Random Flashcards
Management for acute oculogyric/dystonic crisis?
Procyclidine 10mgIV superior to IM
Management of acute COPD on top of ipratropium and salbutamol?
Prednisolone 30mg for 7-14 days
Patient on HRT having withdrawal bleeds, wants a patch that won’t cause withdrawal bleeds?
Everol Conti self adhesive patch. 1 patch transdermal twice a week.
What is contraindicated in peripheral vascular disease?
BB’sThey cause vasoconstriction which can worsen ischaemia
Two medicines that contribute to biventricular failure?
Corticosteroids and CCB’s
What renal meds cause hyperkalaemia?
ACE inhibitors and aldosterone inhibitors (Spiro)
What drugs may contribute to candida?
Oral steroidsAntibiotics e.g. amoxicillin and Clarithromycin
What should you never do with steroids?
Never stop them abruptly, continue them through any illness
Maintenance dose of omeprazole for GORD?
10-20mg
If a patient on biphasic insulin has bad afternoon BM’s, what do we do?
Alter her morning dose
Signs of early scarlet fever and Mx?
Macular red rash, strawberry tongue, red throat, fever >38If can tolerate oral fluids = oral antibiotics = Phenoxymethylpenicillin 125mg PO QDS for 10 daysNo fluids = IV BenPen
INR range for mechanical valve?
3-4
What counts as missing a pill for contraceptive?
> 24 hours
Rules for missed pill?
If miss one anywhere you will be protected. Take the missed pill and todays pill together. If a woman misses 2 or more pills (especially from the first 7 in a packet), she may not be protected. She should take an active pill as soon as she remembers and then resume normal pill-taking. Use condoms for 7 days. If any of these 7 days fall in the pill free week miss this week.
What should you monitor with eplerenone?
Potassium (it is a potassium sparing diuretic)
Advice for men on methotrexate?
Contraception taken during and for at least 6 months after stopping treatment Same advice for women
Side effect of mirtazapine?
Abnormal dreams
Which diuretics cause hypokalaemia?
Thiazide like diuretics e.g. indapamide
What interacts with simvastatin to increase severe myopathy risk?
Gemfibrozil - potent CYP inhibitor
Unconscious hypoglycaemic Mx?
1st line = glucose 20% 50-100mL IV, over less than 20 minutes2nd line = Glucagon
How to monitor BB effect in AF?
Check heart rate
What to monitor electrolyte wise for amiodarone?
Potassium - check prior to starting treatment
When do you stop the statin in myopathy?
If CK is > 5 times the upper normal limit or severe muscular symptoms
How does fentanyl convert to oral morphine?
25ug/hour of fentanyl = 60mg of morphine
What to give to alleviate breathlessness and oedema in heart failure?
Furosemide 40mg IV IV IV
Patient needs post-op prophylaxis, scared of needles?
Apixiban can be given orallyApixiban oral 2.5mg PO BD
Treatment for moderate severe acne, having tried topical therapy?
DoxycyclineLymecycline
Standard dose for tacrolimus?
Maintenance dose is commonly 1-2mg BD
What electrolyte abnormality do both tacrolimus and Dalteparin cause?
Hyperkalaemia
When should anti-platelets be stopped prior to surgery?
7 daysExcept if recent vascular stenting
What drugs to hold in renal function?
ACEI’s, ARBSAllopurinol is really excreted so BNF advises max daily dose of 100mg in renal failure
How can AKI cause confusion?
Decreased clearance of medicines e.g. co-codamol and diazepam
How do steroids affect blood sugar levels?
Hyperglycaemia
How does citalopram affect electrolytes?
Cause hyponatraemia, due to inappropriate ADH secretion
Do you take levothyroxine daily or weekly?
Daily
Monitoring furosemide effect in heart failure?
Check weight
Alcohol withdrawal Tx?
Chlordiazepoxide hydrochloride 20mg PO TDS
If INR >1.5 on the day before surgery what do you give?
Phytomenadione (Vitamin K) 1-5mg orally
What should you advise with anti-depressants?
Suicidal idealation may worsen before it gets better / May take 6 weeks to work
What should the patient report if on rivoroxaban?
Any abnormal unexplained bruising / bleeding
How does topiramate affect progesterone only contraception?
It reduces the efficacy, so you should an alternative contraceptive during the treatment and for at least 4 weeks afterwards
Side effect of beta blockers ?
Erectile dysfunction
What is an example of a cholestatic drug and who it primarily affects?
