[PWS] Difficult prescriptions Flashcards
How do you adjust insulin?
Total daily dose (TDD) = long acting + short acting
100/TDD = correction factor
The correction factor is how much 1U of insulin decreases blood glucose by
Then: (actual glucose - target glucose)/ correction factor
How do you change insulin if patient is sick?
You don’t
Continue normal insulin but with more monitoring
What do you do if patient is NBM to insulin?
Continue basal insulin
Omit bolus insulin
Give 3 examples of osmotic laxative
Lactulose
Movicol
Phosphate enema
How does an osmotic laxative work?
It draws water into stool > softens stool and stimulates peristalsis (increased bulk)
Containdication of osmotic laxatve
Bloating (may exacerbate it)
Phosphate enema: acute abdomen
Give 2 examples of stimulant laxatives
Senna
Bisacodyl
How do stimulant laxatives work?
Stimulate GI nerves > stimulate movement of bowel
Contraindications of stimulants
Examples of stimulants: senna, bisacodyl
Colitis
Cramps
Bowel obstruction
Colostomy
Which laxative is good for patients on opioids?
Stimulant laxative e.g. Senna
because they counteract the slowing down of gut movement caused by opioid
What anti-diarrhoeal meds can you give if NOT infective?
Loperamide 2mg PO - take after each loose movement
Alternative: codeine 30mg PO 6-hourly
What is the steroid ladder?
Help Carol Beat Medicine
Hydrocortisone
Clobetasone
Betamethasone
Mometasone
Very high potency = Clobetasol propionate (rarely used)
When do you need to wean a patient off steroids (rather than stopping abruptly)?
> 40mg pred for 1 week
3 weeks of treatment
repeated course
What situation is it okay to abruptly withdraw steroids?
If given for emergency (COPD/asthma)
What time of day should you take simvastatin?
in the evening (as cholesterol metabolism is predominantly in the evening and overnight)
Commonest side effect of statins
Muscle pains
When should you stop statins following LFT monitoring?
stop statins if AST/ALT >3 x ULN
continue statin otherwise
When must you stop statins in muscle myopathy?
if CK elevated (>5ULN) or severe muscular sx > STOP STATIN
resume at lower dose once CK has returned to normal
Why is warfarin + statins a concerning combination?
Because they will lead to a high INR
due to competitive inhibition of CYP by statin
Outline WHO pain ladder
- Non opioid (NSAID, paracetamol)
- Weak opioid
- Strong opioid
List some weak opioids (3)
Codeine
Tramadol
Morphine (oromorph PO, modiphied release morphine)
List some strong opioids (4)
Morphine
Diamorphine
Fentanyl
Oxycodone
How do you convert codeine / tramadol to oral morphine?
DIVIDE by 10
How do you convert oral morphine to subcut morphine?
DIVIDE by 2 (subcut is STRONGER than oral)
How do you convert oral morphone to oxycodone?
DIVIDE by 2 (oxycodone is stronger than morphine)
Which opioids can you give in CKD?
Oxycodone (GFR >30)
Fentanyl, alfentanyl, buprenorphinie (GFR<30)
How does warfarin work?
inhibits vit K epoxide reductase > reduces levels of 2, 7, 9 and10
What is INR target for AF, cardioversion, MI
2-3
What is INF target for mechanical heart valve
3-4
What does 1% mean in terms of mg in mL
10mg in 1mL
Remember: 1g in 100mL = 1000g in 100mL = 10mg in 1mL
How do you change / adapt COCP if surgery?
stop COCP 4 weeks beforee surgery
restart COCP 2 weeks post surgery
consider POP in interim
What kinds of laxatves are good for HAEMORRHOIDS?
Bulk forming laxative
Give examples of bulk formming laxative
Ispaghula hysk
Methylcellulose
When can biphosphonates be deprescrbed?
When taken for more than 10 years
as there is no evidence that they still work
What unit can you use for topical medications?
fingertip units (FTU)
Is aspirin technically an NSAID? What must you keep in mind?
Yes - it is technically an NSAID
but because it exists at a much lower dose, it is not necessarily subject to same level of caution
What is the only situation when cyclizine is contraindicated?
In HF (as it worsens fluid retention)
Give metoclopramide instead
What is the first line anti-HTN in a 60yo Caucasian?
