PSA/pharmacology Flashcards
What is an example of a GLP- 1 mimetic and how do they work?
Exanatide
Works by Reducing gastric emptying
Decreasing appetite
And acting on the pancreas to decrease glucagon and increase insulin
What is an example of DPP4 inhibitor and how does it work?
So the DPP-4 enzyme normally acts on GLP1 mimetic and breaks them down, DPP4 inhibitors like SITAGLIPTIN prevents the breakdown of GLP-1
How do SGLT-2 work?
They cause glucose to be lost through the kidney
Campagliflozin, empagliflozin, dapagliflozin
What are the side effects of SGLT-2 inhibitors (gliflozins)
Glucoseuria
Increase in UTIs and cadida (thrush)
WEIGHT LOSS - osmotic diuresis, water is drawn into the urine through osmosis
Dehydration
DKA= rare complication
What is a side effect of gliclazide (sulfonylurea)?
Hypoglycaemia
WEIGHT GAIN
What are the two regimes for insulin?
Basal bolus
This mimics normal and involves long acting at night and fast acting
Twice daily
This involves intermediate and short acting
What should you do to someones insulin
If
A) they are hyperglycaemia
B) they are hypoglycaemic
A) increase insulin dose by 10%
B) decrease insulin dose by 20%
What are the common reasons why hypoglycaemia occurs?
Taking too much insulin Not having regular meals/missing meals Not eating enough carbs/overestimating the amount you have eat Stress Too much alcohol or drinking Physical activity Hot weather Recreational drugs
What are the symptoms hypoglycaemic pts experience?
Tingling Feeling hot and sweaty Light headed Blurred vision Hunger Dizziness Fast pulse or palpitations Trembling or shakiness Anxiety or irritability Disorientated Lack of concentration Change in personality or irritability Confusion or vagueness
How do you treat hypoglycaemia if the pt is concious?
15-20g rapid acting carbs- like 200ml orange juice, this can be repeated up to 3 times!
If 15-20g of quick acting carbs is given and this doesnt work, then what can be done next?
IM glucagon if no improvement after ten mins then move to IV
IV 15-20g over 15 mins
20% glucose (75-100ml) or 10% (150-200ml)
How do you treat DKA?
Identify if need for fluid rescucitation (SBP<90mmHg)
Fixed rate quick acting IV insulin ie actrapid 0.1units/kg/hr
Start/continue s/c long acting insulin
Glucose 10% once BM<14
Monitor K+
Identify cause
Why is pioglitazone thought to be a ‘dirty drug’?
Weigh gain
Bladder cancer
Fracture risk
How does COCP work?
Inhibits ovulation
Thins endometrium
What are the contraindications of COCP?
HTN Smoking BMI>35 Migraine VTE history
What are the side effects of COCP?
Increased risk of breast cancer
Increased risk of cervical cancer
Decreased risk of endometrial cancer
Decreased risk of ovarian cancer
When can you start COCP after pregnancy?
6 weeks
How does POP work?
Thins endometrium and thickens cervical mucus
What is the contraindication of POP?
PV bleeding
What are the side effects of POP?
Irregular bleeding
Nausea
Sore breasts
What are the side effects of ACE-I?
Hyperkalaemia
Cough
Angioedema
First dose hypotension
What are the cautions and comtraidications for ACE- I?
Pregnancy and breastfeeding
- avoid
Reno vascular disease - may result in renal impairment
Aortic stenosis- may result in hypotension
Hereditary or idiopathic angioedema
Specialist advice should be sought before starting ACE I in patients with a K+ > or equal to 5mmol/L
What does ACE- I interact woth?
Patients recieving high dose diuretic therapy (more than 80mg of furosemide a day) significantly increases the risk of hypotension
What are the monitoring requirements for ACE- I?
Urea and electrolytes should be checked before treatment is initiated and after increasing the dose
What is tamsulosin?
What side effects does it cause?
