Specific Cards Flashcards
Veterinary Prescriptions
Record Keeping Requirements:
> Batch number
If there is a written prescription, the name and address of the prescriber
Name of the medicine
The date of receipt or supply
under the veterinary cascade:
dispensing label:
>Date of supply
>Name and address of the animal owner
>Name and address of the pharmacy
>The words ‘For animal treatment only’
Revalidation
2 planned
2 unplanned
1 reflective
1 peer review
HIV Patient
The human immunodeficiency virus (HIV) is a retrovirus that causes immunodeficiency by infecting and destroying cells of the immune system, particularly the CD4 cells. AIDS (cannot be transmitted) below 200 cells/microlitre
The regimen of choice contains a backbone of emtricitabine and either tenofovir disoproxil or tenofovir alafenamide. An alternative backbone regimen is abacavir and lamivudine. The third drug of choice is either atazanavir or darunavir both boosted with ritonavir, or dolutegravir, or elvitegravir boosted with cobicistat, or raltegravir, or rilpivirine. Efavirenz may be used as an alternative third drug.
Breast-feeding by HIV-positive mothers may cause HIV infection in the infant and should be avoided.
HIV is found in the body fluids of an infected person. This includes semen, vaginal and anal fluids, blood and breast milk. HIV cannot be transmitted through sweat, urine or saliva.
Vaccines: HepB, HPV, flu, pneumonia, meningococcal, DTP
AVOID (live): BCG, polio, typhoid, smallpox/chickenpox, rotavirus, yellow fever, MMR
HIV positive patients cannot transmit the virus through sex if their viral load has been undetectable for over 6 months; undetectable=untransmittable (U=U)
Citalopram
SSRI (depression, panic disorder)
Hyponatraemia (drowsiness, confusion, and
convulsions)
can take up to 4-6 (6 in elderly, in part response use for another 2-4 weeks) weeks to start feeling benefit from treatment do not stop taking after a week or two
do not drink alcohol, can increase side effects (sleepy)
can effect glucose
do not take with St. John’s wort
skin may become more sensitive to sunlight, use SPF
SE: nausea, sleepy, dry mouth, headache, mood changes (anxious, shaky)
Speak with GP: increased sweating, loss of appetite, weightless, tingling, reduced sex drive, palpitations, runny nose, itching
contra: epilepsy
QT-interval prolongation
***postpartum haemorrhage
Amlodipine
Diltiazem
Felodipine
Lercaidipine
Nifedipine
Verapamil
CCB
***avoid grapefruit juice
A: hypertension, avoid in pregnancy
D: angina/ hypertension/chronic anal fissure, avoid in pregnancy, MR: Swallow this medicine whole. Do not chew or crush
F: MR: Swallow this medicine whole. Do not chew or crush, dose reduction, avoid pregnancy and BF okay, uncommon to feel fatigue
L: avoid in hepatic and pregnancy, take 30 to 60 minutes before food
N: caution Diabetes, MR: Swallow this medicine whole. Do not chew or crush, constipation, avoid before 20 weeks pregnant
V: unlicensed for cluster headaches, avoid in 1st trimester, MR: swallow this medicine whole. Do not chew or crush, avoid in pregnancy, overdose: hypotension, arrhythmia
contra: acute acute porphyria (pain, digestive, muscle, mental changes), cariogenic shock, HF, severe bradycardia
caution: elderly, hepatic impairment, sudden withdrawal exacerbation of myocardial ischaemia
SE: headache, flushed, hot, abdominal discomfort, oedema, dizzy
poisoning: nausea, vomiting, dizziness, agitation, confusion, and coma in severe poisoning. Metabolic acidosis and hyperglycaemia may occur. severe hypotension secondary to profound peripheral vasodilatation.
