Student formulary Flashcards
Ranitidine is H2 receptor blocker (in gastric parietal cells). Name another.
cimetidine
What is mechanism of action of ranitidine?
h2 receptor blocker in gastric parietal cells. reduce acid secretion.
important caution for use of H2 receptor blockers and PPIs?
may mask gastric cancer symptoms - make sure to rule out before prescribing in pts with ALARMS
Inhibits final transport of hydrogen ions into gastric lumen; thereby inhibiting gatsric acid
secretion. who’s mechanism of action is this?
PPI
what is the daily dose range of omeprazole?
20- 40mg
name a common SE of omeprazole
GI disturbance e.g. nausea/vom/abdo pain
what does omeprazole do to warfarin?
increases its anticoagulant effect
what is mechanism of action of loperamide?
opioid mu receptor agonists (in myenteric plexus of large bowel) – inhibits peristalsis - slows intestinal motility
give an uncommon but important SE of loperamide
paralytic ileus
name other aminosalicylates apart from mesalazine
osalazine
sulfasalazine
sulfasalazine prescribed alongisde azathioprine increases risk of …
leukopenia
what monitoring does sulfasalazine need?
3 monthly FBC, LFTs, ESR, CRP,
U&E (but less freq)
**pts should be asked about oral ulcer/sore throat & unexplained bruising/rash at every consultation
- risk of leukopenia!
which UC drug causes yellowish discolouration of skin/body fluids?
sulfasalazine!
give example of bulk forming laxative?
Ispaghula Husk (Fybogel) - stimulates peristalsis by stretching bowel fibrous
give two examples of osmotic laxatives
lactulose
macrogol
give two examples of a stimulant laxatives
senna
sodium picosulphate
what should you tell pts to do when taking laxatives?
drink plenty of fluids to avoid dehydration
what effects does digoxin have on heart?
positive inotropic (increases contractility) negative chonotropic (slows rate)
what are the indications for digoxin?
persistent AF
heart failure
tell me about digoxin’s therapeutic index
its narrow.
what is an interesting and important interaction of digoxin’s?
amiodarone causes an increased plasma digoxin conc, so you need to half the dose!!
name two other drugs similar to bendroflumethiazide
hydrochlorothiazide
indapamide (thazide-like diuretic)
what is thiazide mechanism of action?
decreases Na and Cl reabsorption in distal convoluted tubule
(inhibits the channels)
thiazides cause HYPO what?
thiazide –> hypo:
K
Na
Mg
and postural HYPOtension!
thiazides cause HYPER what?
thiazide –> hyper:
Ca
glycaemia
uricaemia
as well as electrolyte/metabolic disturbances, name another SE of thiazides
postural hypotension
name two loops diuretics
furosemide, bumetanide
how does furosemide work
inhibits reabsorption of sodium in the loop of Henle
name three indications for furosemide
pulm oedema due to LV failure
chronic HF
resistant hypertension
what time of day do you give furosemide?
morning
Name 4 HYPOs of furosemide
hypoNa
hypoK
hypoCa
postural hypotension
name 2 HYPERs of furosemide
hyperglycaemia
hyperuricaemia
how does furosemide interact w lithium?
lithium renally excreted so increases risk of lithium toxicity
as well as spironolactone, name another alodosterone dependent postassium sparing diuretic.
eplerenone
amiloride is also K sparing
what is the effect/mechanism of spironolactione?
stops Na/K exchange in distal tubule and collecting ducts
- K retention;
- Na and water loss
name an electrolyte disturbance from spironolactone
hyperkalaemia
which diuretic can be used to treat primary hyperaldosteronism?
spironolactone
avoid in Addisons
spironolactone/furosemide and NSAIDs interact to cause…
increased risk of nephrotoxicity
what does amiodarone do to an ECG
prolongs QT interval
what is the starting then maintenance dose of amiodarone?
200mg TDS for 1 week
BD for next week
OD for maintenance
name 6 common SEs of amiodarone
bradycardia slate grey skin jaundice pulm fibrosis hepatotoxicity - dont drink wine tremor sleep disorders phototoxicity - avoid sunlight hyper/hypoTHYROIDism
name two SERIOUS SEs of amiodarone
peripheral neuropathy
optic neuritis!
why do you need CXR before starting amiodarone
pulm fibrosis SE
which blood tests should be done before starting amiodarone and repeated every 6 months?
