PSA Flashcards
Effect of enzyme inducers
Increase activity of CYP450s, decreasing effect of drugs broken down by these
Effect of enzyme inhibitors
Decrease activity of CYP450s, increasing effect of drugs broken down by these
Interaction between warfarin and CYP inhibitor (e.g erythromycin)
Increase in INR due to raised warfarin levels - risk bleeding
Common inducers
PC BRAS Phenytoin Carbamazepine Barbiturates Rifampicin Alcohol (chronic excess) Sulphonureas
Common inhibitors
Ketoconazole, ciprofloxacin, erythromycin and grapefuit juice AO DEVICES Allopurinol Omeprazole Disulfiram Erythromycin Valproate Isoniazid Ciprofloxacin Ethanol (acute intox) Sulphonamides
Drugs to stop before surgery
I LACK OP Insulin Lithium Anticoags/platelets COCP/HRT K-sparing diuretics Oral hypoglycaemics Perindropril (and other ACE-inhibs)
Drugs to increase before surgery
Corticosteroids if adreno-supressed - IV steroids at induction of anaesthesia to support adequate stress response to surgery
What does taking metformin risk prior to surgery
Lactic acidosis as nill by mouth. Other oral-hypoglycaemics risk hypo
How long before op should COCP/HRT be stopped
4 weeks
How long before op should Lithium be stopped
Day before
How long before op should potassium-sparing diuretics be stopped
Day of op
Max daily dose of paracetemol
4g
PReSCRIBER
Patient details REaction (allerfies plus what happens) Signing chart Contraindication for each drug Route Iv fluids required? Thromboprophylaxis required? (anti)Emetics required? (pain)Relief required?
Side effects of steroids
STEROIDS mneumonic Stomach ulcers Thin skin Edema Right/left heart failure Osteoporosis Infection (inc. candida) Diabetes (common cause of hyperglycaemia, uncommonly progresses to diabetes) Syndome - cushing's
Contraindications to NSAIDs
NSAID mnemonic No urine (i.e AKI/renal failure) Systolic dysfunction (i.e heart failure) Asthma Indigestion (any cause) Dyscrasia (clotting abnormality)
Aspirin contraindications
Same as NSAIDs except not contra in renal/heart failure or asthma
Effect of beta blockers in asthmatics
Wheeze
Unique ACE-inh effects
Dry cough and angiooedema
Which antihypertensives cause bradycardia?
Beta blockers and rate limiting Ca2+ channel blockers
Side effects of calcium channel blockers
Hypotensive effects, peripheral oedema and flushing
Effect of beta blockers on heart failure (acute and chronic)?
Worsens acute and beneficial in chronic
Side effects of diuretics
Hypotensive effects and renal failure. Other specific effects depend on type. Spironolactone causes gynaecomastia (eplerenone reduces this), Loops cause gout
Which fluid should be used as replacement if patient has ascites?
Human albumin solution
What level of fluid loss is indicated by reduced UO? (no tachycardia)
500ml
What level of fluid loss is indicated by reduced UO and tachycardia?
1L
What level of fluid loss is indicated by shock?