Tamsulosin
Dutasteride
Finasteride
Benign Prostatic Hyperplasia (BPH)
> alpha blocker
contra: severe hepatic impairment, postural hypotension, micturition syncope, may affect driving
SE: dizzy/faint/sweating, sexual dysfunction
> 5-alpha reductase inhibitors
***women should not handle if pregnant, use condom
D: contra in sever liver, caution in mild/moderate liver, 500 micrograms once a day, Consider reducing the dosing frequency of dutasteride if adverse effects occur during long-term concurrent treatment with potent CYP3A4 inhibitors (such as itraconazole, ritonavir, and clarithromycin
F: 5 mg once a day
SE: sexual dysfunction tends to improve, breast changes
Methylphenidate
ADHD
Sch 2
Ensure same brand
Diabetes in Pregnancy
use effective contraception until good blood glucose control has been achieved
Offer up to monthly measurement of HbA1c levels for women with diabetes who are planning a pregnancy
5mg folic acid for diabetic pregnancy to prevent spina bifidaup to 12 weeks
Advise women with diabetes who are planning a pregnancy to aim to keep their HbA1c level below 48 mmol/mol (6.5%), Strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant until their HbA1c level is lower
T1DM fasted: 5-7
unfasten: 4-7
Feed your baby as soon as possible after the birth (within 30 minutes) to help keep their blood glucose at a safe level.
Baby will have heel prick test to check glucose
Stop ACE/AII as well as statins in pregnancy
preparation of intravenous infusions
preparing and administering injections from a multi-dose vial
once running, intravenous infusions should be intermittently checked for signs of interaction or contamination
> the bung of each multi-dose vial must be cleaned with an alcohol wipe and allowed to air dry before use
the date and time of reconstitution should be marked on each vial
a single dose canNOT be drawn from more than one multi-dose vial if necessary
a new sterile syringe and needle should be used each time a dose is withdrawn from a vial
the time that the vaccine must be used by should be marked on each vial
H. Pylori infection
common cause of peptic ulcer (duodenal, gastric), NSAIDs (ibuprofen, aspiring) may exacerbate
presence of H. Pylori to be confirmed before treatment, ‘test and treat’ strategy
urea (13C) breath test, Stool Helicobacter Antigen Test (SAT), or laboratory-based serology
urea (13C) breath test and SAT should not be performed within 2 weeks of treatment with a proton pump inhibitor or within 4 weeks of antibacterial treatment, as this can lead to false negatives.
Retesting should be performed at least 4 weeks (ideally 8 weeks) after treatment
comprises a PPI and 2 antibacterials for 7 days
1st: a proton pump inhibitor, plus amoxicillin, and either clarithromycin or metronidazole
PENICILIN ALLERGY: A proton pump inhibitor, plus clarithromycin, and metronidazole.
2nd: A proton pump inhibitor, plus amoxicillin, and either clarithromycin or metronidazole (whichever not used in first line)
expiry date
use by
should not take after the end of the last day of month given (July 2020=July 31 2020)
used before date given
Canesten Combi Pessary and Cream
if symptoms do not improve in 7 days, seek GP
not recommended in children
-more than two infections of candidal vaginitis in the last 6 months.
-previous history of sexually transmitted disease or exposure to partner with sexually transmitted disease.
-pregnancy or suspected pregnancy.
-ages 16-60 years.
Canesten Combi Pessary and External Cream should not be used if the patient has any of the following symptoms whereupon medical advice should be sought:
-irregular vaginal bleeding, abnormal vaginal bleeding or a blood-stained discharge.
-vulval or vaginal ulcers, blisters or sores.
-lower abdominal pain or dysuria.
-any adverse events such as redness, irritation or swelling associated with the treatment.
-fever or chills, nausea or vomiting, diarrhoea, foul smelling vaginal discharge.
Treatment during the menstrual period should not be performed due to the risk of the pessary being washed out by the menstrual flow. The treatment should be finished before the onset of menstruation.
Do not use tampons, intravaginal douches, spermicides or other vaginal products while using this product.
Vaginal intercourse should be avoided in case of vaginal infection and while using this product because the partner could become infected.
in pregnancy, the pessary should be inserted without using an applicator
PSD vs PGD
T1DM
offer the structured education programme 6 to 12 months after diagnosis
offer carbohydrate‑counting training
Measure HbA1c levels every 3 to 6 months in adults with type 1 diabetes, then 6 month intervals
Lifestyle including diet management — 48 mmol/mol (6.5%).
