/min
HTN with T2DM (any age or origin) or HTN without T2Dm in aged 55 or below and not of BA or ACB origin
- 1st line – ARB or ACE-I
- 2nd line add CCB or thiazide like diuretic
- 3rd line add Thiazide Diuretic or CCB
A patient is taking ramipril, amlodipine for HTN with T2DM. What do you add next ?
- Thiazide diuretic
- E.g. indapamide
HTN without T2DM in patients 55 or over or all ages BA or ACB without T2DM
- 1st line CCB
- 2nd ACE, ARB or thiazide like diuretic
- 3rd ACE, ARB or thiazide like diuretic
What is recommended in the treatment of opioid induced constipation ?
- Combination of an osmotic laxative (e.g. lactulose or macrogol) and a stimulant laxative (e.g. senna or docusate)