2L
Daily potassium requirement
40mmol
Max potassium infusion speed
10mmol/hour
Signs of fluid overload
Increased JVP, peripheral oedema, pulmonary oedema
Contraindications to compression stockings
Peripheral arterial disease (absent foot pulses)
Standard anti-emetic post-op
PRN if not nauseated, regular if nauseated
Cyclizine 50mg 8-hourly IM/IV/oral
If heart failure then metoclopramide 10mg IM/IV 8-hourly
Patients to avoid metoclopramide in
Parkinson’s - exacerbates symptoms
Young women - risk of dyskinesia esp acute dystonia
Neuropathic pain killers
Amitriptyline 10mg oral nocte
Pregabalin 75mg oral 12 hourly
If diabetic neuropathy pain duloxetine 60mg oral daily
Major side effect of clozapine
Agranularcytosis (at least monthly bloods)
4 categories of hypernatreamia causes
4 d's Dehydration Drips (too much IV saline) Drugs (effervescent tabs and IV preps with high sodium) Diabetes insipidus
Causes of microcytic anaemia
Iron deficiency anaemia is major
Minor are thalassaemia and sideroblastic anaemia
Causes of normocytic anaemia
Major causes: Anaemia of chronic disease, acute blood loss
Minor causes: haemolytic anaemia, Chronic renal failure
Causes of macrocytic anaemia
Major: B12/folate deficiency, Excess alcohol and liver disease
Minor: Hypothyroid, heam diseases beginning with M (myeloproliferative, myelodysplastic, multiple myeloma)
Causes of high neutrophils
Major: bacterial infection
Minor: Tissue damage (inglam/infarct/malignancy) and steroids
Causes of low neutrophils
Major: Clozapine, carbimazole, viral infection
Minor: Chemo/radiotherapy
Causes of high lymphocytes
Major: Viral infection
Minor: Lymphoma and CLL
Causes of low platelets (reduced production)
Penicillamine, infection (usually viral), myelodysplasia, myelofibrosis, myeloma
Causes of low platelets (increased destruction)
Heparin, hypersplenism, DIC, idiopathic thrombocytopaenic purpura (ITP), HUS, TTP
High platelets
Bleeding, tissue damage (inflamm/infarct/malignancy), post splenectomy and myeloproliferative disorders
Categories of hyponatraemia causes
Hypovolaemic, euvoleamic and hypervolaemic
Hypovolaemic causes of hyponatraemia
Fluid loss (esp D&V), diuretics and addison’s disease
Euvolaemic causes of hyponatraemia
SIADH, psychogenic polydipsia and hypothyroidism (all relatively uncommon)
Hypervolaemic causes of hyponatraemia
Major: Heart failure and renal failure
Minor: Liver failure, nutritional failure (hypoalbuminaemia), thyroid failure (hypothyroid-can be be euvolaemic)
Causes of SIADH
SIADH mnemonic Small cell lung tumour Infection Abscess Drugs (esp carbamezipine and antipsychotics) Head injury
Causes of hypokalaemia
DIRE mnemonic Drugs (loop and thiazide diuretics) Inadequate intake/intestinal loss (D&V) Renal tubular acidosis Endocrine (cushing's/conn's)
Causes of hyperkalaemia
DREAD mnemonic Drugs (esp K+ sparing and thiazide diuretics) Renal failure Endocrine (addison's disease) Artefact (clotted sample) DKA
Raised urea and normal creatinine in a well hydrated patient may be a sign of what?
Upper GI bleed - test Hb levels
Drugs causing AKIs - intrinsic causes
Gentamicin, vancomycin and tetracyclines
ACEinh
NSAIDS
How to differentiate prerenal AKI from intrinsic/post-renal causes?
Multiply urea by 10 - if it exceeds creatinine then its pre-renal
NOT FULLY COVERED NON-DRUG CAUSES OF AKIs/LFT derrangement NOT BEEN FULLY COVERED
…
What does isolated raised billirubin indicate?
Pre-hepatic jaundice - usually indicates haemolysis
Lab signs of cholestasis
Increased bilirubin and ALP
Drugs causing cholestasis
Flucloxacillin, co-amoxiclav, nitrofurantoin, steroids and sulphonureas
Lab signs of hepatitis
Increased bilirubin and AST/ALT
Drugs causing hepatitis
Paracetemol overdose, statins and rifampicin
Actions to be taken according to TSH in patients taking thyroxine
<0.5 decrease dose
0.5-5 no action
>5 increase dose
Always change dose by smallest increment unless unless grossly abnormal
Medication to avoid in people with hypertrophic cardiomyopathy
ACE-inh
Causes of raise ALP
ALK PHOS Any fracture Liver damage (post hepatic) K (for kancer) Pagets disease of bone and Pregnancy Hyperparathyroidism Osteomalacia Surgery
Causes of metabolic alkalosis
Vomiting, diuretics and conn’s syndrome
Causes of metabolic acidosis
Lactic acidosis, DKA, renal failure, methanol/ethanol/ethylene glycol intoxication and Addison’s disease
CXR signs of pulmonary oedema
ABCDE Alveolar oedema (bat wings) kerley B lines (interstitial oedema) Cardiomegaly Diversion of blood to upper lobes (vessels bigger in upper lobes than lower lobes) pleural Effusions
Alteration of gentamicin dose/schedule if levels are too high?
