Safe prescribing Y4 Flashcards
When might you avoid prescribing Alendronic acid?
Bisphosphonate given for bone protection.
AVOID if eGFR < 35
Seek medical attention if
- dysphagia
- worsening GORD
- retrosternal pain
Important side effect of Alendronic acid:
Osteonecrosis of Jaw
Also
- anaemia
- constipation
- GI discomfort
- malaise
- myalgia
How to take bisphosphonates?
- tablet once a week
- same day each week
- take on empty stomach with large glass of water
- at least 30 mins before meal
- stay upright for 30-60 min after
How to take bisphosphonates?
- tablet once a week
- same day each week
- take on empty stomach with large glass of water
- at least 30 mins before meal
- stay upright for 30-60 min after
Effect of omeprazole on magnesium levels?
can cause low magnesium
A patient with renal impairment and on morphine - what will you switch them too?
oxycodone
Drugs to avoid in renal impairment?
DAMN
D- diuretics
A- ACEi / ARB
M-metformin
N-NSAIDs
Key clinical features of nephrotic syndrome
overt proteinuria > 3.5 g
- frothy urine
hypoalbuminemia < 30 g/L
Also
- oedema
- generalised fluid retention
- intravascular volume depletion
Nephrotic
- podocyte injury
- changed architecture
–> scarring
–> deposition of matrix
Key clinical features of nephritic syndrome?
HAEMATURIA
oedema
generalised fluid retention
HTN
oliguria
Nephritic
- inflammation
- crescent formation
- breaks in GBM
General management of nephrotic syndrome?
- Symptomatic improvement
- dietary sodium restriction
- loop diuretic - ACEi
- DIET
- normal protein intake - STATIN
- For complications
- DVT Risk –> LMWH
- Infection –> pneumococcal vaccine one off - Specific management
–> IMMUNOSUPPRESSIVE tx
———> high dose corticosteroid
OR
—–> corticosteroid sparing agent
———> ciclosporin
———> tacrolimus
organisms which may cause pelvic inflammatory disease (2)
- CHALMYDIA
- GONORRHOEA
Important differential diagnosis for pelvic inflammatory disease
Tubo-ovarian abscess
Long term complications of pelvic inflammatory disease
- infertility
- ectopic
- chronic pelvic pain
Management of pelvic inflammatory disease
Single dose
- IM CEFTRIAXONE
14 days
- doxycycline + metronidazole
CONTACT TRACING
Advise
- abstinence or barrier contraception
Management of pelvic inflammatory disease if patient is severely ill
Initial treatment with DOXYCYCLINE + IV ceftriaxone + IV metronidazole
Then switch to Tx w/ DOXYCYCLINE and metronidazole for 14 days
Chlamydia symptoms
Dysuria
Discharge: penile and vaginal
Abdo pain: female
Post coital bleeding
Intermenstrual bleeding
Pain and swelling of testicles
Complications of chlamydia
- PID
- infertility
- Epididymo-orchitis
- SARA
- Fitz-hugh-curtis syndrome
—> perihepatitis
—> adhesions between liver capsule and peritoneum
Treatment of chlamydia
1st line: 100mg BD Doxycycline 7 days
2nd line: Azithromycin 1g STAT then 500mg OD for 2 days
- 1st line in pregnancy
Gonorrhoea symptoms
- thicker greeny / yellowy discharge
- dysuria
- intermenstrual bleeding
Gonorrhoea treatment
1st line = Ceftriaxone 1g IM STAT
OR
CIPROFLOXACIN 500mg if sensitive
2nd line = Gentamicin + Azithromycin IM
OR
Cefuxime PO + Axithromycin
OR
Azithromyicn 2g PO ALONE
Complications of Gonorrhoea
- infertility
- epididymo-orchitis
- SARA
- disseminated gonococcal infection
Notes: Disseminated Gonococcal infection
- Gonorrhoea invades blood stream
- spreads to distant sites in body
- clinical manifestations such as:
—-> septic arthritis
—-> tenosynovitis
—-> bacteraemia
Bacterial vaginosis treatment
Tx = ORAL METRONIDAZOLE (5-7 days)
