revise

Question 1

RESCUE PACK for COPD –> less lung damage, faster recovery, less admissions.

Answer 1

ANTIBIOTIC (non-macrolide if on prophylactic azithromycin)
- Amoxicillin 500mg three times daily for 5 days
- Doxycycline (Pen all) 200mg first day then 100mg daily total 5 days course
- Clarithromycin 500mg twice daily for 5 days
STEROID
- prednisolone 30mg (COPD) - 40mg (asthma)
PPI

Question 2

Prophylactic antibiotics in COPD ?

Answer 2

Azithromycin
MOA: kills bacteria and reduce inflammation ()
Dose: 250mg THREE time a WEEK
Counsel: Prophylaxis to reduce chest infections and chest symptoms. Avoid indigestion/PPI within 2h
Interactions: theophylline, warfarin, digoxin, statins
doesn’t sig affect CYP450 like other macrocodes
Caution: severe hepatic/renal, QT interval
Criteria: pulmonary rehabilitation completed, 2+ exacerbation in 12m, non-smoker (won’t work if current smoker),

Question 3

Medication that can affect QT interval

Answer 3

Quinolone, macrolide, azole antifungal or co-trimoxazole

Question 4

Switching anti epileptic

Answer 4

Category 1: stay on same brand (CP3)
- Carbamazepine, Phenobarbital, Phenytoin, Primidone

Category 2: depends
Clobazam, Clonazepam, Eslicarbazepine, Lamotrigine, Oxcarbazepine, Perampanel, Retigabine, Rufinamide, Topiramate, Valproate, Zonisamide

Category 3: NO evidence to remain on same brand
Brivaracetam, Ethosuximide, Gabapentin, Lacosamide, Levetiracetam, Pregabalin, Tiagabine, Vigabatrin

Question 5

Refeeding

Answer 5

= Severe electrolyte and fluid shift by rapid reintro (oral enteral or parental) [electrolytes move from extra to intracellular compartment] after little nutritional intake for 5+ days.

Question 6

Muscarinic agents

Answer 6

SAMA = Ipratropium bromide (atrovent) (3-6 hours)
LAMA = Aclidinium (eklira) (12 hours),
Tiotropium (respimat, Braltus), Glycopyrronium (breezhaler), Umeclidinium (ellipta) – (24 hours)

SE: Dry mouth, headache, urinary retention, constipation
Caution: narrow angle glaucoma, GI motility disorder, BHP
Consider CV SE for px that can be affect by anticholinergic action (recent MI, arrhythmia or HF)
Interaction: beta2 agonist and xanthine (additive bronchodilatory)
Renal: (tiotropium caution eGFR <50mL/min [Tio] increases with decreased renal function); glycopyrronium caution eGFR<30mL/min).

• LAMAs are only licensed for COPD, with the exception of Spiriva Respimat® (tiotropium)
• SAMAs should be discontinued when long-acting antimuscarinic agents (LAMAs) are initiated.

Question 7

Severity of Liver cirrhosis

Answer 7

Child-Pugh score assess severity of liver cirrhosis
considering (higher score if …): total bilrubin (high), serum albumin (low), INR (high), ascites, hepatic encephalopathy

Question 8

Spontaneous bacterial peritonitis

Answer 8

= infection of ascites. WCC/Neutrophil in ascitic fluids.
Tx: Tazocin IV 4.5g tds (if severe) 5-7 days or Co-trimoxazole PO 960mg BD 5-7d
Prophylaxis: Co-trimoxazole PO 960mg OD

Question 9

Ascites

Answer 9

Tx: spironolactone, furosemide

Discontinue all diuretics if there is severe hyponatremia, progressive renal failure, worsening hepatic encephalopathy or incapacitating muscle cramps

Rifaximin prevent episodes of Hepatic Encephalopathy (tx: lactulose).

Question 10

Prokinetics Antiemetics

Answer 10

Prokinetics (metoclopramide and domperidone) should not be given concurrently with drugs with antimuscarinic activity (for example cyclizine, hyoscine) because antimuscarinic drugs competitively block the action of prokinetics.