Keep dose the same but decrease frequency by 12 hours (e.g. changing every 24 hours to every 36 hours)
Features of digoxin toxicity
Confusion, nausea, visual halos and arrythmias
Features of lithium toxicity
Early: tremor
Intermediate: tiredness
Late: arrythmias, seizures, coma, renal failure and diabetes insipidus
Features of phenytoin toxicity
Gum hypertrophy, ataxia, nystagmus, peripheral neuropathy and teratogenicity
Features of gentamicin toxicity
Ototoxicity and nephrotoxicity
Features of vancomycin toxicity
Ototoxicity and nephrotoxicity
Typical gentamicin dose
5-7mg/kg once daily except renal failure (1mg/kg 12 hourly) and infective endocarditis (1mg/kg 8 hourly)
Methods of genamicin monitoring
Hartford nomogram if 7mg/kg or Urban and Craig nomogram if 5mg/kg if dosed once daily
If divided dose use peak (1h post dose; 3-5mg/l in IE, 5-10 everything else) and trough (just before next dose; <1 mg/l in IE, <2 in everything else) levels
Target INR
Usually 2.5 (2-3), raised to 3.5 (3-4) if recurrent thromboembolism or metallic heart valve
Treatment of major bleed in warfarin (hypotension or confined space)
Stop warfarin, 5-10mg IV vit K and prothrombin complex (beriplex)
Management of warfarin over-anticoagulation
INR<6 reduce dose
INR 6-8 omit for 2 days then reduce dose when INR less than 5
INR>8 stop warfarin and give 0.5-1mg IV (minor bleeding) or 5mg PO (no bleeding) vit k
Why do ACE-inh cause AKI in renal artery stenosis?
Efferent vessels require angiotensin 2 for constriction so ACEinh cause dilation. Combined with the stenosis in afferent vessel, this results in low renal blood flow
Effect of carbemazepine on sodium
Causes hyponatraemia via SIADH
Drugs causing SIADH
Carbemazepine and antipsychotics
SSRIs too
Management of STEMI
Initial: 12 lead ECG, Bloods (FBC, lipids, U&E’s, glucose, and cardiac enzymes), 300mg aspirin, 10mg IV morphine and anti-emetic (metoclopramide 10mg IV). PCI if possible
Oxygen may be necessary
After: ACEinh, beta blocker and clopidogrel (300mg load followed by 75mg after). Statins too, Keep in for around 5 days. Off work for 2 months,
Management of NSTEMI
Admit CCU, aspirin 300mg and clopidogrel/ticagrelor/prasugrel (300mg then 75mg,180mg then 90mg, 50mg then 10mg). 5-10mg IV morphine and anti-emetic (metoclopramide 10mg IV).
Oral beta blocker and fondeparinux
Angiography within 72 hours to identify need for PCI/angioplasty
Management of acute left ventricular failure
Sit patient upright, morphine 5-10mg IV + 10mg metoclopramide IV, GTN spray/tablet, furosemide 40-80mg IV. If inadequate response, isosorbide dinitrate infusion +/- CPAP
Management of SVT
Vagal manoeuvres followed by 6mg Adenosine rapid IV bolus. Can repeat twice using 12 mg if unsuccessful
Management of SVT
Vagal manoeuvres followed by 6mg Adenosine rapid IV bolus. Can repeat twice using 12 mg if unsuccessful. Monitor with continuous ECG.
Management of VT
Unstable: Synchronised DC shock (up to 3 times)
Stable: AMiodarone 300mg IV over 20-60mins followed by 900mg over 24 hours
Management of torsade de pointes
Give magnesium 2g over 10mins if stable, shock if not.
Management of anaphylaxis adult
Secure airway - call anaesthetist if necessary or likely to be
100% oxygen
Remove cause
0.5mg IM adrenaline (0.5ml of 1:1000) - repeat every 5 mins as needed
10mg chlorphenamine IV and 200mg hydrocortisone IV
If wheeze present treat for asthma
If further treatment required (e.g IV adrenaline), admit to ICU
Measure mast cell tryptase 1-6 hours later
If itching 4mg chloramphenamine every 6 hours oral
Admit and monitor with ECG
Management of acute asthma exacerbation
15l high flow oxygen non-re-breathe mask, 5mg Salbutomol neb, 100mg hydrocortisone IV (40-50mg oral pred if moderate), 500ug ipratropium bromide neb. Can give theophyline if life threatening
Management of acute COPD exacerbation
Start on 28% O2 (high flow if peri-arrest or very sick - review after ABG later). 5mg Salbutomol neb, 100mg hydrocortisone IV (40-50mg oral pred if moderate), 500ug ipratropium bromide neb. Antiobiotics if infective.
