PSA: data interpretation

Question 1

what do you need to monitor gentamicin levels

Answer 1

1. check in ‘therapeutic drug monitoring’ what the PRE-DOSE and PEAK serum concentration should be for your indication and compare this with your results
2. if pre-dose is < req concentration –> continue with current treatment
3. if pre-dose is > req concentration –> need to increase INTERVAL between doses
4. If peak levels greater than req range reduce the DOSE of gentamicin to be administered

Question 2

ramipril and eGFR review

Answer 2

stopping or reducing the dose of ACE-inhibitor therapy if eGFR declines by 25% or more after commencing or increasing the dose of ACE inhibitors

Question 3

what to do if renal impairment and on morphine for pain relief and showing signs of toxicity? how to control pain

Answer 3

Because morphine is renally excreted, it is generally avoided in patients with renal impairment. Oxycodone is typically used as a substitute as it is metabolised by the liver.

eg if were on morphine 30mg bd
switch to oxycodone 15mg bd

Question 4

name some causes of SIADH

Answer 4

SIADH

Small cell lung tumours
Infection (particularly atypical pneumonia)
Abscess
Drugs (use SIADH cannot void)
Head injury
post-op from major surgery

Drugs:
SSRIs
Inhibitors (ACEi, PPI)
Antidepressants eg TCAs
Diuretics
Haloperidol
Cannot: carbamazepine
Void: vincristine

Question 5

causes raised ALP

Answer 5

ALKPHOS

Any fracture
Liver damage
Kancer
Pagets disease of the bone and Pregnancy
Hyperparathyroidism
Osteomalacia
Surgery

Question 6

drugs that cause cholestasis

Answer 6

COCP
abx:
co-amoxiclav
flucloxacillin
nitrofurantoin
S:
steroids
sulphonylureas

Question 7

features of digoxin toxicity

Answer 7

confusion, nausea, visual halos, arrythmias

Question 8

features of phenytoin toxicity

Answer 8

gum hypertrophy, ataxia, nystagmus, peripheral neuropathy, teratoegenicity

Question 9

features of gentiamicin toxicity

Answer 9

nephrotoxicity and ototoxicity

Question 10

features of vancomycin toxicty

Answer 10

nephrotoxicity and ototoxicity

Question 12

warfarin Major bleeding (e.g. variceal haemorrhage, intracranial haemorrhage)

Answer 12

Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*

Question 13

warfarin INR > 8.0
Minor bleeding

Answer 13

Stop warfarin
Give intravenous vitamin K 1-3mg
Repeat dose of vitamin K if INR still too high after 24 hours
Restart warfarin when INR < 5.0

Question 14

INR > 8.0
No bleeding

Answer 14

Stop warfarin
Give vitamin K 1-5mg by mouth, using the intravenous preparation orally
Repeat dose of vitamin K if INR still too high after 24 hours
Restart when INR < 5.0

Question 15

warfarin INR 5.0-8.0
Minor bleeding

Answer 15

Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0

Question 16

warfarin INR 5.0-8.0
No bleeding

Answer 16

Withhold 1 or 2 doses of warfarin (2 days)
Reduce subsequent maintenance dose

Question 17

most common reason to withold digoxin

Answer 17

bradycardia

Question 18

when might digoxin be the appropriate tretament for AF

Answer 18

when bisoprolol and CCBs CI eg asthma and fluid retention