alternatives
- topical metronidazole 5 days
OR
- topical clindamycin for 7 days
Common pathogens causing tubo-ovarian abscess
- E-coli
- Actinomyces Israeli
Compare and contrast PID with TOA
TOA
- CT or laparoscopy will show abscess
- persistent high temp
- infection markers high
PID
- no mass on imaging
- infection markers improve with Abx treatment
TX = local antimicrobial guidelines
Premature menopause is before
40 years
Complications of menopause
CVD issues –> IHD, Stroke
Bone –> osteoporosis
Increased risk of Alzheimer’s dementia
Decreased pelvic floor muscle tone
Key investigation for menopause
- Serum FSH
—> higher FSH suggests fewer oocytes - Anti-Mullerian hormone
—> low AMH suggests ovarian failure - TSH
—> thyroid - DEXA
—> assess osteoporosis
Discuss different ways of taking HRT
1. TABLET
Advantages
- easy, convenient
- wide range of doses
Disadvantages
- increased VTE risk
- avoid in migraines
- avoid if stroke risk
- avoid in bowel issues
2. PATCHES
Advantages
- decreased nausea
- decreased VTE risk
- decreased migraine risk
- can shower and bathe
Disadvantages
- local irritation
- increased absorption
3. GEL
Advantages
- dose adaptation easier
Disadvantages
- only available as oestrogen
Also
1. Implant –> oestrogen
2. IUS –> progesterone (contraception)
How might topical vaginal oestrogen be taken?
- Tablet / cream nightly for 2 weeks
- pessaries / gels = 3 weeks
- then twice weekly for maintenance
Discuss deciding what HRT a patient will get
If hysterectomy?
- oestrogen only
- take every day without break
If no hysterectomy?
OESTROGEN AND PROGESTERONE
- If premenopausal –> Cyclical HRT
a) Monthly: oestrogen every day, progestogen too for last 14 days
b) 3-montly: oestrogen everyday, progestogen too for 14 days every 3 months
—> will get withdrawal bleed
—> to try and mimic natural cycle - If post-menopausal –> CONTINUOUS COMBINED
a) oestrogen and progesterone every day without break
Will be switched to continuous combined
- if over 54
- or been on HRT for 5 years
- BLEED FREE!
- slight increased risk of breast cancer 1/100
HRT side effects and management: OESTROGEN
Oestrogen related
- breast tenderness
- bloating
- nipple sensitivity
- leg cramps
- nausea
- heart burn
- fluid retention
Management
- side effects tend to settle within 3 months
- decrease dose
- change route: oral to patch
- change type of oestrogen
HRT SIDE EFFECTS –> Progestogen
Side effects
- breast tenderness
- fluid retention
- headache
- mood swings
- bloating
- acne
- greasy skin
Mx
- change type
- decrease dose
- change route
- change regime
Recurrent UTI is defined as
2 episodes within 6 months
More than 3 episodes within 12 months
Common causative organism of UTI
E-COLI
RARE
- candida albicans may be seen in:
—-> immunocompromised
—-> indwelling catheter
Management of UTI in men
1st line: Nitrofurantoin or Trimethoprim 7 days
Management of UTI in females
NON PREGNANT
1st line –> Nitrofurantoin OR trimethoprim
2nd line –>
- Nitrofurantoin
- Fosfomycin
- Amoxicillin (After culture)
PREGGERS BABYYY
1st line –> NITROFURANTOIN
2nd line –> AMOXICILLIN
CAUTION
- do not use trimethoprim in 1st trimester
- teratogenic
Advice given to a patient with UTI
Safety net
- Seek urgent help if: FEVER, LOIN PAIN, VOMITTING
Complete full course of ABx
- even if patient feels fine
Wipe back to front
Avoid sexual intercourse
Nitrofurantoin can colour urine
Management of stress incontinence
Involuntary leakage due to increase in intrabdominal pressure aar of sneezing, coughing or laughing.
