Specific Cards Flashcards

Question

Azathioprine

Answer 1

Crohn's disease, rheumatoid arthritis, autoimmune conditions, transplant rejection immunisation with live vaccines should be avoided Manufacturer advises reduce dose to one-quarter of the usual dose with concurrent use of allopurinol and in elderly, risk of myelosuppression (decrease bone marrow) in patients with reduced thiopurine methyltransferase activity withdraw in RA if nausea, vomiting and diarrhoea counsel on bone marrow suppression: brusing, bleeding, infection withdraw in RA if nausea, vomiting or diarrhoea reduce dose in elderly Using azaTHIOprine together with mesalamine may increase the effects of azaTHIOprine warning signs: malaise, dizziness, diarrhoea, fever, myalgia, rash, hypotension, nausea, vomiting, unexplained bruising, bleeding or infection (bone depression/myelosuppresion) monitoring: full blood count (can cause low blood count: thrombocytopenia and low white blood cell: leucopenia), renal and liver function interaction: risk of anaemia/leucopenia with ACE, anticoagulant reduced: coumarins, haematological toxicity: allopurinol, risk of infection with live vaccine

Answer 2

depression, pop, 2 month supply, increased risk of dry eye syndrome, vitamin a toxicity prescriptions are valid only for seven days max 30 day supply retinoid severe acne ***PPP ****neuropsychiatric reactions and sexual dysfunction: erectile dysfunction and decreased libido, depression Caution: Avoid blood donation during treatment and for at least 1 month after treatment, dry eye syndrome (associated with risk of keratitis); history of depression (risk of neuropsychiatric reactions) contra: Hyperlipidaemia; hypervitaminosis A

Answer 3

night terrors advise the parents to continue administering montelukast but make an immediate appointment with the GP

Answer 4

low Hb, low MCV, low ferritin would experience breathlessness aim of treatment: eliminate symptoms of diarrhoea, bloating, and abdominal pain treatment: strict, life-long GF diet increased risk of malabsorption of calcium and vitamin D=>risk of osteoporosis

Answer 5

>familial hypercholesterolaemia >type 1 diabetes >QRISK 3 score of 23.4 % >chronic kidney disease

Answer 6

an autoimmune condition where your immune system produces antibodies that cause the thyroid to produce too much thyroid hormone once euthyroid, the woman may need to adjust her daily calorie intake Carbimazole should be offered as first-line definitive treatment if radioactive iodine and surgery are unsuitable treatment options.

Answer 7

muscle cramps

Answer 8

a common side effect of treatment with metformin is vitamin B12 deficiency: >depression >fatigue >glossitis: inflammation of the tongue >paraesthesia: burning/prickling sensation in hands, arms, legs, feet

Answer 9

CD NO REGISTER POM except from safe custody

Answer 10

Treatment of vaginal atrophy due to oestrogen deficiency in postmenopausal women aged 50 years and above, who have not had a period for at least 1 year estradiol 10 micrograms vaginal tablets Initial dose: One vaginal tablet daily for two weeks. Maintenance dose: One vaginal tablet twice a week. Treatment may be started on any convenient day. If a dose is forgotten, it should be used as soon as the patient remembers. A double dose should be avoided. Gina may be used in women with or without an intact uterus. contra: endometrial cancer, genital bleeding, endometrial hyperplasia, vulval dermatoses, current vaginal infection, vulval rash, severe vaginal itching, breast cancer/ovarian cancer, DVT, angina/myocardial infarction, ischaemic stroke, liver disease, porphyria

Answer 11

Loop Diuretics (Potassium Loss) Hypokalaemia, which can be caused by potassium-depleting diuretics such as the loop diuretics, increases the toxicity of the digitalis glycosides. oedema/resistant hypertension contra: liver cirrhosis, renal failure, anuria (kidney failure), severe hypokalaemia/hyponatraemia (nausea, diarrhoea, palpitations and feeling faint) caution: can exacerbate diabetes and gout, hypotension be corrected before, elderly, urinary retention in enlarged prostate

Answer 12

Breast Cancer Tamoxifen should be taken daily to reduce the risk of the breast cancer returning must not get pregnant, contraception must be used during treatment and for 2 months after stopping, risk of multiple pregnancy SE: hot flush, vaginal discharge, nausea, headache, dizzy, itchiness urgent: unusual vaginal bleeding (risk of endometrial cancer), [breathlessness, pain/swelling in lower leg/calf and is warm to the touch=>DVT] Tamoxifen should be taken daily to reduce the risk of the breast cancer returning, with ongoing review of the benefits versus risks of continuing. Tamoxifen may increase the risk of endometrial cancer. Paroxetine reduces the effectiveness of tamoxifen through inhibiting its conversion to its active form. Timing of tamoxifen will not reduce the hot flush which is a common side effect. Tamoxifen increases the risk of venous thromboembolism and a swollen leg could suggest a deep vein thrombosis which requires urgent medical attention in a hospital. Tamoxifen may increase the risk of endometrial cancer. Paroxetine reduces the effectiveness of tamoxifen through inhibiting its conversion to its active form. Timing of tamoxifen will not reduce the hot flush which is a common side effect. Tamoxifen increases the risk of venous thromboembolism and a swollen leg could suggest a deep vein thrombosis which requires urgent medical attention in a hospital.

Answer 13

prolonged immobility

Answer 14

Antibiotic with Steroid 1st line: Amoxicillin 500mg TDS for 5 days 2nd: Doxycycline: 200 mg on first day, then 100 mg once a day for 5 days 3rd: Clarithromycin: 500 mg twice a day for 5 days Prednisolone 5mg tablets: 30 mg oral prednisolone once daily for 5 days

Answer 15

inform the parents that independent purchases of nebulisers without medical supervision is not recommended

Answer 16

prescribe an additional inhaler containing a corticosteroid

Answer 17

prescribe an additional inhaler containing a corticosteroid

Answer 18

the strength of solution when prepared for intravenous infusion is 0.1% w/v

Answer 19

Low risk (aggregate score 1 to 4) – prompt assessment by ward nurse to decide on change to frequency of monitoring or escalation of clinical care. Low to medium risk (score of 3 in any single parameter) – urgent review by ward-based doctor to determine cause and to decide on change to frequency of monitoring or escalation of clinical care. Medium risk (aggregate score 5 to 6) – urgent review by ward-based doctor or acute team nurse to decide on escalation to critical care team. High risk (aggregate score of 7 or over) – emergency assessment by critical care team, usually leading to patient transfer to higher-dependency care area.

Answer 20

L: 3 days/72hrs, levonogestrel 1500mcg, prevents about 84% of expected pregnancies * stopping your ovaries from releasing an egg; * preventing sperm from fertilising any egg you may have already released If vomiting occurs within three hours of taking the tablet, another tablet should be taken immediately. can be used at any time during the menstrual cycle unless menstrual bleeding is overdue After using emergency contraception it is recommended to use a local barrier method (e.g. condom, diaphragm spermicide, cervical cap) until the next menstrual period starts. not recommended in patients with severe liver dysfunction, Crohn's disease (inhibits absorption). menstrual periods are usually normal and occur at the expected date. They can sometimes occur earlier or later than expected by a few days E: 5 days, ulipristal acetate 30mg by postponing ovulation Of 100 women who take this medicine approximately 2 will become pregnant if your period is more than 7 days late; if it is unusually light or unusually heavy; or if you experience symptoms such as abdominal (stomach) pain, breast tenderness, vomiting or nausea, you may be pregnant

Answer 21

>3-hour progestogen-only pill (traditional progestogen-only pill) – must be taken within 3 hours of the same time each day (Noriday) >12-hour progestogen-only pill (desogestrel progestogen-only pill) – must be taken within 12 hours of the same time each day (Cerazette, desogestrel) if sick within 2 hrs of taking it, take another one and the next at the usual time can take if over 35, smoke, can be used if you cannot use contraception that contains oestrogen must take at the same time each day there's no break between packs of pills – when you finish a pack, you start the next one the next day. can start any time during menstrual cycle: day 1 to 5 (the first 5 days of your period), it'll work straight away and you'll be protected against pregnancy. You will not need additional contraception. If you have a short menstrual cycle, you'll need additional contraception, such as condoms, until you've taken the pill for 2 days. If you start on any other day, you will not be protected from pregnancy straight away and will need additional contraception until you've taken the pill for 2 days. if you miss less than 3 or 12 hrs: take the late pill as soon as you remember, and take the remaining pills as normal, even if that means taking 2 pills on the same day if you miss more than the 3 to 12 hr window: >take a pill as soon as you remember – only take 1, even if you've missed more than 1 pill >take the next pill at the usual time – this may mean taking 2 pills on the same day (1 when you remember and 1 at the usual time); this is not harmful >carry on taking your remaining pills each day at the usual time >use extra contraception such as condoms for the next 2 days (48 hours) after you remember to take your missed pill, or do not have sex >if you have unprotected sex from the time that you miss your pill until 2 days after you start taking it reliably again, you may need emergency contraception

Answer 22

The standard way to take the pill is to take 1 every day for 21 days, then have a break for 7 days, and during this week you have a bleed like a period. You start taking the pill again after 7 days. if you get sick within 3 hrs, take another pill and the next one at the usual time. starting day 1-5, you will be protected straight away if you start after day 5, You will not be protected from pregnancy straight away and will need additional contraception until you have taken the pill for 7 days. heavy periods or painful periods, PMS (premenstrual syndrome) or endometriosis the combined pill may help if you miss one pill: >take the last pill you missed now, even if this means taking 2 pills in 1 day >carry on taking the rest of the pack as normal >take your 7-day pill-free break as normal, or if you're on an everyday (ED) pill, take your dummy (inactive) pills You do not need to use extra contraception. if you miss 2 or more: week 1 If you’ve missed 2 to 7 pills in the first week of a pack, or you’ve started a new pack 2 or more days late, you may need emergency contraception if you’ve had unprotected sex. Take the last pill you missed, even if that means taking 2 in a day, and leave any earlier missed pills. Use extra contraception, such as condoms, for the next 7 days. week 2-3 take the last pill you missed even if that means taking 2 pills in a day and leave any earlier missed pills. You do not need emergency contraception, but use extra contraception, such as condoms, for the next 7 days. Then take the rest of the pills in your pack as normal if week 2. If week 3, start a new pack the next day. no evidence that the pill will make you gain weight, low risk of serious side effects, such as blood clots and cervical cancer, link between the pill and depression contra: blood clots, stroke, heart abnormality, migraine, breast cancer, gallbladder/liver disease, diabetes SE: DVT, stroke, heart attack increase risk: breast, cervical cancer decrease risk: uterus cancer, ovarian cancer, bowel cancer interaction: antibiotics: rifampicin and rifabutin enzyme inducer: the epilepsy drugs carbamazepine, oxcarbazepine, phenytoin, phenobarbital, primidone and topiramate St John's wort (a herbal remedy) antiretroviral medicines used to treat HIV Blood pressure should be measured as hypertension is a known risk factor that increases the risk of arterial disease associated with oral contraceptives.

Answer 23

Microgynon, Marvelon and Yasmin Logynon Microgynon ED

Answer 24

anhydrous lanolin

Answer 25

common side effect: epistaxis (nosebleed) discard after two months of opening

Answer 26

do not take milk, indigestion remedies, or medicines containing iron or zinc, 2 hours before or after you take this medicine quinolones are contra-indicated in patients with a history of tendon disorders related to quinolone use.

Answer 27

*very common (≥ 1/10) *common (≥1/100 to <1/10) *uncommon (≥1/1000 to <1/100) *rare (≥1/10000 to <1/1000) *frequency not known (cannot be estimated from available data

Answer 28

amitriptyline, duloxetine, gabapentin, or pregabalin Do not prescribe more than one neuropathic pain drug at the same time Consider capsaicin 0.075% cream (Axsain®) for people with localized neuropathic pain duloxetine 60 mg capsules, 1 OD Gabapentin 300 mg capsules

Answer 29

Class 1: the defect presents a risk of death or disability=>immediate action Class 2: the defect may cause mistreatment or harm to the patient, but it is not life-threatening or serious=>recall with 48 hrs Class 3: the defect is unlikely to cause harm to the patient, and the recall is carried out for other reasons, such as non-compliance with the marketing authorisation or specification=>action to be taken within 5 days Class 4: the MHRA also issues “Caution in Use” notices, where there is no threat to patients or no serious defect likely to impair product use or efficacy.

