Safe prescribing 2

Question 2

COPD severity scale in re to % of FEV1

Answer 2

Question 4

Patient with: T2DM, COPD and HTN

What’s the target BP?

Answer 4

140/80

• With diabetes alone and no microvascular or macrovascular complications target BP is 140/80
• With CKD, Proteinuria, retinopathy etc this would reduce to 130/80

Question 5

Pt with T2DM, COPD and HTN

Has had a productive cough & increased breathlessness for 5 days. On examination, he has coarse crackles to the base of his left lung on auscultation, a moderate polyphonic wheeze elsewhere & the following observations

Obs as follows on the picture

What do you do as a GP?

Answer 5

Call an ambulance 999 as he needs urgent hospital admission due to suspected sepsis

*even if CURB 65 is only 1, but if sepsis is suspected -> hospital admission is required

Question 6

Patient with COPD, HTN and T2DM (on dual therapy)

What’s HbA1C target?

Answer 6

53 mmol/mol

• if pt on dual therapy for their sugar - target is 53
• step up in treatment if 58 mmol/mol

Question 8

CURB 65 sore of 1

What antibiotics are adviced by PanMersey?

Answer 8

Amoxicillin AND Clarithromycin, or doxycycline

Question 9

Classification of CKD

(according to eGFR and albumin: creatinine ratio)

Answer 9

Question 10

CURB 65 score of 0; what antibiotics are adviced by PanMersey?

Answer 10

either amoxicillin or clarithromycin or doxycycline

Question 11

What medication increases the risk of non-fatal pneumonia in COPD?

Answer 11

Seretide

Question 13

What’s target BP in pt:

Diabetes with signs of micro or macrovascular disease aim for the lower blood pressure target

Answer 13

130/80

Question 14

You review a patient who has had diarrhoea and vomiting. Looking at his records you see they have Diabetes Mellitus Type II and Heart Failure.

Thinking about the risk of Acute Kidney Injury, which medication would be the most appropriate to continue?

Metformine

Amlodipine

Ramipril

Furosemide

Naproxen

Answer 14

Amlodipine is CCB and is the only one out of this list that does not cause/ increase AKI

Question 15

A 74 year old lady attends Accident and Emergency feeling breathless, complaining of a productive cough for the last 2 weeks. She is otherwise well in herself.

Her observations include a respiratory rate of 24/min, Oxygen saturations in room air of 94%, a pulse rate of 88/min and a blood pressure 100/74 mmHg.

What other marker do you need to complete her CURB-65 score?

Answer 15

Blood urea

Question 16

What blood test would be most helpful in deciding if a patient presenting with chest infection symptoms requires antibiotic?

Answer 16

CRP

• no antibiotic if it’s <20
• consider delayed prescription if it’s 20-100
• immediate antibiotic if it’s over 100

Question 17

A lady presents with chest infection symptoms. Excluding respiratory disease and immunosuppression, what two co-morbidities, if present, would increase your likelihood of prescribing an antibiotic?

Answer 17

• Diabetes Mellitus
• Congestive Heart Failure

Question 18

What are the benefits of delayed antibiotic prescription?

Answer 18

• Reduced antibiotic resistance - around 40% of patients don’t use the delayed prescription
• Reduced consultation rates in General Practice
• A cost saving for the NHS
• Reduced complications from antibiotic usage, e.g. Clostrium difficile infection

Question 19

What (acute cardiac) condition binge drinking increase risk of?

Answer 19

AF

Question 20

Can we give bisoprolol and verapamil together?

Answer 20

No. Do not combine VERAPAMIL with beta blockers

As verapamil is rate-limiting CCB -> together with other drugs it beings HR down extremely

*other CCB (non-rate limiting) e.g. Amlodipine can be combined with b- blockers

Question 21

What can Metronidazole do to Warfarin?

Answer 21

Metronidazole is an inhibitor of P450 -> will inhibit the metabolism of other drugs (e.g. Warfarin) -> potentially levels of warfarin will raise/ become toxic

Question 22

Is Lithium + NSAIDs good combination?

Answer 22

No. NSAIDs reduce Lithium exertion

Question 23

What antibiotics can cause Achilles tendonitis?

Answer 23

Ciprofloxacin (Quinolones)

If any problem in back of the ankle (Achilles tendon) after starting the antibiotic -> STOP it

Question 24

(4) bloods in investigation of Rheumatoid Arthritis

Answer 24

• Rheumatoid factor
• anti-CCP antibody
• CRP
• ESR

Question 25

What further Ix to perform in a man with UTI?