Management of pneumothorax
If secondary (patient has lung disease), always treat. CHest drain if >2cm, patient over 50 or SOB - aspirate if not. Tension pneumothorax requires emergency aspiration followed by chest drain. Primary - <2cm and not SOB, discharge and review in 4 weeks. If >2cm, attempt aspiration twice, if unsuccessful then chets drain.
CURB-65 and location of management accordingly
Confusion (AMTS of 8 or less) Urea >7.5mmol/L RR>30/min Blood pressure (systolic) <90mmHg 65 years old or over 1 or 0 can consider home treatment, 2 must be hospitalised, if 3 then consider ICU
PE management
High flow oxygen, 5-10mg morphine IV, 10mg metoclopramide IV, LMWH (tinzaparin 175units/kg SC daily)
If low BP: IV gelofusine, noradrenaline and thrombolysis.
Start warfarin. Consider altepase earlier if peri-arrest.
Correcting prolonged PT
If over 1.5x normal, give FFP. If platelets <50 then give platelets. If due to warfarin then give give prothrombin complex such as beriplex instead.
GP treatment of suspected bacterial meningitis
1.2g benzypenicilline IM (300mg <1y/o, 600mg 1-9y/o)
Hospital management of meningitis
High flow oxygen, IV fluid, IV dexamethasone (unless severely immunocomp), LP (+/- CT head), 2g cefotaxime IV (pre LP if likely to be prolonged or CT first). Consider ITU.
Management of seizures lasting over 5 mins
2-4mg lorazempam IV, 10mg buccal midazolam or 10mg diazepam IV
If continues, repeat diazepam after 2 mins.
If continues, inform anaesthetist, phenytoin infusion, intubate then propofol.
Acute management of ischaemic stroke
<80y/o and onset <4.5 hourse then consider thrombolysis with altepase. Aspirin 300mg oral too.
Fluid management in DKA
1L stat, 1L over an hour, then 2 hours, then 4 hours, then 8 hours
Hypoglycaemia management
If can eat, then eat sugary snack. If they can’t, but have a cannula in place, 100ml 20% dextrose IV. If no cannula then 1mg glucagon IM.
Management of AKI
Address the cause. 500ml STAT then 1L 4-hourly. Catheterise for strict fluid monitoring.
Antidote for benzodiazepine overdose
Flumazenil
When do you initiate drug treatment for hypertension?
ABPM/HBPM 150/95 or more. Or 135/85 or more plus over 80y + clinic BP >150/90, target organ damage, CVD, renal disease, diabetes or 10 year CVD risk of 10% or more (consider if less than 10% but <60y/o)
If over 180/120 on first clinic visit can start immediately and review if now damage
Step 1 hypertension treatment
Diabetic - ACEi/ARB
Non-diabetic and <55y - ACEi/ARB
Non-diabetic and >55y - CCB
Non-diabetic and black (any age) - CCB
Step 2 and 3 hypertension treatment
If already on ACEi/ARB, start CCB or thiazide-like diuretic.
If already on CCB, start ACEi/ARB or thiazide-like diuretic.
For step 3, start whichever of the 3 they are not already on.
Step 4 hypertension treatment
Confirm with ABPM/HBPM, check for postural hypotension and discuss adherence. Consider specialist referral. If potassium 4.5 or less, sonsider low dose spironolactone, if over 4.5 consider alpha or beta blocker. If this doesn’t work then must refer.
BP targets
<80y - clinic 140/90, ABPM/HBPM 135/85
Over 80 - clinic <150/90, ABPM/HBPM 145/85
Chronic HF management first line
Diuretics for congestive symptoms and fluid retention.
If reduced ejection fraction, ACEi and BB, followed by K+ sparing diuretic if symptoms continue.
Chronic HF management second line
Can swap ACEi/ARB for sacubitril valsartan (monitor U&Es) if ejection fraction <35%. If sinus rhythm and HR >75 and EF<35% can try ivabradine.
Hydralazine and nitrate useful in black patients.
