Safe prescribing 1 Flashcards
Explain to a patient - Metformin
- common SE
The most common side effects are changes in your bowel habit; it can make you very loose and pass more wind that way
Explain to a patient - Metformin
Its correlation with kidney failure
- it doesn’t affect your kidney directly however does nee(d your kidney to be working well for it to be taken safely
- may need to adjust the dose of the medication based on how well your kidney is working, and during times your kidney is under strain (such as when dehydrated, or unwell with an infection) we will stop metformin to let your kidney recover (otherwise it can make the strain on your kidneys worse)
Explain to a patient - Metformin
- monitoring
The main way we will check metformin is helping is through a blood test called HBA1c; we will do one to check 3 months after starting or changing the dose.
Explain to a patient - Atorvastatin
- aim of treatment
- MoA
- Lowers cholesterol and so - reduces risk of developing heart disease and stroke
- It works by blocking part of the process the body does to actually make the cholesterol in the liver
Explain to a patient - Atorvastatin
- how to take it
- Take it once a day at night
(physiological studies have shown most cholesterol is made when dietary intake is low in the day - HMG CoA reductase seemingly works better at night and this is what is blocked)
- lifelong or until we decide to stop it
Seide effects of Statins
- general increase in aches and pains
- headaches
Rare:
- it can trigger Diabetes
- rhybdomyolysis
Explain Rhabdomyolysis to a patient being started on statins
- serious condition where muscles become very inflamed and broken down
- this will make you feel very unwell and can cause your kidney to fail
- The risk of this is very very low (around 1 in 250,000) but as it is so serious please seek medical advice straight away if you are concerned
Explain to a patient - Atorvastatin
- monitoring
- Due to the way it works through the liver we check your liver blood tests at 3 and 12 months
- We will usually check your cholesterol at 3 months too and look for a positive change (40% reduction LDL for primary prevention)
Explain to a patient - Gliclazide
- aim of Rx
- MoA
- Aim: to reduce your blood sugar -> to lower risk of kidney, eye and sensation problems that can be caused by high sugar readings in diabetes
- MoA: works by helping to release more of your body’s own natural insulin
Explain to a patient how to take gliclazide
- usually taken twice a day but depends on response too
- take lifelong or until decided otherwise
Explain to a patient - Gliclazide
- common side effects
- weight gain
- some change in bowel habit
- can lower your blood sugar levels too much and cause a HYPOglycaemic episode – you may feel shivery, tremble, drowsy, and worse case may pass out
Explain to a patient - Gliclazide
- rare side effect + what to look for
- Rarely they can cause a serious irritation of your liver, or lead to a reduced number of blood cells that fight an infection, or stop bleeding, or cause a significant anaemia
- These are very rare but if you notice any changes in your skin colour, or easy bruising see doctor straight away
Explain to a patient - Gliclazide
- monitoring
Effect is monitored by checking your blood sugar levels usually 3 months after starting or changing the dose (HBA1c) and we will probably check your liver blood tests and full blood count then too
Explain to a patient - Omeprazole
- aim
- MoA
- Aim is to reduce your natural stomach acid and so get rid of your heartburn/indigestion or allow your stomach ulcer to heal
- MoA: They block the final stage of releasing the acid into the stomach
Explain to a patient - Omeprazole
How to take it
- usually you would take them once a day (at least at the start)
- sometimes it can be twice a day, especially if treating Helicobacter infection
- the course is usually short term, and for most cases can be reassessed at about 4 weeks but longer courses may be required
Explain to the patient - Omeprazole
- common, short term SEs
- Usually well tolerated
- like all medications can cause some side effects such as abdominal bloating, abdominal pain, and bowel changes
Explain to a patient - Omeprazole
- long term side effects
Long term use can lead to:
- low blood magnesium and sodium levels
*worth checking these if patients at high risk (on diuretics or digoxin),
- can increase risk of C.Diff infection alongside certain antibiotics (and risk of pneumonias)
- MAY be associated with increased risk of dementia and heart disease but that causality has not yet been fully established but worth stating at initiation re the short term nature of the prescription
What’s to do with rebound symptoms when we stop Omeprazole?
- H2 receptor antagonist ie ranitidine as short-term replacement
*this is because we do not want to use Omeprazole as long-term as it MAY be linked to dementia and also heart disease
Explain to a patient - Omeprazole
- monitoring
- monitoring for longterm use is targeting high-risk groups
- yearly renal, and magnesium blood checks and obviously checking clinical need for ongoing treatment
Explain to a patient
Beclometasone inhaler (Clenil)
- MoA
Asthma attacks are caused by inflammation and swelling in the airways
This leads to narrowing of the passages and the subsequent difficulty breathing/wheeze/cough etc. Inhaled corticosteroids work to reduce this
inflammation by reducing the type of blood cells and proteins involved with this process. So should cause a reduction in your asthma symptoms
Explain to a patient - Beclometasone inhaler (Clenil)
- how to use
- how long for
- Inhaled – usually 2 puffs twice a day (obviously depending on dose of inhaler and age etc)
- One puff at a time (worth going in to inhaler technique here?)