Question 11

Clozapine

Answer 11

Indication = Tx-resistant schizo, psychosis for parkinsons
Dose:
If >48hr, retitrate as tolerance to common SE

SE: Constipation, drowsiness, hypertension, increase in saliva production (tx 2 pillow, hyoscine) and weight gain.
WARNING SIGN: neutropenia (monitor FBC), agranulocytosis, intestinal obstruction

Interactions:
Potential to cause agranulocytosis: carbamazepine, co-trimoxazole, trimethoprim, chloramphenicol
Myelosuppressive drugs: carbamazepine
Risk of NMS: lithium
Causes constipation: anticholinergics, opioids
Reduce [Clozapine]: smoking
Increase [Clozapine]: liver enzyme inhibitors. esp CYP1A2 enzyme. SSRI (inhibit CYP2D6)

Question 12

Insulin aspart (novorapid, Fiasp (with nicotinamide )

Answer 12

Indication: fast onest of action (when tight control required, if pt has rapid post meal BG increase)

T1 usual dose: 0.4 to 1 unit/kg/day with approximately 50% provided as prandial insulin (mealtime or bolus)
With Multiple daily injection – match prandial insulin dose to carb intake, pre-meal BG and anticipated activity

T2 usual dose (based on metabolic needs, blood glucose monitoring results, and glycemic goal)
Prandial Insulin: Initial dose: 4 units (or 10% of basal dose) subcutaneously with largest meal of the day. Titrate with additional injections of prandial insulin (i.e., 2, then 3) with meals.

Comparators: Apidra® (insulin glulisine)  Humalog® (insulin lispro)

NICE: don’t advise routine us of RA insulin analogue after meals in T1DM adults

Question 13

Which condition do you avoid Calcium channel blocker?

Answer 13

Dihydro (-pine) CI: cardiac outflow obstruction, uncontrolled HF

Rate limiting (diltiazem, verapamil): cardiac outflow obstruction, AF, HF, severe bradycardia, sick sinus syndrome, second- or third-degree AV block (unless pacemaker fitted)

Pt with Heart failure (with reduced EF) –> instead rx amlodipine

CCB caution: Elderly, hepatic impairment (dose adjustment)

CCB with exception of amlodipine, should be avoided in heart failure as they can further depress cardiac function and exacerbate symptoms. As they can also increase mortality after MI in patients with left ventricular dysfunction and pulmonary congestion.

Question 14

Triple immunosupression

Answer 14

Steroid + biologic + thiopurine/methotrexate e.g CD

ADD co trimoxazole 480mg BD 3 days a week for Pneumocystis jirovecii prophylaxis {monitor renal and FBC}

Avoid live vaccines

Question 15

Live vaccines

Answer 15

live vaccines = oral polio, yellow fever, BCG (tuberculosis), chickenpox, MMR (measles, mumps and rubella) and shingles.

Question 16

Amlodipine & Simvastatin interaction

Answer 16

Simvastatin is metabolised by the cytochrome P-450 isoenzyme CYP3A4 and is very sensitive to the effects of CYP3A4 inhibitors.

Amlodipine is a weak inhibitor of CYP3A4.

Concurrent use of amlodipine and simvastatin causes a significant increase in blood levels of simvastatin.

Fluvastatin, pravastatin and rosuvastatin are not metabolised by CYP3A4 to any significant extent and they do not interact with amlodipine.

Question 17

Medication Alzheimers pt should avoid. Anti——

Answer 17

Anti-cholinergics such as medication for insomnia stomach cramps, incontinence, asthma, motion sickness, and muscle spasms.