An alpha 1 antagonist used to treat BPH
Postural hypotension, drowsiness, dyspnoea, cough
What is doxazosin?
Used to treat BPH
Causes postural hypotension
What drugs cause gynaecomastia?
spironolactone (most common drug cause) cimetidine digoxin cannabis finasteride GnRH agonists e.g. goserelin, buserelin oestrogens, anabolic steroids
What are the side effects of sodium valproate?
Increased appetite Weight gain Alopecia- regrowth may be curly P450 enzyme inhibitor (may affect warfarin INR- INR increases) Ataxia Tremor Hepatitis Pancreatitis Thrombocytopaenia Teratogenic (neural tube defects)
What are the side effects of carbamazepine?
P450 enzyme inducer dizziness and ataxia drowsiness leucopenia and agranulocytosis syndrome of inappropriate ADH secretion visual disturbances (especially diplopia)
What are the side effects of lamotrigine?
Steven Johnson syndrome
What are the side effects of phenytoin?
P450 enzyme inducer Dizziness and ataxia Drowsiness Gingival hyperplasia Hirsutism Coarsening of facial features Megaloblastic anaemia Peripheral neuropathy Enhanced vit D metabolism causing osteomalacia Lymphadenopathy
Why do you use isosorbide mononitrate assymetrically (morning and lunch)?
Isosorbide mononitrate is a nitrate drug used in the management of angina pectoris. It is a vasodilator that acts on both arteries and veins. Venous vasodilation reduces venous return to the heart and therefore preload which reduces the oxygen requirement of the myocardium. The arterial vasodilation results in a reduction in systemic vascular resistance and improved coronary blood flow. Nitrate tolerance is a phenomenon whereby patients experience reduced therapeutic effects due to the continuous use of nitrate drugs. This can be overcome by ensuring the patient’s blood-nitrate concentrations fall to a low level for 4-12 hours of the day. This is achieved by ‘asymmetric dosing’ which means giving a dose in the morning and a dose in the mid-afternoon, rather than giving it 12-hourly. This means the patient will have a period of time overnight where there is a lower level of nitrates in their blood, which should minimise tolerance. Asymmetric dosing is only a requirement for the standard-release formulation. Modified-release preparations are available that are given once daily.
What are the drugs which are enzyme inducers?
What are the drugs which are enzymes inhibitors?
SICKFACES.COM Sodium valproate Isoniazid Cimetidine Ketoconazole Fluconazole Alcohol Clarithromycin Erythromycin Sulphonamides Ciprofloxacin Omeprazole Metronidazole Grapefruit juice
What drugs are used as enzyme inducers?
SSSCRAPG Sulphonylureas St jogns wort Smoking CARBAMAZEPINE Rifampicin Alcohol (chronic use) Phenobarbital Phenytoin Griseofulvin
What medications should be stopped for surgery?
It can be remembered by ‘ILACKOP’
Insulin (varies between hospitals)
Lithium- day before
Anticoags/antiplatelets- variable and can sometimes continue during surgery
When are warfarin, aspirin and heparin contraindicated?
In patients who are bleeding, at risk of bleeding or have suspected bleeding.
Prophylactic heparin is contraindicated in acute ischaemic stroke due to the risk of bleeding into the stroke. Also important to remember that erythromycin can increase warfarin’s effect (and hence prothrombin time0 and INR despite stable dose)
When are steroids contraindicated?
STEROIDS... S- Stomach ulcer T- thin skin E- Edema R- Right and left heart failure O- Osteoporosis I- Infection D- Diabetes (steroids raise blood glucose) S- Cushings SYNDROME
What are the contraindications for NSAIDS?
N= No urine output (renal failure) S= Systolic dysfunction A= Asthma I= Indigestion D= Distorted clotting
What are the side effects of antihypertensives?
Hypotension (including postural) that may result from all groups of antihypertensives
Bradycardia may occur with some CCBS and beta blockers
Electrolyte disturbance occurs with ACE-I and diuretics
Individual drugs have specific side effects…….
