PSA Flashcards
Prescribe the most appropriate drug to rapidly relieve bronchospasm (COPD/asthma).
Salbutamol 1 mg/mL OR 2.5 mg/mL nebuliser liquid
Dose = 2.5-5 mg
Route = nebulised/inhaled
Frequency = PRN, up to 4 times daily
Treatment of confirmed DVT/PE
Factor Xa inhibitors:
Apixaban 10 mg PO BD
Rivaroxaban 15 mg PO BD
When is LMWH contra-indicated?
- Current or history of heparin-induced thrombocytopaenia
- Conditions that put the patient at high risk of bleeding complications (acute GI bleed, cerebral haemorrhage, serious coagulation disorders, recent stroke)
What is the treatment dose of LMWH for DVT/PE?
1.5 mg/kg every 24 hours until oral anticoagulation established
INITIAL TREATMENT of dehydration (no cardiac failure)
Sodium chloride 0.9% + Potassium chloride 0.3%/0.15
500 mL over 4-6 hours or 1 L over 8-12 hours
How quickly should potassium be replaced on the ward?
Max 10 mmol/hour
Primary prevention of cardiovascular disease
QRisk score >10% = atorvastatin 20 mg OD at night
QRisk score <10% = simvastatin 20 mg OD at night
What is the QRisk3 score?
Calculates a person’s risk of developing a heart attack or stroke over the next 10 years
What are the important dose-related adverse effects of statins?
Myalgia (rarely risk of myopathy, myositis, and rhabdomyolysis) Disturbed liver function GI disturbance Sleep disturbance Headache
How do NSAIDs work?
Inhibit COX2 enzyme and production of prostaglandins which protect the gastric mucosa against acid-related erosion and ulceration.
How does ibuprofen effect the kdneys?
Ibuprofen inhibits prostaglandin synthesis in the kidney so reduces cortical blood flow and renal function.
What is the significance of renal function and ramipril?
Ramipril is an ACE inhibitor which blocks intrarenal production of angiotensin 2. Angiotensin 2 is important for protecting GFR when renal blood flow is reduced.
Why are U&Es checked 1-2 weeks after starting ramipril?
If the patient has undiagnosed renal artery stenosis, then the kidney function will be significantly impaired.
Which two drugs (anti-hypertensive and NSAID) and taken together are bad for kidneys?
Ramipril and ibuprofen
What kind of drug is bendroflumethiazide and where does it work?
Thiazide diuretic - acts on the sodium/chloride-co-transporter in the distal convoluted tubule.
Causes excess sodium and water loss.
What kind of drug is spironolactone and where does it work?
Potassium-sparing diuretic - aldosterone agonist which inhibits aldosterone-dependent sodium-potassium-exchange channels in the DCT.
What is atenolol, what is it used for and how would it be prescribed?
Cardio-selective beta-blocker
Used to treat hypertension, angina, and arrhythmias
Normal range of dose = 25-50 mg for hypertension and 100 mg for angina
Absolute contra-indications for beta-blockers
History of asthma/bronchospasm Severe: Heart failure Bradycardia Heart failure Hypotension Peripheral arterial disease
What common drugs should be held in renal impairment?
Ramipril - reduced effectiveness of renin-angiotensin system means renal blood flow will not be correctly maintained and potassium is not excreted enough
Metformin - contraindicated in significant renal impairment and acutely unwell patients
What kind of drug is pioglitazone and what is one adverse effect?
Thiazolidinedione
Higher risk of hypoglycaemia episodes
What drugs can cause urinary retention?
Morphine + other opioid analgesics Anticholinergics (antipsychotics, detrusor relaxants, antidepressants) General anaesthetics Benzodiazepines NSAIDs CCBs Alcohol
What drugs can cause disorientation/confusion?
Metoclopramide Morphine Antipsychotics Antidepressants Anticonvulsants
Treatment of Wernicke’s encephalopathy?
Vitamin B substances with ascorbic acid (Pabrinex IV high potency)
IV infusion over 30 minutes 8-hourly
Management of DKA
Soluble short-acting insulin:
50 units in 50 mL 0.9% sodium chloride by IV infusion at a rate of 0.1 units/kg/hour
Treatment of hypertension
Age <55 = ACE inhibitor (Ramipril)
Age >55 or Afro-Caribbean of any age = CCB (Amlodipine)
Folic acid in pregnancy
Prevention of neural tube defects, taken until week 12 of pregnancy
High risk = e.g. family history of spina bidifa, malnutrition
5 mg OD
Low risk = 400 micrograms OD
What is alendronic acid and how should it be taken?