Side effects, such as confusion, can be serious for a person with Alzheimer’s

Question 18

Cinacalcet (calcimimetics? = bone resorption inhibitors)

Answer 18

MOA: reduces parathyroid hormone –> decreases in serum calcium concentrations.
Indication: hyperparathyroidism, hypercalcaemia

CI: hypocalcaemia (caution esp if condition that worsen with hypo e.g. QT, Seizures, impaired cardiac function) –> Monitor [Ca]
Counsel: dizziness, sign of hypocalcaemia (paresthesia, muscle spasms, cramps, tetany, circumoral numbness, seizures.)

Question 19

status epilepticus

Answer 19

treated if last >5m
Buccal midazolam is recommended by NICE as the first line treatment of prolonged or repeated seizures in the community, rectal diazepam is an alternative.

Question 20

insulin sick day rules

Answer 20

DO NOT STOP TAKING your insulin (illness increases bodies need for insulin)
- test BG and urine for ketones every 2 hours
- Drink 2.5L per day, eat normally if smaller appetite replace solid with milk, fruit juice
- Avoid XS exercise

Question 21

How to manage HypoKalaemia (<3.5)

Answer 21

Diet or potassium supplements (SE: N/V -> poor compliance)
(smaller dose if renal imp to reduce risk of hyperK)

IV (if need to treat more rapidly) potassium chloride with sodium chloride (not Glucose as will decrease K [ ] )

K sparing diuretic (amiloride, eplerenone, spironolactone) if kidney functioning normally and if caused by furosemide/ thiazide

Common cause (by inadequate potassium intake, increased potassium excretion, or a shift of potassium from the extracellular to the intracellular space): diuretics, vomiting/diarrhoea, CKD, DKA, insulin overdose, metabolic or respiratory alkalosis, chloroquine, antipsychotic drug (risperidone, quetiapine), amphotericin B, adrenal gland disorder, long term CS

Both extremes are related to risk of cardiac arrythmias
IMPT to compensate for K loss in pt taking antiarrythmic (digoxin), pt with XS loss of K in stool (lax abuse), elderly (low K in diet)

Question 22

HyperKalaemia management >5.3mmol/L

Answer 22

1.IV Ca chloride/gluconate 10% [protect heart]

2. to reduce K
   2a. IV soluble insulin 5-10 units (actarapid?) + 50ml 50% glucose over 5-15m
   2b. Salbutamol neb/slow IV
3. sodium bicarbonate [correct acidosis]

if mild-mod with no ECG change can use ion exchange resin to remove XS [K]

Question 23

Management of Hyponatraemic

Answer 23

Check medication and fluid balance (osmolality)
Common causes: diuretic, ARB, TCA, SSRI, MAO inhibitor, PPI, anticonvulsant, xs water

Tx: Sodium chloride 0.9% infusion or balanced crystalloid solution (Hartmann)

Question 24

Management of uncontrolled asthma

Answer 24

Signs: In last month: difficulty sleep ~ A(sthma) symptoms; usual A symptoms in daytime; interfered with usual activity?

–> Check diagnosis, inhaler technique, adherence, use of rescue med, lung function, exposure to trigger, SE.

–> think TTT (adherence to Therapy, inhaler Technique, eliminate Trigger), consider stepping up
Aim for lowest ICS dose for maintenance therapy
Move up if 3+ Salbutamol doses / wk
Step up if asthma uncontrolled 4-8 weeks

Question 25

Results of Spirometry test (measurement of flow and capacity)

Answer 25

Measure how much air you can breathe out in 1 forced breath and breathe in, in 1 seconds.
Normal adult peak flow scores range between around 400 F and 700 M.

Obstructive airway (asthma, COPD) = narrow airway. Normal amount can hold in lungs but affect ability to breathe out quickly.
–> low FEV1
–> FEV1/FVC ratio <70% in ?COPD?

Restrictive (PF) = lung unable to fully expand ∆ reduce amount to breathe in
–> Both FEV1 and FVC lower ≠ ratio between the two will not be reduced

Asthma = Mild/moderate (>50-75% best or predicted); acute severe (33-50% best or predicted); life threatening (<33% best or predicted)

Question 26

Diabetic foot ulcer

Answer 26

MILD - PO: 1st Flucloxacillin
2nd clarithromycin, doxycycline, or erythromycin (in pregnancy).