- ACE-I= dry cough
- Beta blockers= wheeze in asthmatics and also worsening of acute heart failure
- CCBS= peripheral oedema and flushing
- Diuretics can cause renal failure, loop diuretics (Furosemide) can also cause gout, K+ sparing diuretics can cause gynaecomastia.
How should you go about prescribing fluids?
First assess the patient
Secondly look at the chart
Thirdly look at the bloods- U and ES.
What is a good choice of antiemetics?
Cyclizine
When should you avoid Metaclopramide?
Metaclopramide is a pro kinetic and a dopamine receptor antagonist, therefore avoid in bowel obstruction, avoid in parkinsons
It can cause acute dystonia
What are anticholinergics used for and what are the side effects?
They work by blocking the muscarinic receptors from the neurotransmitter acetylcholine, this is released from the cholinergic nerve endings in the airways.
They inhibit the parasympathetic nervous system
Side effects= confusion/drowsiness, dry skin, constipation, urinary retention, dry mouth, palpitations, blurred vision, increased intraocular pressure
When should you avoid cyclizine?
In heart failure as it can cause fluid retention
What can be used in painful diabetic neuropathy?
Duloxetine
What analgesia should be used for; a) no pain b) mild pain c) severe pain ???
a) No regular but can prescribe paracetamol PRN
b) Paracetamol regularly, codeine 30mg up to 6 hourly oral
c) Co-codamol if severe pain, 2 tablets 6 hourly oral or morphine sulfate as required
Which dopamine receptor antagonist is more likely to be used as an anti emetic in parkinsons- domperidone or metoclopramide?
Domperidone, despite them both being dopamine antagonists, metoclopramide crosses the blood brain barrier and so exacerbated parkinsonian symptoms by acting on central dopamine receptors
domperidone does not cross the BBB so is safer to use in Parkinson’s disease
How do ACE- I cause hyperkalaemia?
They reduce the potassium excretion in the kidneys due to reduction of production of aldosterone
How does ibuprofen lead to inflammation and ulceration?
Ibuprofen inhibits prostaglandin synthesis needed for gastric mucosal protection from acid, it is therefore at risk of influencing inflammation and ulceration
How do steroids predispose to gastric ulceration?
They inhibit gastric epithelial renewal
What antibiotic should not be used alongside methotrexate and why?
Trimethoprim, as they are both folate antagonists
This can lead to bone marrow toxicity- pancytopaenia and neutropenic sepsis
When should you withhold methotrexate?
If patient is septic
What should patients on warfarin with an INR of >2 not be given?
They shouldn’t be given any prophylactic heparin as it increases the risk unnecessarily
What is the usual route for insulin to be administered?
Normally sub cut, incept in variable rate where it is IV.
What is the most worrying side effect of clozapine?
Clozapine is an antipsychotic (Atypical) and the most worrying side effects (for which all patients are monitored with at least monthly blood tests) is agranulocytosis, resulting in neutropoenia
When there is agranulocytosis and neutropoenia, it requires immediate cessation of the drug and referral to haematology
What are the most important results of a FBC to look at?
Hb
WCC
Platelets
What are the most common causes of neutrophilia (high neutrophils)?
Bacterial infection
Steroids
Tissue damage (inflammation, infarct and malignancy)
What are the most common causes of neutropaenia?
Viral infection
Chemotherapy or radiotherapy
Clozapine (Antipsychotic)
Carbimazole (antithyroid)
What are the causes of high lymphocytes (lymphocytosis)
Viral infection
Lymphoma
Chronic lymphocytic leukaemia
What is the first thing you should assess if someone has deranged sodium function?
Their fluid status
What are the causes of hypernatraemia?
3DS
Dehydration
Drugs
Drips (too much IV saline)
What are the causes of microcytic anaemia (low Hb) ?