Lifestyle including diet combined with a single drug not associated with hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%).
Drug treatment associated with hypoglycaemia (such as a sulfonylurea): 53 mmol/mol (7.0%).
Fasted: 5-7
before meal/other times: 4-7
unfasted: 5-9
Consider ketone monitoring (blood or urine) as part of ‘sick‑day rules’ for adults with type 1 diabetes, to help with self‑management of hyperglycaemia, especially in DKA
hypoglycaemia signs
DKA signs
sick days: Medication may be restarted once the person is feeling better and eating and drinking for 24–48 hours (unless insulin, do not stop, dose may be altered), An increase in monitoring frequency may be needed, such as at least every 3–4 hours including through the night and advice to record the result, onsider the need for blood or urinary ketone monitoring (ketone level is greater than 2+, or blood ketone level is greater than 3 mmol/L, the person should seek immediate medical advice)
Retinopathy
low: every 2 years (no signs after two successive test)
everyone else: every year
Foot Problems
low: annually
moderate: 6-8 weeks
high: 2-4 weeks
driving/diabetes BNF
notify DVLA due to hypos
>they should test their blood glucose every 2 hours when on a long journey
>drivers should monitor their blood glucose more frequently when their meal routine has been altered
>drivers treated with insulin should ensure that a supply of sugar is always available in the vehicle
>If hypoglycaemia occurs, stop the vehicle in a safe place, wait until 45 minutes after blood glucose has
returned to normal before continuing journey
>If hypoglycaemia occurs, then drivers must stop the vehicle in a safe place and switch off the engine and
move from the driver’s seat
Colchicine
no antidote to overdose is currently available
gout
monitor full blood ocunt
caution: cardiac, elderly, GI
contra: blood disorder
SE: Abdominal pain; diarrhoea; nausea; vomiting
Cefalexin
cephalosporin
UTI, HAP
adjust in renal impairment
false positive: urinary glucose, Coombs’ test
cannot take if penicillin allergy
can be taken either before or after food, although it may start to work a little sooner if it is taken before food
contraceptive can be reduced due to vomitng and diarrhoea
can stop oral typhoid vaccine
okay in pregnancy
SE: diarrhoea, stomach discomfort
allergy: swelling of the tongue
ordering and supply of ‘unlicensed specials’
if a licensed medicinal product is available, despite being ‘off-label’, this should be used in preference to an ‘unlicensed special’
Spiolto Respimat
once in use, the cartridge has a shelf life of three months
Spiolto Respimat is effective for 24 hours so you will need to take Spiolto Respimat only ONCE A DAY, if possible at the same time of the day. Each time you use it take TWO PUFFS.
Breathe out slowly and fully.
Close your lips around the mouthpiece without covering the air vents. Point your Inhaler to the back of your throat.
While taking a slow, deep breath through your mouth, PRESS the dose-release button and continue to breathe in slowly for as long as comfortable.
Hold your breath for 10 seconds or for as long as comfortable
epeat TURN, OPEN, PRESS for a total of 2 puffs.
Air vent
ONCE DAILY
• Close the cap until you use your inhaler again.
supply of pseudoephedrine and ephedrine
regulations apply due to the potential for use in the illicit production of crystal meth (methylamphetamine)
Pseudoephedrine can only be sold from a pharmacy when the responsible pharmacist is present
cannot be sold together
pseudo: 720, ephin: 180
Maloff Protect (atovaquone 25 mg and proguanil hydrochloride 100 mg) Tablets
bite avoidance and sun protection
chloroquine
(Avloclor®) tablets.