Answer 30

domperidone patients whose motor symptoms decrease their quality of life should be offered levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa) Parkinson's disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride) drooling: Glycopyrronium bromide

Answer 31

In a NHS pharmacy, there must be a pharmacist present whenever pharmaceutical services are being provided. >Handing out of dispensed and checked medicines to the delivery driver >Making an emergency supply of a medicine at the request of a patient >Supervising the consumption of buprenorphine >Wholesaling of medicines can only take place when the responsible pharmacist is in charge of the pharmacy and need to take place under the supervision of a pharmacist and the supervising pharmacist will need to be physically present at the pharmacy. RP not needed: Ordering stock from a wholesaler RP absence: >You can hand over the responsible pharmacist role to the second pharmacist >If the second pharmacist takes over as responsible pharmacist, they canNOT also be absent for two hours during the same day >If you remain the responsible pharmacist, you do need to record the absence in the pharmacy record >Trained pharmacy staff can carry on date checking of medicines in your absence >You can continue to be the responsible pharmacist whilst you are absent RP pharmacy record: >If an amendment is made to the record, it should be clear who made this change and when they made it >either an electronic record or paper records is kept >The Record must be kept for a minimum of five years >The Record should include the registration number of the responsible pharmacist >The Responsible Pharmacist is required to personally make entries in the pharmacy record

Answer 32

symptoms of severe exhaustion, episodes of breathlessness and paleness of the skin are normal and should subside upon completion of treatment

Answer 33

amlodipine 5 mg tablets < 140/90 mmHg

Answer 34

Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. Persistent Hypertension: High blood pressure at repeated clinical encounters. Stage 1: 140/90 mmHg to 160/100, ABPM 135/85* over 80: target 150/90 (145/85 ABPM) under 80: target 140/90 (135/85 ABPM) ***treat under 80 if they have target-organ damage, CVD, renal disease, diabetes, or QRISK 10% Stage 2: 160/100 mmHg or higher but less than 180/120, ABPM 150/95+ ***treat stage 2 regardless of age Stage 3: Clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher ***treat promptly Offer treatment and lifestyle advice in stage 2, stage 1 in adults under 80 with organ damage/CVD/renal disease/diabetes/QRISK 10% T2DM (with or without)/under 55: ARB or ACE (cough), if not controlled then add CCB or thiazide, then ACE or ARB and CCB and thiazide if ACE not tolerated use ARB, do not combine ACE with ARB 55+/noDM/Afro: CCB, if not controlled add ACE/ARB/thiazide, then ACE or ARB and CCB and thiazide T1DM, under 80: ACR less than 70, target 140/90 ACR more than 70, target 130/80 T1DM, over 80: below 150/90 T2DM, any age: above 140 should receive treatment, normal BP 130/80 Hypertension in Pregnancy (140/90): labetalol=>nifedipine MR=>methyldopa, target 135/85 Renal Disease: ACE, risk of hyperkalaemia

Answer 35

Chickenpox: itchy, spots filled with fluid, associated with red spots that typically look like blisters. The spots can appear on any part of the body. small erythematous macules on her stomach and arms, and a few some pustules. paracetamol may be used to reduce pain and fever

Answer 36

pale, cold, clammy skin sweating rapid, shallow breathing weakness and dizziness feeling sick and possibly vomiting thirst yawning sighing call 999 as soon as possible and ask for an ambulance

Answer 37

a variable, high-pitched respiratory sound that can be assessed during breathing

Answer 38

the main symptom of hives (urticaria) is a rash.

Answer 39

'Tall-Man lettering' used in differences between drugs check for high risk indication/usage between drug

Answer 40

pharmacists should challenge the prescription if they believe there is no legitimate use for the drug for dental purposes

Answer 41

High Risk Drug long half-life (3-2-1 dosing), no grapefruit juice caution: elderly, HF, bradycardia (increased risk with beta blockers, dilimiazem, verapamil) increase risk of myopathy with simvastatin monitoring: liver, potassium, chest xray, thyroid function, ECG (IV use) WARNING: vision impairment (sore, painful, dim, dazzled by headlights at night), contains iodine so can cause thyroid dysfunction, liver toxicity (jaundice), shortness of breath/breathless/cough (pulmonary toxicity), skin can be sensitive to sunlight (burning sensation, grey discolouration, use sunscreen), numbness (peripheral neuropathy), tremor (neurological effects) ***sofosbuvir with daclatasvir; sofosbuvir and ledipasvir; simeprevir with sofosbuvir: risk of severe bradycardia and heart block when taken with amiodarone ***can cause serious adverse reactions affecting the eyes, heart, lung, liver, thyroid gland, skin, and peripheral nervous system that may persist for a month or longer after treatment discontinuation

Answer 42

Gaviscon Advance is high in sodium and must be taken into account if the patient is on a low sodium diet

Answer 43

severe pain/Adjunct in treatment of opioid dependence when starting methadone, a low dose should be prescribed if tolerance is unknown *respiratory depression (benzos and opioids), risk of dependance and addiction caution: QT prolongation (Domperidone increases QT prolongation)

Answer 44

Prevent and treat osteoporosis Black Box Warning: Increased risk of deep vein thrombosis and pulmonary embolism leg pain; feeling of warmth in the lower leg; swelling of the hands, feet, ankles, or lower legs; sudden chest pain; shortness of breath; coughing up blood; or sudden changes in vision, such as loss of vision or blurred vision.

Answer 45

Antiepileptic ***risk of suicidal thoughts/behaviour, severe respiratory depression

Answer 46

Antipsychotic, second generation schizophrenia, bipolar, mania patients taking antipsychotics, particularly olanzapine are susceptible to hyperglycaemia and diabetes therefore fasting BG must be tested at baseline and at regular intervals thereafter. caution: ECG may be required in CVD risk factors, elderly monitor: hyperprolactin at start, 6 months, then yearly=> gynaecomastia "manboobs", CVD risk assess annually, blood lipids and weight at baseline every 3 months for first year, then yearly, fasting blood glucose after one month, then every 4-6 months withdrawal in neonates when taken in 3rd trimester **monitor blood concentration for toxicity CLOZAPINE: schizophrenia, psychosis in Parkinson's blood counts (leucocyte) monitored for toxicity: For the first 18 weeks, blood counts should be monitored every week, then fortnightly for up to one year, then monthly blood lipids and weight: at baseline, at 3 months (weight at frequent intervals in first 3 months), then yearly. every three months for the 1st year, then yearly fasting blood glucose: after 1 month treatment, then every 4-6 months prolactin concentration: at start, at 6 months, then yearly caution: ECG required in CVD risk patients (fatal myocarditis common in first 2 months), elderly, hypothermia in antipsychotic agents Cigarette smoking induces metabolism of clozapine, resulting in significant increases in levels when quitting, hence dose adjustment and increased monitoring is required. This is not related to the nicotine component, hence the effect is not negated by NRT. ***fatal risk of intestinal obstruction, faecal impaction, and paralytic ileum, monitor blood concentration (smoking changes, pneumonia/infections) ***aripripazole: preparation for acute apisode not to be confused with depot preparation for maintenance ***clozapine: fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus (varying degrees of impairment of intestinal peristalsis) ***risperidone confused with ropinirole

Answer 47

Measurement of serum-magnesium concentrations should be considered before and during prolonged treatment with a proton pump inhibitor, especially when used with other drugs that cause hypomagnesaemia or with digoxin. ***Very low risk of subacute cutaneous lupus: lesions in sun-exposed areas can occur from weeks/months/years after exposure of drug can increase the risk of fractures when used in high doses for over a year in elderly, risk of osteoporosis may mask symptoms of gastric cancer increased risk of C. difficile SE: muscle weakness, cramps

Answer 48

hypercalcaemia: frequent nausea,vomitting constipation and palpitations

Answer 49

patient will suffer from hypocalcaemia=>osteoporosis

Answer 50

patient will suffer from hypocalcaemia=>osteoporosis patients should be advised to stop taking the tablets and to seek medical attention if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain

Answer 51

annual influenza vaccine pneumococcal

Answer 52

9 month old: BCG

Answer 53

importance of good hand hygiene as one of the vaccines is a ‘live’ vaccine that can be excreted in the baby’s faeces

Answer 54

apply one patch daily between 8am and 8pm Tablet: Put 1 tablet under your tongue as soon as possible. If you're still in pain after 5 minutes you can have a second dose by putting 1 more tablet under your tongue Spray: Use 1 or 2 sprays under your tongue. If you're still in pain after 5 minutes you can have a second dose of 1 or 2 sprays under your tongue. call 999: if you've taken 2 doses of GTN and you're still in pain 5 minutes after your 2nd dose, your pain is getting worse, you feel unwell Side effects of GTN include postural hypotension, tachycardia (but paradoxical bradycardia also reported); throbbing headache, dizziness; less commonly nausea, vomiting, heartburn, flushing, syncope, temporary hypoxaemia.

Answer 55

apply one patch once weekly for 6 weeks followed by a 7-day patch free interval

Answer 56

apply one patch once weekly for 3 weeks followed by a 7-day patch-free interval

Answer 57

apply one patch 5-6 hours before needed

Answer 58

Mastitis is an inflammation of breast tissue that sometimes involves an infection. The inflammation results in breast pain, swelling, warmth and redness. You might also have fever and chills. Mastitis most commonly affects women who are breast-feeding (lactation mastitis) signs of sepsis (tachycardia, fever, chills): hospital admission Treatment: analgesic for pain and discomfort (paracetamol and ibuprofen), use warm compress, continue breastfeeding infected nipple fissure not improved 12-24 hrs: flucloxacillin 500 mg four times a day for 10–14 days if allergic: erythromycin 250–500 mg four times a day or clarithromycin 500 mg twice a day for 10–14 days.

Answer 59

causes muscle weakness, droopy eyelids double vision difficulty making facial expressions problems chewing and difficulty swallowing slurred speech weak arms, legs or neck shortness of breath and occasionally serious breathing difficulties managed with long term prednisolone

Answer 60

causes muscle weakness, droopy eyelids double vision difficulty making facial expressions problems chewing and difficulty swallowing slurred speech weak arms, legs or neck shortness of breath and occasionally serious breathing difficulties managed with long term prednisolone

Answer 61

a highly contagious, serious airborne disease caused by a virus that can lead to severe complications and death high fever, cough, runny nose, and watery eyes

Answer 62

Lithium Salt HIGH RISK Bipolar disorder If lithium is to be discontinued, the dose should be reduced gradually over a period of at least 4 weeks (preferably over a period of up to 3 months). Narrow therapeutic range: 0.4 to 1 mmol/L (lower end for maintenance and elderly) and 0.8 to 1 mmol/L for acute episodes of mania and relapse patients Warning: serum conc over 2 mmol/L, seizure, coma, BP change, GI disturbance, blurred vision, CNS disturbance, tremor, weight gain, fatigue, headache, renal dysfunction monitoring: conc weekly, then every 3 months, renal, cardiac, and thyroid every 6 months may impair driving interactions: ACE, ARB, diuretics, NSAIDs, SSRI, tricyclic, metronidazole, amiodarone caution: long-term use associated with thyroid disorder, cognitive/memory impairment preparations have wide bioaviailbily treatment pack to be given, toxicity worse by sodium depletion so consume adequate salt and wanter, avoid NSAID/alcohol do not stop until told Warning: Read the additional information given to you with this medicine

Answer 63

shelf life if stored at room temperature: 1 hr The solution itself must not be boiled. Must be stirred well in water, discarded after 24 hours. 1-2 sachets after each loose motion

Answer 64

increased risk of peri-operative diabetic ketoacidosis, so blood ketones are to be measured whilst treatment with a particular anti-diabetic is interrupted. Risk of diabetic ketoacidosis with sodium-glucose co-transporter 2 (SGLT2) inhibitors (canagliflozin, dapagliflozin or empagliflozin) monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)

Answer 65

reduce the usual daily dose of one of their treatment by 20% the day before surgery

Answer 66

sedating antihistamine ***C: children under 6 should not be given OTC cough and cold with chlorphenamine ***H: Risk of QT-interval prolongation and torsade de pointes (avoid in elderly max dose 50 mg, max dose in adult 100mg, children up to 40kg 2 mg max/kg) antimuscarinic: used with caution in prostatic hypertrophy, urinary retention, susceptibility to angle-closure glaucoma rare: hypotension, palpitation, arrhythmias, extrapyramidal effects, dizziness, confusion

Answer 67

non-drowsy antihistamine safe in renal impairment but caution is advised, initial dose reduction to alternate days Age Groups: cetirizine, loratatinde, chlorphenamine, promethazine

