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Y4 - Finals Edition > Safe prescribing Y4 > Flashcards

Safe prescribing Y4 Flashcards

1
Q

When might you avoid prescribing Alendronic acid?

A

Bisphosphonate given for bone protection.

AVOID if eGFR < 35

Seek medical attention if
- dysphagia
- worsening GORD
- retrosternal pain

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2
Q

Important side effect of Alendronic acid:

A

Osteonecrosis of Jaw

Also
- anaemia
- constipation
- GI discomfort
- malaise
- myalgia

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3
Q

How to take bisphosphonates?

A

- 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
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4
Q

How to take bisphosphonates?

A
  • 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
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5
Q

Effect of omeprazole on magnesium levels?

A

can cause low magnesium

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6
Q

A patient with renal impairment and on morphine - what will you switch them too?

A

oxycodone

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7
Q

Drugs to avoid in renal impairment?

A

DAMN

D- diuretics

A- ACEi / ARB

M-metformin

N-NSAIDs

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8
Q

Key clinical features of nephrotic syndrome

A

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

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9
Q

Key clinical features of nephritic syndrome?

A

HAEMATURIA

oedema

generalised fluid retention

HTN

oliguria

Nephritic
- inflammation
- crescent formation
- breaks in GBM

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10
Q

General management of nephrotic syndrome?

A
  1. Symptomatic improvement
    - dietary sodium restriction
    - loop diuretic
  2. ACEi
  3. DIET
    - normal protein intake
  4. STATIN
  5. For complications
    - DVT Risk –> LMWH
    - Infection –> pneumococcal vaccine one off
  6. Specific management
    –> IMMUNOSUPPRESSIVE tx
    ———> high dose corticosteroid
    OR
    —–> corticosteroid sparing agent
    ———> ciclosporin
    ———> tacrolimus
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11
Q

organisms which may cause pelvic inflammatory disease (2)

A
  • CHALMYDIA
  • GONORRHOEA
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12
Q

Important differential diagnosis for pelvic inflammatory disease

A

Tubo-ovarian abscess

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13
Q

Long term complications of pelvic inflammatory disease

A
  • infertility
  • ectopic
  • chronic pelvic pain
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14
Q

Management of pelvic inflammatory disease

A

Single dose
- IM CEFTRIAXONE

14 days
- doxycycline + metronidazole

CONTACT TRACING

Advise
- abstinence or barrier contraception

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15
Q

Management of pelvic inflammatory disease if patient is severely ill

A

Initial treatment with DOXYCYCLINE + IV ceftriaxone + IV metronidazole

Then switch to Tx w/ DOXYCYCLINE and metronidazole for 14 days

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16
Q

Chlamydia symptoms

A

Dysuria

Discharge: penile and vaginal

Abdo pain: female

Post coital bleeding

Intermenstrual bleeding

Pain and swelling of testicles

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17
Q

Complications of chlamydia

A
  • PID
  • infertility
  • Epididymo-orchitis
  • SARA
  • Fitz-hugh-curtis syndrome
    —> perihepatitis
    —> adhesions between liver capsule and peritoneum
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18
Q

Treatment of chlamydia

A

1st line: 100mg BD Doxycycline 7 days

2nd line: Azithromycin 1g STAT then 500mg OD for 2 days
- 1st line in pregnancy

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19
Q

Gonorrhoea symptoms

A
  • thicker greeny / yellowy discharge
  • dysuria
  • intermenstrual bleeding
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20
Q

Gonorrhoea treatment

A

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

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21
Q

Complications of Gonorrhoea

A
  • 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

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22
Q

Bacterial vaginosis treatment

A

Tx = ORAL METRONIDAZOLE (5-7 days)

alternatives
- topical metronidazole 5 days
OR
- topical clindamycin for 7 days

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23
Q

Common pathogens causing tubo-ovarian abscess

A
  • E-coli
  • Actinomyces Israeli
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24
Q