Co-amoxicalvClassically affects men > 65
What interacts with dabigatran etexilate to cause increased bleeding risk?
Citalopram
What is an acceptable rise in creatinine when starting an ACEI?
<20% is acceptable, if it rises to <20% do not stop, just repeat renal function tests in 1 week
Monitoring in carbimazole?
FBC for neutropenia
monitoring the affect of ACEI in heart failure?
Excercise tolerance - think NYHA classification is how we grade severity
Most serious adverse affect of ciclosporin and monitoring?
NephrotoxicityBefore starting you must assess renal functionThen check it 2-weekly until stable
Whats the usual increase of an insulin dose when the patient goes on glucocorticoids?
10% increase
What should non-HDL cholesterol have decreased by once started on statins?
> 40% reduction in is the target. If you don’t hit this you need to up the dose
When should gentamicin levels be measured after the dose?
Within a 6-14 hour window
What anti-emetic do you give in patients who are at risk of extra-pyramidal SE’s or prolonged QT?
Cyclizine 50mg TDS
Management of shingles in a high risk / immunocompromised patient e.g. oncology?
Aciclovir at the higher 800mg 5/day dose. For 7 days
How much and how long for a fluid challenge?
ideally 500ml in under 15mins, or 1 litre under 30 minutes
Starting dose for metformin?
500mg PO OD
Max dose of citalopram in old people?
20mg
What drugs cause ‘indigestion’?
Steroids, NSAIDS, alendrotnic acid
Two common drugs causing diarrhoea?
Alendronic acid and PPI’s
Other than CCB’s, what can cause ankle swelling?
Naproxen
Pregnant lady with vaginal candidiasis, whats the Tx?
It has to be prolonged therapy. Clotrimazole pessary / creamDon’t give oral anti-fungals in pregnancy
Patient with DKA on short acting insulin (Humulin) and long acting (Lantus). How do we manage her insulin ?
Fixed rate insulin infusionStop short actingContinue long acting
Management of pain in post-herpetic neuralgia?
Paracetamol NSAIDs too but caution if old people with renal risk / ulcer risk
Important information to give to people taking loperamide?
Initial dose of 4mgthen take 2mg after each loose stool - MAX 16mg/24 hour period
What must we monitor in ciclosporin?
Renal function as it is highly nephrotoxic.Monitor creatinine every 2 weeks for first 3 months then 3 monthly
Is ciclosporin an absolute contra-indication to pregnancy?
No, just not recommended
Most likely SE of Liraglutide (GLP1 mimetic)
Vomiting
What does tramadol do the given with SSRI’s?
Increases risk of serotonin syndrome
What TB drug increases metabolism or oestrogen / progestogens?
Rifampicin
Mx of anti-psychotic induced Parkinsonism?
Procyclidine 2.5mg oral TDS
What does COCP cause short term and how should it be monitored?
BP increase, BP
What should you measure prior to initiating azathioprine / mercaptopurine?
TPMT
What should be monitored with apixiban?
nothing, just tell patient to report any bleeding / bruising
If someone has renal impairment what analgesics should be avoided?
Morphine is metabolised in liver and active metabolite is excreted in the kidneys - so will accumulate in renal impairmentOxycodone is metabolised to inactive metabolites by the liver, so use this in renal impairment
Management of warfarin and bleeding?
> 8 = PTC, IV Vit K and stop warfarin Minor bleeding > 8 IV Vit K and Stop warfarinminor bleeding 5-8 = Oral Vit K and stop warfarin5-8 = withhold 2 doses of warfarin
If amiodarone causes thyrotoxicosis what should we do?
Stop the amiodarone
Drugs contraindicated in heart failure?
Thiazolinediones = Fluid retentionVerapamil = negative inotropeNSAIDs / glucocorticoids = = Fluid retention (except low dose aspirin) Class 1 anti-arrhythmics = Flecainide (Don’t use in those with structural heart disease)
What electrolyte values do people need as maintenance?
25-30ml / kg1mmol/kg of potassium, sodium and chloride50-100g/day of glucose
What does 0.9% saline have in it?
Sodium = 154Chloride = 154
What is in Hartmann’s?
Sodium = 131Chloride = 111Potassium = 5 HCO3 = 29
What laxative do you use in opioid induced constipation?
Osmotic laxative e.g. lactulose
What oxygen should be given in critically ill patients?
Resevoir mask 15L/minute
What three drugs are contraindicated in asthma?