Answer 68

https://bnf.nice.org.uk/treatment-summaries/dyslipidaemias/ High intensity: Atorvastatin 20, 40, 80 Rosuvastatin 10 20 40 Simvastatin 80 Medium intensity: Atorvastatin 10 Rosuvastatin 5 Simvastatin 20, 40 Low intensity: Fluvastatin 20, 40 Pravastatin 10, 20, 40 Simvastatin 10 Amlodipine slightly increases the exposure to simvastatin. Manufacturer advises adjust simvastatin dose to a max. 20 mg daily with concurrent use of amlodipine Stop statin while on clarithromycin (metabolised by CYP3A4, risk of myopathy which affects the muscle) (Transaminases (ALT/AST) should be checked 3 and 12 months after commencing treatment by requesting LFTS. Statins should be used with caution in patients with a history of liver disease as they are metabolized by the liver, so hepatic impairment will increase their levels and thus the risk of myopathy. Simvaststin is contraindicated in active liver disease or if transaminases ALT & AST are raised more than 3 times the normal range. Statins are the drugs of first choice for treating hypercholesterolaemia and moderate hypertriglyceridaemia. Severe hypercholesterolaemia or hypertriglyceridaemia not adequately controlled with a maximal dose of a statin may require the use of an additional lipid-regulating drug such as ezetimibe. Fenofibrate may be added to statin therapy if triglycerides remain high even after the LDL-cholesterol concentration has been reduced adequately. Familial hypercholesterolaemia: high-intensity statin with LDL reduction of 40%+ is 1st line, then titrated to a LDL reduction of 50% Treatment with a fibrate or a bile acid sequestrant (such as colestyramine (patient with gallstones can help lower lipids too) or colestipol hydrochloride) can be considered under specialist advice, in patients for whom statins or ezetimibe are inappropriate. primary prevention: DM, hypertension, smoking, CKD, 85+ secondary prevention of cardiovascular disease, including elderly: atorvastatin 80 mg tablets, one to be taken at night SE: myopathy, myositis, rhabdomyolysis, muscle toxicity

Answer 69

Sulphonylureas glibenclamide (long acting, gliclazide short acting) take with breakfast, recognise hypoglycaemia (low blood sugar: sweating, anxious palpations, dizzy=>oral gel), SE: feeling sick, constipation/diarrhoea, weightGAIN avoid high dose in elderly consider DVLA due to hypos avoid in: porphyria, G6PD deficient SGLT2 (-flozins), T2DM/HF/CKD dapgaliflozin (Forxiga), empagliflozin (Jardiance), canagliflozin (Invokana) SE: dizzy, dehydration, urine/genital infections, back pain, weightLOSS ***risk of DKA, Fournier's gangrene, lower limb amputation (canagliflozin), excess excretion of glucose=>UTI/candida, hypovolarmia, footsore metallic taste call GP Thiazolidinediones/Glitazones (Pioglitazone) reduces insulin resistance risks: cardiac failure, liver toxicity (hepatotoxicity), bone fracture, bladder cancer (blood in urine, painful/difficult), weightGAIN contraindications with digoxin (HF) T2DM 1st line: Metformin (biguanides), if not tolerated, then MR SE: altered taste, dry mouth, frequent urination, low B12, GI discomfort Incretin mimetics/GLP-1 (Ozempic, Trulicity, VIctoza) DPP-4 inhibitors (-gliptins) Linagliptin (Januvia) Gum, Foot, and Eye care

Answer 70

Conjunctivitis: gritty, uncomfortable, sticky, self-limiting Chloramphenicol eye drops Refer when painful

Answer 71

As this is a new medicine is it important to ensure all side effects, no matter how mild are reported using in accordance with usual reporting procedures. This includes known side effects. In this case, the vaccine is known to cause headaches - see SmPC for more information. The Yellow Card Scheme is a national scheme for reporting side effects with any medicine, which can be used by patients and healthcare professionals.

Answer 72

Aclidinium / Formoterol (DuaKlir Genuair®) Glycopyrronium / Indacaterol (Ultibro Breezhaler®) Ipratropium (Atrovent Inhaler CFC-Free®) Tiotropium (Spiriva Handihaler®) Triotropium (Spiriva Respimat®)

Answer 73

>In emergencies, a doctor can be supplied with a schedule 2 controlled drugs on the condition that they will furnish a requisition within 24 hours >Supplies made against faxed requisitions are NOT legally acceptable >The pharmacy must send the original requisition to the relevant NHS agency >The purpose of the requisition must be included on the form >The use of the approved form applies to both requisitions for human and veterinary use

Answer 74

Tetracycline Respiratory Infections/UTI/Susceptible disease (Clamhydia) Alcohol dependence; children 8–11 years—use only in acute or severe infections when there are no adequate alternatives (deposition in growing bone and teeth, by binding to calcium, causes staining and occasionally dental hypoplasia); children under 8 years—use only in severe or life-threatening conditions (e.g. Rocky Mountain spotted fever) when there are no adequate alternatives (deposition in growing bone and teeth, by binding to calcium, causes staining and occasionally dental hypoplasia) avoid: pregnancy Manufacturer advises capsules and tablets should be swallowed whole with plenty of fluid, while sitting or standing. Take with a full glass of water Do not take indigestion remedies, or medicines containing iron or zinc, 2 hours before or after you take this medicine Protect your skin from sunlight—even on a bright but cloudy day. Do not use sunbeds (adverse drug reaction) caution: myasthenia graves (muscle weakness increased), systemic lupus erythematosus (exacerbated)

Answer 75

BV: 2 g orally as a single dose. tooth infection: 400 mg three for seven days Patients should to avoid alcohol drugs while taking metronidazole and for at least 48 hours after stopping the drug. Monitor for flushing, nausea, and vomiting if the combination is used.

Answer 76

The patch should be applied to the lateral chest every 24 hours. It does not need to be removed for showering/bathing and should be used regularly to prevent angina rather than when required.

Answer 77

loading doses may be required, therapeutic range: 0.8 to 2 mcg/L Dose adjustment: reduce dose by half with concurrent use of amiodarone, dronedarone and quinine caution: hypercalcaemia (digitalis toxicity), hypokalaemia (digitalis toxicity), hypomagnesaemia, hypoxia (low oxygen), elderly, monitoring: digoxin concentration after 6 hrs, electrolytes (K, Mg, Ca), renal function, HR about 60 b/min WARNING: cardiac (arrhythmia, heart block), neurological (weakness, lethargy, headache), GI (vomitting, diarrhoea, abdominal discomfort), visual (blurred, yellow vision), toxicity range of 1.5-3 Bioavilablity: IV (100%), Tablet (50-90%), 75% interactions: NSAIDs, ACE inhibitors, St. John's wort, looop/thiazide diuretics, acetazlmide/amphotericin, cyclosporine, mirabegron, itraconazole Digoxin toxicity: Advise the patient to stop taking digoxin and refer for medical review urgently. The BNF monograph recommends that if toxicity occurs, digoxin should be withdrawn as serious manifestations can occur requiring urgent specialist management. A digoxin plasma concentration within the therapeutic range does not exclude digoxin toxicity.

Answer 78

Thiazides and related diuretics Bendroflumethiazide is a thiazide diuretic that causes hypokalaemia by increasing potassium excretion by the kidney.

Answer 79

Oxycodone immediate release tablets most appropriate: Morphine is metabolised to morphine-6-glucuronide which accumulates in renal impairment, resulting in CNS depression. Similarly, the clearance of codeine, and its metabolites are significantly reduced in renal impairment. The pharmacokinetics of oxycodone is also affected in renal failure, however it may be preferred to morphine in some circumstances. The BNF recommends to avoid codeine in renal failure and to use morphine and oxycodone with caution. The BNF also recommends to avoid ibuprofen (systemic NSAID) in severe renal impairment. Fentanyl patches and slow release tablets are not appropriate for acute pain due to their slow onset of action and long duration of action.

Answer 80

taken once weekly SE: nausea and loose stools effective contraception avoid NSAIDS/aspirin live vaccine avoided, should obtain flu vaccine men should not father a child after 6 months of treatment end strategy to prevent the side effects: Folic acid 5 mg once a week, taken on a different day to methotrexate Folic acid is indicated for the prevention of side effects from methotrexate however it needs to be taken on a different day to the methotrexate, otherwise it will reduce the effectiveness of the methotrexate. The use of folinic acid is reserved for use as a part of treatment protocols for methotrexate infusions. methotrexate toxicity: cough, sore throat Cefalexin in appropriate: Amoxicillin-clavulanic acid, amoxicillin, trimethoprim, and ciprofloxacin may increase the risk of methotrexate toxicity. Nitrofurantoin is not recommended for pyelonephritis as its penetration is limited to the lower tract only. monitoring: full blood count, renal, liver function warning: GI toxicity, liver toxicity (jaundice, dark urine), blood disorder (bone marrow suppression: sore throat, mouth ulcers, bruising), pulmonary toxicity (cough), pregnancy/breastfeeding hepatotoxicity with acitretin, nsaids, penicillins, haemotological toxicity with co-trimoxazole/trimethoprim, PPI, tetracycline

Answer 81

Microcytic Anaemia (low MCV) most commonly due to iron deficiency.

Answer 82

Pharmacists currently do not have write access to SCR although this may change soon. There is a consent form however verbal consent is also accepted. The use of SCR in the pharmacy setting is linked to quality payment scheme in community pharmacies and is available to technicians. Must seek consent unless in emergency e.g. unconscious patient. To access the SCR consent needs to be gained for each patient, at each pharmacy, on a need-by- need basis

Answer 83

the immune system that causes an increased risk of blood clot Levonorgestrel-releasing intrauterine system is most appropriate: NSAIDs would be contra-indicated as they increase the risk of bleeding when given with warfarin. Tranexamic acid and the combined oral contraceptive pill are also contra-indicated in antiphospholipid syndrome due to the additive increase in thrombosis risk.

Answer 84

Adults with symptoms of hypoglycaemia who have a blood-glucose concentration greater than 4 mmol/litre, should be treated with a small carbohydrate snack such as a slice of bread or a normal meal, if due. Any patient with a blood-glucose concentration less than 4 mmol/litre, with or without symptoms, and who is conscious and able to swallow, should be treated with a fast-acting carbohydrate by mouth. Fast-acting carbohydrates include Lift® glucose liquid (previously Glucojuice®), glucose tablets, glucose 40% gels (e.g. Glucogel®, Dextrogel®, or Rapilose®), pure fruit juice, and sugar (sucrose) dissolved in an appropriate volume of water. Oral glucose formulations are preferred as absorption occurs more quickly. Orange juice should not be given to patients following a low-potassium diet due to chronic kidney disease, and sugar dissolved in water is not effective for patients taking acarbose which prevents the breakdown of sucrose to glucose. Chocolates and biscuits should be avoided if possible, as they have a lower sugar content and their high fat content may delay stomach emptying. If necessary, repeat treatment after 15 minutes, up to a maximum of 3 treatments in total. Once blood-glucose concentration is above 4 mmol/litre and the patient has recovered, a snack providing a long-acting carbohydrate should be given to prevent blood glucose from falling again (e.g. two biscuits, one slice of bread, 200–300 mL of milk (not soya or other forms of 'alternative' milk, e.g. almond or coconut), or a normal carbohydrate-containing meal if due). Insulin should not be omitted if due, but the dose regimen may need review. In an emergency, if the patient has a decreased level of consciousness caused by hypoglycaemia, intramuscular glucagon can be given by a family member or friend who has been shown how to use it. If glucagon is not effective after 10 minutes, glucose 10% intravenous infusion should be given.

Answer 85

Allergic rhinitis is inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mould, or flakes of skin from certain animals: moderate; nasal itching, congestion, sneezing and rhinorrhoea. The patient is suffering from allergic rhinitis, therefore the most appropriate treatment is nasal irrigation with saline (local treatment is recommended as first line).

Answer 86

Cryotherapy with liquid nitrogen can be carried out to freeze a wart Topical salicylic acid (15–50%) should be applied once or twice daily for up to 12 weeks Warts are caused by infection in the outer layer of the skin (epidermis) with a virus called the ‘human papilloma virus’. refer to GP for facial warts. Without any treatment, warts may spontaneously resolve but may take many months or even years Preparations of formaldehyde, glutaraldehyde, and silver nitrate are also licensed for the treatment of warts on hands and feet.

Answer 87

A written signed order signed by principal/headteacher at the school must be provided

Answer 88

Temporary hearing loss is a common symptom of Otitis Externa and therefore is not a referral point. Refer: Fever, Mucopurulent discharge, Pain, spreading towards the jaw, Symptoms that are not improving and have been present for 3 or more days 2% acetic acid (Earcalm) cellulitis: infection of deeper layers of skin and surrounding tissue=>antibiotic

Answer 89

* 1–3 months 30–60 mg TDS * 3–6 months 60 mg QDS; * 6 months–2 years 120 mg QDS * 2–4 years 180 mg QDS * 4–6 years 240 mg QDS * 6–8 years 240–250 mg QDS * 8–10 years 360–375 mg QDS * 10–12 years 480–500 mg QDS * 12–16 years 480–750 mg QDS * 16 and over 500 mg–1 g QDS

Answer 90

* 1–3 months 5 mg/kg QDS * 3–6 months 50 mg TDS * 6 months–1 year 50 mg QDS * 1–4 years 100 mg TDS * 4–7 years 150 mg TDS * 7–10 years 200 mg TDS * 10–12 years 300 mg TDS * 12 and over initially 300–400 mg QDS; increased if necessary to max. 600 mg QDS

Answer 91

For disclosures required by law, pharmacists should be satisfied that those requesting confidential information have a legitimate interest NOT TRUE: >If you are asked to disclose confidential information without the consent of the person receiving care, it is not necessary to ask for the request in writing >Pharmacists should not disclose confidential information to the police >Under no circumstances, should pharmacists disclose confidential information without consent >Your professional duty to a patient’s confidentiality ends after they have died

Answer 92

Aspirin (secondary prevention) Clopidogrel is recommended if aspirin is not tolerated. Aspirin/dipyridamole would not be recommended for this patient as it may worsen headaches/migraines. Prasugrel and ticagrelor are not indicated for ischaemic stroke/CVA.

