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
Premature menopause is before
40 years
26
Complications of menopause
CVD issues --> IHD, Stroke Bone --> osteoporosis Increased risk of Alzheimer's dementia Decreased pelvic floor muscle tone
27
Key investigation for menopause
1. Serum FSH ---> higher FSH suggests fewer oocytes 2. Anti-Mullerian hormone ---> low AMH suggests ovarian failure 3. TSH ---> thyroid 4. DEXA ---> assess osteoporosis
28
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)
29
How might topical vaginal oestrogen be taken?
- Tablet / cream nightly for 2 weeks - pessaries / gels = 3 weeks - then twice weekly for maintenance
30
Discuss deciding what HRT a patient will get
*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
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
32
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
33
Recurrent UTI is defined as
2 episodes within 6 months More than 3 episodes within 12 months
34
Common causative organism of UTI
E-COLI *RARE* - candida albicans may be seen in: ----> immunocompromised ----> indwelling catheter
35
Management of UTI in men
1st line: Nitrofurantoin or Trimethoprim 7 days
36
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
37
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
38
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
39
Management of urge incontinence : Lifestyle
- decrease caffeine - aim to drink 7-8 glasses of water - weight loss - smoking cessation
40
Management of urge incontinence
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
Paediatric fluoxetine counselling
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
Do not give codeine to under what age
UNDER 12
43
Why should you not give NSAID in patient with asthma
can cause bronchospasm
44
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
45
Key points in history when dealing with suspected paracetamol overdose
1. Quantify what was taken (close, preparation) 2. Time 3. Co-morbidities 4. PMH, previous Over doses 5. Depression 6. Pregnancy
46
Treating paracetamol overdose
Look at treatment line - if ON or above tx line --> N-ACETYLCYSTINE treatment
47
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
48
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
49
Important side effects of Lamotrigine
1. Steven Johnson syndrome 2. Toxic epidermal necrosis Increased risk in first 8 weeks of tx.
50
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
51
For anti-epileptic medication: it is important not to switch the brand of the followin:
- carbamazepine - phenobarbital - phenytoin - primidone
52
AED + pregnancy
If wanting to get pregnant - take 5mg FOLIC acid daily before pregnancy - continue up to 12 week pregnancy
53
AED and breast feeding
ENCOURAGED TO BREAST FEED Monitor baby for - sedation - feeding - weight gain - developmental milestones
54
Lithium toxicity levels
Maintenance = 0.6-1 Mild = 1 - 1.5 Moderate = 1.6 - 2.5 SEVERE = > 2.5
55
Common interactions which will increase lithium levels
NSAID ACEi / ARB Diuretics (thiazide like)
56
Lithium levels timing
12 hours post dose Once stable - monitor every 3-6 months
57
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
58
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
59
Key lithium counselling
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
Key features of serotonin syndrome
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
Immediate action is suspecting serotonin syndrome
STOP SEROTONGERIC DRUGS close observation consider critical care
62
Treatment of serotonin syndrome
1. Anxiety --> provide sedation --> DIAZEPAM, (5-10mg) 2. Agitation --> for neuromuscular agitation --> CYPROHEPTADINE (single dose 12mg repeated once according to response)
63
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
64
Risk factors for neuroleptic malignant syndrome
- male - older - ETOH use - dehydration - DEPOT antipsychotic - iron deficiency
65
Management of neuroleptic malignant syndrome
**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
How long should you wait before re-challenging anti-psychotic medication in a patient who has had neuroleptic malignant syndrome?
wait 2 weeks
67
Key features of acute dystonic reaction
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
Risk factors for acute dystonic reaction
- high potency 1st gen APM - lack of previous APM exposure - abrupt discontinuation of APM - male - younger - cocaine use
69
Management of acute dystonic reaction
1. Stop Haloperidol For acute dystonia 1st Line --> 10mg procyclidine IM 2nd Line --> trihexyphenidyl or orphendrine
70
How might you manage akathisia caused by antipyshotic medication
- lower dose - propanolol or low dose clonazepam - serotonin antagonist ----> MIRTAZAPINE ----> CYPROHEPTADINE
71
Management of tardive dyskinesia
involuntary movements of tongue, face, jaw, lip smacking Stop drug, substitute with another Licensed treatment --> TETRABENAZINE