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
Conjunctivitis
**when to refer in eye conditions
Conjunctivitis: gritty, uncomfortable, sticky, self-limiting
Chloramphenicol eye drops
Refer when painful
Yellow Card Scheme
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.
chronic obstructive
pulmonary disease (COPD) maintenance therapy, dosing
Aclidinium / Formoterol (DuaKlir Genuair®)
Glycopyrronium / Indacaterol (Ultibro Breezhaler®)
Ipratropium (Atrovent Inhaler CFC-Free®)
Tiotropium (Spiriva Handihaler®)
Triotropium (Spiriva Respimat®)
standardised controlled drug requisition forms
> 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
Doxycycline
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)
metronidazole
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.
glyceryl trinitrate patch (Transiderm Nitro®), to be applied once a day for the management of his angina.
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.
Digoxin
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.
Bendroflumethizide
Co-amilozide
Indapamide
Thiazides and related diuretics
Bendroflumethiazide is a thiazide diuretic that causes hypokalaemia by increasing potassium excretion by the
kidney.
short-term management
of his acute post-operative pain in CKD
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.
methotrexate
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
microcytic anaemia
Microcytic Anaemia (low MCV) most commonly due to iron deficiency.
Summary Care Records (SCR)
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
Hughes Syndrome (antiphospholipid syndrome), contraception
ie. patient on warfarin
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.
Treatment of Hypoglycaemia
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.
first line over the counter treatment for allergic rhinitis
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).
Warts
Verruca (tiny black dot)
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.
supply of adrenaline auto-injectors to schools
A written signed order signed by principal/headteacher at the school must be provided
Otitis Externa: itchy, inflamed, painful ear, swimmer (common)
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
Paracetamol in Children dosing
- 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
Ibuprofen Dosing in Children
- 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
patient confidentiality
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
Stroke Prevention
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.
Patient Consent
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
Doxorubicin
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
Sch 2 CD
> 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
management of nausea and
vomiting as a result of the apomorphine therapy in advanced Parkinson’s disease
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.
Patient Safety
> 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
Naproxen
***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
Safe Management of Healthcare Waste V
> 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
Psoriasis
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.
Clinical Audit
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
Metered Dose Inhaler (MDI) usage
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
Impetigo
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)
emergency supply at the request of a patient
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
Common Side Effects
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
Amorolfine 5% nail lacquer can be sold over the counter for the treatment of fungal nail infection.
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
mild acne purchases a tube of benzoyl peroxide
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
Threadworm
Entire household must be treated
One time Mebendazole 100mg
Co-amoxiclav
most likely causes jaundice
contra: history of co-amoxiclav-associated jaundice or hepatic dysfunction; history of penicillin-associated jaundice or hepatic dysfunction
Dyspepsia (indigestion)
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
Pain management in palliative care
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
Hives
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
trigger for an epilepsy seizure
> Flashing lights
Having an illness causing a high body temperature
Lack of sleep
Not taking prescribed epilepsy medicines
Stress
Excipients
> 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
Buscopan (hyoscine butylbromide 10mg)
Hyoscine butylbromide causes constipation. Constipation; dizziness; drowsiness; dry mouth; dyspepsia;
flushing; headache; nausea; palpitations; skin reactions; tachycardia; urinary disorders; vision disorders;
vomiting
Eye preparations
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
Meningitis
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.
Ringworm
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.
most accurate oral temperature reading
Oral temperature is taken by inserting the bulb of the thermometer under the tongue and sealing the lips around
the thermometer
nicotine patches side effects
Headaches
Skin irritation
Upset stomach
Vivid dreams
Insomnia but not sleepiness
anaphylaxis vs ADR
anaphylaxis/hypersensitivity:
Clammy skin
Collapse
Difficulty breathing
Lightheaded feeling
increased HR
safe
use of stimulant laxatives when sold or supplied over the counter (MEP)
> 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
St John’s Wort (enzyme inducer)
decrease the effectiveness of:
warfarin
aminophylline/theophylline
phenytoin
tacrolimus
apixaban
desogestrel/levenogestrel
chc
dabigatran
digoxin
Wholesale Dealer’s License (WDL)
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
Symbicort Turbohaler® (budesonide/formoterol) device
Form a tight seal around the mouthpiece with their lips, then breathe in quickly and
deeply
Vancomycin
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.
Propranolol
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.
Clindamycin
Specific side effects Common or Very Common Abdominal pain, Antibiotic associated colitis,
diarrhoea.
adverse drug reaction: abdominal pain
Trimethoprim
SE: may cause fungal overgrowth
Tramadol
contraindicated in uncontrolled epilepsy
Rubella
rash tends to start behind ears and on face before spreading to the rest of the body
Hand, foot, and mouth
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
Croup
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.
Colic
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.
Eplerenone
Spirnolactone
Amiloride HCl
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
Lamotrigine
Warning. Do not stop taking this medicine unless your doctor tells you to stop
Methylpenicillin V
Take this medicine when your stomach is empty. This means an hour before food or 2 hours after
food
Mirtazapine
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
Amitriptyline HCl
Dosulepin HCl
Doxepin
Nortriptyline
Vortioxetine
Tricyclic antidepressant
Depressive Illness
sulfasalazine
New 5-AMA: (avoids SE of sulfasalzine)
mesalazine
balsalazide
olsalazine
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).