Answer 93

If verbal consent is obtained a record must be kept of this Not True: >If the patient has previously consented to having a vaccination you would not need to obtain consent this time round >Implied consent would be acceptable here in giving a vaccination >The patient does not need to be made aware about information that will be shared with their GP >Written consent must be obtained prior to providing the service >patient consent to share information is not needed if the disclosure can be justified in the public interest >As the patient is a young person, you should use the same criteria to assess competence as you would for an adult >If on this occasion it is deemed that the person lacks capacity, you should not assume that they lack capacity to make all future decisions >If this individual lacked the capacity to consent, the person with parental responsibility for her could give consent if it was in the best interest of the patient to have a health check >You can assume the patient has the capacity to make their own decisions unless there is sufficient evidence to suggest otherwise

Answer 94

most likely to cause neutropenia: Decreased neutrophil levels may be the result of severe infection, liver disease, enlarged spleens or other conditions, such as responses to various medications or chemotherapy

Answer 95

>If the prescription is written by a dentist, it must contain the words ‘For dental treatment only’ >Pharmacist independent prescribers can issue prescriptions for Schedule 2 controlled drugs >The prescription is valid for 28 days after the appropriate date on the prescription >The prescription must include a clearly defined dose >The total quantity must be written in both words and figures

Answer 96

Domperidone Metroclopramide, haloperidol and prochlorperazine should not be used in Parkinson’s disease as they cross the blood brain barrier and cause dopamine blockade, resulting in worsening of symptoms. Ondansetron is contraindicated with apomorphine due to additive QTc prolongation and risk of serious arrhythmia. The manufacturers of apomorphine recommend the use of domperidone to control nausea and vomiting, however there is still a risk of QT prolongation with this combination , hence an assessment of cardiac risk factors and ECG monitoring is recommended to ensure that the benefits outweight the risks.

Answer 97

>Concerns can be reported to someone outside of the organisation >The General Pharmaceutical Council Standards for Pharmacy Professionals require pharmacists to speak up when they have concerns >You can obtain advice from external organisations such as a professional body or union if you are not sure if you should raise a concern >You should follow the organisation’s policy for raising concerns wherever possible DONOT: the first step is to always contact the General Pharmaceutical Council about your concerns

Answer 98

***NSAIDS, BNF primary dysmenorrhea/gout/migraine/pain and inflammation in RA 250 mg tablet 3 times per day Do not exceed three tablets daily Naproxen (1 g daily) is associated with a lower thrombotic risk, and low doses of ibuprofen (1.2 g daily or less) have not been associated with an increased risk of myocardial infarction. COX-2 inhibitors), diclofenac and high dose ibuprofen are associated with increased CVD risk

Answer 99

>Pharmacies can accept waste medicines from patients >Pharmacies cannot accept other household waste such as cosmetics >Pharmacies should remove blister strips from their outer packaging >Schedule 2 controlled drugs should be denatured prior to disposal >Waste medicines must be kept in secure waste containers in a designated area preferably away from medicines

Answer 100

This is a skin condition that causes pink red, flaky, crusty patches of skin covered with silvery scales. These patches normally appear on your elbows, knees, trunk, scalp and behind ears, but can appear anywhere on your body. In some cases, the patches can be itchy or painful Offer topical treatment first-line to all patients with psoriasis. Topical treatment options include emollients, topical corticosteroids, coal tar preparations, and topical vitamin D or vitamin D analogues Emollients are widely used in psoriasis; they moisturise dry skin, reduce scaling, and relieve itching. They also soften cracked areas and help other topical treatments absorb through the skin to work more effectively Continuous long-term use of potent or very potent topical corticosteroids may cause psoriasis to become unstable, and lead to irreversible skin atrophy and striae. Consecutive use of potent topical corticosteroids should not be used for more than 8 weeks at any one site; 4 weeks for very potent topical corticosteroids.

Answer 101

PSNC Clinical audit >Audits can be conducted on topics where clinical guidance does not exist >Data collection is part of the audit cycle >Ethics approval is not required to conduct a clinical audit >NHS community pharmacies are not required to conduct at least one audit per year >Re-audit performance is part of the audit cycle

Answer 102

Care should be taken not to scrub the inside of the spacer as it will affect the way it works. Spacers help improve the distribution of the medicine to the intended site of action and reduce the risk of side effects, hence they should be used wherever possible/feasible, not just indoors. Spacers are only compatible with MDs. Spacers should be cleaned before initial use, and then once a month afterwards

Answer 103

Impetigo is a skin infection that's very contagious but not usually serious. It often gets better in 7 to 10 days if you get treatment. Anyone can get it, but it's very common in young children. Impetigo starts with red sores or blisters, but the redness may be harder to see in brown and black skin. The sores or blisters quickly burst and leave crusty, golden-brown patches. The patches can: look a bit like cornflakes stuck to your skin get bigger spread to other parts of your body be itchy sometimes be painful Advise the person, and their carers if appropriate, about good hygiene measures to aid healing and reduce the spread of impetigo to other areas of the body and to other people. Recommend that the person: Washes affected areas with soap and water. Washes their hands regularly, in particular after touching a patch of impetigo. Avoids scratching affected areas. Avoids sharing towels, face cloths, and other personal care products and thoroughly cleans potentially contaminated toys and play equipment. Ensure optimal treatment of any pre-existing skin conditions such as eczema, head lice, scabies or insect bites. For localised non-bullous (sores) impetigo: Consider prescribing hydrogen peroxide 1% cream (apply two or three times daily for 5 days) for people who are not systemically unwell or at a high risk of complications. If this is unsuitable, prescribe a short course (5 days) of a topical antibiotic, offer: Fusidic acid 2% (apply three times a day for 5 days), or Mupirocin 2% (apply three times a day for 5 days) if fusidic acid resistance is suspected or confirmed. referral if signs of sepsis, blisters (bullous impetigo)

Answer 104

Does an entry need to be made in the POM register within 72 hours? >You have ascertained that the patient previously had the medication dispensed from checking his summary care record >You have ascertained there is an immediate need for the medication and that it is not practical for the patient to obtain a prescription without undue delay >You have added the words ‘Emergency Supply’ to the dispensing label >You have decided to issue enough tablets for 30 days treatment

Answer 105

Sildenafil is not associated with cold hands and feet >Orlistat and urgent bowel movements >Sumatriptan and tingling sensations in the skin >Tamsulosin and dizziness E. Tranexamic acid and diarrhoea

Answer 106

61 year old female is correct. Amorolfine is licensed from 18 years, should not be used in diabetes or in pregnancy. People with three affected nails should be referred. The doctor referring them doesn’t override the licensing

Answer 107

Benzoyl peroxide prevents new lesions rather than shrinking existing ones, and therefore should be applied not just to active lesions. Advise that the face should be washed and left to dry for 20 minutes before applying treatment. Treatment should start with the lower strength product to allow the skin time to adjust to the medication. Acne is notoriously slow to respond to treatment and it can take months to see the maximum benefit. During the first few days, the skin is likely to redden and be irritated

Answer 108

Entire household must be treated One time Mebendazole 100mg

Answer 109

most likely causes jaundice contra: history of co-amoxiclav-associated jaundice or hepatic dysfunction; history of penicillin-associated jaundice or hepatic dysfunction

Answer 110

Symptoms include but are not limited to upper abdominal pain or discomfort, heartburn, gastric reflux, bloating, nausea and/or vomiting. Symptoms can be attributed to an underlying cause (e.g. Gastro-oesophageal reflux disease, Peptic ulcer disease, gastro-oesophageal malignancy, or side effects from drugs), but the majority of patients are likely to have functional dyspepsia, where an underlying cause cannot be identified and endoscopy findings are normal. Urgent endoscopic investigation is required for patients with dysphagia, significant acute gastrointestinal bleeding, or in those aged 55 years and over with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia. Initial management: PPI for 4 weeks, test for H. Pylori Then H2 receptor antagonist, NSAID such as paracetamol, cox2 (celecoxib) unintentional weightloss requires a referral

Answer 111

Opioids reduce peristalsis, increase the anal sphincter tone, and promote absorption of water from the large intestine; this leads to hard stools and constipation. Ispaghula husk, a bulk-forming laxative, can cause obstruction and increase the risk of faecal impaction in opioid-induced constipation especially if fluid intake is inadequate. Constipation from opioid use is best treated with a stimulant laxative, or a stool-softening laxative, or both if necessary. Adequate fluid intake should be maintained. (Source MHRA) Methylnaltrexone and naloxegol are reserved for where first line therapies have failed. distressing cough in terminal lung cancer: diamorphine and methadone, morphone preferred

Answer 112

A raised, itchy red rash (hives) can appear as an allergic reaction to things like stings, medicines or food. The main symptom of hives is an itchy rash. usually get better within a few minutes to a few days The rash can: be raised bumps or patches in many shapes and sizes appear anywhere on the body be on 1 area or spread across the body feel itchy, sting or burn look pink or red when affecting someone with white skin; the colour of the rash can be harder to see on brown and black skin treatment: antihistamine

Answer 113

>Flashing lights >Having an illness causing a high body temperature >Lack of sleep >Not taking prescribed epilepsy medicines >Stress

Answer 114

>Binders are used to help ingredients come together >Colouring agents are used to improve patient acceptability >Diluents are used to provide bulk and accurate dosing >Film coatings are used to protect the tablet from the environment >Glidants are used to improve flow of powders during tablet manufacturing, NOT to allow the tablet to be swallowed with ease

Answer 115

Hyoscine butylbromide causes constipation. Constipation; dizziness; drowsiness; dry mouth; dyspepsia; flushing; headache; nausea; palpitations; skin reactions; tachycardia; urinary disorders; vision disorders; vomiting

Answer 116

hypromellose+latanoprost: leave 5 minutes between using each product Eye drops are generally instilled into the pocket formed by gently pulling down the lower eyelid, blinking a few times to ensure even spread, and then closing the eye; in neonates and infants it may be more appropriate to administer the drop in the inner angle of the open eye. A small amount of eye ointment is applied similarly; blinking helps to spread it. Eye drops and ointments may cause temporary blurring of vision. When two different eye preparations are used at the same time of day, the patient should leave an interval of at least 5 minutes between the two, to allow the first to be fully absorbed; eye ointment should be applied after drops. normally discarded 4 weeks after first opening

Answer 117

an infection of the protective membranes that surround the brain and spinal cord (meninges), can cause sepsis, common in babies, young children, teenagers and young adults symptoms: a high temperature (fever) being sick a headache a rash that does not fade when a glass is rolled over it (but a rash will not always develop) a stiff neck a dislike of bright lights drowsiness or unresponsiveness seizures (fits) call 999 benzylpenicillin, cefotaxime, or chloramphenicol.

Answer 118

fungal infection, can form anywhere even scalp and groin, can be scaly, dry, swollen or itchy Must refer to GP to treat scalp ringworm. Scaling and hair loss are common symptoms. Hydrocortisone cannot be sold in this situation, ringworm is contagious and transferable through objects and often treatment must continue sometime after the rash has disappeared anti fungal cream: terbinafine cream or an imidazole such as clotrimazole, miconazole, or econazole cream inflammation: Hydrocortisone 1% cream to be applied once daily for a maximum of 7 days.