Bisphosphonate
10 mg daily or 70 mg once weekly
Take on empty stomach first thing in the morning, with water
Sit upright for 30 minutes
What are the main adverse events associated with bisphosphonates?
Atypical femoral fracture
Osteonecrosis of the jaw - dental appointment before starting
Osteonecrosis of the internal auditory canal
Hormone replacement therapy options
Combined = used in women with a uterus, used to reduce the risk of endometrial carcinoma associated with unopposed oestrogen Oestrogen-only = used in women without a uterus
What does a % solution mean?
grams per 100 mL
What are the adverse events associated with methotrexate?
Bone marrow suppression
GI toxicity
Liver toxicity
Pulmonary toxicity
What are the side effects most commonly associated with methotrexate?
Anaemia Anorexia Diarrhoea Fatigue GI upset Increased risk of infection Leucopaenia Skin reactions Vomiting
What antibiotic can cause ototoxicity?
Gentamicin - aminoglycoside antibiotic that can damage the vestibular nerve
Which antibiotic interacts with drugs metabolised by P450 system?
Clarithromycin
E.g. interacts with simvastatin and causes reduced clearance
How does allopurinol work?
Reduction of serum urate levels by inhibiting xanthine oxidase
What needs to be monitored in lithium therapy?
Renal function - nephrotic syndrome and nephrogenic DI
What can HRT do to blood pressure?
Hypertension
What should be done with LFTs when starting statins?
Measure before treatment
Repeat at 3 months and 12 months if asymptomatic
Stop therapy if 3x upper limit
Peak and trough concentration of gentamicin
Peak concentration = determined by dose
Trough concentration = determined by interval
Note: if the trough is too high - toxicity
Most common enzyme inducers
Enzyme inducers will decrease drug concentration.
PC BRAS:
Phenytoin
Carbamazepine
Baribiturates
Rifampicin
Alcohol (chronic excess)
Sulphonylureas
Most common enzyme inhibitors
Enzyme inhibitors will increase drug concentration.
AO DEVICES:
Allopurinol
Omeprazole
Disulfiram Erythromycin Valproate Isoniazid Ciprofloxacin Ethanol (acute intoxication) Sulphonamides
Why should metformin be stopped before surgery?
Will cause lactic acidosis
What drugs should be stopped in any patient that is bleeding?
Antiplatelets (aspirin)
Anticoagulants (LMWH, Factor Xa inhibitors)
Heparin - e.g. stroke
Consider drug interactions - e.g. erythromycin and warfarin causing a very high INR
What are the side effects of steroids?
STEROIDS
Stomach ulcers Thin skin oEdema Right and left heart failure Osteoporosis Infection Diabetes cushing's Syndrome
Side effects of anti-hypertensives
- Hypotension
- Bradycardia - beta blockers and some CCBs
- Elecrolyte imbalances - ACEi and diuretics
Specific:
- Ramipril = dry cough
- Beta blockers = wheeze in asthmatics
- CCBs = peripheral oedema and flushing
- Diuretics = renal failure, spironolactone = gynaecomastia, thiazide diuretics = gout
What is typically given for VTE prophylaxis for hospital inpatients?
Dalteparin 5000 units daily SC + compression stockings
What kind of drug is metoclopramide and when should it be avoided?
Dopamine antagonist
Avoid in patients with Parkinson’s and young women due to risk of dyskinesia
What is first-line treatment for neuropathic pain?
Amitriptyline 10 mg OD PO at night
Pregabalin 75 mg PO 12 hourly
How do ACE inhibitors affect potassium?
Cause hyperkalaemia through reduced aldosterone production and thus reduced potassium excretion in the kidneys
What drugs are notorious for causing confusion (esp in the elderly)?
Tramadol
Cyclizine
Diazepam
Why should NSAIDs be used with caution in patients on methotrexate?
Increased risk of nephrotoxicity
What drugs should DEFINITELY be avoided in patients taking methotrexate?
Other folate antagonists such as trimethoprim
What should be done to methotrexate in patients with active infection?
Stop it
Long half-life means it won’t affect control of chronic disease
What do potassium-sparing diuretics and ACE inhibitors do to potassium?
Hyperkalaemia
What do loop and thiazide diuretics do to potassium?
Hypokalaemia
What is the main side effect of amlodipine and what should be done?
Peripheral oedema
Stop the medication
What life-threatening side effect can be caused by clozapine?
Agranulocytosis
Stop the drug immediately and refer to a haematologist
Causes of normocytic anaemia
Anaemia of chronic disease
Acute blood loss
Haemolysis
Renal failure
Causes of neutropaenia
Viral infection
Chemo/radiotherapy
Clozapine
Carbimazole
What does raised urea indicate?