Digoxin can improve symptoms if in sinus rhythm
CHA2DS2-VASc
Risk of TE event in non-coagulated patient with non-valvular AF. Congestive heart failure (or left only) Hypertension Age >75y (2 points) Diabetes mellitus Stroke or TIA previosuly (2 points) Vascular disease (PAD or IHD) Age 65-74 Sex (female) Score of 0 - aspirin 75mg daily, 1 - aspirin or warfarin, 2 - warfarin
When do you rhythm control in atrial fibrillation?
If young/symptomatic/first episode/due to a treated precipitant (e.g. sepsis or electrolyte disturbance)
How do you pharmacologically cardiovert patients in AF?
5mg/kg amiodarone IV over 20-120 mins. Anticoagulation required prior to cardioversion if onset more than 48 hours ago.
At what heart rate do you start rate control in AF?
90 BPM
Rate control drugs in AF
Beta blockers eg propanolol 10mg 6 hourly
Rate-limiting calcium channel blockers eg diltiazem 120mg daily.
Do not combine Verapamil and beta blockers due to profound bradycardia (worse than other Ca blockers)
If first line in effective or both contraindicated, digoxin can be used. Load then 62.5-125ug daily.
Drugs to treat stable angina
Aspirin/statin for secondary prevention and GTN spray as needed
Calcium channel or beta blocker to reduce symptoms
If needed, can add the other one. If contraindicated add isosorbide mononitrate or nicorandil.
If 2 drugs doesn’t work then needs revascularization
Contraindications to calcium channel blockers
Hypotension, bradycardia and peripheral oedema
Contraindications to beta blockers
Hypotension, bradycardia, asthma and acute heart failure
Chronic asthma management (adults)
Step 1 - low dose ICS
Step 2 - LABA and low dose ICS
Step 3 - Increase ICS to medium dose or add LTRA (maybe remove LABA if ineffective)
Step 4 - refer
Chronic COPD management
Not limited by symptoms / no exacerbations - SAMA/SABA as required
Limited by symptoms/exacerbations - Step 1 is LABA+LAMA if no asthmatic features, LABA+ICS ifthey do
Step 2 - persistent symptoms effecting quality of life or 1 severe/2 moderate exacerbations a year, give triple therapy (review after 3 months if no exacerbations or exacerbations and remove ICS if no improvement)
Most common Parkinson’s meds
Co-beneldopa and co-careldopa. If very mild may be a dopamine agonist (ropinirole) or MAO-inh (rasagiline)
Lamotrigine side effects
Rash, rarely Stevens-Johnson syndrome
Carbamazepine side effects
Rash, dysarthria, ataxia, nystagmus and hyponatraemia
Phenytoin side effects
Ataxia, peripheral neuropathy, gym hyperolasia, hepatotoxicity
Sodium valproate side effects
Tremor, teratogenicity, tubby (weight gain)
First choice drug in generalised tonic-clonic seizures
Sodium valproate (lamotrigine if unsuitable)
First choice drug in absence seizures
Sodium valproate or ethosuximide
First choice drug in myoclonic seizures
Sodium valproate (leviteracetam or topiramate)
First choice drug in tonic seizures
Sodium valproate
First choice drug in focal seizures
Carbamazepine or lamotrigine
Should you give flumazenil in a mixed overdose potentially containing benzodiazepines?
NO!!!
Alzheimer’s disease treatments
Mild/moderate - acetylcholinesterase inhibitors (donepezil, rivistigmine and galantamine)
Moderate/severe - NMDA antagonist (memantine)
ACR threshold for prescribing ACEi in diabetics
3mg/mmol or more
Anti-depressants prolonging QT interval
Citalopram and escitalopram
Drug treatment of type 2 diabetes
Step 1 - metformin 500mg with breakfast, increasing u to max 3x a day (with meals - up to 2g) to achieve acceptable HbA1c. Then add sulphonylurea, DPP-4inh (gliptin), pioglitazone or SGLT-2inh. 3rd step more complicated
Contraindications to pioglitazone
Heart failure or history of heart failure Hepatic impairment Diabetic ketoacidosis Current, or a history of, bladder cancer Uninvestigated macroscopic haematuria.
Drug to induce remission in Crohn’s disease
Oral prednisolone 30mg daily if mild, 100mg hydrocortisone IV 6-hourly if severe with supportive care. If rectal disease for either can give rectal hydrocortisone too.
What must be checked prior to starting azathioprine/6-mercaptopurine?
Thiopurine S-methyl transferase (TPMT) levels. Low in 10% population increasing bone marrow and liver toxicity. Use methotrexate instead.