Management
1. PELVIC FLOOR
Medical
1. DULOXETINE –> SNRI
- 20mg BD for 2 weeks then 40mg BD
REVIEW in 2-4 weeks
Management of urge incontinence : Lifestyle
- decrease caffeine
- aim to drink 7-8 glasses of water
- weight loss
- smoking cessation
Management of urge incontinence
- Bladder retraining
- increase time between toilet trips
- aim to bring this down to 6-8 times in 24 hours - MEDICAL
a) ANTI-MUSCARINIC
–> oxybutynin
OR
–> tolterodine
OR
–> darifenacin
b) Beta-3 agonist
–> MIRABEGRON
REVIEW
- after 4 weeks, then 12 weeks, then annually
UNLESS
- if over 75 –> review every 6 months
Paediatric fluoxetine counselling
- Weekly monitoring –> to assess mood
- Dose increased slowly
- Monitor for emerging suicidal thoughts
- If no improvement after (4-6 weeks) consider alternative Tx
Common side effects
- GI discomfort
- constipation
- possible changes to concentration
- insomnia / yawning
SERIOUS SE
- increased risk of bleeding
- increased risk of self harm
Red Flags
Sign post
Do not give codeine to under what age
UNDER 12
Why should you not give NSAID in patient with asthma
can cause bronchospasm
How might you help children to swallow tablets?
- swallow w/ drink or squash
- ask them to take few sips
- place tablet on centre of tongue
- take large sip of water
- wash tablet down
Key points in history when dealing with suspected paracetamol overdose
- Quantify what was taken (close, preparation)
- Time
- Co-morbidities
- PMH, previous Over doses
- Depression
- Pregnancy
Treating paracetamol overdose
Look at treatment line
- if ON or above tx line –> N-ACETYLCYSTINE treatment
Why is ethnicity important when deciding what type of AED to choose?
Asian, Chinese, Japanese and Thai
–> high risk of STEVEN JOHNSON SYNDROME
——–> with carbamazepine
——–> phenytoin
Unless you have screened for the HLA-B*1502 allele
How might COCP interact with AEDs?
COCP + Carbamazepine
- carbamazepine is a hepatic enzyme inducer and reduces efficacy of COCP
COCP + lamotrigine
- COCP can increase clearance of lamotrigine
- leading to decreased concentration
Important side effects of Lamotrigine
- Steven Johnson syndrome
- Toxic epidermal necrosis
Increased risk in first 8 weeks of tx.
Epilepsy and DVLA guidance
If a patient has a seizure –> STOP driving & INFORM DVLA
If after 6 months they are assessed and no further risk –> can drive
IF they have history of unprovoked seizure –> NO DRIVING
EPILEPSY DIAGNOSIS –> CAN DRIVE IF:
- seizure free 12 months
- compliant w/ medication
For anti-epileptic medication: it is important not to switch the brand of the followin:
- carbamazepine
- phenobarbital
- phenytoin
- primidone
AED + pregnancy
If wanting to get pregnant
- take 5mg FOLIC acid daily before pregnancy
- continue up to 12 week pregnancy
AED and breast feeding
ENCOURAGED TO BREAST FEED
Monitor baby for
- sedation
- feeding
- weight gain
- developmental milestones
Lithium toxicity levels
Maintenance = 0.6-1
Mild = 1 - 1.5
Moderate = 1.6 - 2.5
SEVERE = > 2.5
Common interactions which will increase lithium levels
NSAID
ACEi / ARB
Diuretics (thiazide like)
Lithium levels timing
12 hours post dose
Once stable
- monitor every 3-6 months
Summarise side effects of lithium toxicity
MILD
- N + V + D
- fine resting tremor
- muscle weakness
- increased urination
- light headedness
- blurred vision
MODERATE
- increased confusion
- blackouts
- fasciculations