TAILS Thalassaemia Anaemia of chronic disease IRON DEFICIENCY ANAEMIA Lead poisoning Sideroblastic
What are the causes of normocytic anaemia (Normal MCV)?
Anaemia of chronic disease
Acute blood loss
Haemolytic anaemia
Renal failure (Chronic)
What are the causes of macrocytic anaemia?
B12/Folate deficiency (megaloblastic anaemia)
Excess alcohol
Liver disease (including non alcoholic causes)
Hypothyroidism
Haematological diseases beginning with M- myeloproliferative, myelodysplastic, multiple myeloma
What are the causes of low platelets (thrombocytopaenia)?
Can be split into: reduced production and increased destruction
Reduced production-
Infection (usually viral)
Drugs- penicillamine ie: in RA treatment
Myelodysplasia, myelofibrosis, myeloma
Increased destruction-
Heparin
Hypersplenism
DIC
ITP (idiopathic thrombocytopenic purpura)
Haemolytic uremic syndrome/ thrombotic thrombocytopenic purpura
What is idiopathic thrombocytopenic purpura?
What are the signs in symptoms?
This is where antibodies are made against the platelets (GPIIb/IIIa receptor)
Occurs in children and in pregnancy
Symptoms Acutely Usually occurs commonly after a viral infection with bruising and bleeding Epistaxis Mucosal bleeding Purpuric rashes Easy or spontaneous bruising
Chronically
Splenomegaly (spleen eats more platelets)
Ix- FBC, blood films (fewer platelets), LFTS (tell the bone marrow to make the platelets), TFTS, IgA deficiency
It is a disease of exclusion
What is DIC?
Situation in which haemostasis starts to run out of control, when this happens lots of blood vessels form in different organs leading to organ ischaemia (coagulation uses up platelets and clotting factors), paradoxically it causes too little and too much clotting at the same time.
What are the causes of high platelets (thrombocytosis)?
Reactive; bleeding, tissue damage (infection, malignancy, inflammation), post splenectomy
Primary: myeloproliferative disorders
What are the causes of hyponatraemia?
A) Hypovolaemic
B) Euvolaemic
C) Hypervolaemic
A) diuretics and fluid loss (D+V)
Addison’s disease
What are the causes of euvolemic hyponatraemia?
SIADH, psychogenic polydipsia, hypothyroidism
What are the causes of hypervolaemic hyponatraemia?
Heart failure Renal failure Liver failure Nutritional failure Thyroid failure (hypothyroidism can be euvolaemic too)
How can you remember the causes of SIADH?
S= Small cell lung cancer I= infection A= Abscess D= drugs (carbamazepine and antipsychotics) H= Head injury
What are the causes of hypokalaemia?
Drugs (loop and thiazide diuretics)
I= inadequate intake or intestinal loss (D+V)
R= renal tubular acidosis
E= endocrine (cushings and conns syndromes)
What are the causes of hyperkalaemia?
DREAD
Drugs- K+ sparing diuretics and ACE-I
Renal failure
Endocrine (Addisons)
Artefact (very common, due to clotted sample)
DKA (when insulin is given to DKA the potassium drops requiring regular hourly monitoring +/- replacement)
What does raised urea indicate?
Either renal failure or upper GI Bleed
If a patient has a raised urea but they are not dehydrated then look at their Hb (may be an upper GI bleed)
What are the causes of renal failure?
70% are prerenal=
Get a rise in urea is greater than the creatinine rise
Caused by dehydration, sepsis, blood loss, renal artery stenosis
Intrinsic renal 10%=
Urea rise is less than the creatinine rise
Intrinsic can be caused by acute tubular necrosis causing ischaemia
Nephrotoxic antibiotics, ACE-I/NSAIDS, Radiological contrast, rhabdomyolysis, Gout (negatively bifringement crystals), Inflammation, cholesterol emboli
Post renal 20%= Urea rise is less than creatinine rise Stone Tumour BPH, prostate cancer, aneurysm
What antibiotics cause renal failure?