First line medication for maintenance in Crohn’s disease
Azathioprine or Mercaptopurine. Methotrexate if low levels of TPMT.
Alternative medication for severe Crohn’s not responding to conventional therapy
Infliximab or adalimumab
First line maintenance treatment for rheumatoid arthritis
Methotrexate plus another DMARD (usually sulfasalazine or hydroxychloroquine)
Medications for RA flare treatment
Glucocorticoids such as IM methylprednisolone and NSAIDs with gastro protection
Second line RA maintenance treatment
If severely active RA that has failed to respond to 2 DMARDs, try TNFa inhibitor infliximab
Main contraindication to laxatives
Bowel obstruction
Chronic, non-infectious diarrhoea treatment
Loperamide 2mg oral up to 3 hourly or codeine 30mg up to 6 hourly (good if pain)
First line hypnotic and dose
Zopiclone 7.5mg oral in adults, 3.5mg in elderly
Best laxatives for faecal impaction
Stool softeners such as docusate sodium (stimulant at high dose) or rectal arachis oil (not if nut allergy)
Laxatives to avoid in faecal impaction and colonic atony
Bulking agents such as isphagula husk
Stimulant laxatives (examples, contraindications and side effect)
Senna and bisacodyl. Bisacodyl contra in acute abdomen. May exacerbate abdo cramps
Osmotic laxatives (examples, contraindications and side effect)
Lactulose and phosphate enema. Phosphare enema contraindicated in acute abdomen. May exacerbate bloating.
Laxatives contra-indicated in acute abdomen
Bisacodyl and phosphate enema
Indication of inadequate asthma treatment
Using SABA more than twice a week or the presence of nocturnal symptoms
First line antibiotic for skin infections
Flucloxacillin 500mg 6-hourly 7 days
Antimuscarinic side effects
Dry mouth with difficulty swallowing and thirst
Dilation of the pupils with blurred vision/light sensitivity
Increased intraocular pressure
Hot, flushed, dry skin
Bradycardia followed by tachycardia, palpitations and arrhythmias
Difficulty with micturition - urinary retention
Constipation
Drugs causing neutropenia
Carbimazole
Carbamazepine
Dopamine antagonists
Metoclopramide Haloperidol Domperidone (doesn't cross BBB so safe in Parkinson's)
Conversion from morphine sulphate to diamorphine
2mg morphine = 1mg diamorphine
BP meds to avoid during pregnancy
ACEi - teratogenic during the first trimester
Diuretics not ideal either
At what point in pregancy does blood pressure fall?
2nd trimester
Side effects/interactions of tamoxifen
Increased risk of endometrial cancer
Increases efficacy of warfarin
Increased hot flushes
Increased risk of VTE
Important information to tell patients about sulphonureas
Hypoglycaemic risk - eat regular meals, don’t miss them and take it with breakfast.
Which oral hyoglycaemic risks lactic acidosis?
Metformin
Methotrexate monitoring
Blood tests required 1-2 weekly to monitor FBC. Folic acid should be used alongside to limit myelotoxicity.
Effect of alcohol on warfarin
Alcohol consumption effects INR (acute inhibits, chronic induces) so should moderate and spread drinking.
When should renal function and potassium be monitored after initiating ACEi therapy?
1-2 weeks later
Important information to tell patients about ACEi
Cause cough. Take care if develop D&V as risk AKI - esp elderly.
What medications should be prescribed concurrently with long-term steroids?
Gastro-protection and bisphosphonate
Risks of long-term steroid therapy
Diabetes Osteoporosis Gastric/duodenal ulceration Hypertension Adrenal suppresion
Warfarin monitoring
Weekly at first, monthly when stable
Antibiotics contraindicated with methotrexate
Folate antagonists - trimethoprim and co-trimoxazole
Medication used to limit methotrexate toxicity
Folic acid - limits myelotoxicity
How long does it take for antidepressants to take effect?
Up to 6 weeks
Medications increasing photosensitivity
Citalopram Doxycycline Tetracycline Amiodarone Hydrochlorothiazide Naproxen Chlorpromazine
Symptoms of serotonin syndrome
Agitation or restlessness Confusion/Hallucinations Rapid heart rate and high blood pressure Dilated pupils Loss of muscle coordination or twitching muscles Muscle rigidity Heavy sweating Diarrhea Headache Shivering Goose bumps Fever
Effect of illness on required insulin dose
More insulin required (increase basal dose) as blood glucose rises. However, if oral intake decreases, the opposite may be true.