- Use of a spacer is recommended especially for those with poorer technique and to help prevent local side effects of the inhaler
- patients with asthma would either stay on forever (BTS) or be reviewed once symptoms controlled for 3 months (NICE) *depends on the guidelines
Explain to a patient - Beclometasone inhaler (Clenil)
- side effects
Side effects are relatively limited:
- sore throat, oral thrush, hoarse voice can happen
* they can be reduced/avoided by use of spacer and swilling mouth out after taking dose
- Some evidence that usage is associated with increased risk of pneumonias
Risk of what complication is a pt at if taking the combination of: Ramipril, spironolactone, metformin, NSAIDs?
AKI, especially if a pt becomes acutely unwell
Combination of: Ramipril and Spironolactone
What risk is a patient at?
Increased risk of hyperkalaemia on Ramipril and spironolactone
- need to monitor U&E especially when dosage changes or acute illness
Long-term use of which (2) drugs may cause gynecomastia?
- spironolactone
- amlodipine
Which T2DM drug is contraindicated in HF?
Pioglitazone
Long term use of NSAIDs, aspirin. What do we need to think of to co-prescribe in a pt >45 yo?
PPI - to provide stomach protection from ulcer
*but then, is it long term? as risks of osteoporosis/dementia?
Can Ibuprofen and aspirin be taken at the same time/day?
Not, as they are both NSAIDs
- increased risks of: nephrotoxicity, GI bleed
- can take paracetamol instead of Ibuprofen
Adverse effects of NSAIDs
fluid retention -> HF -> hypertension
Pt with anxiety and asthma. Can we use B-blocker?
- risk of bronchospasm with BB and asthma
- propranolol is block beta 1 and 2 adrenoreceptors (also found on bronchial and vascular smooth muscles.) More appropriate alternatives or use other methods to manage anxiety/stress – psychological therapies, exercise
Can beta-blockers be used in COPD patient?
Potentially yes, but with caution and cardiologist supervision.
Atenolol and bisoprolol are more cardio-effective (selective)
Combination of warfarin and aspirin
What is a patient at risk of?
Increased risk of bleeding
* need to review it; if no ACS/cardiac intervention for 12 months -> possibly stop aspirin
Patient with pneumonia. Combination of drugs: Simvastatin + clarithromycin. What are the issues and what to do?
Clarithromycin is hepatic CYP450 enzyme inhibitor -> less metabolism of statin -> toxic levels -> rhabdomyolysis
What to do:
Either stop simvastatin or replace Clarithromycin with Doxycycline
Clarithromycin + Warfarin
What are the issues?
Clarithromycin increases half-life of Warfarin -> increased INR
PPI + broad spectrum antibiotics
Risks of what are increased?
Risks of C Diff
Bisoprolol + Verapamil
What is the risk?
Verapamil is a Non-dihydropyridine calcium channel blocker = it is rate limiting
Should NOT be used in combination with a beta blocker
*will induce extreme bradycardia
What additional drug do we prescribe if a pt is on methotrexate? what are the instructions to take it?
Folic acid
- do not take it in the same day as methotrexate
Azathioprine + Allopurinol
Is that combination safe?
Not, as it may induce bone marrow suppression
Allopurinol inhibits Xanthine Oxidase, increasing 6-MP levels – severe bone marrow suppression
Can pt with Penicillin allergy be prescribed Co-amoxiclav?
Not, as co-amoxiclav is penicillin based
Prescription: (is it safe?)
Paracetamol x4 a day
and
Co-codamol 30/500 x4 a day
Not, as co-codamol contains paracetamol -> overdose
Is it safe:
Methotrexate + Trimethoprim
Methotrexate and Trimethoprim – severe interaction
Both inhibit Dihydrofolate reductase (related to folate) causing severe bone marrow suppression
What’s the problem with that drug combination: Apixaban + Warfarin
Risk of overcoagulation as both of the drugs are anti-platelets (Apixaban = NOAC)
Either Apixaban or Warfarin -> they both do same job
What’s the diagnosis?
AF
- no P wave
- irregularly irregular HR
- narrow QRS (supraventricular)
What medication do we prescribe to the patient with AF in order to prevent stroke?
Warfarin OR NOAC (e.g. Apixaban)
Name the assessment tool used to assess for anti-coagulant needs in AF patients
CHA2DS2-VASC
Components and scoring in CHA2DS2-VASC
Name the assessment tool used to assess the risk of major bleeding in a patient on anti-coagulants
HASBLED
Components and recommendations (score) of HAS-BLED