MODERATE/SEVERE - po/iv:
1st Flucloxacillin (in pen allergy = co-trimoxazole “” ) with/out IV gentamicin and/or metronidazole,
Or Co-amoxcilav with/out IV gentamicin
Or intravenous ceftriaxone with metronidazole.

Question 27

Acute alcohol withdrawal diagnosis

Answer 27

Symptoms: tremor, agitation, nausea, vomiting, disorientation, anxiety, hallucinations.

MONITOR
Pulse, BP, temp indicates withdrawal severity
AUDIT = identifying alcohol misuse. The 10-item questionnaire for px to identify probable hazardous -> harmful alcohol use.
CIWA-Ar = monitor severity alcohol withdrawal symptoms. X/67, 10 things scored out of 7. Nausea, headache, anxiety, agitation, tremor, sweat, orientation; tactile, visual and auditory disturbances. >11 suggests that a significant detoxification regimen will be required.

Question 28

Acute alcohol withdrawal complications

Answer 28

Risk of Wernicke’s encephalopathy (Confusion, Ataxia, Ophthalmoplegia) = neuropsychiatric complication caused by thiamine (B1) deficiency; Occur in chronic alcohol dependence, with detox being a major RF. Untreated can lead to permanent brain damage and korsakoff’s syndrome.
Early treatment (for reversal) = high dose parenteral B vitamins.

Can lead to Delirium tremor = delirium, auditory/visual hallucinations, coarse tremor, disorientation and reduced consciousness –> PO lorazepam 2mg, if severe IM/IV. Treat psychiatric symptoms w/ haloperidol IM/PO 1-5mg TDS (lower in elderly and liver)

Question 29

Acute alcohol withdrawal medication

Answer 29

Pabrinex (Vit Bs, C, thiamine) Protection against WE
1-2 pair TDS for 3-5 days
Route: IV infusion over 30mins in 100mls of sodium chloride 0.9%. monitor for 30m for anaphylaxis

Thiamine 100mg TDS and multivitamin on discharge

Chlordiazepoxide (LA BZD – 1st line)/ lorazepam / diazepam (LA BZD higher abuse potential) for symptom & seizure control.
Dose: 10-50 mg, upto QDS ∞ SADQ score
May need Loading if high risk (lower in elderly, lower weight)
1st dose 6-8h after last drink. (dangerous with alcohol)
In liver impairment (low albumin, raised INR, deranged LFTs)/ cirrhosis, use SA BZD lorazepam / oxazepam.
Caution in COPD as overdose can cause respiratory depression (monitor pulse, oximetry and respiratory rate)

Question 30

Difference between GORD, dyspepsia, PUD

Answer 30

UMBRELLA TERM = Dyspepsia
GORD = stomach acid leaks up into oesophagus (gullet). Symptoms: heartburn, unpleasant taste, chest pain (behind breastbone)
Can lead to change in oesophagus lining cell = Barrett’s oesophagus and can become cancerous

Indigestion (dyspepsia) = discomfort in middle of upper stomach, below where the ribs join. feeling sick, bloated, flatulence, bringing up food,
Tx: lifestyle (lose weight, avoid fatty food, caffeinated, smoking and avoid eating before bed and use pillwo for slight slope when sleeping)

Peptic ulcer
Open sore on lining of your stomach (gastric ulcer) or small intestine (duodenal ulcer).
Symptoms: Indigestion, possible H. pylori infection
RF/CAUSE: age, socioeconomic conditions, NSAID, H.pylori

Question 31

Dyspepsia medication

Answer 31

Medication that may cause or worsen dyspepsia: anticholinergics, beta-blockers, corticosteroids, NSAIDs and tricyclic antidepressants.
alpha-blockers, anticholinergics (TCA, Urinary incontinence ), benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), nitrates, theophyllines, and tricyclic antidepressants, Steroids, SSRIs

Antacids not to be take at the SAME TIME as some antibiotics, oral iron
PPIs may interact with several medicines (e.g. digoxin, antifungals, protease inhibitors, methotrexate and warfarin). and cautioned with caution in people at risk of osteoporosis or low magnesium levels.
can also mask symptoms of upper gastrointestinal cancers.