- deep tendon reflexes
- urinary / faecal incontinence
- increasing restlessness
SEVERE
- coma
- convulsions
- cardiac dysarthmias
- cerebellar signs
- peripheral neuropathy
- renal failure
- collapse
Monitoring in lithium toxicity
- after 6 hours
- then every 6-12 hours dependent on patients condition
- when level is in normal range –> consider reinstating lithium
Key lithium counselling
- Discuss risk factors for lithium toxicity
- what patient needs to avoid
- signs and symptoms to look out for
- dehydration in hot weather - When to seek medical help:
- blurred vision
- severe hand shaking
- stomach, nausea, diarrhoea
- slurring of words
- difficulty speaking
- muscle weakness
- confusion
- feeling unusually sleepy
- unsteady on feet - Avoid buying over the counter NSAIDs
- Sick day rules
- safer to withhold doses of lithium where they risk toxicity than carry on with treatment - PURPLE LITHIUM BOOK
- lithium therapy information book
Key features of serotonin syndrome
- Altered mental state
—> restlessness, agitation, anxiety, delirium, coma - Neuromuscular hyperactivity
—> tremor, clonus, hyper-reflexia, respiratory failure - Autonomic hyperactivity
—> tachycardia, sweating, HTN, diarrhoea, shivering, fever, flushing
Immediate action is suspecting serotonin syndrome
STOP SEROTONGERIC DRUGS
close observation
consider critical care
Treatment of serotonin syndrome
- Anxiety –> provide sedation –> DIAZEPAM, (5-10mg)
- Agitation –> for neuromuscular agitation –> CYPROHEPTADINE (single dose 12mg repeated once according to response)
Key features of neuroleptic malignant syndrome
1. Fever > 38.5
2. Altered mental state –> drowsiness, coma, seizures, delirium, confusion
3. Rigidity of muscles –> extrapyramidal SE, rhabdomyolysis, chorea
4. Autonomic changes
—> t.cardia
—> incontinence
—> diaphoresis
—> fluctuating BP
—> tachypnoea
Risk factors for neuroleptic malignant syndrome
- male
- older
- ETOH use
- dehydration
- DEPOT antipsychotic
- iron deficiency
Management of neuroleptic malignant syndrome
IMMEDIATE ACTION
- STOP anti-psychotic medication
- supportive care: fluids
TREATMENT
- Managing agitation and catatonia –> oral / IV Lorazepam
- Have on hand Flumazenil (benzo antagonist) just in case
LIMITED EVIDENCE
- Rigidity and hyperthermia –> DANTROLENE
- Dopaminergic agonists –> Bromocriptine, Amantadine
Serious cases –> ECT
How long should you wait before re-challenging anti-psychotic medication in a patient who has had neuroleptic malignant syndrome?
wait 2 weeks
Key features of acute dystonic reaction
- EYES –> oculogyric crisis
- NECK –> torticollis
- LIMBS –> abnormal movements, posturing
- Mouth / Jaw –> trismus, tongue protrusion, dysarthria
In severe cases
- Jaw can dislocate
Risk factors for acute dystonic reaction
- high potency 1st gen APM
- lack of previous APM exposure
- abrupt discontinuation of APM
- male
- younger
- cocaine use
Management of acute dystonic reaction
- Stop Haloperidol
For acute dystonia
1st Line –> 10mg procyclidine IM
2nd Line –> trihexyphenidyl or orphendrine
How might you manage akathisia caused by antipyshotic medication
- lower dose
- propanolol or low dose clonazepam
- serotonin antagonist
—-> MIRTAZAPINE
—-> CYPROHEPTADINE
Management of tardive dyskinesia
involuntary movements of tongue, face, jaw, lip smacking
Stop drug, substitute with another
Licensed treatment –> TETRABENAZINE