Answer 119

Oral temperature is taken by inserting the bulb of the thermometer under the tongue and sealing the lips around the thermometer

Answer 120

Headaches Skin irritation Upset stomach Vivid dreams Insomnia but not sleepiness

Answer 121

anaphylaxis/hypersensitivity: Clammy skin Collapse Difficulty breathing Lightheaded feeling increased HR

Answer 122

>Large packs of laxatives are not available to purchase in newsagents >One of the reasons these changes have been introduced is due to the misuse and abuse of stimulant laxatives >Stimulant laxatives available on general sale are recommended for use in people aged 18 years or over >Stimulant laxatives can be purchased over the counter for children aged 12 or over

Answer 123

decrease the effectiveness of: warfarin aminophylline/theophylline phenytoin tacrolimus apixaban desogestrel/levenogestrel chc dabigatran digoxin

Answer 124

When supplying a medicine without a WDL, the supply must not be for onward wholesale distribution NOT CORRECT: Pharmacies with a WDL do not need any additional licences for commercially trading controlled drugs B. The requirements for wholesale dealing without a WDL still apply if there is exchange of stock between two pharmacies that are part of the same legal entity C. There is an exemption in UK law for pharmacies to hold a WDL D. When supplying a medicine without a WDL, any amount of profit can be made on the supply

Answer 125

Form a tight seal around the mouthpiece with their lips, then breathe in quickly and deeply

Answer 126

HIGH RISK Loading doses may be required due to long half-life; Therapeutic Range: trough 10 to 15mg/L (15 to 20mg/L for endocarditis or less sensitive strains of methicillin-resistant Staphylococcus aureus or complicated infections caused by S. aureus) Monitoring (all glycopeptides): blood counts, hepatic and renal function, urinalysis, plasma levels, auditory function in elderly warning: (patients advised to report all to doctor immediately) * Ototoxicity (hearing loss, vertigo, dizziness, tinnitus) * Red man syndrome (flushing of the upper body) * Blood disorders (fever, sore throat, mouth ulcers, unexplained bleeding or bruising) * Phlebitis (drug irritates tissue causing inflammation) * Nephrotoxicity (elevated serum creatinine levels) * Skin disorders (rashes, pruritic, SJS) * Hypotension and anaphylaxis occur if administered too quickly Pregnancy and breastfeeding: Manufacturer advises to avoid – if used plasma concentration monitoring essential to minimise foetal toxicity; present in milk, significant absorption unlikely Drug Interactions: * Increased risk of nephrotoxicity and ototoxicity when vancomycin given with ciclosporin, aminoglycosides, polymixin antifungals * Increased risk of ototoxicity when vancomycin given with loop diuretics * Vancomycin enhances effects of suxamethonium A vancomycin trough plasma concentration level should be taken before the 4th dose All patients require serum-vancomycin measurement (on the second day of treatment, immediately before the next dose if renal function normal, earlier if renal impairment—consult product literature). The next vancomycin dose should not be withheld whilst awaiting results unless toxicity is suspected. Administration rate should not exceed 10mg/min to reduce the risk of red-man’s syndrome.

Answer 127

Beta Blocker adverse drug reaction: Fatigue is a lesser known side effect of beta blockers but important to mention in counselling. Causes bradycardia rather than tachycardia.

Answer 128

Specific side effects Common or Very Common Abdominal pain, Antibiotic associated colitis, diarrhoea. adverse drug reaction: abdominal pain

Answer 129

SE: may cause fungal overgrowth

Answer 130

contraindicated in uncontrolled epilepsy

Answer 131

rash tends to start behind ears and on face before spreading to the rest of the body

Answer 132

an acute viral illness characterized by vesicular eruptions in the mouth and papulovesicular lesions of the distal limbs. It is not to be confused with foot and mouth disease of animals, which is caused by a different virus. sore throat, low-grade fever and tender lesions in the mouth and papulovesicular lesions of the distal limbs

Answer 133

characterised by the sudden onset of a seal-like barking cough, often accompanied by stridor, voice hoarseness, and respiratory distress. Mild croup is largely self-limiting; but treatment with a single dose of a corticosteroid e.g. dexamethasone is usually offered. More severe croup (or mild croup that might cause complications) calls for hospital admission, dexamethasone or budesonide (by nebulisation) will often reduce symptoms; the dose may need to be repeated after 12 hours if necessary. If still not controlled, nebulised adrenaline solution is given.

Answer 134

presents with excessive crying, inconsolable crying which occurs in late afternoon or evening and draws its knees up to abdomen when crying. signs of colic which starts in the first weeks of life and resolves by around 3–4 months of age.

Answer 135

Diuretic>Potassium-Sparring Diuretic>Aldosterone Antagonist Adjunct in stable patients with left ventricular ejection fraction ≤40% with evidence of heart failure, following myocardial infarction (start therapy within 3–14 days of event), Adjunct in chronic mild heart failure with left ventricular ejection fraction ≤30% Initially 25 mg daily, then increased to 50 mg daily, increased within 4 weeks of initial treatment. Contra: hyperkalaemia ***causes potassium retention, potassium supplement not to be given thiazide: relieve oedema due to HF to reduce blood pressure loop: in pulmonary oedema due to left ventricular failure/chronic heart failure

Answer 136

Warning. Do not stop taking this medicine unless your doctor tells you to stop

Answer 137

Take this medicine when your stomach is empty. This means an hour before food or 2 hours after food

Answer 138

Tetracyclic antidepressant Major depression Warning: This medicine may make you sleepy. If this happens, do not drive or use tools or machines. Do not drink alcohol

Answer 139

Tricyclic antidepressant Depressive Illness

Answer 140

Aminosalicylate: High Risk Drug Ulcerative Colitis/Crohns Disease ***Sulfasalazine has been confused with sulfadiazine monitoring: full blood count (white and platelet, bc prone to blood disorders), renal function, liver function This medicine may colour your urine/body fluids yellow/orange. This is harmless; contacts may be stained. SE: insomnia, stomatitis (sore mouth), taste altered; tinnitus (hearing), urine abnormalities Warning: jaundice, unexplained bruising/bleeding (blood disorder), signs of infection (fever, malaise, sore throat) maintain fluid intake, need folic acid, caution in G6PD reduces digoxin, bone marrow suppresion/leucopenia with azathioprine/6-meraptopurine Treatment of mild to moderate ulcerative colitis, acute attack >2.4g in divided doses (Asacol MR 400) >2.4g-4.8g in divided doses (Asacol MR 800) >2.4g-4.8g OD or divided doses (Octasa) >4g OD or divided doses (Pentasa tablets: Manufacturer advises tablets may be halved, quartered, or dispersed in water, but should not be chewed. Pentasa granules: Manufacturer advises granules should be placed on tongue and washed down with water or orange juice without chewing In Children: Expert sources advise contents of one sachet should be weighed and divided immediately before use; discard any remaining granules.) Hepatic/Renal Impairment: caution in mild to moderate, avoid in severe MR tablet: Take with or just after food, or a meal, Swallow this medicine whole. Do not chew or crush GR tablet: Do not take indigestion remedies 2 hours before or after you take this medicine, Swallow this medicine whole. Do not chew or crush MR granules: Swallow this medicine whole. Do not chew or crush Hepatic/Renal impairment: caution in mild to moderate, avoid in severe >Renal function should be monitored before starting, at 3 months, and annually during treatment Breast feeding: diarrhoea in breast-fed infant Contra-indicated: blood clotting abnormalities Stick to same brand Side Effects: gastrointestinal symptoms, aches and pains, blood disorder: unexplained bleeding, bruising, red or purple discolourations of the skin (purpura), sore throat, a high temperature (fever), or if you feel generally unwell (malaise).

Answer 141

antidote and chelator recombinant form of human factor Xa Reversal of apixaban or rivaroxaban in life-threatening or uncontrolled bleeding

Answer 142

treatments not recommended bulk-forming laxatives for constipation/diarrhoea, antibacterials not recommended, paracetamol for analgesia

Answer 143

Antispasmodic IBS 200mg BD Symptomatic relief: max. single dose is 135 mg, max. daily dose is 405 mg; For uses other than symptomatic relief of irritable bowel syndrome: max. single dose is 100 mg and max. daily dose is 300 mg. Suspension not for children under 10, Tablet/MR capsule not for use in children. Avoid in pregnancy Side effects: mild, rarely causes problem, allergy (itchy rash, swelling), angiodema/face oedema isphagula husk to aid dietary fibre, do not use lactulose second-line: can use tricyclic antidepressant (amitriptyline) or if not tolerated, SSRI

Answer 144

Bulk-forming: isphagula husk, methycellulose, sterculia (onset 72 hrs) Stimulant: senna, co-danthramer, bisacodyl Faecal softeners: decussate sodium, glycol Osmotic: lactulose, macrogrol opiod-induced: bulk avoided, osmotic or docusate and a stimulant are recommended, naloxegol/methylnaltrexone recommended when response to others is inadequate in pregnancy: bulk is 1st choice, osmotic can be used as well as Senna/bisacodyl children: laxative with dietary change, bulk then stimulant Diarrhoe: ORT, loperamide

Answer 145

Magnesium-containing: laxative Aluminium-containing: constipating Bismuth-containing: not recommended, can be neurotoxic calcium-containing: can induce rebound acid, high-doses can cause hypercalaemia

Answer 146

H2 receptor antagonists: heal ulcers/relieves symptoms of GERD by reducing gastric acid output ***Zollinger-Ellison syndrome (too much gastric acid) better treated by PPI Pregnancy: if lifetyle changes and antacid/alginate don't work, omeprazole or ranitidine can be used in severe cases. FA: chlorphenamine

Answer 147

cholestasis: impairment of bile formation cholestatis pruritus: colestyramine GB: paracetamol=>IM diclofenac=>IM opiod ursodeoxycholic acid can be used but no evidence

Answer 148

bulk forming or osmotic as an alternative, topical prep (lidocaine ointment) or paracetamol chronic AF (6 weeks+): GTN rectal ointment 0.4% 0r 0.2% (higher strength has more side effects), alternative diltiazem hcl 2% or nifedipine 0.2-0.5% H: if constipated, bulk forming and paracetamol. opioids avoided cause constipation, NSAIDs avoided cause rectal bleeding. topical corticosteroid no more than 7 days (anusol HC, sheriproct, proctosedyl) and local anasthetic for a few days (excessive application avoided bc irritation and sensitisation of anal skin) pregnancy: no preparation for use, only bulk forming

Answer 149

reduced secretion of pancreatic enzymes causing maldigestion, malnutrition treatment: pancreatic enzyme replacement (Creon)

Answer 150

***all patients should be assessed for risk of stroke, thromboprophylaxis need, and risk of bleeding using CHA2DS2-VASc (0 for men, 1 for women is low risk) assessment tool for stroke risk and the HAS-BLED tool for bleeding risk 1st line: rate control with beta blocker, CCB (diltiazem) or verapamil as monotherapy digoxin: mono therapy in sedentary patients when single drug fails, combination of beta blocker, digoxin, or diltiazem can be used. sinus-rhythm post-cardioversion: beta blocker (sotalol, flecainide, propafenone, and amiodarone)

Answer 151

abnormal heart rhythm: regular but rapid heartbeat that starts and stops abruptly treat with adenosine, digoxin **verapmil cannot be used after beta blocker

Answer 152

Tranexamix acid (inhibits fibrinolysis) Desmopressin (mild to moderate haemophilia and von Villebrand's disease

Answer 153

anti-embolism stockings (mechanical) worn all day and night until patient is sufficiently mobile patients with risk factors should only be on pharmacological prophylaxis low molecular weight heparin suitable in all types of surgery; heparin (unfractioned) in renal impairment, or fondaparinux. acute illness: LMWH as 1st line or Fonda birth/miscarriage/termination: in past 6 weeks, start LMWH 4-8 hrs after event and continued min 7 days pregnancy: heparins dont cross placenta, lmwh preferred bc lower risk of osteoporosis and heparin-induced thrombocytopenia, lmwh more rapidly eliminated requiring alteration of dose (dalteparin, enoxaparin, tinzaparin) and treatment should be stopped at onset of labour endoxaban not an alternative to unfractioned heparin Initial treatment of deep-vein thrombosis and pulmonary embolism uses a low molecular weight heparin or unfractionated heparin IV infusion. Warfarin is usually started at the same time (the heparin needs to be continued for at least 5 days and until the INR is ≥2 for at least 24 hours). Laboratory monitoring for unfractionated heparin, preferably on a daily basis, is essential.