How should alendronic acid be taken?
Once weekly. Swallow with a full glass of water and remain upright for 30mins. Avoid eating for the next 2 hours.
Can Adcal D3 be taken at then same time as bisphosphonate?
No, reduces absorbtion of bisphosphonate.
What does 1% mean in g/ml?
1g in 100ml
100% = 100g in 100ml
Weight to volume ratio units
Grams to millilitres
Contra-indication to high dose gentamicin
Creatinine clearance of <20ml/min
What 2 pieces of info do you need to provide if medication prescribed PRN?
Indication and max frequency/dose
Which blood test is important prior to commencement of Vancomycin?
Renal function
Main contra-indication to statin therapy
Hepatic impairment - measure ALT prior to commencement
For assessing phenytoin dose appropriateness, when should blood sample be taken?
Pre-dose trough level - should be 40-80umol/L
How long after previous dose should lithium levels be sampled?
12 hours
Normal lithium levels
0.4-0.8mmol/L
Lithium monitoring regime
Weekly until stable, then 3 monthly
Frequency of methotrexate monitoring
Every 1-2 weeks at first, then every 2-3 months once stabilised
Can methotrexate be started if LFTs abnormal
No - risks cirrhosis
Dose adjustment in methotrexate if clinically significant drop in white cells or platelets
Stop immediately!
Predominant excretion organ for methotrexate
Renal
Amiodarone monitoring
Baseline CXR, TFTs (T3 T4 and TSH) and LFTs at baseline and every 6 months. Measure serum potassium before use (caution hypokalaemia due to arrythmia risk).
Most important Ix in patient taking carbimazole reporting a sore throat
Neutrophil count - bone marrow suppression risk
Most important parameter to measure during valproate therapy
LFTs - esp during first 6 months
Primary route of digoxin excretion
Renal - take care in impairment. Check U&Es prior to initiation of therapy.
Clozapine monitoring
WCCs weekly for first 18 weeks, fortnightly for a year and then monthly. Blood lipids, glucose and weight as measured at baseline and then after a few months
Nephrotoxic antibiotics
Gentamicin and vancomycin
Ototoxic antibiotics
Gentamicin and vancomycin
Antibiotics causing C.Diff
All antibiotics - particularly broad specs like cephalosporins and ciprofloxacin
ACEi side effects
Hypotension, electrolyte abnormalities (hyponatraemia and hyperkalaemia), AKI and dry cough
Beta-blocker side effects
Hypotension, bradycardia, fatigue, cold extremities, wheeze in asthma and worsens acute HF
CCB side effects
Hyptension, bradycardia, peripheral oedema and flushing
Diuretic side effects
Hypotension, electrolyte abnormalities, AKI - subclass dependent effects
Heparin side effects
Haemorrhage (esp if renal failure or <50kg), heparin induced thrombocytopenia
Aspirin side effects
Haemorrhage, peptic ulcers and gastritis
Tinnitus in large doses
Digoxin side effects
Nausea, vomiting and diarrhoes, blurred vision, confusion and drowsiness, xanthopsia (disturbed yellow/green visual perception inc. halo vision)
Effect of serum potassium on digoxin
Low K+ augments effect, high K+ inhibits effect
Amiodarone side effects
Interstitial lung disease, hyper/hypothyroid disease, skin greying, hepatoxic and corneal deposits
Haloperidol side effects
Dyskinesias (such as acute dystonic reactions) and drowsiness
Clozapine side effects
Agranulocytosis (monitor for)
Fludrocortisone side effects
Hypertension/sodium and water retention
Ibuprofen side effects
NSAID No urine (renal failure) Systolic dysfunction (heart failure) Asthma Indigestion (any cause) Dyscrasia (clotting abnormality)
Statins side effects
Myalgia, abdo pain, Increased ALT/AST (can be mild), rhabdomyolysis (can be just a mildly increased CK)
How long should blood be given over?
Must be less than 4 so give over 1-3 hours
Main drugs causing GI bleeds when with alcohol
NSAIDs such as ibuprofen and aspirin
Interaction between alcohol and monoamine oxidase inhibitors
Hypertensive crisis
Interaction between metformin and alcohol
Lactic acidosis
How long do patients need to be on corticosteroids for weaning to be necessary?