AKI or upper GI bleed (digestion of blood)
How do urea and creatinine rise in pre-renal vs post-renal AKI?
Pre-renal = urea > creatinine Post-renal = creatinine > urea
What are the vitamin K dependent clotting factors?
2, 7, 9 and 10
Causes of raised ALP
Fracture Post-hepatic liver damage Cancer Paget's disease Pregnancy Hyperparathyroidism Osteomalacia Surgery
In which projection does the heart appear larger on a CXR?
AP
How to tell if there is adequate inspiration on a CXR?
7th anterior rib (down-sloping) transects the diaphragm
Which way does the trachea deviate if there is a collapsed lung?
Towards affected side
Which way does the trachea deviate in a tension pneumothorax?
Away from the affected side
What would suggest a right upper lobe collapse on a CXR?
Widened mediastinum with tracheal deviation
Signs of heart failure on CXR
Alveolar oedema (bat wings) Kerley B lines Cardiomegaly Diversion of blood to upper lobes (large vessels) Pleural effusions
Causes of metabolic alkalosis
Vomiting
Diuretics
Conn’s syndrome
LBBB on ECG
W in V1
M in V6
RBBB on ECG
M in V1
W in V6
Small complexes throughout ECG
Pericardial effusion
ST segment convex and raised in all leads
Pericarditis
Down-sloping/reverse tickmark ST segment in all leads
Digoxin toxicity
Where is T wave inversion normal?
aVR and lead 1
Common examples of drugs which need monitoring
Digoxin Theophylline Lithium Phenytoin Some antibiotics - gentamicin and vancomycin
Signs of lithium toxicity
Early = tremor Intermediate = tiredness Late = arrhythmias, seizures, coma, renal failure, diabetes insipidus
Paracetamol metabolism
Metabolised by the liver
Relies on antioxidant known as glutathione
How does paracetamol overdose cause acute liver damage?
Limited hepatic stores of glutathione are quickly depleted, leading to accumulation of the toxic metabolite NAPQI which causes acute liver damage
How does warfarin work?
Inhibits synthesis of vitamin K-dependent clotting factors
Prolongs the PT
What to do if there is a major bleed in a patient on warfarin?
Stop warfarin
Give 5-10 mg IV vitamin K
Give prothrombin complex
Can trimethoprim be given in pregnancy?
No
Folate antagonist and so predisposes to neural tube defects
What happens if too much digoxin is given?
Bradycardia
How should you treat fast AF if the patient is asthmatic and/or has peripheral oedema?
Digoxin
1st line = beta blockers (not in asthmatics)
2nd line = diltiazem (not if peripheral oedema as will worsen fluid retention)
What kind of drug is amitryptiline and what does it get used for?
Tricyclic antidepressant
Treatment of neuropathic pain
Treatment of STEMI
300 mg aspirin 75 mg ticagrelor/300 mg clopidogrel Oxygen if sats <94% GTN spray/tablet Morphine 5-10 mg IV + cyclizine 50 mg IV Bisoprolol 2.5 mg oral Primary PCI preferred
Treatment of NSTEMI
300 mg aspirin 75 mg ticagrelor/300 mg clopidogrel LMWH OR Fondaparinux Oxygen if sats <94% GTN spray/tablet Morphine 5-10 mg IV + cyclizine 50 mg IV Bisoprolol 2.5 mg oral
Drug treatment of anaphylaxis
ABCDE approach
500 micrograms of 1:1000 IM
10 mg chlorphenamine IV
200 mg hydrocortisone IV
Drug treatment of acute asthma
ABCDE approach Oxygen Salbutamol 5 mg nebs Ipratropium 500 micrograms nebs 100 mg hydrocortisone IV if severe/life-threatening or prednisolone 40-50 mg oral
Drug treatment of COPD
SAME AS ASTHMA + Antibiotics
ABCDE approach Oxygen Salbutamol 5 mg nebs Ipratropium 500 micrograms nebs 100 mg hydrocortisone IV if severe/life-threatening or prednisolone 40-50 mg oral
What is CURB-65?