Answer 154

TIA: Aspirin 300 mg immediately (if aspirin contraindicated clopidogrel 75 mg immediately) Acute ischaemia stroke: alteplase within 4.5 hrs of onset, treatment with aspirin 300 mg once daily for 2 weeks should be initiated 24 hours after thrombolysis (clopidogrel 75mg once daily if aspirin contraindicated) long-term management tia/is: clopidogrel, if contraindicated then MR dipyridamole with aspirin, if aspiring and clopidogrel contraindicated, then MR dipyridamole only, if MR and clopidogrel contraindicated then aspirin alone high-intensity statin to be started 48 hrs after onset, blood pressure checked (less than target 130/80) and treatment initiated but not with beta blockers

Answer 155

2.5, within 0.5 units is generally satisfactory Oral anticoagulants: coumarins and phenidione warfarin (drug of choice) acenocoumarol phenidone takes 48-72 hrs for effect to develop fully not to be used in cerebral artery thrombosis, peripheral artery occlusion, tia risk (aspiring more appropriate) main adverse effect: haemorrhage give phytomenadione to stop bleeding stop warfarin 5 days before surgery

Answer 156

unfractioned heparin initiates anticoagulation rapidly but has a short duration of action meaning more frequent dosing compared to LMWH which have a longer duration of action unfractioned heparin used in high risk of bleeding because effect can be terminated rapidly, whereas LMWH are for routine use LMWH (dalteparin, enoxaparin, tinzaparin) preferred over unfractioned heparin in venous thromboembolism prophylaxis since they are as effective and lower risk of heparin-induced thrombocytopenia

Answer 157

Warfarin High Risk Drug Avoid Cranberry juice While amoxicillin, benzylpenicillin, clindamycin, ciprofloxacin, co-amoxiclav, tigecycline and trimethoprim all have the potential to interact with warfarin Clarithromycin is in the BNF as a potentially serious interaction. Take at least 48 to 72 hours for the anticoagulant effect to develop fully Target INR: 1.1 or below in healthy people, 2.5 for most indications, 3.5 for recurrent DVT or PE Duration: 6 weeks for isolated calf-vein DVT 3 months for venous thromboembolism provoked by surgery or other transient risk factor (e.g. combined oral contraceptive use, pregnancy, plaster cast) at least 3 months for unprovoked proximal DVT or PE; may be required long-term WARNING: * Haemorrhage – reversed with phytomenadione (nosebleeds, bleeding from wounds, bruising) * Deep-vein thrombosis / Pulmonary embolism (pain, swelling, tenderness usually in calf, redness of skin, chest pain, shortness of breath) * Haemorrhagic stroke (Headaches, confusion) * Rash, skin necrosis, purple toes * Diarrhoea and vomiting (may lead to poor absorption) monitoring: * INR: on alternate days in early days of treatment, then at longer intervals up to every 12 weeks * Liver function * Renal function * Full blood count * Blood pressure * Thyroid function Pregnancy: teratogenic in 1st and 3 trimester * Anticoagulant treatment booklet/ alert card * Take at the same time of day, once a day with a full glass of water, if a dose is missed DO NOT double the dose the next day * Patient should notify their anticoagulation clinic of any changes to medication, lifestyle or diet; not to change vitamin K intake (dark leafy greens) * Brown tablets = 1mg Blue tablets = 3mg Pink tablets = 5mg * dose is expressed in milligrams and not the number of tablets

Answer 158

aspirin only to be use as secondary prevention of CVD; clopidogrel as an alternative MR dipyridamole (take 30-60min before food, discard after 6 weeks, enhances adenosine) for secondary prevention of is/tia Prasugrel or Ticagrel in combination with aspirin for up to 12 months for the prevention of atherothrombotic events in patients with acute coronary syndrome Aspiring not to be given under age of 16 due to Reye's syndrome (vomiting, fatigue, seizures, liver and brain damage) or anyone hypersensitive to aspiring/NSAIDs Clopidogrel interacts with statins, -pines (carbamazepine), -zoles (ketoconazole), SSRI, methotrexate

Answer 159

cardioselective (atenolol, bisoprolol, metoprolol, nebivolol) avoid in patients with asthma or bronchospasm (or give with caution if no other alternative) Water-soluble beta-blockers (such as atenolol, celiprolol hydrochloride, nadolol, and sotalol hydrochloride) are less likely to enter the brain, and may therefore cause less sleep disturbance and nightmares. Water-soluble beta-blockers are excreted by the kidneys and dosage reduction is often necessary in renal impairment. can be used in prophylaxis of migraine HF: bisoprolol, carvedilol, nebivolol glaucoma: beta-, levo-, timo-lol bradycardia with IV injection propranolol can reverse thyrotoxicosis within 4 days can mask hypo in diabetic

Answer 160

-pines, diltiazem, verapamil nifedipine prescribed by brand

Answer 161

-prils caution in Afro-Caribbean

Answer 162

-artans caution in Afro-Caribbean

Answer 163

ACE and a beta blocker (biso, carvedi, nebiv) should be first line if ACE not tolerated, ARB (candesartan, losartan, valsartan) if symptoms worsen, aldosterone antagonist as an add-on (spirinolactone, eplerenone) if ACE and ARB not tolerated, hydralazine with a nitrate

Answer 164

acute attacks of stable angina/prophylaxis managed with GTN sublingual long-term chest pain prevention in stable angina: beta blocker, then ccb instead if not tolerated can combine ccb with beta blocker neither beta or ccb works, then nitrate, ivabradine, nicorandil, ranolazine used as mono therapy

Answer 165

cleaned once a month by washing with mild detergent and then left to air dry without rinsing, mouthpiece wiped clean of detergent before use should be replaced every 6-12 months

Answer 166

severe/life-threatening asthma attacks: administered over 5-10 minutes from the nebuliser, driven by oxygen nebuliser converts a solution of drug into an aerosol for inhalation, delivering higher dose of drug to the airway than standard inhaler indications for usage are to deliver: beta2 agonist or ipratropium with an acute exacerbation/COPD beta 2 agonist, corticosteroid, or ipratropium regularly in patient with severe asthma or unable to use other inhalation device antibiotic (colistimethate) or mucolytic in cystic fibrosis budesonide or adrenaline/epinephrine in child with severe croup pentamidine for prophylaxis/treatment of pneumocystis pneumonia =>home trial should be undertaken for 2 weeks on standard treatment and up to 2 weeks on nebulised treatment before prescribing patient must have clear instruction, not treat acute attacks without seeking help, have regular followup after 1 month then annually

Answer 167

Complete control of asthma is defined as no daytime symptoms, no night-time awakening due to asthma, no asthma attacks, no need for rescue medication, no limitations on activity including exercise, and normal lung function and minimal side effects lifestyle: weightloss can improve symptoms, smoking cessation, breathing excersises Age 5-16: >Offer SABA (reliever inhaler: salbutamol or terbutaline) in newly diagnosed >Paediatric low dose ICS (preventer) as 1st-line maintenance with symptoms 3 times a week+/causing waking at night or uncontrolled with SABA alone >uncontrolled with ICS, add LTRA >uncontrolled with ICS and LTRA, then stop LTRA and start LABA (salmeterol/formoterol) >uncontrolled with ICS and LABA, then ICE with MART 17+: >Offer SABA as reliever >low dose ICS as first-line maintenance with symptoms 3 times a week+/causing waking at night or uncontrolled with SABA alone >if uncontrolled with ICS, add LTRA (montelukast) >if uncontrolled with ICS and LTRA, offer LABA with ICS (with or without LTRA) >if Uncontrolled, change to MART with ICS >if uncontrolled MART and ICS with/without LTRA, increase ICS (either continuing on a MART regimen or changing to a fixed dose of an ICS and a LABA, with a SABA as a reliever therapy). >consider theophylline

Answer 168

Moderate: increasing symptoms, Peak flow >50-75% Severe: Peak flow >33-50% Respiratory rate ≥ 25/min Heart rate ≥ 110/min Inability to complete sentences in one breath Life-Threatening: * Peak flow < 33% best or predicted * Arterial oxygen saturation (Sp02) < 92% * Partial arterial pressure of oxygen (PaO2) < 8 kPa * Normal partial arterial pressure of carbon dioxide (PaCo2) (4.6–6.0 kPa) * Silent chest * Cyanosis (blue discoloration) * Poor respiratory effort * Arrhythmia * Exhaustion * Altered conscious level * Hypotension Near-Fatal: Raised PaCO2, requiring mechanical ventilation with raised inflation pressures, or both Management: supplementary oxygen to maintain SpO2 between 94-98% 1st line: high dose SABA (salbutamol, terbutaline) Prescribe prednisolone Can add the following if no improvement: a. nebulised ipratropium bromide b. intravenous dose of magnesium sulfate c. intravenous aminophylline (caution if patient already on theophylline) Under 2: high flow oxygen in tight-fitting mask/cannula to achieve SpO2 94-98% 1st-line: SABA asap, discontinue LABA Prescribe prednisolone treatment up to 3 days

Answer 169

smoke cessation; pneumocococcal vaccine and influence vaccine offered, pulmonary rehabilitation, treat comorbidities, develop self-management plan Inhaled therapies: SABA or SAMA as needed Route 1 (no asthmatic features): LABA+LAMA =>if day to day symptoms impact quality of life, 3 month trial: LABA+LAMA+ICS no improvement back to LABA+Lama =>1 severe or 2 moderate exacerbating in 1 year: LABA+LAMA+ICS Route 2 (asthmatic features): LABA+ICS =>1 severe or 2 moderate exacerbating in 1 year: LABA+LAMA+ICS xAsthmatic features/features suggesting steroid responsiveness in this context include any previous secure xxdiagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time xx(at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%). Prophylactic antibiotics: azithromycin to reduce risk of exacerbations in nonsmokers

Answer 170

risk of hypokalaemia Caution and monitoring: severe asthma as risk is increased with concomitant theophylline, corticosteroid, and diuretic use, as well as with hypoxia.

Answer 171

HIGH RISK Xanthanes SE: arrythimias, diarrhoea, dizziness, GORD, tremor Theophylline is a antimuscarinic used as a bronchodilator in asthma, and stable COPD. Aminophylline is rarely given as an infusion for severe acute asthma. Therapeutic Range: 10 to 20mg/L (although a plasma theophylline concentration of 5 to 15mg/L may still be effective); loading doses may be required WARNING: toxicity (vomiting, hypokalaemia, arrhythmia/tachycardia, restless), uncontrolled asthma (cough, wheeze, tight chest), frequent antibiotic courses interactions: diltiazem, oestrogen, quinolones, alcohol, carbamazepine caution: HF, hepatic, viral infection, elderly use same brand monitoring: potassium, theophylline conc. Potentially serious hypokalaemia may result from beta agonist therapy. Caution required in severe asthma, because this effect may be potentiated by concomitant use of theophylline, corticosteroids, and diuretics as well as hypoxia. Plasma potassium should be monitored in severe asthma concentration decreased in smokers, inform GP before stop/starting as adjustment needed continue with monitoring in pregnancy

Answer 172

Antihistamine, non-sedating A: (12-adult) 8mg TDS C: 2-5: 2.5mg BD 6-11: 5mg BD 12-adult: 10mg OD seasonal allergy F: 6-11: 30mg BD 12-Adult: 120mg OD chronic allergy 12-adult: 180 mg OD L: 5mg OD Lora: child ups 11 under 31kg: 6mg OD 10mg OD

Answer 173

secure airway, restore BP (lay patient flat, lift legs OR recovery position if unconscious/nauseous) 1 month-5 yrs: 150mcg 6yrs-11yrs: 300mcg 12-17: yrs: 500 mcg Adult: 500 mcg repeat in 5 min intervals

Answer 174

Corticosteroid SE: oral candidiasis beclometasone inhaler by brand Easyhaler beclometasone is not licensed for children under 18 years; Qvar, Clenil 200 and 250 are not licensed for children under 12. alleviation of symptoms with 3-7 dats in asthma (Beclometasone, budesonide, fluticasone, and mometasone appear to be equally effective) discontinue if bronchospasm steroid card for high doses SE in children: growth failure, reduced bone mineral density, and adrenal suppression. Small risk of glaucoma; monitor eyes for cataracts, and weight and height for growth

Answer 175

indicated: seasonal hay fever caused by pollen that has not responded to anti-allergic drugs hypersensitivity to wasp/bee venom avoid in patients: asthma, pregnant, child under 5, beta blockers, ACE

Answer 176

evidence of lung disease (mucolytic): dornase alpha, if adequate response add hypertonic sodium chloride OR hypertonic NaCl alone if dornase alpha is unsuitable, use mannitol dry powder Lumacaftor is not recommended ursodeoxycholic can be given to retire liver function in liver function is abnormal monitor: cystic fibrosis-related low bone mineral density and diabetes

Answer 177

Children under 6 years should not be given OTC cough and cold medicines containing the following ingredients: * antihistamines * cough suppressants * expectorants * decongestants OTC cough/cough medicines for children 6-12 restricted to 5 days or less treatment OTC codeine containing cough suppressant avoided: children under 12 CYP2D6 ultra rapid metaboliser breastfeeding mother children under 18 with respiratory problems, tonsil removal, sleep apnea dextromethorphan avoided under 12 (cough suppressant)

Answer 178

mild to moderate, monotherapy with: acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are 1st line if not tolerated, then alternative memantine (moderate to severe Alzheimers) if already receiving acetylcholinesterase, addition of memantine if Alzheimers develops to moderate/severe discontinuing acetylcholinesterase can worsen cognitive function

Answer 179

donepezil or rivastigmine should be given with mild-moderate dementia with Lewy bodies, galantamine can only be considered if other two not tolerated D or R can be used in severe as well where acetylcholinesterase are contraindicated, memantine can be used antipsychotic drugs only offered if risk of harm to self/others, agitation, severe distress, hallucinations=>increase risk of stroke/death when used in elderly, lowest dose, short time should be used and reviewed every 6 weeks depression/anxiety antidepressants reserved for pre-existing mental health condition sleep disturbance non-drug treatments

