Section 2: Prescription review Flashcards

1
Q

When do you stop COCP pre-operatively?

A

4 weeks before surgery

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2
Q

When do you stop lithium pre-operatively?

A

24h before major surgery, but dose may be continued for minor surgery with careful monitoring of fluids and electrolytes.

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3
Q

When do you stop spironolactone pre-operatively?

A

K+ sparing diuretics are withheld on the morning/ day of surgery because of the risk of hyperkalemia. This also applies to ACE-i and ARB. which are a/w severe hypoTN after anaesthesia. The BNF treatment summary is entitled ‘Surgery and long-term medication’.

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4
Q

When do you stop ramipril pre-operatively?

A

24h before surgery, due to risk of severe hypotension under general anaesthetic.

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5
Q

Dose and frequency of methotrexate?

A

Once weekly. Usually a loading dose dependent on condition being treated, with stepwise 2.5mg increase weekly.

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6
Q

If patient is nauseous and vomiting, what antiemetic would you prescribe?

A

Cyclizine 5mg TDS, metoclopramide 10mg TDS given by IV/ IM/ SC i.e. non-oral routes

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7
Q

When do you stop aspirin before surgery?

A

1 week

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8
Q

Do you stop metformin before surgery?

A

Yes, due to risk of lactic acidosis when patients are NBM i.e. prolonged pre-operative fasting. Stop it 48h before and sometimes 48h after surgery.

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9
Q

Which diuretics cause hypo and hyperkalemia?

A

Hypo - loop and thiazide

Hyper - K+ sparing i.e. aldosterone antagonists ~ also ACE-i

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10
Q

What anti-folates do you need to avoid prescribing together?

A

Methotrexate, trimethoprim, proguanil (anti-malarial), pyrimethamine

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11
Q

Following an acute stroke, when do you start heparin thromboprophylaxis?

A

Around 2 months following the stroke due to risk of bleed (although this varies throughout the UK) - consider mechanical compression

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12
Q

If a patient is taking warfarin with a therapeutic INR, do they still require prophylactic heparin in hospital?

A

No. This increases risk of bleeding unnecessarily.

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13
Q

Why should verapamil not be used with beta blockers?

A

Verapamil is a cardio selective CCB and when used with beta blockers may cause profound bradycardia (even asystole) and hypotension.

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14
Q

What drugs to stop in asthma exacerbation?

A

Ibuprofen and beta blockers - these cause bronchospasms

Aspirin is usually fine in asthmatics but usual at dose of 75mg for cardioprotection (and max 300mg for stroke)

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15
Q

What routes are insulin given by?

A

Always S/C except for sliding scales using short-acting insuln, which is given IV e.g. Actrapid or NovoRapid

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16
Q

What antibiotic to treat UTI in pregnancy?

A

In 1st trimester, avoid trimethoprim (folate antagonist, NTDs)
In 3rd trimester, avoid nitrofurantoin.
Co-amoxiclav 625mg 8 hourly for 3 days if not penicillin allergic.
Give folic acid anywayn

17
Q

What are the sick day rules for patients with Addison’s?

A

Increase intake of steroids to provide adequate cortisol for stress response.

18
Q

Patient with acute asthma is on ibuprofen and bisoprolol and reg salbutamol inhaler. When treated with salbutamol nebs, what should be withheld?

A

Stop ibuprofen, bisoprolol, salbutamol inhaler

19
Q

Patient has fast AF and peripheral oedema but with no adverse features. What is appropriate management?

A

Rate control, which has a mortality benefit in heart failure beta blockers (avoid in asthmatics), diltiazem (avoid in fluid retention) or digoxin.

Consider pharmacological cardioversion.

20
Q

What drug is contraindicated in peripheral vascular disease?

A

Beta blockers e.g. atenolol, which can cause peripheral vasoconstriction and worsen ischaemia.

If patient has signs of critical ischaemia, also avoid ACE inhibitors.

21
Q

What drugs exacerbate heart failure?

A

Calcium channel blockers e.g. diltiazem, amlodipine, verapamil
Corticosteroids
Piogitazone

22
Q

Why is it dangerous to withhold steroids for patient on long term Tx?

A

Long term steroid use may result in chronic adrenal suppression. Abrupt stoppage of steroid may lead to an Addisonian type crisis (hypoglycaemia, hypotension, hyperkalemia)

23
Q

What are the starting and max dosages of citalopram in adults and elderly?

A

Adult - 20mg OD up to 40mg OD

Elderly - 10mg OD up to 20mg OD

24
Q

What drugs can cause iron deficiency anaemia?

A

NSAIDs e.g. aspirin or ibuprofen - due to reduced gastroprotection.

25
Q

What drugs can cause hypoglycaemia?

A

Sulfonylureas e.g. gliclazide
SGLT2 inhibitors e.g. sitagliptin, dapagliflozin
Thiazolidinediones e.g. pioglitazone
Insulin

26
Q

What drugs cause urinary retention?

A

Morphine and other opioids. Also anticholinergics (antipsychotics, antidepressants, detrusor relaxants), general anaesthetic, alpha agonists (e.g. clonidine, methyldopa), benzodiazepines, NSAIDs, CCBs, antihistamines, alcohol.

27
Q

What drugs may cause confusion?

A

Centrally acting drugs such as morphine, anticholinergics, antipsychotics, antidepressants, metoclopramide, anticonvulsants, anti-histamines, corticosteroids, etc.

28
Q

What drugs are eliminated by the kidneys? (adjust dose in renal impairment!)

A
CVS: atenolol, digoxin
Neuro: opioids, gabapentin, pregablin, lithium
Micro: aminoglycosides, penicillins
Haem: LMWH
Endo: metformin
29
Q

Which drugs should be withheld if patient is dehydrated?

A

ACE inhibitors/ ARBs, diuretics, NSAIDs, metformin (generally due to risk of AKI and for the latter, lactic acidosis)

30
Q

What drugs lower seizure threshhold?

A

Opioids, isoniazid, metronidazole, beta-lactams (in toxic dose), buprorpion, TCAs, antipsychotics

31
Q

Should metformin and insulin be continued pre-operatively?

A

Metformin should be stopped the day before surgery, alongside any insulin. These should be converted to sliding scale insulin/ VRII.

32
Q

What drugs should be stopped pre-operatively?

A
  • ACE inhibitors
  • Angiotensin 2 antagonists
  • Consider diuretics
  • Diabetic Tx
  • Aspirin, clopidogrel, dipyridamole, warfarin (unless coronary stent)
  • Lithium
  • NSAIDs