Malaria
if you have diarrhoea, you should continue to take your tablets as normal
DEET (N,N-Diethyl-meta-toluamide) 30 % and sunscreen SPF 20
A 50% DEET-based insect repellent is recommended as the first choice; there is no further increase in duration of protection beyond a DEET concentration of 50%. DEET is safe and effective when applied to the skin of adults and children over 2 months of age. It can also be used during pregnancy and breast-feeding. However, ingestion should be avoided, therefore breast-feeding mothers should wash their hands and breast tissue before handling infants. When sunscreen is also required, DEET should be applied after the sunscreen. DEET reduces the SPF of sunscreen, so a sunscreen of SPF 30–50 should be applied.
Length of Prophylaxis: Prophylaxis should generally be started before travel into an endemic area; 1 week before travel for chloroquine and proguanil hydrochloride (avoid in epilepsy); 2–3 weeks before travel for mefloquine; and 1–2 days before travel for atovaquone with proguanil hydrochloride or doxycycline. Prophylaxis should be continued for 4 weeks after leaving the area (except for atovaquone with proguanil hydrochloride prophylaxis which should be stopped 1 week after leaving).
Avloclor: Two tablets should be taken once a week, on the same day each week. Continuing for 4 weeks after return from
malarias area.
any illness that occurs within 1 year and especially within 3 months of return might be malaria
creating a local formulary
> improved cost management of medicines and appliances across the health community
improved local care pathways
improved patient outcomes by optimising the use of evidence-based therapies
support for prescribers in implementing prescribing guidance published by regulatory bodies
fridge items
label the items clearly ‘under quarantine’ and place in the pharmacy fridge
Praxbind (idarucizumab) antidote
dabigatran
Sodium Valproate
HIGH RISK DRUG
Epilepsy
Unlicensed use:
Migraine prophylaxis
***risk of suicidal thoughs/behaviors can occur in 1st week, PPP plan to be met
if potential pregnancy: advise the woman to take a pregnancy test, continue to take the sodium valproate and discuss the result with her GP
withdrawal after patient has even seizure-free after two years, avoid abrupt withdrawal, at least 4 weeks
caution: systemic lupus erythematosus, liver toxicity
Sodium Valproate is associated with hepatotoxicity therefore liver function should be measured at
baseline and at regular intervals throughout therapy.
monitor: liver function for 6 months (ALT), full blood count, false positive urine test for ketones, weight and BMI
SE: nausea, shaky, hair loss, headache, sleepy, increased weight
urgent: vomiting, abdominal pain, jaundice, oedema, drowst/malaise, loss of seizure control, suicidal ideation…uncontrolled movements, yellowing of eyes, unexplained cough/sore throat, unusual bleeding/bruising
should supplement with calcium if immobilised or limited sun exposure
brand dispensing
potentiated MAOI, antidepressants, benzo
increases warfarin
increased lamotrigine metabolism (serious skin reaction)
erythromycin
Azathioprine
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
isotretinoin
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
Montelukast
night terrors
advise the parents to continue administering montelukast but make an immediate appointment with the GP
ceoliac disease
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
lipid modification therapy for primary prevention of cardiovascular disease
> familial hypercholesterolaemia
type 1 diabetes
QRISK 3 score of 23.4 %
chronic kidney disease
Grave’s disease
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.
T2DM Side Effect for Immediate Attention
muscle cramps
sign or symptom of vitamin B12 deficiency (Riboflavin)
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
midazolam CD
CD NO REGISTER POM
except from safe custody
Gina
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
Bumetanide
Furosemide
Co-amilofruse
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
Tamoxifen
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.
risk of developing venous thromboembolisim (VTE)
prolonged immobility
COPD rescue pack
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
home nebuliser device
inform the parents that independent purchases of nebulisers without medical supervision is not recommended
acute exacerbation of chronic obstructive pulmonary disease (COPD)
prescribe an additional inhaler containing a corticosteroid
acute exacerbation of chronic obstructive pulmonary disease (COPD)
prescribe an additional inhaler containing a corticosteroid
reconstitution of Velcade (bortezomib)
the strength of solution when prepared for intravenous infusion is 0.1% w/v
NEWS2
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.
Emergency Contraceptive
Levonelle
EllaOne
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
progestogen-only pill (pop)
> 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
biphasic contraceptive (combined)
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.