Gentamicin
Tetracyclines (doxycycline)
Vancomycin
What does a raised bilirubin with normal LFTS normally indicate?
Indicates prehepatic jaundice that is rarely due to any liver problem itself
What can raised ALP indicate?
May indicate posthepatic jaundice Any fracture Liver damage Cancer Pagets disease of bone Pregnancy Hyperparathyroidism Osteomalacia Surgery
Deranged LFTS….
A) What are the causes of raised bilirubin?
B) What are the causes of raised bilirubin and raised AST/ALT?
C) What are the causes of raised bilirubin and raised ALP?
A) Haemolysis
B) fatty liver, hepatitis, cirrhosis, malignancy, heart failure, Wilsons disease/haemochromatosis
C) Stone, drugs causing cholestasis, tumour, primary biliary cirrhosis, sclerosing cholangitis, pancreatic or gastric cancer and lymph node
How do you adjust the dose of levothyroxine?
Levothyroxine dose is changed according to the TFT results for patients with hypothyroidism, TSH is used as a guide and the range required= 0.5-5IU/L
If TSH range is <0.5 then decrease the dose
If TSH range is 0.5-5 then keep it at the same dose
If TSH range is >5 then increase the dose of thyroxine
What are the features of digoxin toxicity?
Confusion, nausea, visual halos and arrhythmias
What are the features of lithium toxicity?
Early: Coarse tremor
Intermediate: tiredness
Late: Arrhythmias, seizures, coma, renal failure, diabetes insipidus
What are the features of phenytoin toxicity?
Gum hypertrophy Ataxia Nystagmus Peripheral neuropathy Teratogenecity
What are the features of gentamicin toxicity?
Ototoxicity and nephrotoxicity
What are the features of vancomycin toxicity?
Ototoxicity and nephrotoxicity
How do you measure gentamicin doses?
You measure the concentration 1 hour post dose to get the peak
Normal range in IE= 3-5 Normal range in everything else= 5-10
You measure the concentration just before the next dose to get the trough
Normal in IE <1 Normal in everything else is <2
What should you do if there are signs of toxicity with some drugs?
You should stop the drug, potentially give an alternative, give supportive care ie: fluids, and give antidote if one is available!
What is the management of anaphylaxis?
ABC and O2 by non rebreathe mask Remove the cause ASAP i.e.: blood transfusion Adrenaline 500 micrograms of 1:1000 IM Chlorphenamine 10mg IV Hydrocortisone 200mg IV Asthma tx if wheeze Amend drug chart allergies box
What is the treatment of acute exacerbation of asthma?
ABC 100% by non rebreather mask Salbutamol (%mg NEB) Hydrocortisone 100mg IV (severe/ life threatening) or prednisolone (40-50mg if moderate) Ipratropium (500 micrograms NEB) Theophylline (Only if life threatening)
What is the management of acute exacerbation of COPD?
Same treatment as asthma, but add antibiotics if infective exacerbations
Patients are also more likely to have type 2 respiratory failure, so use high flow oxygen will case
If in peri arrest; apply high flow oxygen
28% oxygen is a safe starter in patients if they are not in peri arrest, ABG 30 mins later to assess the effect
How do you treat a secondary pneumothorax?
The pt has underlying lung disease
They always need treatment: chest drain if >2cm or SOB or if >50 years old
Otherwise aspirate
What is the treatment of primary pneumothorax?
If <2cm rim and not SOB then discharge with OP follow up in 4 weeks
If >2cm rim on CXR or feels SOB then aspirate and if unsuccessful aspirate again, and if still unsuccessful aspirate again and then if still unsuccessful chest drain
What fluids should you give for replacement?
Give all patients 0.9% saline (normal saline, a crystalloid), unless the patient…
1) is hypernatraemic or hypoglycaemic (give 5% dextrose instead)
2) has ascites- give human albumin solution instead, the albumin maintains oncotic pressure; furthermore the higher sodium content of 0.9% saline will worsen ascites
3) is shocked from bleeding- give blood transfusion but a crystalloid first if no blood available
How much replacement fluid should you give and how fast?
