Questions Flashcards
What are the common side effects of amlodipine?
Headache and ankle swelling are common side-effects of calcium channel blockers. Diarrhoea and dry mouth may be seen but they are less common than the correct answers. Gout is not a common side-effect of calcium channel blockers.
Calcium channel blockers
Calcium channel blockers are primarily used in the management of cardiovascular disease. Voltage-gated calcium channels are present in myocardial cells, cells of the conduction system and those of the vascular smooth muscle. The various types of calcium channel blockers have varying effects on these three areas and it is therefore important to differentiate their uses and actions.
Examples Indications & notes Side-effects and cautions
Verapamil Angina, hypertension, arrhythmias
Highly negatively inotropic
Should not be given with beta-blockers as may cause heart block Heart failure, constipation, hypotension, bradycardia, flushing
Diltiazem Angina, hypertension
Less negatively inotropic than verapamil but caution should still be exercised when patients have heart failure or are taking beta-blockers Hypotension, bradycardia, heart failure, ankle swelling
Nifedipine, amlodipine, felodipine
(dihydropyridines) Hypertension, angina, Raynaud’s
Affects the peripheral vascular smooth muscle more than the myocardium and therefore do not result in worsening of heart failure but may therefore cause ankle swelling Flushing, headache, ankle swelling
Drugs to avoid in AKI
Drugs to avoid in renal failure antibiotics: tetracycline, nitrofurantoin NSAIDs lithium metformin
Drugs likely to accumulate in chronic kidney disease - need dose adjustment
most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin
digoxin, atenolol
methotrexate
sulphonylureas
furosemide
opioids
Drugs likely to accumulate in chronic kidney disease
Drugs likely to accumulate in chronic kidney disease - need dose adjustment
most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin
digoxin, atenolol
methotrexate
sulphonylureas
furosemide
opioids
Drugs safe in AKI?
Drugs relatively safe - can sometimes use normal dose depending on the degree of chronic kidney disease
antibiotics: erythromycin, rifampicin
diazepam
warfarin
When should steroids be withdrawn gradually?
The BNF suggests gradual withdrawal of systemic corticosteroids if patients have:
received more than 40mg prednisolone daily for more than one week
received more than 3 weeks treatment
recently received repeated courses
How is angina pectoris managed?
The management of stable angina comprises lifestyle changes, medication, percutaneous coronary intervention and surgery. NICE produced guidelines in 2011 covering the management of stable angina
Medication
all patients should receive aspirin and a statin in the absence of any contraindication
sublingual glyceryl trinitrate to abort angina attacks
NICE recommend using either a beta-blocker or a calcium channel blocker first-line based on ‘comorbidities, contraindications and the person’s preference’
if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine). Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)
if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa
if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine
if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG
How is gentamicin dosed?
Dosing due to the significant ototoxic and nephrotoxic potential of gentamicin it is important to monitor plasma concentrations both peak (1 hour after administration) and trough levels (just before the next dose) are measured if the trough (pre-dose) level is high the interval between the doses should be increased if the peak (post-dose) level is high the dose should be decreased
What are the side effects of gentamicin?
Gentamicin is a type of aminoglycoside antibiotic. It is poorly lipid-soluble and is therefore given parentally (e.g. for infective endocarditis) or topically (e.g. for otitis externa).
Adverse effects
ototoxicity
due to auditory or vestibular nerve damage
irreversible
nephrotoxicity
accumulates in renal failure
the toxicity is secondary to acute tubular necrosis
concomitant use of furosemide increases the risk
lower doses and more frequent monitoring is required
Contraindications
myasthenia gravis
How can urinary incontinence be managed?
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Risk factors advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
Classification
overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigation
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant: bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women' mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
If stress incontinence is predominant:
pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction
Why should verapamil and beta blockers should never be co prescribed?
Beta-blockers and verapamil should never be prescribed together due to the risk of life-threatening bradycardias.
What analgesic is safe snd should be avoided in pregnancy?
Ibuprofen is commonly prescribed to breastfeeding women, particularly if mastitis develops. Aspirin should be avoided due to the risk of Reye’s syndrome.The BNF advises that a short course of trimethoprim is not known to be harmful.
There is no need for folic acid supplementation.Asian women are at an increased risk of vitamin D deficiency (not vitamin B) so consideration should be given to offering supplements.
What drugs can reduce hypoglycaemic awareness?
beta-blockers reduce hypoglycaemic awareness
What are the side effects of propranolol?
insomnia
Abdominal discomfort; bradycardia; confusion; depression; diarrhoea; dizziness; dry eye (reversible on discontinuation); dyspnoea; erectile dysfunction; fatigue; headache; heart failure; nausea; paraesthesia; peripheral coldness; peripheral vascular disease; rash (reversible on discontinuation); sleep disorders; syncope; visual impairment; vomiting
How can tonsillitis be treated?
Centors criteria-FEVERPAIN
assess need for antibiotic
pencillin V
How can Supraventricular tacky be treated?
Vagal maneoures
Adenosine
(S/E-chest pain, dizziness,cannot be used in reactive airway disease)