Compare and contrast PID with TOA

A

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

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25
Q

Premature menopause is before

A

40 years

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26
Q

Complications of menopause

A

CVD issues –> IHD, Stroke

Bone –> osteoporosis

Increased risk of Alzheimer’s dementia

Decreased pelvic floor muscle tone

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27
Q

Key investigation for menopause

A
  1. Serum FSH
    —> higher FSH suggests fewer oocytes
  2. Anti-Mullerian hormone
    —> low AMH suggests ovarian failure
  3. TSH
    —> thyroid
  4. DEXA
    —> assess osteoporosis
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28
Q

Discuss different ways of taking HRT

A

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)

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29
Q

How might topical vaginal oestrogen be taken?

A
  • Tablet / cream nightly for 2 weeks
  • pessaries / gels = 3 weeks
  • then twice weekly for maintenance
30
Q

Discuss deciding what HRT a patient will get

A

If hysterectomy?
- oestrogen only
- take every day without break

If no hysterectomy?
OESTROGEN AND PROGESTERONE

  1. 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
  2. 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

31
Q

HRT side effects and management: OESTROGEN

A

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

32
Q

HRT SIDE EFFECTS –> Progestogen

A

Side effects
- breast tenderness
- fluid retention
- headache
- mood swings
- bloating
- acne
- greasy skin

Mx
- change type
- decrease dose
- change route
- change regime

33
Q

Recurrent UTI is defined as

A

2 episodes within 6 months

More than 3 episodes within 12 months

34
Q

Common causative organism of UTI

A

E-COLI

RARE
- candida albicans may be seen in:
—-> immunocompromised
—-> indwelling catheter

35
Q

Management of UTI in men

A

1st line: Nitrofurantoin or Trimethoprim 7 days

36
Q

Management of UTI in females

A

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

37
Q

Advice given to a patient with UTI

A

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

38
Q

Management of stress incontinence

A

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

39
Q

Management of urge incontinence : Lifestyle

A
  • decrease caffeine
  • aim to drink 7-8 glasses of water
  • weight loss
  • smoking cessation
40
Q

Management of urge incontinence

A
  1. Bladder retraining
    - increase time between toilet trips
    - aim to bring this down to 6-8 times in 24 hours
  2. 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

41
Q

Paediatric fluoxetine counselling

A
  1. Weekly monitoring –> to assess mood
  2. Dose increased slowly
  3. Monitor for emerging suicidal thoughts
  4. 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

42
Q

Do not give codeine to under what age

A

UNDER 12

43
Q

Why should you not give NSAID in patient with asthma

A

can cause bronchospasm

44
Q

How might you help children to swallow tablets?

A
  • 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
45
Q

Key points in history when dealing with suspected paracetamol overdose

A
  1. Quantify what was taken (close, preparation)
  2. Time
  3. Co-morbidities
  4. PMH, previous Over doses
  5. Depression
  6. Pregnancy
46
Q

Treating paracetamol overdose

A

Look at treatment line
- if ON or above tx line –> N-ACETYLCYSTINE treatment

47
Q

Why is ethnicity important when deciding what type of AED to choose?

A

Asian, Chinese, Japanese and Thai
–> high risk of STEVEN JOHNSON SYNDROME
——–> with carbamazepine
——–> phenytoin

Unless you have screened for the HLA-B*1502 allele

48
Q

How might COCP interact with AEDs?

A

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

49
Q

Important side effects of Lamotrigine

A
  1. Steven Johnson syndrome
  2. Toxic epidermal necrosis

Increased risk in first 8 weeks of tx.