3 weeks or 1 week if over 40mg a day. If other causes of adrenal suppression eg excess alohol then further caution.
First choice treatment in pericarditis
Ibuprofen
Effect of lithium on thyroid function
5x increase of hypothyroidism
Ciclosporin monitoring once stable in transplant patients
Monthly LFTs, FBCs and U&Es as well and baseline then periodic lipids
Fluids to avoid in cerebral injury
Glucose!!!
CVD primary prevention dose for atorvastatin
20mg nocte
Drugs causing urinary retention
Opiods (esp post op) Anticholinergics (eg, antipsychotic drugs, antidepressant agents, anticholinergic respiratory agents, detrusor relaxants), General anaesthetics, Alpha-adrenoceptor agonists, Benzodiazepines (e.g. diazepam), Non-steroidal anti-inflammatory drugs (e.g. ibuprofen), Calcium-channel blockers, Antihistamines, Alcohol.
Drugs causing confusion
Opiods
Metoclopramide
Anticholinergics (eg, antipsychotic drugs, antidepressant agents, anticholinergic respiratory agents, detrusor relaxants),
Antipsychotics,
Antidepressants,
Anticonvulsants.
Less common causes (histamine H2 receptor antagonists, digoxin, beta-blockers, corticosteroids, non-steroidal anti-inflammatory agents and antibiotics.
Best method of monitoring during early stages of fluid replacement?
Blood pressure
When should statins be stopped because of raised liver enzymes?
When they are 3x the upper limit
Safest diuretics with lithium
Loop diuretics
Drugs decreasing lithium excretion
ACE-i, diuretics (esp. thiazides) and NSAIDs
Best way of relieving nausea in bowel obstruction
Large bore nasal cannula and de-compression
First medication in severe HF decompensation
40-80mg furosemide IV stat
When should statins be taken?
At night (not strictly necessary for atorvastatin)
Important sign to look for after starting fluoxetine
Skin rash - suggests impending systemic reaction
When to adjust enoxaparin dose
Weight under 50kg or eGFR<30
Contra-indication to nitrofurantoin
eGFR<45
Ideal INR for surgery
<1.5 - if over the day before, give oral vit K (1-5mg)
What contraception should be avoided when taking enzymer inducers?
Progesterone only
What size rise in creatinine is acceptable after commencing ACEi?
<20%
Which DOAC is licensed for anticoagulation post THR/TKR?
Rivaroxaban
Infusion time of 20% glucose for hypo
100ml in up to 20mins
How should rivaroxaban be taken?
With food
First line treatment for acute dystonia
Procyclidine hydrochloride 5-10mg IV/IM
What do you do if suspect statin has caused a myopathy and raised CK (>5x upper limit)?
Stop statin and if symptoms resolve restart at lower dose
Painkiller to avoid with SSRIs
Tramadol - risks serotonin syndrome
Best PPI in pregnancy
Omeprazole over lanzoprazole
What blood test is raised in serotonin syndrome?
CK
Most common drug for reducing portal hypertension and preventing variceal bleeds
Propanalol
What medication is used to control blood pressure in phaeochromocytoma?
Phenoxybenzamine
Common side effects of levadopa
Nausea, somnolence, dizziness and headache
Maximum length of missed clozapine dose at which normal dose can be restarted
48 hours - any longer and retitration is required
Maximum length of missed clozapine dose at which normal dose can be restarted
48 hours - any longer and retitration from 12.5mg is required
Fasting glucose cut off for initiating drug management in gestational diabetes
7mmol - try exercise and diet for a couple of weeks if uncomplicated pregnancy before adding metformin
Contraindication to triptans
IHD
High risk drugs for falls
Antipsychotics, antidopaminergics, anticholinergics and anti-depressants
Also ACEi, diuretics, opiates and antihistamines
Nebulised adrenaline dose in croup
1 in 1000 400mcg/kg - max 5mg
Drugs causing erythema multiforme
Anti-convuslants (valproate, phenytoin, lamotrigine and carbamazepine), antibiotics (sulphonamides and penicllins) and aspirin.
Also hydralizine, allopurinol and cimetidine
First line diuretic for acites
Spironolactone 100mg (plus fluid restriction and low salt diet)
Loop and thiazide diuretic effect on bone mass
Loop decreases, thiazide protects