If tachycardia or hypotensive then give 500ml bolus immediately (‘haemodynamically unstable’), after bolus given then reassess the patient especially HR, BP and urine output to assess response and speed of next IV fluid bag
If only oliguric (<0.5ml/kg/hour) then give 1L over 2-4 hours then reassess the patient
What maintenance fluids should you give in a pt?
As a general rule…
Adults require 3L (but be wary of night time)
Elderly require 2L
Adequate electrolytes are given by 2 sweet 1 salty
1L 0.9% Nacl followed by 2L 5% dextrose
Add potassium to the two dextrose bags (20mmol in each bag)
K+ intake should be 0.5mmol/L
How fast should you give maintenance fluids?
It depends on how much you are giving…
If you are giving 2L per day= 12 hourly bags
If you are giving 3L per day= 8 hourly bafs
What does co codamol 30/500 mean?
It means they are taking 30mg codeine and 500mg paracetamol
What side effects can antimuscarinics cause?
Pupillary dilation
Loss of accommodation
Dry mouth
Tachycardia (after a transient bradycardia)
What are differentials you should consider in confused elderly patients?
Acute intracranial event Infection Electrolyte disturbance Constipation Urinary retention
What drugs can cause confusion in the elderly?
Diazepam
Tramadol!!!! (Should be avoided unless absolutely necessary)
Cyclizine= antiemetic which can cause drowsiness and confusion, reduced doses are recommended in the elderly
What drugs should be used in caution in patients on methotrexate and why?
NSAIDS and ibuprofen should be used with caution in patients on methotrexate due to increased risk of nephrotoxicity
Trimethoprim
What is co-dydramol?
Dihydrocodeine and paracetamol
2 tablets contain 500mg paracetamol each
When is methotrexate contraindicated?
In active infection
If someone is on two rate limiting drugs and they are bradycardic, should you stop both?
No, it could cause a rebound tachycardia
What would the projection be in a normal Xray?
PA
How do you determine whether there is no rotation in a CXR?
If the distance between the clavicles and the spinous process is equal then there is no rotation.
How do you know if the quality of the CXR is adequate?
The 7th rib should transect the diaphragm
How do you manage pneumonia?
A to E
High flow O2
Antibiotics (amoxicillin for CAP, co amoxiclav for HAP), paracetamol, IV fluids if haemodynamically unstable
What is the treatment of PE?
A to E High flow oxygen Morphine 5-10mg IV Cyclizine 50mg IV DOAC If low BP- IV fluid bolus, contact ITU, consider thrombolysis
How do you treat GI bleeding?
A to E Cannulae 2 large bore Catheter and strict fluid monitoring Crystalloid bollus Cross match 6 units of blood Correct clotting abnormalities (terlipressin in varices) (tranexamic acid in Lower GI bleed)
How do you treat bacterial meningitis?
A to E High flow oxygen IV fluid 4-10mg dexamethasone IV unless severely immunonocompromised LP (+/- CT head)
2g cefotaxime IV
If immunocompromised or >55y/o add 2g ampicillin IV (give antibiotics pre LP if having CT head or prolonged LP)
Consider ITU
What should you do initially if someone has a seizure?
Ensure the airway is patent and put in recovery position with oxygen to prevent aspiration if patient vomits and perform bedside tests for provoking factors (plasma glucose, electrolytes, drugs and sepsis)
If the seizure lasts for more than 5 minutes
What is the first line therapy in parkinsons disease?
Co careldopa (levodopa + carbidopa) Co beneldopa (levedopa + benserazide)
What should you give if the patient is worried about the finite period of benefit from levodopa?