LFT (hepatotoxicity)
TFT (hyper/hypothyroidism)
name three cardioselective beta blockers (b1 only)
bisoprolol
atenolol
metoprolol
name two non cardioselective beta blockers (b1 and b2)
propanolol
carvedilol
describe bisprolol’s effects on the heart
negative chonotropy (reduce heart rate) negative inotropy (reduce contractility)
name 5 indications for beta blockers
angina MI HF resistant hypertension hyperthyroid/migraine/anxiety
what dose of bisoprolol should you start at low and go slow in HF?
1.25mg OD, increase if tolerated
standard dose 5-10mg OD
name 2 common SEs of beta blockers
cold hands
impotence
name a SE of beta blockers important in asthma and COPD
bronchoconstriction
why do beta blockers exacerbate Raynaud’s and intermittent claudication?
peripheral vasoconstriction
what do you worry about with beta blockers and diabetic pts?
may mask hypo warning signs
name two a1 specific alpha blockers
doxazosin
tamsulosin
(prazosin, indoramin)
what are the physiological effects of a1 blockers
vascular smooth muscle relaxation, vasodilation and reduce arterial BP
name three indications for a1 blockers
hypertension
BPH
raynaud’s (prazosin!)
name an important SE of alpha1 blockers
postural hypotension
ramipril. name 4 other ACE-is.
captoppril
enalapril
lisinopril
perindopril
how do ACE-is work?
inhibit synthesis of angiotensin 2 leading to smooth muscle relaxation and vasodilation
for whom is ACE-i first line for hypertension?
<55yrs
its ACE to be young and white
name 3 common SEs of ACEis
dry cough
hyperkalaemia
increase in serum creatinine
name 2 important SEs of ACEIS
acute renal failure
angiooedema
ACEis interact w diuretics to …
increase risk of hypotension
if K sparing, increase risk of hyperkalaemia
why should you not eat too many bananas when you’re on ramipril
hyperkalaemia
which blood test do pts on ACE is need ?
U&E
baseline, then 2wks after starting.
look out for hyperkaelamia and deterioration in renal function
inhibition of angiotensin II (potent vasoconstrictor) leading to smooth muscle relaxation and vasodilation. what drugs do this?
angiotensin II receptor blockers (ARBs)
name two important side effects of ARBs
acute renal failure
angiooedema
name three cautions for ARBs
aortic stenosis
mitral stenosis
renal artery stenosis
whats the blood test to check on ARBs?
U&E
renal function
name 2 drugs that interact with ARBs
ACEis
potassium sparing diuretics (risk of hyperK)
what is the indication that you use ARBs for and not ACEis
type 2 diabetic nephropathy
in which situations are ARBs preferred to ACEis?
unable to tolerate ACEi
t2 diabetic nephropathy
what is the difference between GTN and isosorbide mononitrate?
GTN is short acting: 1-2mins
ISMN and isosorbid dinitrate are LONG acting - 8hrs
GTN used for acute relief ISMN used for prophylaxis
name 3 side effects of nitrates
headache
tachycardia
flushing
what drugs interact with nitrates and you should avoid concomitant use?
sildenafil and tadalafil
- significantly increased hypotensive effect
how do calcium channel blockers work?
inhibit influx of ca ions into smooth muscle cells - vasodilation of arteries
(diltiazem and verapamil favour the ca channels in cardiac muscle cells)
CCBs are first line treatment for which groups of ppl with hypertension?
> 55 or afro-carribean
name 2 side effects of CCBs
ankle swelling
palpitations
abdo pain
CCB + statin does what
increases risk of myopathy
statin dose should be reduced
what is the effect of verapamil and diltiazem?
rate-limiting CCBs
negative intoropes - decrease cardiac contractility
name 3 dihydropyridine CCBs
amlodipine
nifedipine
felodipine
name a side effect of verapamil and diltiazem than normal CCBs dont cause
AV block
sino-atrial block
do you prescribe beta blockers alongside CCBs?
noo!!!
what happens if you prescribe beta blockers alongside CCBs?
asystole
severe hypotension
heart failure
nicorandil is a potassium channel activator with nitrate-like effects. what is it used for?
long term treatment of chronic stable angina in pts with …
previous MI, previous CABG, LVH etc
what type of drug is enoxaparin?