Confusion Urea > 7 Resp rate >30 Blood pressure (systolic) <90 Age > 65
Treatment of PE
ABCDE High flow oxygen Morphine 5-10 mg IV Cyclizine 50 mg IV LMWH e.g. tinzaparin If unstable - IV fluid bolus, contact ITU, consider thrombolysis
Seizure management
1) Ensure airway is patent
2) Put in recovery position
3) Bedside tests for provoking factors - glucose, electrolytes, drugs, sepsis
If >5 mins then treat with IV lorazepam
Features of hyperosmolar hyperglycaemic state
Hyperglycaemia - usually > 35 mmol/L
Hyperosmolar - osmolality >340
Non-ketotic
First-line treatment of angina
GTN spray as required
Secondary prevention
Anti-anginal drugs dependent on contraindications - beta blocker or calcium channel blocker
Contraindications of CCBs
Hypotension
Bradycardia
Peripheral oedema
Chronic asthma management
SABA as required throughout Low-dose ICS Add inhaled LABA or combine with MART Consider adding LTRA (Montelukast) Refer to specialist care
Treatment of Parkinson’s
Co-beneldopa (levodopa + peripheral dopa decarboxylase inhibitor)
UNLESS very mild disease - try dopamine agonist like ropinirole or monoamine oxidase inhibitor (rasagiline)
Drugs for generalised tonic-clonic seizures
Valproate for males
Lamotrigine for females
Drugs for myoclonic seizures
Valproate for males
Levetiracetam for females
Which anti-epileptic drug causes a rash?
Lamotrigine
Can rarely cause Steven-Johnson syndrome
What drugs are used to treat Alzheimer’s?
Acetylcholinesterase inhibitors
Donepezil, rivastigmine, galantamine
Drugs used to maintain remission of Crohn’s
Azathioprine
6-mercaptopurine
What do you HAVE to check before starting Azathioprine or 6-mercaptopurine?
TPMT levels
Treatment of Rheumatoid arthritis
Methotrexate
+ additional DMARDs
Short-term glucocorticoids = IM methylpred
Short-term NSAIDs with gastric protection
TNF-alpha inhibitors e.g. infliximab
Paracetamol antipyretic dose
1 g every 6 hours
Max 4 g in 24 hours
Stimulant laxatives + contraindication
Senna
Bisacodyl
Contraindicated in acute abdomen
Osmotic laxatives + contraindication
Lactulose
Phosphate enema
Contraindicated in acute abdomen + IBD
Treatment of chronic diarrhoea
Loperamide 2 mg PO or codeine 30 mg PO
Drugs to help patients sleep in the PSA
Zopiclone 7.5 mg oral nightly in adults
3.75 mg in elderly
What would signify SABA overuse?
Tremor
Antibiotics for skin infections
Flucloxacillin 500 mg QDS for 7 days
What kind of unintended side effects can amitriptyline have?
Antimuscarinic side effects - dry mouth, dry eyes
Why should haloperidol and metoclopramide not be used in patients with Parkinson’s?
They are dopamine antagonists and so can precipitate parkinsonian symptoms.
Note: domperidone is safe as it does not cross the BBB.
What type of contraceptive pill should be used in a woman with significant VTE risk factors?
POP
Treatment of hypertension in pregnancy
Labetalol 100 mg BD to be titrated, can go up to 200 mg BD
Treatment of gout in someone with significant CKD
No NSAIDs
Colchicine ok
Depo-Medrone (steroid injection)
Which blood pressure drug should NOT be taken during pregnancy?
Ramipril - teratogenic
Which blood pressure drug should be given during pregnancy?
Labetalol
Which class of diabetes drugs are associated with hypoglycaemia?
Sulphonylureas
When should gliclazide be taken?
Morning
What is the mechanism behind the cough caused by ACE-inhibitors?
Release of bradykinin
Dose-dependent
Use ARB instead - Losartan
What features are suggestive of serotonin syndrome?
Mild = hypertension, tachycardia, fever Moderate/severe = fever, agitation, hyperreflexia, tremor, dilated pupils
How should bisphosphonates be taken?
Swallowed with a full glass of water
Remain upright for 30 mins
What does a 1% solution mean?
1 g of drug in 100 mL for weight/volume calculations
1 g in 100 g for weight/weight calculations
What does adrenaline 1:1000 mean?
1 g in 1000 mL
Risk factors for development of myopathy with statins
Personal or family history of muscular disorders Previous history of muscular toxicity High alcohol intake Renal impairment Hypothyroidism Elderly
What should be checked at baseline when starting simvastatin?
Creatine kinase
Two classic side effects of vancomycin
Nephrotoxicity
Ototoxicity
After a week - can cause neutropaenia
What level of transaminitis should make you stop the statins?
3x upper limit of normal
Check after 3 months of treatment
Normal reference range for lithium
0.4-0.8 mmol/L
When are toxic effects of lithium likely to manifest?
Levels >1.5 mmol/L
When should blood tests for lithium be done?
Weekly after initiation and after dose changes until concentration is stable, then every 3 months thereafter
What can increase the risk of lithium toxicity?