NSAIDs - increased risk in those with nasal polypsBB’s Adenosine
What type of fluids should you avoid in stroke patients?
5% glucose - increases risk of cerebral oedema
Two emergency contraceptions and when you take them?
Levonogesterol - within 72 hours, can be used twice in the cycle Ulipristal - Within 120 hours, only once within a cycle. Affects other contraception so restart normal stuff after 5 days and use barrier protection in the mean time.
what are the CYP450 inducers?
PC BRAS = Enzyme up = drug conc. down PhenytoinCarbamazepineBarbituratesRifampicinAlcohol (CHRONIC EXCESS)Sulphonylureas
CYP450 inhibitors?
AO DEVICES = enzyme down = drug conc. increaseAllopurinolOmeprazole
DisulfiramErythromycinValproateIsoniazidCiprofloxacinEthanolSulphonamides
Drugs to stop pre-surgery?
LICK OAPSLithium = day beforeInsulinCOCP = 4 weeks beforeK-sparing diuretics = day ofOral hypoglycaemicAnticoags / plateletsPerindopril (ACEI’s) = Day of
Steroid side effects (and loosely the CI’s)
STEROIDS
Stomach ulcersThin skinEdemaR + LHFOsteoporosisInfection (Candida)DiabetesSyndrome of Cushings
When not to use NSAIDs?
Heart failureRenal failureStomach ulcersAsthma
Which diuretic causes gout?
Thiazides
Which diuretic causes gynaecomastia?
K Sparing
When do you give 5% glucose?
If patient is hypernatraemic| Hypoglycaemic
When do you give gelofusin?
Systolic <90 in trauma etc
When shouldn’t you use cyclizine as an anti-emetic?
Heart failure as can cause fluid retention
When shouldn’t you use metoclopramide?
Parkinsons
When should you not use COCP?
Migraines
What causes hypovolaemic hyponatraemia?
Urine Na < 20 = extra-renal e.g. D&V, fistula, burnsUrine Na > 20 = renal e.g. Diuretics, salt losing nephropathy
What causes euvolaemic hyponatraemia?
SIADH, adrenal insufficiency or hypothyroid
What causes hypervolaemic hyponatraemia?
Cardiac failure, cirrhosis, and kidney failure
What causes hypernatraemia?
Unreplaced losses = GI, DI
Causes of hypokalaemia?
1) Renal loss = RTA, thiazides/Gitelmans and Loops/Barters2) GI loss3) Excess aldosterone = Conns4) insulin and salbutamol
causes of hyperkalaemia?
1) Renal failure2) Drugs e.g. NSAIDs, ACEI, ARBs and Spiro3) Low aldosterone = Addisons4) Redistribution = Rhabdomyolysis or any acidosis
Drugs causing neutropenia?
Carbimazole and Clozapine
Drugs causing cholestasis?
FlucloxacillinCo-amoxiclavNitrofurantoinSteroidsSulphonylureas
Signs of digoxin toxicity?
Visual halos, yellow-green vision, arrhythmias
Lithium toxicity?
Early = tremorLate = Arrhythmias, seizures and DI
Phenytoin toxicity?
Gum hypertrophy, ataxia, nystagmus and peripheral neuropathy
Gent and vancomycin toxicity?
Ototoxic and nephrotoxic
Dosing in gentamicin normal vs renal failure?When do you measure?
Normally high dose = 5mg/kgRenal failure = 1mg/kg6-14 hours post dose
What interacts with erythromycin to prolong QT?
Domperidone
What interacts with fluconazole to cause QT prolongation?
Domperidone and haloperidol
Side effects of quinolones?
Convulsions and tendon damage
Side effects of barbiturates?
Behavioural disturbances
SE’s of carbamazepine?
Skin reactions. Asians get Steven Johnsons
Management of hyperkalaemia?
10ml 10% calcium gluconate 100ml 20% glucose + 10 units actrapidSalbutamol 5mg
Management of HTN?
1) Under 55 = ACEI / ARB. Over 55 / black = CCB2) A+C3) A+C+ diuretic4) A + C + D + Spiro / alpha blocker / BB / SPECIALIST
STEMI and NSTEMI Mx?
GTN, morphine, STEMI = PCI / thrombolysis. GRACE >3% = Tirofiban. NSTEMI = LMWH. Angioplasty if GRACE >3% ± PCI. If GRACE>3% = tirofiban.Long term = Aspirin + clopidogrel, statin, BB and ACEI
Anaphylaxis Mx?