LMWH
name 3 types of LMWH
enoxaparin, dalteparin, tinzaparin
how does LMWH work?
activate antithrombin which inhibits factor Xa so prothrombin cant be converted to thrombin
what does HIT stand for
heparin induced thrombocytopenia
when does heparin induced thrombocytopenia usually develop
5-10ds later - immune mediated
give 2 signs of heparin induced thrombocytopenia
30% reduction in plt count, skin allergy, or can be complicated by thrombosis
tell pts this: dont take any OTC meds (especially ASPIRIN) without checking with the pharmacist as it could interact with…
warfarin
how does rivaroxaban, apixaban and edoxaban work
factor Xa inhibitor
what is dabigatran
a direct thrombin (factor II) inhibitor
lack of thrombin does what?
prevents conversion of fibrinogen to fibrin therefore inhibits clotting
is there a reversal agent licensed for rivaroxaban
no
should you reduce dose of rivaroxaban in renal impairment?
yes
give 2 important side effects of aspirin
GI ulceration
bronchospasm
can you take your gaviscon and aspirin at same time?
no
take it with food
if a pt is at high risk of GI bleed, what do you co-prescribe with their aspirin?
PPI
the overall effect of both aspiirin, clopi and dipyridamole is
reduced plt aggregation
discontinue clopidogrel ___ days before elective surgery
discontinue clopi 7 days before elective surgery
what dose simvastatin commonly do to LFTs?
elevated transaminases
pts w hypothyroid and low BMI are more likely to get myositis with statins, true or false?
true
elevated transaminases can be normal w statins. at what point would you discontinue them?
if they are elevated 3x upper limit of normal
also stop if creat kinase >5 x uln
which blood tests should be monitored every 3 months for pts on statins?
LFTs
name another commonly used SABA
terbutaline
name 4 common SEs of Salbuatmol
fine tremor
headache
muscle cramps
palpitations
what electrolyte imbalance can salbutamol cause in high doses
hypokalaemia
what metabolic imbalance can salbutamol cause in high doses
lactic acidosis
what can salbutamol do to the heart
myocardial ischaemia
how many times can u take salbutamol inhaler in a day
1-2 puffs up to 4 times daily PRN
what kind of drug is ipratropium bromide
short acting muscarinic antagonist (SAMA)
what kind of drug is tiotropium bromide
long acting muscarinic antagonist (LAMA)
how do muscarinic antagonists work in astham?
compete w Ach bindng sites on bronchial smooth muscle
prevents ach mediated constriction of bronchi
is tiotropium bromide appropriate in acute bronchospasm?
NO. long acting !
what are the SEs of ipratropium bromide (remember its an anti-muscarinic)
dry mouth
diarrhoea/constip
urinary retention
what kind of drug is montelukast?
leukotriene receptor antagonist
what can be a SE of montelukast in young children
hyperkinesia
what are some dangerous but rare SEs of montelukast to look out for
churg strauss(vasculitis rash and worsening pulm symps)
suicidal thoughts
seizures
name 5 anti hists
cetirizine fexofenadine loratadine promethazine chlorphenamine
which are the sedating antihists
promethazine
chlorphenamine
name some SEs of antihists
blurred vision dry mouth psychomotor impairment, urinary retnetion
drowsiness if prometh/chlorphen
what should you advise pts taking sedating antihists
dont drive/operate machinery until effects worn off
what side effects of benzos can lead to risk of falls in elderly?
ataxia
name 3 important side effects of benzos
ataxia
dependence
resp depression
what neurotransmitter do benzos enhance the effect of?
GABA
if having lorazepam in hosp what obs should you watch out for?