Answer 180

When monotherapy with a first-line antiepileptic drug is unsuccessful (does not reduce or stop seizures, or if side-effects are intolerable), monotherapy with an alternative drug should be tried; the diagnosis should be checked before starting an alternative drug if the first drug showed lack of efficacy. The change from one antiepileptic drug to another should be cautious, slowly withdrawing the first drug only when the new regimen has been established. Combination (adjunctive) therapy with two or more antiepileptic drugs may be necessary, but the concurrent use of antiepileptic drugs increases the risk of adverse effects and drug interactions. If combination therapy does not reduce seizures, revert to the regimen (monotherapy or combination therapy) that provided the best balance between tolerability and efficacy. A single antiepileptic drug should be prescribed wherever possible. ***antiepiletics: increased risk of suicidal thoughts and behaviour ***switching 1. Patient should be maintained on a specific brand Phenytoin, carbamazepine, phenobarbital, primidone 2. Supply of a specific brand based on clinical judgment Valproate, lamotrigine, perampanel, retigabine, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate 3. Unnecessary to supply a specific brand Levetiracetam, lacosamide, tiagabine, gabapentin, pregabalin, ethosuximide, vigabatrin ***antiepileptic hypersensitivity syndrome (carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide) ***withdraw antiepileptic drugs from a seizure-free patient may be considered after the patient has been seizure-free for at least two years ***DVLA: patients who have had a first unprovoked epileptic seizure or a single isolated seizure must not drive for 6 months, then can be resumed if assessed, can drive if not a danger and compliant with treatment (to continue driving, these patients must be seizure-free for at least one year) Patients who have had a seizure while asleep are not permitted to drive for one year from the date of each seizure (unless history/pattern only occurs while asleep over one year or established pattern over 3 yrs if had zeisure while awake) should not drive during any changes to medications and 6 months after last dose ***valpraote/valproic: teratogenic, lamotrigine and levetiracetam are safer Focal seizures with or without secondary generalisation: >monotherapy of lamotrigine or levetiracetam as first-line options >carbamazepine, oxcarbazepine, or zonisamide as second-line monotherapy options >Lacosamide should be considered as third-line monotherapy Tonic-clonic seizures >sodium valproate as first-line monotherapy > lamotrigine or levetiracetam [unlicensed use] as alternative second-line options Absence > ethosuximide as first-line treatment >sodium valproate as second-line monotherapy or adjunctive treatment for males, and females unable to have children >lamotrigine or levetiracetam [unlicensed use] should be considered as third-line monotherapy or adjunctive treatment Myoclonic seizures > sodium valproate as first-line treatment for myoclonic seizures in males, and females unable to have children >levetiracetam should be offered as second-line monotherapy or adjunctive treatment >For females who are able to have children, offer levetiracetam [unlicensed use] as first-line monotherapy Atonic or tonic seizures > sodium valproate as first-line treatment >lamotrigine should be offered as second-line monotherapy or adjunctive treatment >females who are able to have children, offer lamotrigine as first-line monotherapy. Dravet Syndrome >Sodium valproate should be considered as first-line >consider triple therapy with clobazam and stiripentol as first-line adjunctive therapy. Lennox-Gastaut syndrome >Sodium valproate should be considered as first-line treatment >lamotrigine as second-line monotherapy or adjunctive treatment >Third-line adjunctive treatment options include cannabidiol with clobazam in certain patients, or clobazam, rufinamide, or topiramate. Repeated or cluster seizures, or prolonged seizures >treatment with a benzodiazepine (such as clobazam or midazolam) Convulsive status epilepticus >Parenteral thiamine should be considered if alcohol abuse is suspected; pyridoxine hydrochloride should be given if the status epilepticus is caused by pyridoxine deficiency >buccal midazolam or rectal diazepam in the community >intravenous access and resuscitation facilities are immediately available, intravenous lorazepam can be used

Answer 181

High Risk inhibits voltage-gated sodium channels, thus preventing repetitive firing of action potentials) Therapeutic range: 4 to 12mg/L (20 to 50 micromol/litre); brand-specific category 1 warning: toxicity (incoordination, blurred/double vision, nausea, vomiting, hyponatraemia), blood disorder, skin disorder (mouth ulcer, rash), hepatic disorder, antiepiletpic hypersensitivity syndrome (fever, rash, swollen lymph nodes) monitoring: plasma concentration after 2 weeks, full blood count, renal and hepatic function interations: cemitidne, clarithromycin, phenytoin, rifabutin, st john, corticosteroid, oestrogen, progestogen, simvastatin, orlistat

Answer 182

Lisdexamfetamine or methylphenidate: 1st line if symptoms not improved within 6 week trial, switch to alternative 1st line drug. Dexamfetamine sulfate [unlicensed] can be tried if the patient is having a beneficial response to lisdexamfetamine mesilate but cannot tolerate its longer duration of effect Modified-release preparations of stimulants are preferred: pharmacokinetic profile, convenience, improved adherence, reduced risk of drug diversion, and the lack of need to be taken to work In patients who are intolerant to both methylphenidate hydrochloride and lisdexamfetamine mesilate, or who have not responded to separate 6-week trials of both drugs, treatment with the non-stimulant atomoxetine can be considered specialist service to start with guanfacine if nothing else has worked

Answer 183

Antipsychotic drugs (such as haloperidol, olanzapine, quetiapine, and risperidone) are used in the treatment of acute episodes of mania or hypomania; if the response to antipsychotic drugs is inadequate, lithium or valproate may be added. asenapine: moderate to severe manic episodes associated with bipolar disorder olanzapine: long-term management of bipolar disorder lithium: treatment of acute episodes of mania or hypomania in bipolar disorder, long-term management of bipolar disorder to prevent recurrence of acute episodes, when not tolerated valproate can be used carbamazepine: long-term management of bipolar disorder, to prevent recurrence of acute episodes in patients unresponsive to lithium therapy When discontinuing antipsychotic drugs, the dose should be reduced gradually over at least 4 weeks to minimise the risk of recurrence

Answer 184

High Risk Drug (inhibits voltage-gated sodium channels, thus preventing repetitive firing of action potentials) Therapeutic Range: 10 to 20mg/L (or 40 to 80 micromol/litre); brand-specific category 1; Non-linear relationship between dose and plasma drug concentration (dose changes and missed doses) Preparations containing phenytoin sodium and phenytoin base are not bioequivalent. 100mg of phenytoin sodium is equivalent in therapeutic effect to 92mg phenytoin base. When switching formulations, the difference in phenytoin content may be clinically significant. Warning: toxicity, skin disorder, hepatotoxicity, blood disorder, suicidal thoughts, low vitamin D (rickets, osteomalacia) * Increased plasma concentrations with amiodarone, chloramphenicol, cimetidine, disulfiram, diltiazem, fluconazole, fluoxetine, miconazole, topiramate, trimethoprim, metronidazole, clarithromycin, telithromycin * Reduced plasma concentrations with rifamycins, st Johns Wort, theophylline, itraconazole, ciclosporin

Answer 185

SSRI: better tolerated, safe in overdose Tricyclic: discontinued bc side effects (toxicity in overdosage), more sedating, antimuscarinic, cardiotoxic effects than SSRI MAOI: interaction with foods St. Johns should not be prescribed/recommended for depression, multiple drug interactions as it is a drug inducer risk of hyponatraemia in all antidepressants (more frequent with SSRI) serotonin syndrome: uncommon adverse reaction (can occur with changes in antidepressant during washout period, irreversible MAOI or long half-life), tremor, BP, shivering, tachycardia, confusion, agitation, mania

Answer 186

acute anxiety: benzodiazepine or buspirone hydrochloride chronic: benzo may be required until antidepressant takes effect generalised: psychological treatment before an SSRI (escitalopram, paroxetine, or sertraline [unlicensed]). Duloxetine and venlafaxine (serotonin and noradrenaline reuptake inhibitors (SNRIs)) are also recommended for the treatment of generalised anxiety disorder; if the patient cannot tolerate SSRIs or SNRIs (or if treatment has failed to control symptoms), pregabalin can be considered. Panic: SSRIs, clomipramine hydrochloride [unlicensed] or imipramine hydrochloride [unlicensed] can be used second-line OCD/PTSD/Social anxiety: SSRIs. Clomipramine hydrochloride can be used second-line for obsessive-compulsive disorder. Moclobemide is licensed for the treatment of social anxiety disorder

Answer 187

Tricyclic antidepressant Depressive Illness not effective for treating depression in children

Answer 188

food restrictions, tyramine Drepressive illness Tranylcypromine has a greater stimulant action than phenelzine or isocarboxazid and is more likely to cause a hypertensive crisis. Isocarboxazid and phenelzine are more likely to cause hepatotoxicity than tranylcypromine. Moclobemide should be reserved as a second line treatment.

Answer 189

Other antidepressants should not be started for 2 weeks after treatment with MAOIs has been stopped (3 weeks if starting tricyclic: clomipramine or imipramine), 1 week for SSRI (5 weeks for fluoxetine)

Answer 190

first generation, antipsychotic (more likely to cause SE) schizophrenia ***haloperidol/Zuclophenthixol: preparation for acute apisode not to be confused with depot preparation for maintenance ***Zuclophenthixol acetate confused with Zuclophenthixol decanoate

Answer 191

Treatment should ideally be restricted to 2 days per week and patients should be advised of the risk of developing medication-overuse headache Monotherapy, with either aspirin, ibuprofen, or a 5HT1-receptor agonist (‘triptan’) is recommended as first-line treatment and should be taken as soon as the patient knows that they are developing a migraine (start of headache phase). In patients who experience aura with their migraine, it is recommended that 5HT1-receptor agonists are taken at the start of the headache and not at the start of the aura (unless the aura and headache start at the same time). Treatment with a 5HT1-receptor agonist can be repeated after 2 hours with the same or different drug if there has been an inadequate response to the initial dose. sumatriptan is the 5HT1-receptor agonist of choice. Alternative 5HT1-receptor agonists include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, and zolmitriptan. NSAIDS: naproxen [unlicensed indication], tolfenamic acid, and diclofenac potassium antiemetic: Metoclopramide hydrochloride or prochlorperazine prophylactic: Propranolol (first-line preventative treatment in patients with episodic or chronic migraine). if propranolol is unsuitable, other beta-blockers that can be considered are metoprolol tartrate, atenolol [unlicensed indication], nadolol, and timolol maleate.

Answer 192

treatment based on severity of infection that does not require IV treatment: mild: 1st line flucloxacillin moderate/severe: min 7 days up to 6 weeks in osteomyelitis =>oral/IV=>flucloxacillon with/without IV gentamicin and/or metronidazole (can use co-amoxiclav instead of fluclo)

Answer 193

Otitis externa: fluclolaxacillin, if penicillin allergy then clarithromycin Otitis media: amoxicillin 1st line, co-amoxiclav 2nd line if penicillin allergy, clarithromycin

Answer 194

tetracycline initial phase 4 drugs: rifampicin, ethambutol, pyrazinamide, isoniazid for 2 months continuation phase 2 drugs: rifampicin and isoniazid (with pyridoxine) for 4 further months

Answer 195

1st choice: nitrofurantoin 100mg MR BD for 3 dats trimethoprim: 200mg BD for 3 days 2nd choice: nitrofurantoin 100mg MR BD for 3 days pivmecillinam: 400mg initial, then 200mg TDS for 3 days Fosfomycin: 3g single dose sachet 3 months an over 1st choice: trimethoprim nitrofurantoin 2nd: nitrofurantoin amoxicillin cefalexin

Answer 196

co-trimoxazole

Answer 197

3 month paracetamol/NSAID trial as 1st line hormonal treatment offered (combined, pop) surgery

Answer 198

menoragghia levonorgestrel-releasing intra-uterine system is 1st line (irregular bleeding can occur during first months, can take uo to 6 months to recieve full benefit) if unsuitable, trxnexamic acid, NSAID, coc, or cyclical oral progestogen should be considered

Answer 199

carbimazole (propylthiouracil if carbimazole intolerant) levo with carbimazole in blocking-replacement regimen given for 18 months. not for pregnancy radioactive sodium iodide used in treatment of thyrotoxicosis, not in pregnancy pregnancy: 1st trimester (propylthiouracil, risk of hepatotoxicity), 2nd carbimazole (congenital defects)