Monophasic Contraceptive: 21 day
Phasic Contraceptive: 21 day
Everyday Pill: 21 active, 7 inactive (no break)
Microgynon, Marvelon and Yasmin
Logynon
Microgynon ED
emollient preparation derived from animals
anhydrous lanolin
Clarinaze Allergy Control (mometasone furoate 0.05%) nasal spray
common side effect: epistaxis (nosebleed)
discard after two months of opening
Ciprofloxacin
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.
frequency of this adverse reaction
*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
first-line treatment by the National Institute for Health and Care Excellence (NICE) for the management of painful diabetic neuropathy
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
MHRA Medicines Recall
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.
Parkinson’s
anti-emtic
treatment options
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
Responsible Pharmacist
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
side effects of chemotherapy
symptoms of severe exhaustion, episodes of breathlessness and paleness of the skin are normal and should subside upon completion of treatment
55-year-old white person with type 2 diabetes and hypertension
additional antihyptertensive to losartan 100
NICE recommended BP
amlodipine 5 mg tablets
< 140/90 mmHg
Hypertensive Stages
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
Children Conditions
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
indication of shock
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
stridor
a variable, high-pitched respiratory sound that can be assessed during breathing
urticaria
the main symptom of hives (urticaria) is a rash.
look-alike sound-alike
‘Tall-Man lettering’ used in differences between drugs
check for high risk indication/usage between drug
dentist prescribing temazepam
pharmacists should challenge the prescription if they believe there is no legitimate use for the drug for dental purposes
Amiodarone
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
elevated blood pressure, reducing salt take, medication to look into
Gaviscon Advance is high in sodium and must be taken into account if the patient is on a low sodium diet
treatment of opioid dependence with methadone
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)
Evista (raloxifene)
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.
Gabapentin
Antiepileptic
***risk of suicidal thoughts/behaviour, severe respiratory depression
Olanzapine
Clozapine
Amisulpiride
Aripriprazole
Quetiapine
Risperidone
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
PPI: omeprazole
Esomeprazole
Lansoprazole
Omeprazole
Pantoprazole
Rabeprazole
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
vitamin D toxicity
hypercalcaemia: frequent nausea,vomitting constipation and palpitations
alendronic acid
patient will suffer from hypocalcaemia=>osteoporosis
alendronic acid
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
vaccines in COPD
annual influenza vaccine
pneumococcal
childhood immunisation schedule
9 month old: BCG
rotavirus
importance of good hand hygiene as one of the vaccines is a ‘live’ vaccine that can be excreted in the baby’s faeces
Deponit 5 mg/24 hours (glyceryl trinitrate) transdermal patches for the prophylaxis of angina
spray usage
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.
Qutenza (capsaicin 8%) patches to help manage the pain
apply one patch once weekly for 6 weeks followed by a 7-day patch free interval
Evra (6 mg norelgestromin and ethinyl estradiol 600 micrograms per 20 cm2) patches
apply one patch once weekly for 3 weeks followed by a 7-day patch-free interval
Scopoderm (hyoscine 1.5 mg) patches
apply one patch 5-6 hours before needed
Mastitis
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.
myasthenia gravis
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
myasthenia gravis
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
measles
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
Lithium carbonate
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
Dioralyte Relief oral powder sachets (potassium chloride with rice powder, sodium chloride and sodium citrate
oral rehydration sachets
(Dioraltye®)
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
Gestational diabetes 1st line
metformin
dapagliflozin (SGLT2)
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)
insulin degludec
reduce the usual daily dose of one of their treatment by 20% the day before surgery
Chlorphenamine maleate (Piriton)
Hydroxyzine HCl
Promethazine Hal (Phenergan)
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
loratidine (Clarityn)
Acrivastine (Benadryl)
Cetirizine HCl
Fexofenadine (Allevia)
Levocetirizine HCl (isomer of cetirizine)
non-drowsy antihistamine
safe in renal impairment but caution is advised, initial dose reduction to alternate days
Age Groups: cetirizine, loratatinde, chlorphenamine, promethazine
statins
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
Diabetic Medicines and side effects
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