RR and sats
resp depression
why dont we use to flumazenil?
can cause seizures - status - death
name 3 typical antipsychotics
haloperidol
flupentixol
prochlorperazine
chlorpromazine
name 4 atypical antipsychotics
risperidone quetiapine clozapine aripiprazole olanzapine amisulpride
how do antipsychotics work
dopamine2 receptor antagonists
pt taking lithium has high WCC. you worried?
no. lithium benign leucocytosis
Zopiclone is a benzodiazepine-like agent who’s side effects include…
metallic taste and headache
What kind of anti-depressant is imipramine?
tricyclic
Why do tricyclics cause urinary retention and overflow incontinence?
anti-cholinergic
Which atypical anti-psychotic has a higher risk of dyslipidemia and obesity?
olanzapine
Which drug can help treat tardive dyskinesia (as SE of anti-psychotics)?
tetrabenazine
Procyclidine is useful for treatment of what SEs of anti-psychotics?
Extra-pyramidal SEs (except tardive dyskinesia)
Acute dystonia
Which drug is useful to treat akathisia (restlessness) as anti-psychotic SE?
propanolol
Which types of anti-psychotic tend to cause extra-pyramidal SEs?
typical
Which anti-psychotic is particularly risky for prolonged QT ?
haloperidol
venlafaxine and duloxetine and both what type of drug…
SNRI
SNRI stands for
serotonin norepinephrine inhibitor
SSRI stands
selective serotonin reuptake inhibitor
Why is it important to know if someone has been compliant with taking their clozapine?
you lose clozapine tolerance within 48hrs
if give again at normal dose then can be fatal
When an anti-depressant in indicated in child/adolescent, what is the drug of choice?
fluoxetine
Describe tardive dyskinesia
abnormal involuntary movements
e.g. grimacing, tongue poking or excessive blinking
affects patients on typical antipsychotics
Is hypo or hyper thyroid a SE of lithium?
hypo
A patient on an SSRI is getting agitation, hyperthermia, hyperreflexia, sweating and dilated pupils. What could this be?
serotonin syndrome
How do you manage serotonin syndrome?
stop the antidepressant
supportive care
bad - cyproheptadine (5HT antagonist)
a rare but potentially life-threatening reaction to antipsychotics ?
neuroleptic malignant syndrome
What antipsychotic is particularly bad for neuroleptic malignant syndrome?
haloperidol (the typicals)
What are 3 key signs of neuroleptic malignant syndrome?
lead-pipe muscle rigidity
hyperthermia temp >38
autonomic instability
What is the treatment for neuroleptic malignant syndrome?
stop the drug
rapid cooling + antipyretics
IV benzos for agitation
What’s procyclidine for?
EPSEs except tardive dyskinesia
What’s tetrabenazine for?
tardive dyskinesia
What’s propanolol for?
akithisia (restlessness)
What common drugs are a bad combo with SSRIs
NSAIDs
consider PPI
You’ve started a 27yr old on an anti-depressant at the GP. How soon should you review him?
within 1 week (<30)
You’ve started a 35 yr old on an anti-depressant at the GP. How soon should you review her?
within 2 weeks (>30)
Name me some withdrawal effects of benzos and other hypnotics….
irritability, insomnia, anxiety, seizures!
Name me 4 SSRIs
sertraline
fluoxetine
citalopram
paroxetine
Give me three SEs of tricyclics
sedation
cardiac arrhythmias
anticholinergic SEs!
Cheese and red wine make you think of
MAO inhibitors, hypertensive crisis
Which kinds of antipsychotics cause metabolic syndrome > EPSEs?
atypical
olanzapine worst, aripiprazole best
Give me three SEs of clozapine
weight gain
hypersalivation
agranulocytosis!
What do SSRIs do to your electrolytes?
HYPONATRAEMIA SSRIs
How long should I take anti-depressant for doctor?
at least 6 months following remission of symptoms,
reduces risk of relapse
cyproheptadine. What is it and when is it used?