For dyspepsia in pregnancy, dietary and lifestyle advice are the first-line management approaches. If these fail to control symptoms, an antacid or an alginate may help. If this is ineffective or symptoms are severe, a GP may prescribe omeprazole. Or ranitdine (unlicensed)

Question 32

Dyspepsia red flag

Answer 32

RED FLAGS: unable to swallow, Significant acute gastrointestinal bleeding, over 55 years of age with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia –> endoscopy to possible diagnose barrett’s oesphagus.

PPI can also mask symptoms of upper GI cancers.

Question 33

PPI side effects

Answer 33

Hypomagnesaemia (esp w/ digoxin, diuretic), osteoporotic fracture (>1yr use), C.diff, pneumonia, and vitamin B12 deficiency –> these adverse effects relate to the reduced acidity in the stomach – possibly causing reduced absorption of vitamins/minerals (hypomagnesaemia, osteoporotic fracture, vitamin B12 deficiency) and bacterial colonisation of the normally sterile upper GI tract (C.difficile and pneumonia).

Antacids / alginates may be useful to be taken as required when patients are stepping down or stopping treatment with long-term PPI/acid suppression therapy.

Question 34

Iron overdose

Answer 34

Desferrioxamine (iron chelator)
SE: Ototoxicity, Yersinia infection (Diarrhoea, abdominal pain and fever), Growth impairment
MONITOR: hearing and vision, height, diarhoea (stop drug and investigate for Yersinia infection)

Question 35

Clopidogrel interaction with omeprazole

Answer 35

Both are metabolised by P450 System 2c19 and 3a4. PPIs affect these enzymes affecting clopidogrel (converted to active metabolite) efficacy. Discouraged use of omeprazole and esomeprazole in patients taking clopidogrel. Pantoprazole is the least likely to interact and lansoprazole and rabeprazole are also suitable alternatives.

Question 36

Black triangle medication

Answer 36

New medication have black triangle for around 5 years. Current black triangle medication are all biosimilars, a new active substance; new medicines or vaccines, drug given conditional approvals.

Question 37

Drugs in palliative care

Answer 37

Minimum amount of oral drug preferred. Consider: polypharmacy, medical conditions, Impaired drug metabolism and clearance and drug administration difficulties.

Analgesics: non opioid, opioid, adjuvant (antidepressant, antiepileptics)
Opioids ADR: constipation, nausea and vomiting. Parental opioids: morphine, diamorphine. Transdermal opioids not for acute pain or if requirements changing rapidly as rapid dose titration is not possible.
Bone metastases pain: analgesics, radiotherapy, bisphosphonates, and radioactive isotopes (strontium)
Neuropathic pain: TCA (gabapentin, pregabalin), ketamine, dexamethasone (educe oedema and pain from compression)
Anorexia tx: corticosteroids (prednisolone or dexamethasone_
Bowel colic, excessive respiratory secretions tx: S/C hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium.
Capillary bleeding: short term PO tranexamic acid
Constipation tx: co-danthramer, lactulose with senna, methylnaltrexone.
Dry mouth: SF gum, artificial saliva. If thrush, nystatin, miconazole, fluconazole.
Hiccup tx. (~ to gastric distention) Metoclopramide, Baclofen, Nifedipine, Chlorpromazine

Question 38

Report adverse drug reactions

Answer 38

Yellow card scheme. The reporting of suspected ADR to the yellow card scheme is professional responsibility, following an investigation. Licensed, unlicensed medication or herbal medicines, OTC or vaccine suspected side effects are reported through the MHRA yellow card scheme. Particularly serious reaction and black triangle drugs.