Answer 25

• PR
• PSA
• cystoscopy

(this is because men do not usually get UTI -> therefore most would be considered as complicated)

Question 26

(3) side effects of Ramipril

Answer 26

• cough (normally in first few months)
• postural hypotension
• renal failure (if bilateral renal artery stenosis)

Question 27

What do we do if a patient that was started on Ramipril develop a cough?

Answer 27

A. If occasional cough and a patient can cope with that -> may persist on Ramipril

B. If pt cannot cope with cough -> change to alternate e.g. Losartan (if HF), CCB (if HTN)

Question 28

How to start a patient on Metformin?

Answer 28

Gradually -\> to avoid GI disturbance (SE) Start at low dose -\> once daily \* start one in the morning \* then increase by one a week -\> until x4 tablets daily (x2 tablets twice a day)

Question 29

What GI side effects is ***Metformin*** associated with?

Answer 29

- diarrhoea - nausea - anorexia - abdominal pain SEs appear initially but they will subsidise

Question 30

What's metformin association with lactic acidosis and kidney problems?

Answer 30

***Metformin*** itself does not cause problems with the kidneys; but if something else causes AKI/reduced renal function -\> then if use of metformin -\> potential for lactic acidosis Therefore, in AKI, we do reduce metformin (or stop it) to avoid lactic acidosis

Question 31

What are the long-term side effects of ***Omeprazole*** use?

Answer 31

- reduced cognition (possible association with dementia) - osteoporosis \* however, the evidence for above SEs is not confirmed \* use of omeprazole is recommended only for short term (e.g. H.Pylori/GI upset management) \* sometimes when we stop Omeprazole -\> a patient will have rebound symptoms -\> if that happens, give ***Ranitidine***

Question 32

What is the best time to take statins?

Answer 32

Night time -\> most cholesterol is made at night

Question 33

What advice to give to a patient who is started on a statin?

Answer 33

If dark urine develops -\> stop statin and get in touch with a doctor \*potential for rhabdomyolysis

Question 34

What's the treatment aim for statins?

Answer 34

At least 40% reduction in LDL cholesterol

Question 35

What do we need to monitor and when if we start a patient on a statin?

Answer 35

**LFTs at 3 months** after we start treatment This is to ensure it did not cause hepatitis

Question 36

Common side effects of ***statins***

Answer 36

* nausea * vomiting * pains and aches - general, mild ones

Question 37

Side effects of ***gliclazide*** - common ones (4) - rare (1)

Answer 37

* Common: abdominal pain, nausea, hypoglycaemia, weight gain * Rare: agranulocytosis

Question 38

What (2) things we need to monitor when we start a patient on ***gliclazide***

Answer 38

* **hypos** -\> monitor BM, explain to a patient how to recognise them * **agranulocytosis**: fever, bleeding/bruising/pale, monitor by doing an annual FBC

Question 40

(2) potential side effects of ***Beclomethasone*** (inhaler) use

Answer 40

* horse voice * candida - advice pt to rinse mouth after taking the puff

Question 41

Do ICS inhalers cause systemic steroid side effects?

Answer 41

Usually not

Question 43

Explain to the patient: ***Ramipril*** - aim - MoA (how does it work)

Answer 43

* **Aim:** to lower your blood pressure and so reduce your risk of heart disease etc. * **MoA:** They work through your kidneys to make your blood vessels wider (dilate), this lowers the pressure inside them and so bringing your blood pressure down

Question 44

Explain to the patient: How to take ***Ramipril***

Answer 44

Take it **once a day**, usually in the morning but that doesn’t matter too much. It is a **lifelong** medication (or at least until we decide to stop)

Question 45

Explain to the patient Common side effects of ***Ramipril***

Answer 45

A common side effect is: - a cough - it lowers blood pressure so you may feel dizzy \*if anything significant please speak to your GP

Question 46

How to explain to the patient a potentially Ramipril's adverse effect on the kidney?

Answer 46

* For most people this medication helps keep their kidneys healthy * for a small number it has the opposite effect * For this reason we need to check your **kidney blood test 1-2 weeks after you start** the prescription and after every time we increase the dose * We will need to see you back for a blood pressure check in **X weeks** to ensure it is helping otherwise we may need to adjust your treatment.

Question 48

Explain to a patient - ***Metformin*** - aim of Rx - MoA

Answer 48

* **Aim:** to lower your blood sugars and so reduce your risk of diabetic complications such as kidney, eye and sensation problems; and also to lower risk of developing heart disease * **MoA**: It works by stopping your liver making sugar, reducing the amount of sugar you absorb from you food, and makes your own body’s insulin work better

Question 49

Explain to a patient - ***Metformin*** - how to take it

Answer 49

* Usually metformin will be taken twice a day but that can vary depending on your response to it * Take it until told to stop