Andexanet alfa antidote
antidote and chelator
recombinant form of human factor Xa
Reversal of apixaban or rivaroxaban in life-threatening or uncontrolled bleeding
diverticulosis
treatments not recommended
bulk-forming laxatives for constipation/diarrhoea, antibacterials not recommended, paracetamol for analgesia
mebeverine
alverine citrate
peppermint oil
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
Constipation
Diarrhoea
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
Antacids
Magnesium-containing: laxative
Aluminium-containing: constipating
Bismuth-containing: not recommended, can be neurotoxic
calcium-containing: can induce rebound acid, high-doses can cause hypercalaemia
Gastric and Duodenal ulcers/GERD
GERD in pregnancy
Food Allergy
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
biliary disorders
gallstone disease
cholestasis: impairment of bile formation
cholestatis pruritus: colestyramine
GB: paracetamol=>IM diclofenac=>IM opiod
ursodeoxycholic acid can be used but no evidence
anal fissure
heamorrhoids (piles)
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
Pancreatic Insufficiency
reduced secretion of pancreatic enzymes causing maldigestion, malnutrition
treatment: pancreatic enzyme replacement (Creon)
Atrial Fibrillation/Atrial Flutter
***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)
Terminating paroxysmal supraintraventricular tachycardia
abnormal heart rhythm: regular but rapid heartbeat that starts and stops abruptly
treat with adenosine, digoxin
**verapmil cannot be used after beta blocker
Antifibrinolytics and haemostatics
Tranexamix acid (inhibits fibrinolysis)
Desmopressin (mild to moderate haemophilia and von Villebrand’s disease
Thromboembolism
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.
Stroke
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
Target INR
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
Heparins
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
Warfarin
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
Antiplatelet Drugs
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
Beta blockers (-lols)
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
CCB
-pines, diltiazem, verapamil
nifedipine prescribed by brand
ACE
-prils
caution in Afro-Caribbean
ARBs
-artans
caution in Afro-Caribbean
Heart Failure
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
Angina
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
Spacers
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
solution for nebulisation
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
Inhaler Protocol: Asthma
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
Acute Asthma Severity
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
COPD
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
Beta2 Agonist (asthma)
risk of hypokalaemia
Caution and monitoring: severe asthma as risk is increased with concomitant theophylline, corticosteroid, and diuretic use, as well as with hypoxia.
Aminophylline (Phyllocontin continus)
Theophylline (Uniphyllin Continus)
Nebuliser solutions (hypertonic sodium chloride solutions)
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
Acrivastine (Benadryl)
Cetirizine HCl
Fexofenadine (Allevia)
Levocetirizine HCl (isomer of cetirizine)
Loratidine (Clarityn)
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
Anaphylaxis
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
Beclometasone dipropionate (Clenil modulite, Qvar (fine particles, twice a potent as clenil)
Beclometasone with formoterol (Fostair nexthaler, Fostair)
Becloemtasone with formoterol and glypyrronium (Trimbow)
Budesonide with formoterol (Duoresp spiromax, Symbicort turbohaler)
Fluticasone with formoterol (Flutiform)
Fluticasone with salmertol (Sereflo, Seretide 250 Evohaler, Seretide 500 Accuhaler)
Fluticasone with umeclidinium and vilanterol (Trelegy Ellipta)
Fluticasone with vilanterol (Relver Ellipta 184/22, 92/22)
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
desensitising vaccines
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
Cystic Fibrosis
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
Cough in Children
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)
Alzheimer’s disease
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
Non-Alzheimer’s dementia
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
Epilepsy
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
- Patient should be maintained on a specific brand Phenytoin, carbamazepine, phenobarbital, primidone
- Supply of a specific brand based on clinical judgment
Valproate, lamotrigine, perampanel, retigabine, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate - 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
Carbamazepine
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
ADHD
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
Mania
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
Phenytoin
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
Antidepressants
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
Anxiety
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
Amitriptyline HCl
Dosulepin HCl
Doxepin
Nortriptyline
Vortioxetine
Tricyclic antidepressant
Depressive Illness
not effective for treating depression in children
Monoamine-oxidase inhibitor (MOAI), less used than tricyclic/SSRIs
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.
Antidepressant Washout
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)
Chlorpromazine HCl
Flupentixol
Haloperidol
Prochlorperazine
Sulpiride
Zuclophenthixol acetate
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
Migraine
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.
Diabetic Foot infection
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)
Ear Infection
Otitis externa:
fluclolaxacillin, if penicillin allergy then clarithromycin
Otitis media: amoxicillin 1st line, co-amoxiclav 2nd line
if penicillin allergy, clarithromycin
MRSA
Tuberculosis
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
UTI
non-pregnant women aged 16 years and over
children and young people under 16 years
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
UTI
pneumocystis pneumonia
co-trimoxazole
Endometriosis
3 month paracetamol/NSAID trial as 1st line
hormonal treatment offered (combined, pop)
surgery
Heavy menstrual bleeding
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
hyperthyroidism (FT3/FT4)
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)
Rheumatoid Arthritis
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
Vincristine
IV only, intrathecal cause severe neurotoxicity
Diclofenac Sodium
NSAID
not in HF, renal, hepatic impairment, pregnancy, GI disorders
avoid contact with eyes, broken skin, mucous membranes
NSAID
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
Gentamicin and Amikacin
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
ciclosporin
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
Tacrolimus
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
Corticosteroid
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
Insulin
- 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) - Short (neutral or soluble)
Used PRN, longer duration of action, should be injected 30 mins before eating
e.g. Actrapid, Humulin S, Insuman Rapid - 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) - Long-acting
For 24hrs cover, used at the same time each day e.g. Detemir (Levemir), Glargine (Absaglar, Lantus), Deglubec (Tresiba) - 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
Opiod Analgesic
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)
Chemotherapy
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