First line fluid for DKA
To restore circulating volume, the most appropriate initial management is a bolus of sodium chloride 0.9% via intravenous infusion, run over 10-15 minutes. Once this blood pressure is stabilised, fluids should be given at a rate that replaces the deficit and provides maintenance.
First line mucolytic in patients with cystic fibrosis
The BNF recommends dornase alfa as the first-choice mucolytic in patients with evidence of lung disease and a background of cystic fibrosis. This can be increased to twice a day in patients over 21 years old, if once daily isn’t effective. If there is an inadequate response, dornase alfa may be combined with hypertonic sodium chloride, or hypertonic sodium chloride alone should be considered.
Alternative correct answers include:
* Hypertonic sodium chloride
* Mannitol dry powder (used where dornase alfa is unsuitable secondary to ineligibility, intolerance, or inadequate response)
What to give for H.pylori eradication aside from antibiotics (clarithromycin and amoxicillin)?
This patient is presenting with peptic ulcer disease in the presence of H.pylori infection. H. pylori is a key risk factor in the development of peptic ulcers and if detected requires treatment with a ‘triple therapy’ regime that includes a PPI and two antibiotics for 7 days, and the continuation of full PPI therapy for 2 months in total. In patients who are not penicillin-allergic antibiotics will include amoxicillin 1g BD and either clarithromycin 500mg BD or metronidazole 400mg BD.
If the patient is penicillin-allergic, Clarithromycin 500mg PO BD and Metronidazole 400mg PO BD should be prescribed.
There is a range of PPIs that can be used in this situation, all of which would be considered correct:
Omeprazole 20-40mg BD for 7 days
Lansoprazole 30mg BD for 7 days
Esomeprazole 20mg BD for 7 days
Management of cranial diabetes inspidus
The BNF recommends the use of desmopressin or vasopressin for the treatment of cranial diabetes insipidus. Treatment may be required for a limited period only in diabetes insipidus following trauma or pituitary surgery.
Other alternative answers include:
Vasopressin 5-20 units every 4 hours (IM)
First line treatment for absence seizures?
Ethosuximide or valproate are prescribed first-line for absence seizures in children. The dose of ethosuximide is age-dependent. For example, for a child aged 6 – 17 years, the initial dose is 250 mg twice daily. The dose of valproate is age and weight-dependent. For example, for a child aged 1 month – 11 years, the initial dose is 10 – 15 mg/kg daily in 1 – 2 divided doses (max. per dose 600 mg).
Alternative answer(s):
Sodium valproate 200 – 300 mg PO daily in 1-2 divided doses
First line medication for type 2 diabetes control
The BNF recommends the following for the initiation of metformin immediate-release treatment:
Initially 500 mg once daily for at least 1 week, dose to be taken with breakfast, then 500 mg twice daily for at least 1 week, dose to be taken with breakfast and evening meal, then 500 mg 3 times a day, dose to be taken with breakfast, lunch and evening meal; maximum 2 g per day.
Modified release preparations can also be prescribed if patient’s struggle to tolerate the immediate release side effects.
First line therapy for acute mania (bipolar)
Antipsychotic drugs (such as haloperidol, olanzapine, quetiapine, and risperidone) are used in the treatment of acute episodes of mania or hypomania; if the response to antipsychotic drugs is inadequate, lithium or valproate may be added.
First line treatment for a cutaneous (non-facial) wart
The patient has a diagnosis of a cutaneous common wart, characterised by small skin-coloured lumps that feel firm and rough, commonly appearing on the palms, knuckles, knees and fingers.
Warts do not cause the patient harm, but some patients may find them itchy, painful or embarrassing.
The BNF recommends the use of salicylic acid for common warts, although warns not to apply the cream to large areas of skin or broken skin for risk of skin irritation. Cryotherapy is a commonly used alternative to medication.
Initial dose of first line SSRI for depression
The BNF recommends selective serotonin reuptake inhibitors (SSRIs), such as sertraline, for the management of moderate-to-severe depression as they are better tolerated by patients and safer in overdose. The starting dose of sertraline is 50mg once daily and this can be increased in steps of 50mg at intervals of at least 1 week, guided by patient responsiveness.
If AF onset is >48 hours or uncertain, is rate or rhythm control preferred?
RATE
What should be given in suspected meningitis (GP setting) if penicillin allergic?
Cefotaxime