Sodium depletion/dehydration
Methotrexate blood monitoring
Weekly but once on stable treatment, every 2-3 months
When should methotrexate NOT be started?
Abnormal LFTs
How is methotrexate excreted?
Renally
What needs to be checked before a patient starts the contraceptive pill?
Blood pressure - can make the patient hypertensive
Weight
What should be done at baseline before starting amiodarone and why?
Chest xray
Pulmonary toxicity - fibrosis
Why do we need to warn people on carbimazole to come to hospital if they get a sore throat?
Carbimazole-induced bone marrow suppression/agranulocytosis
Neutrophil count
1 hour peak serum concentration of gentamicin multiple daily dose regimen for treatment of endocarditis
3-5 mg/L
What electrolyte derangement increases risk of digoxin toxicity?
Hypokalaemia
What organ dysfunction is associated with sodium valproate therapy?
Liver
Measure LFTs regularly
Clozapine monitoring
Weekly FBC for the first 18 weeks
Most common drugs with a narrow therapeutic index
Warfarin
Digoxin
Phenytoin
Digoxin side effects
Nausea & vomiting Diarrhoea Blurred vision Drowsiness/confusion Xanthopsia (disturbed yellow/green visual perception, "halo")
Amiodarone side effects
Interstitial lung disease
Thyroid disease - hypo and hyper
Grey skin
Corneal deposits
Side effects of steroids
Stomach ulcers Thin skin Oedema Right and left heart failure Osteoporosis Infection Diabetes Cushing's syndrome
Which diabetic drug can cause lactic acidosis?
Metformin
Which antidepressants can trigger a hypertensive crisis?
Monoamine oxidase inhibitors
Why is 50% glucose generally avoided?
High risk of extravasation injury
Which drug classes should NOT be stopped before surgery?
Antiepileptics Antiparkinsonian drugs Antipsychotics Anxiolytics Bronchodilators Cardiovascular drugs Glaucoma drugs Immunosuppressants Drugs of dependance Thyroid/antithyroid drugs
Metformin + surgery - should it be stopped? What should it be replaced with?
Yes, stop if there is a chance of the patient missing more than 1 meal or of AKI
Variable rate IV insulin infusion ONLY if metformin dose is >1 daily
Do not recommence metformin until patient is eating/drinking and renal function is normal.
Very important information to warn patients of on rivaroxaban
Severe or spontaneous bruising - seek medical attention
What bloods need to be monitored in patients on rivaroxaban + how often?
Depends on patient factors/level of risk
FBC
U&Es
LFTs
Every 6-12 months
When should rivaroxaban be taken?
With food to maximise absorption
Any time of day
Management of hypoglycaemia
If conscious + able to swallow - 15-20g of fast-acting carbohydrate
Reduced GCS - 15-20g of 10% or 20% glucose IV over 15 minutes
Emergency/no IV access - IM glucagon
Common side effects of furosemide
Dizziness Electrolyte imbalances Fatigue Headache Muscle spasms
What patient factors mean a woman is not suitable for the COCP?
Migraines with aura
Age >35 AND smokes > 15 per day
BMI > 35
Medical management of anxiety
First-line = SSRI (sertraline, paroxetine, escitalopram) or SNRI (duloxetine or venlafaxine)
What is the mechanism of ipratropium bromide?
Anti-muscarinic
When to offer lipid modification therapy?
People aged 84 or younger if estimated QRISK score is 10% or more
Offer high intensity statin treatment
What is high intensity statin treatment?
Atorvastatin 20 mg OD at night
Which vaccines should women have in pregnancy?
Flu vaccine
Whooping cough/percussis
NO live vaccines
What is the process around chicken pox exposure in pregnancy?
If exposed - check immunisation status
If immune - no further action
If not immune + within first 10 days = treat with VZIG
VTE prophylaxis dose for high risk surgical patients
Enoxaparin sodium 40 mg SC OD
Rivaroxaban 10 mg PO OD
Diabetes treatment ladder
Metformin
Dual therapy - metformin + gliptin, DPP-4 inhibitor, pioglidazone or sulfonylurea
What needs to be done after any change in levothyroxine dose?
Repeat TFTs in 6-8 weeks
PE treatment
Rivaroxaban 15 mg PO BD
LMWH if not suitable (bc rivaroxaban is renally excreted)
Nitrofurantoin in pregnancy
DO NOT GIVE AT TERM - haemolysis of the newborn
Trimethoprim in pregnancy
DO NOT GIVE
Folate antagonist
Teratogenic
UTI in term pregnant lady
Cefalexin 500 mg PO BD for 7 days