50
Q

Epilepsy and DVLA guidance

A

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

51
Q

For anti-epileptic medication: it is important not to switch the brand of the followin:

A
  • carbamazepine
  • phenobarbital
  • phenytoin
  • primidone
52
Q

AED + pregnancy

A

If wanting to get pregnant
- take 5mg FOLIC acid daily before pregnancy
- continue up to 12 week pregnancy

53
Q

AED and breast feeding

A

ENCOURAGED TO BREAST FEED

Monitor baby for
- sedation
- feeding
- weight gain
- developmental milestones

54
Q

Lithium toxicity levels

A

Maintenance = 0.6-1

Mild = 1 - 1.5

Moderate = 1.6 - 2.5

SEVERE = > 2.5

55
Q

Common interactions which will increase lithium levels

A

NSAID

ACEi / ARB

Diuretics (thiazide like)

56
Q

Lithium levels timing

A

12 hours post dose

Once stable

  • monitor every 3-6 months
57
Q

Summarise side effects of lithium toxicity

A

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

58
Q

Monitoring in lithium toxicity

A
  • after 6 hours
  • then every 6-12 hours dependent on patients condition
  • when level is in normal range –> consider reinstating lithium
59
Q

Key lithium counselling

A
  1. Discuss risk factors for lithium toxicity
    - what patient needs to avoid
    - signs and symptoms to look out for
    - dehydration in hot weather
  2. 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
  3. Avoid buying over the counter NSAIDs
  4. Sick day rules
    - safer to withhold doses of lithium where they risk toxicity than carry on with treatment
  5. PURPLE LITHIUM BOOK
    - lithium therapy information book
60
Q

Key features of serotonin syndrome

A
  1. Altered mental state
    —> restlessness, agitation, anxiety, delirium, coma
  2. Neuromuscular hyperactivity
    —> tremor, clonus, hyper-reflexia, respiratory failure
  3. Autonomic hyperactivity
    —> tachycardia, sweating, HTN, diarrhoea, shivering, fever, flushing
61
Q

Immediate action is suspecting serotonin syndrome

A

STOP SEROTONGERIC DRUGS

close observation

consider critical care

62
Q

Treatment of serotonin syndrome

A
  1. Anxiety –> provide sedation –> DIAZEPAM, (5-10mg)
  2. Agitation –> for neuromuscular agitation –> CYPROHEPTADINE (single dose 12mg repeated once according to response)
63
Q

Key features of neuroleptic malignant syndrome

A

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

64
Q

Risk factors for neuroleptic malignant syndrome

A
  • male
  • older
  • ETOH use
  • dehydration
  • DEPOT antipsychotic
  • iron deficiency
65
Q

Management of neuroleptic malignant syndrome

A

IMMEDIATE ACTION
- STOP anti-psychotic medication
- supportive care: fluids

TREATMENT

  1. Managing agitation and catatonia –> oral / IV Lorazepam
    - Have on hand Flumazenil (benzo antagonist) just in case

LIMITED EVIDENCE

  1. Rigidity and hyperthermia –> DANTROLENE
  2. Dopaminergic agonists –> Bromocriptine, Amantadine

Serious cases –> ECT

66
Q

How long should you wait before re-challenging anti-psychotic medication in a patient who has had neuroleptic malignant syndrome?

A

wait 2 weeks

67
Q

Key features of acute dystonic reaction

A
  1. EYES –> oculogyric crisis
  2. NECK –> torticollis
  3. LIMBS –> abnormal movements, posturing
  4. Mouth / Jaw –> trismus, tongue protrusion, dysarthria

In severe cases
- Jaw can dislocate

68
Q

Risk factors for acute dystonic reaction

A
  • high potency 1st gen APM
  • lack of previous APM exposure
  • abrupt discontinuation of APM
  • male
  • younger
  • cocaine use
69
Q

Management of acute dystonic reaction

A
  1. Stop Haloperidol

For acute dystonia

1st Line –> 10mg procyclidine IM

2nd Line –> trihexyphenidyl or orphendrine

70
Q

How might you manage akathisia caused by antipyshotic medication

A
  • lower dose
  • propanolol or low dose clonazepam
  • serotonin antagonist
    —-> MIRTAZAPINE
    —-> CYPROHEPTADINE
71
Q

Management of tardive dyskinesia

A

involuntary movements of tongue, face, jaw, lip smacking

Stop drug, substitute with another

Licensed treatment –> TETRABENAZINE

Y4 - Finals Edition (40 decks)

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