Dopamine agonist- ropinirole or monoamine oxidase inhibitor (rasagiline)
What is the first line antiepileptic drug for the following seizures…
A) myoclonic B) tonic C) all other focal seizures D) absence seizures E) generalised tonic clonic seizures
A) valproate for males and levetiracetam for females
B) valproate for males or lamotrigine for females
C) carbamazepine or lamotrigine
D) ethosuximide or valproate
E) valrproate for males and lamotrigine for females
What drug treatment can be used for Alzheimers?
If mild/moderate then treat with acetylcholinesterase (AChE) inhibitors
However they are only started by specialist doctors
There are currently 3 licensed- donepezil, rivastigmine and galantamine
If moderate or severe dementia then treat with NDMA antagonist (memantine)
What is the treatment summary for COPD?
Offer treatment and support the pt stopping smoking
Offer pneumococcal and influenza vaccinations
Offer pulmonary rehabilitation if indicated
Co develop a personalised self management plan
Optimise treatment for co morbidities
Offer SABA or SAMA to use as needed if the above interventions have been offered and inhaled therapies are needed to relieve breathlessness and exercise limitation and people have been trained to use inhalers and can demonstrate satisfactory technique
Offer SABA or SAMA to use as needed
If the person is limited by symptoms or has exacerbations despite treatment then offer LABA and LAMA if no asthmatic features
If asthmatic features or steroid responsive then consider LABA + ICS
How do you treat a mild flare of Crohns disease?
Prednisolone 20-40mg daily orally and treat a severe flare with IV hydrocortisone 100-500mg three to four times daily or as required (as per BNF) IV and supportive care (IV fluid, NBM, antibiotics)
How do you maintain remission in crohns?
Azathioprine or active agent 6-mercaptopurine
6 mercaptopurine is metabolized to inactive components by the enzyme TPMT
What drug do you test TPMT for?
Mercaptopurine and azathioprine because if there is a deficiency in TPMT then it would lead to abnormal accumulation of 6- mercaptopurine and azathioprine
This would increase the risk of liver and bone marrow toxicity.
If TPMT is found to be low (but not deficient or ansent) then start lower dose azathioprine
If TPMT levels are deficient/absent then give methotrexate instead
What is an example of a stool softener and what is it good for?
Docusate sodium and arachis oil (rectal)
Good for faecal impaction; reduced gut motility
What is an example of stimulant laxatives and when can’t you use them and why?
Senna, bisacodyl
Cant use them in acute abdomen and may exacerbate abdominal cramps
What are examples of osmotic laxatives and when cant you use it?
Lactulose
Phosphate enema
Phosphate enema cant be used in acute abdomen, IBD
May exacerbate bloating
What is the treatment for rheumatoid arthritis?
Treated started by specialists typically usung methotrexats followed by additional DMARDS
During a flare…
Short term glucocorticoids- IM methylprednisolone 80mg
Short term NSAIDS ie: ibuprofen 400mg 8 hourly with gastro protection (lansoprazole)
Re-instate DMARDS if dose previously reduced
After failure to respond to two DMARDS, sverely active RA may be managed with TNF alpha inhibitors ie: infliximab
What are the commonest causes of diarrhoea?
GI infection- norovirus and C difficile gastroenteritis
What can you treat chronic diarrhoea which is not caused by infectious disease with?
Loperamide or codeine
When should corticosteroids be given and why?
In the morning to prevent disruption of sleep
What can you give for insomnia?
Zopiclone but you don’t really want to give it in the elderly
What should you do if someone
What should you change ramipirl to in pregnancy?
Labetalol
What is some important information to give to a patient taking tamoxifen?
Tell her she should attend hospital straight away if she notices leg swelling, pain or redness.
When should gliclazide be taken?
In the morning with breakfast
What is the frequency of blood tests for a patient on methotrexate?
1-2 weekly blood tests to monitor full blood count
What is the frequency of blood tests for someone taking warfarin?
Weekly, once INR is stabilised then monthly blood tests can be performed
What is the effect of alcohol on warfarin?