Answer 200

onotherapy with a conventional disease-modifying antirheumatic drug (DMARD) (oral methotrexate, leflunomide, or sulfasalazine) should be given as first-line treatment; hydroxychloroquine sulfate, a weak conventional DMARD, is an alternative in patients with mild rheumatoid arthritis or those with palindromic rheumatism. Treatment should be started as soon as possible, ideally within 3 months of onset of persistent symptoms, and the dose should be titrated to the maximum tolerated effective dose. Conventional DMARDs have a slow onset of action and can take 2–3 months to take effect; consider short-term bridging treatment with a corticosteroid Treatment with a tumour necrosis factor (TNF) alpha inhibitor (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab), other biological DMARD (abatacept, sarilumab, or tocilizumab), or targeted synthetic DMARD (baricitinib, filgotinib, tofacitinib, or upadacitinib) is recommended if there has been an inadequate response to combination therapy with conventional DMARDs. Pain relief: NSAID, COX2 as well as PPI if already taking aspirin, other treatment to be considered before NSAID

Answer 201

IV only, intrathecal cause severe neurotoxicity

Answer 202

NSAID not in HF, renal, hepatic impairment, pregnancy, GI disorders avoid contact with eyes, broken skin, mucous membranes

Answer 203

HIGH RISK NSAIDs reduce the production of prostaglandins by inhibiting the enzyme cyclo-oxygenase. Selective inhibition of cyclo-oxygenase-2 is associated with less gastro-intestinal intolerance, but greater cardiovascular risk. WARNING SIGNS (patient to report immediately to a doctor) * Black stools or ‘coffee ground’ vomit, suggesting chronic gastrointestinal bleeding * Iron deficiency anaemia due to GI bleeding (fatigue, dizziness, pale skin, shortness of breath) * Progressive unintentional weight loss or difficulty swallowing * Pregnancy and breastfeeding (contraindicated) * Oedema (swollen ankles or feet) * Unexplained, recent dyspepsia * Worsening of asthma MONITORING * Blood pressure (especially after dose changes) * Renal function * Liver function * Haemoglobin in those with risk factors for GI bleeding DRUG INTERACTIONS * Possible increased risk of convulsions when given with quinolones * Possible enhanced anticoagulant effect of coumarins and phenindione * Possible enhanced effects of sulfonylureas * Increased risk of bleeding with dabigatran, heparins, SSRIs, venlafaxine, antiplatelets * Increased risk of nephrotoxicity when given with ciclosporin, tacrolimus, diuretics (also antagonism of diuretic effect) * May reduce excretion of lithium or methotrexate (increasing risk of toxicity) * Increased side effects with concomitant use of other NSAIDs, aspirin * NSAIDs antagonise hypotensive effect of beta- blockers, calcium-channel blockers, ACEI- inhibitors, angiotensin-II receptor antagonists, alpha-blockers, nitrates OTHER POINTS * All patients of any age prescribed NSAIDs for osteoarthritis or rheumatoid arthritis or patients over 45 years who are prescribed NSAIDs for lower back pain should be co-prescribed gastro- protection (e.g. a proton pump inhibitor) * NSAID should be taken with or just after food

Answer 204

Gentamicin is the aminoglycoside of choice in the UK. Therapy may require loading doses, and it has a narrow therapeutic Range: * multiple daily dose regimens one-hour (peak) serum concentration should be 5 to 10mg/L (3 to 5 mg/L for endocarditis); pre-dose (trough) concentration should be < 2mg/L (< 1mg/L for endocarditis); * once daily doses, consult local guidelines Monitoring (all aminoglycosides): Renal function (nephrotoxicity); auditory and vestibular function (ototoxicity which is irreversible); serum-aminoglycoside concentration must be determined in the elderly, all patients receiving parenteral treatment, those with renal impairment, in obesity and cystic fibrosis, and if high doses given. Warning: (patients advised to report all to doctor immediately) * Nephrotoxicity * Ototoxicity (hearing impairment or hearing disturbance) * Dehydration (ensure patient is well hydrated before treatment to prevent dehydration) pregnancy/breastfeeding: Risk of auditory or vestibular nerve damage in 2nd and 3rd trimester, avoid unless essential interaction: * Increased risk of nephrotoxicity when given with ciclosporin, tacrolimus, vancomycin * Increased risk of ototoxicity when given with loop diuretics, vancomycin

Answer 205

therapeutic range: depends on indication monitoring: full blood count, liver function, potassium, magnesium, blood lipids, renal, BP, dermatological and physical exam warning: tremor, headache, encephalopathy (confusion, convulsion), blood disorder (fever, sore throat, mouth ulcer, brusing, bleeding, leucopenia/thrombocytopenia), liver toxicity, elevated creatinine (nephrotoxicity), vomiting, drowsiness, hypertension, headache, tachycardia, gingivial hyperplasia hypertension is a common SE, monitor BP no live vaccines brand prescribing avoid sunlight avoid high potassium, grapefruit juice (oral formulation can be taken with apple or orange juice) interactions: increased conc with colchicine, clarithromycin, ketoconazole, tacrolimus decreased with carbamazepine, orlistat, phenobarbital, phenytoin, rifampicin hyperkalaemia with ACE/ARB nephrotoxicity with NSAIDs/diclofenac digoxin myopathy with statins

Answer 206

transplant rejection prescribe/dispense by brand name only IR: Adoport, Prograf suspension: Modigraf PR: Advagraf, Dailiport avoid skin lesions, eyes, mucous membranes, infection, immunodeficiency monitoring: whole-blood trough concentration (esp. during diarrhoea), afro-caribbean require higher dose, BP, ECG, fasting blood glucose, haemotological/coagulation parameters, plasma protein, electrolytes (potassium), neurological/visual status, hepatic and renal function, Monitor for posterior reversible encephalopathy syndrome (PRES) warning: tremor, headache (neurotoxicity), elevated creatinine (nephrotoxicity), eyes disorder, skin disorder, blood disorder, hyperglycaemia (DM: increase thirdst, excess urination), CVD disorders (hypertension, arrhythmias, liver toxicity avoid sunlight, report eye disorders, may affect driving avoid live vaccine avoid high K diet, grapefruit juice

Answer 207

High Risk Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex. Two main classes of corticosteroids are involved in a wide range of physiologic processes, glucocorticoids and mineralocorticoids. Glucocorticoids such as cortisol affect carbohydrate, fat, and protein metabolism, and have anti- inflammatory, immunosuppressive, anti- proliferative, and vasoconstrictive effects. Mineralocorticoids such as aldosterone are primarily involved in the regulation of electrolyte and water balance. SE: Mineralocorticoid side effects are most marked with fludrocortisone, and are significant with hydrocortisone, corticotropin, and tetracosactide. Mineralocorticoid actions are negligible with the high potency glucocorticoids, betamethasone and dexamethasone, and occur only slightly with methylprednisolone, prednisolone, and triamcinolone. Mineralocorticoid side effects: * hypertension * sodium retention * water retention * potassium loss * calcium loss Glucocorticoid side effects: * diabetes * osteoporosis (particularly in the elderly) * high doses are associated with avascular necrosis of the femoral head * proximal myopathy * weakly linked with peptic ulceration * psychiatric reactions may also occur * high doses can also cause Cushing's syndrome, with moon face, striae, and acne; it is usually reversible on withdrawal of treatment * weight gain / increased appetite Warning signs (patients advised to report all to doctor immediately; patients undergoing prolonged steroid treatment (>3 weeks) should be given a steroid card; oral steroids are best taken as a single dose in the morning) * Paradoxical bronchospasm (constriction of the airways) * Uncontrolled asthma (cough, wheeze, tight chest) * Adrenal suppression (adrenal atrophy can develop and persist for years after stopping prolonged corticosteroid therapy; acute adrenal suppression can lead to hypotension or death, and occurs after abrupt withdrawal of prolonged treatment; signs include fever, nausea, vomiting, weight loss, fatigue, headache, muscular weakness) o prolonged corticosteroid therapy must be withdrawn gradually to prevent withdrawal or acute adrenal insufficiency o gradual withdrawal should be considered in those who have: a) received more than 40mg prednisolone (or equivalent) daily for more than one week b) been given repeat evening doses c) received treatment for more than three weeks * Frequent courses of antibiotics and/or corticosteroids * Immunosuppression (prolonged treatment increases infection risk, especially severe chicken pox or measles if not already immune, patients should avoid exposure to chickenpox, shingles, or measles; more serious infections e.g. TB and septicaemia, may reach an advanced stage before being recognised; fungal or viral ocular infections may be exacerbated; oral candidiasis can be avoided by rinsing thoroughly after using inhaled corticosteroids) * Psychiatric reactions (linked to high doses and treatment withdrawal; aggravation of epilepsy or schizophrenia; euphoria, suicidal thoughts, nightmares, depression, insomnia; usually subside on reducing dose) monitoring: * blood pressure * blood lipids * serum potassium * body weight and height in children and adolescents (growth can be slowed) * bone mineral density * blood glucose * eye exam (for intraocular pressure, cataracts) * signs of adrenal suppression Pregnancy and breastfeeding: The benefit of treatment during pregnancy and breast- feeding outweighs the risk; pregnant women with fluid retention should be monitored closely; treatment is required during labour. Drug interactions: Metabolism of corticosteroids accelerated by carbamazepine, phenobarbital, phenytoin and rifamycins Corticosteroids may induce or enhance anticoagulant effect of coumarins High dose corticosteroid can impair immune response to vaccines; avoid concomitant use with live vaccines Corticosteroids can mask the gastrointestinal effects of NSAIDs (including aspirin); avoid concomitant use if possible and consider gastroprotection Hypokalaemia can be severe when given with other drugs that lower serum potassium e.g. loop and thiazide diuretics Effects of antihypertensive and oral hypoglycaemic drugs are antagonized by glucocorticoids

Answer 208

1. Rapid Used PRN, faster onset and shorter duration of action that ‘short’, should be injected immediately before or after eating e.g. Aspart (Novorapid), Glulisine (Apidra), Lispro (Humalog) 2. Short (neutral or soluble) Used PRN, longer duration of action, should be injected 30 mins before eating e.g. Actrapid, Humulin S, Insuman Rapid 3. Intermediate Usually BD, up to 16 hours duration, resuspend zinc-insulin particulate before injecting, never use IV as particulate may block a capillary e.g. Isophane/NPH (Insulatard, Humulin I, Insuman Basal) 4. Long-acting For 24hrs cover, used at the same time each day e.g. Detemir (Levemir), Glargine (Absaglar, Lantus), Deglubec (Tresiba) 5. Biphasic combination of shorter- and longer- acting insulins, more convenient but less control, need to resuspend before injecting e.g. Novomix 30, Humalog Mix 25, Humulin M3 Warning signs Recurring episodes of hypoglycaemia e.g. sweating, palpitations, confusion, drowsiness Signs of diabetic ketoacidosis e.g. nausea, vomiting, drowsiness Any symptoms of liver toxicity, heart failure or pancreatitis e.g. jaundice, abdominal pain, Ulceration of foot tissue Interactions: Substances that may enhance blood-glucose- lowering activity (reduce insulin requirements) and increase risk of hypoglycaemia include oral antidiabetics, ACE inhibitors, MAOIs, salicylates, sulphonamide antibiotics Substances that may reduce blood-glucose- lowering activity (increase insulin requirements) include corticosteroids, diuretics, sympathomimetics (e.g. epinephrine, salbutamol, terbutaline), thyroid hormones, oral contraceptives (oestrogens, progestogens) Beta-blockers or alcohol may potentiate and/or weaken the blood-glucose-lowering activity of insulin

Answer 209

Patients should be commenced on a regular oral modified-release morphine preparation, with rescue doses of 'as required' oral immediate-release morphine for breakthrough pain. The standard 'rescue dose' of morphine for breakthrough pain is usually one-tenth to one-sixth of the regular 24-hour dose, repeated every 2–4 hours as required (up to hourly may be needed)

Answer 210

systemic (oral, IV, SC, IM) with aim of maximal therapeutic cytotoxic effect whilst avoiding extreme toxicity to normal healthy tissues regional (intrathecal, intraarterial) which is aimed at delivering cytotoxic directly into cavity in which tumour is located or blood vessel supplying tumour therefore minimising side effects common side effects: extravasation of IV drugs (leakage of cytotoxic drug from vein into subcutaneous or subdermal tissue, which can lead to permanent tissue damage, refer to local guidelines for prevention and prompt management nausea and vomiting (can cause distress and may lead to refusal of treatment so prophylaxis of n+v is very important; drugs have varying emetogenic potential bone marrow suppresion (except vincristine and bleomycin): occurs 7-10 days after administration, important to treat infection before or when starting cytotoxic neutropenia sepsis is a medical emergency warning: unwell, temperature 37.5+, shivering/flu, gum/nose bleed/bleeding, diarrhoea, uncontrolled comiting, mouth ulcers preventing eating/drinking neutropenic sepsis: not to take paracetamol antiemetic to always be prescribe in drugs causing severe/moderate emesis maintain good oral hygiene (rinse mouth more frequently, soft brushing 2-3 times daily) to avoid mucositis