0.5ml 1:1000 adrenaline200mg Hydrocortisone10mg Chloramphenamine
Heart failure Mx?
1st = ACE and BB2nd line = increase dose3rd: ARB if mild. Mod to severe = Spiro in whites, hydrazine and isosorbide nitrate in blacks.
AF Mx?
Rate if >65 or IHD:- metoprolol- asthmatics = diltiazem- heart failure = DigoxinRhythm if 1st time, lone AF, young, secondary precipitant:<48 hours = cardiovert –> DC, flecainide or amiodarone if structural heart disease> 48 hours = anticoagulant until INR 2-3, then cardiovert
Asthma Mx?
1 = SABA PRN2 = Low dose ICS and SABA3 = + LRTA4 = SABA + ICS + LABA ± LRTA if worked5 = SABA + ICS ±LRTA + MART6 = ICS to moderate7 = high dose ICS
COPD Mx?
1 = SABA / SAMA2 = FEV > 50% = LABA or LAMA = FEV < 50% = LABA +ICS, OR LAMA3 = LABA + LAMA + ICS
Diabetes drugs: Metformin MOA and SE’s?
OralDecreases hepatic neogenesis and increases insulin secretionSE’s = NADL = Nausea, abdo pain, diarrhoea and lactic acidosisCI = eGFR < 30
Diabetes drugs: Sulphonylurea MOA and SE’s?
Oral, gliclazideIncrease B cell secretion of insulinSE’s = Hypos, hyponatraemia and weight gain
Diabetic drugs: Thiazolinediones MOA and SE’s?
Oral, pioglitazoneActivates gamma PPAR receptor = increased adipogenesisand fatty acid uptake = increased peripheral insulin sensitivity SE’s = weight gain and fluid retentionCI’s = heart failure and bladder cancer
Diabetic drugs: DPP4 / gliptins MOA and SE’s?
Oral sildagliptin Increases incretin levels = inhibits glucagonSE = pancreatitis
Diabetic drugs: SGLT-2 inhibitors MOA and SE’s?
OralInhibit glucose reabsorption in the kidneyGet weight loss…. but also UTI’s as increased glucose in urine
Diabetic drugs: GLP-1 mimetics MOA and SE’s?
Subcut, ExanitideIncretin mimetic SE’s = nausea, vomiting and pancreatitis
Common AED SE’s?
Lamotrigine = skin hypersensitivityValproate = 3T’s ==> Teratogenic, tremor and tubbyPhenytoin = Ataxia, peripheral neuropathy and gingival hyperplasiaCarbamazepine = SIADH, nystagmus
Alzheimers Mx?
Mild/moderate = AchE inhibitors e.g. donepezil, rivastigmineSevere = memantine
Crohns Mx?
Induction = Prednisolone, then sulfasalazine, then Azathioprine, then infliximabMaintain = Azathioprine
UC Mx?
Induction = Mesalazine, prednisolone then Tacmaintain = Mesalazine, azathioprine then infliximab
What do we do with ramipril in pregnancy?
Stop as teratogenic, give labetalol
What does tamoxifen increase risk of?
DVT and endometrial cancer
How often is methotrexate given, what do you give with it and what do you not give it with?
Once weeklyFolic acidTrimethoprim / co-trimoxazole
If on long term steroids what should you take?
bisphosphonates and PPIs
What does 1% for drugs mean?
10mg in 1ml
What to monitor in vancomycin?
Kidney function as renal cleared
What to monitor in statins?
Baseline LFT’s then check at 3 and 12 monthsBaseline of creatinine if old / renal disease
When do you check phenytoin levels?
Trough at 14 days
What is lithium range, when do we monitor?
0.4-0.8, check 12 hours after last doseMonitor dose weekly after initiation / dose change3 monthly once stable
Methotrexate monitoring?
Monitor 3 monthly FBC’s
What do you monitor in clozapine?
First 18 weeks FBC weeklyAny agranulocytosis = stop ASAP
Sodium valproate monitoring?
Hepatotoxic = LFT’s
Amiodarone monitoring?
Baseline CXR and do TFT’s + LFT’s
What electrolyte affects digoxin levels?
PotassiumPotassium competes for digoxin binding, so low potassium means digoxin level raised!
SE of amiodarone?
Thyroid problems and fibrosis
When to use vancomycin in C.Diff vs Metronidazole?