Acute alcohol intoxication causes enzyme inhibition whereas chronic causes enzyme induction
When should you monitor kidney function (UEs) in a patient on Ramipril (ACE-I)
Kidney function and potassium should be measured 1-2 weeks after initiation of ACE-Is, particularly if they have CKD
What considerations need to be taken when a parient is taking steroids?
Steroids increase diabetes mellitus- regularly check blood glucose
They increase the risk of osteoporisis- therefore bisphosphonate should be commenced
There is an increased risk of gastric irritation and ulceration in steroid therapy, therefore offer PPI omeprazole
Dont stop sterids suddenly- can cause addisonian crisis
Pts on steroids are at risk of hypertension
Whats some important information to give people who are starting on citalopram?
It can take up to 6 weeks to have an improvement in symptoms
Citalopram makes you more photosensitive and precautions should be taken in sunlight
Pts may feel worse immediately after starting antidepressants before they improve
SSRIS can cause a dry mouth
Make them aware of serotonin syndrome (dilated pupils, dilated pupils, loss of muscle co ord and twitching muscles, insomnia, confusion, agitation or restlessness).
How long should you avoid food for after taking alendronic acid?
2 hours
How long does the risk of breast cancer last for after taking HRT?
10 years
What does 1% mean for
A) weight/volune calculations and
B) weight/weight calculations
1g in 100ml or 10mg in 1ml
1g in 100g for weight/weight calculations
What drug would you give to someone presenting with chest pain which is due to ACS?
GTN spray (glyceryl trinitrate) 2 sprays sublingual
What is the first drug used to LOWER potassium in hyperkalaemia?
Short acting insulin (actrapid/novorapid) with glucose
Normally give 10 units actrapid in 100ml of 20% dextrose over 30 min IV
At what creatinine level should you not use metformin?
> 150
When selecting a oral hypoglycaemic drug for patients, what should you pick if…
A) they are overweight
B) they are normal/underweight
A) metformin
B) sulphonylurea
What is really important to check before prescribing vancomycin?
Serum creatinine as clearance of vancomycin is reduced in patients with renal dysfunction
Therefore renal function must be taken into account when choosing a dosing regime
The two classic side effects are nephrotoxicity and ototoxicity
When are statins contraindicated?
They are contraindicated when the liver function tests are three times the normal range
LFTs should be taken before starting, at 3 months and at 12 months
Is creatinine kinase always checked with statins?
No its checked if the patient is at increased risk of myopathy
When should you monitor lithium levels?
Should be performed weekly after initiation and after each dose change until the concentratioms are stable, and then 3 months therafter
Which electrolyte disturbance can cause lithium toxicity?
Sodium depletion
Why cant methotrexate be started if the patient has abnormal LFTS?
There is a risk of cirrhosis!
What must be tested before prescribing onlazapine?
Blood glucose as hyperglycaemia and diabetes ca occur in patients prescribed antipsychotic drug, fasting blood glucose must be tested at baseline and regular intervals thereafter.
What baseline investigation do you need to do before commencing amiodarone?
CXR
What should be monitored when a pt is on sodium valproate?
LFTs, sodium valproate is associated with hepatotoxicity
What do you monitor in a pt taking clozapine?
FBC for the first 18 weeks
What can be used to treat essential tremor?
Beta blockers
What are the aims of statin therapu?
Statins after 3 months should lead to >40% reduction in non HDL cholesterol
>40% reduction then continue the current dose
< or equal to reduction then consider increasing the dose
What parameter is measured with steroid use and what should you di based on the results?
LFTs
ALT and other LFTs are known to increase with the use of statinsb
ALT increase of >1 to <3x of upper limit of normal then continue statin and recheck the LFTs in 4-6 weeks
If the LFTs increase more than or equal to 3x of normal then stop statin (ezotimibe)
Creatine kinase
CK is known to increase with the use of statins
If the CK is more than or equal to 5x normal limit then stop the statin