Acute rise in creatinineEvidence of colitis e.g. fresh bleedingWCC > 15
Anti-emetics in pregnancy?
1st line = cyclizine / promethazine2nd line = metoclopramide
What two cardiac drugs do you not give together as risk pre-syncope?
Verapamil and BB
How do drugs cause digoxin toxicity?
By decreasing potassium / magnesium e.g. loop or thiazidesBy increasing digoxin plasma conc. e.g. Amiodarone, CCB’s and Spiro
Big side effect of tamsulosin?
alpha blocker = postural hypotension
Side effect of clozapine?
Affect glucose metabolism = metabolic syndrome.Polyuria, polydipsia and blurred vision
What is DRESS syndrome and three common drug precipitants?
Drug Reaction with Eosinophilia and Systemic SymptomsAllopurinol, anti-epileptics, and sulphonamides (e.g. co-trimoxazole)
What do you give in corneal abrasion?
1 week of topical eye drops e.g. chloramphenicol
What must you have done monthly on isotrenitoin?
Pregnancy test
Common SE of mirtazapine that puts patients off?
Weight gain
How to monitor adverse affects of caffeine treatment?
Drug levels
Monitoring in venlafaxine?
Regular BP’s and ECGs as can prolong QT
If you have renal impairment what type of heparin should you use?
Unfractionated. LMWH is excreted really, so don’t use if renal impairment.
Post surgery what thromboprophylaxis do you use?
Apixiban, rivaroxiban
Pre surgery or for medical patients what VTE prophylaxis?
All surgery LMWH e.g. dalteparinRenal impairment = unfractionated
Which PPI interacts with clopidogrel to reduce its efficacy?
Omeprazole. Try to use lansoprazole
Which anti-epileptic can cause yellow skin, mistaken for jaundice sometimes?
Carbamazepine
three common drugs that trigger gout?
Thiazides, aspirin and ACEI
When managing AF, what counts as adverse signs meaning we cardiovert?
Heart failureShockMISyncope
If patient has been on long term Benzo’s for anxiety/insomnia what should we do?
Switch to diazepam and taper off
What type of rash does lithium exacerbate?
Psoriasis
What should you monitor in tenofovir?
Renal function e.g. urinalysis
How would you monitor the acute negative effects of aminophylline (i.e. not a theophylline level)?
Cardiac monitoring
Quetiapine monitoring?
Annual BMI, lipids, glucose, FBC and ECG
What should you avoid if penicillin allergic?
Cephalosporins e.g. ceftriaxones
When do you need non-invasive ventilation?
Type 2 respiratory failure
When should you not use nitrofurantoin?
If eGFR is <45. Use trimethoprim instead
Most likely SE when giving steroids and amoxicillin?
Candidiasis
What do you give for urticarial allergic rash, but not full blown anaphylaxis?
Chlorphenamine 4mg PO QDS
Mx of thyroid storm?
Carbimazole
What to tell pregnant people taking LMWH worried about baby?
It does not cross the placenta
What is a patient on a Benzo and nitrate at risk of?
Falls
Benzo = confusionNitrate = postural hypotension
What happens when you give buprenorphine with morphine?
Buprenorphine has a partial agonist effects, counteracting the morphine and reducing efficacy
How do you treat a PC of gout if the person has heart failure?
Use colchicine
NSAIDs are contraindicated in heart failure, particularly diclofenac
Which anti-malarial is contraindicated in pregnancy? Which common medication decreases this drugs absorption?
DoxycyclineAntacids decrease doxycycline absorption - don’t prescribe together
Why is metformin stopped before surgery? When is it stopped?
Risk of lactic acidosis in the event of renal compromise during surgery
Day before surgery
Diabetic patients are all considered for initiation of insulin infusion by ‘sliding scale’
Impact on erythromycin on INR in patients taking warfarin
Erythromycin (a macrolide) is a P450 enzyme inhibitor and may be responsible for a excessively high INR (through reducing warfarin breakdown and thus increasing its accumulation).
Which antihypertensives should NOT be stopped before surgery?
BB and CCBs
Due to tachycardia risk
Which three LMWHs are available?
enoxaparin, dalteparin, and tinzaparin
Unfractionated heparin is used intravenously when tighter control is needed (i.e. much less commonly).
What is the most effective way of relieving nausea on SBO?
Remove the obstruction or decompress the system with a nasogastric tube; concomitant IV fluids should be given to prevent dehydration while nil by mouth, hence the term ‘drip and suck’.