5HT antagonist
in serotonin syndrome if rlly bad
name some conditions in which use of antipsychotics is cautioned
cardiovascular disease
diabetes
Parkinsons (they antagonise dopamine)
why watch out drinking alcohol on antipsychotics
CNS sedation
for antipsychotics, if the drug is effective but pt compliance is poor, what should you consider?
depot injections
caution lithium in which skin condition
psoriasis
MAOIs and WHAT should not be co-prescribed. (forget cheese and wine Maoi man)
tricyclic! dont co-prescribe tricylics and MAOIs. hypertensive crisis
DONT CO-PRESCRIBE MAOIs and SSRIs either
if a pt has SEs to tricyclics can u tell them to persevre cos they wear off?
yeah mostly
why should drs only prescribe limited tricylics at one time?
cardiotoxicity and fatality in overdose
do antipsychotics and SSRIs lower seiure threshold?
yah
why check U&E if someone gets confused on citalopram?
HYPONATRAEMIA SSRIs
name two dopamine antagonist anti-emetics
domperidone
metoclopramide
(prokinetics - increase gastric emptying)
name a antihistamine anti emetic
cyclizine
name a 5HT antag anti-emetic
ondnasetron
when is ondansetron commonly used?
vomitty chemo
give some SEs of domperidone/metoclopramide antiemetics (dopamine antagonists)
EPSEs
hyperprolactinaemia
drowsiness
give some SEs of ondansetron (5HT antagonist)
flushing, headache
should you be on domperidone for more than a week?
no - short term only
which anti-emetic prolongs QT?
domperidone
what can morphine do to BP?
hypotension
which main diabetic drugs cause hypos?
insulin and suphonylureas.
sometimes pioglitazone, sitagliptin and others - but less.
as well as corticosteroids, what other drugs can lead to hyperglycaemia/worse control in diabetics?
antipsychotics
beta blockers (hypo unaware)
thiazides
can high dose PPIs over a long period cause osteoporosis in the elderly?
yes
what drugs should you STOP on sick day rules?
diuretics
ACE-is / ARBs
metformin
NSAIDs
(DAMN medications - stop when sick)
you have vomiting and fever. you take diuretics, ACEis, metformin and NSAIDs. should you stop them?
yes :)
DAMN medications - stop when sick.
should you stop your long term prednisolone abruptly?
no. NO. ERR NO.
take pred w food in morning.
TREATMENT CESSATION section in BNF
how do you decide “what is most important to tell patient”?
think “what will happen if pt does not know this”
check statin after 3 months. there has been a >40% reduction in non-HDL cholesterol. what do you do?
happy. continue dose.
check statin after 3 months. there has not been a 40% reduction in non-HDL cholesterol. what do you do?
consider increasing dose
discuss adherence, lifestyle etc
typical adjustments of insulin are
by 10% of dose
e. g. reducing from 24 units to 22
e. g. increasing from 16 units to 18
patient is on a biphasic insulin Humulin M3, twice daily dose w breakfast and evening meal. blood sugars are often a bit high before breakfast. how do you adjust?
increase the evening meal dose (the night before breakfast)
patient is on a biphasic Humulin M3 twice daily regimen w breakfast and evening meal. blood sugars tend to be a bit low before evening meal. how do you adjust?
decrease the breakfast dose
patient is on basal bolus regime. Long acting Lantus at night and Actrapid before breakfast, lunch and tea. Her blood sugars tend to be too low before tea. How do you adjust?
decrease the actrapid at lunch by 10%
patient is on basal bolus regime. Long acting Lantus at night and Actrapid before breakfast, lunch and tea. Her blood sugars tend to be a bit high before breakfast. How do you adjust?
increase Lantus dose at night by 10%
gliclazide, gilbenclamide and tolbutamide are all…
suphonylureas
eGFR is <45. what do you do w metformin?
review dose (or creat >130)
eGFR is <30. what do you do with metformin.
contraindicated!
or creat >150
why is metformin good for overweight pt at CV risk?
weight loss, reduces CV risk
name a common side effect of metformin.
GI upset (nausea, diarrohoea)
what can metformin cause if you take it during MI/sepsis/dehydration?
lactic acidosis
why should you titrate metformin up slowly when starting it?
reduce GI upset
name 3 side effects of insulin
weight gain
hypoglycaemia
lipodystrophy
how do beta blockers interact w insulin?
enhanced hypoglycaemic effect and masks hypo warning signs
name 3 drugs that interact w insulin
beta blockers
corticosteroids
suphonylureas (hypos)
bms should be less than what after meals (for pts on insulin)
<9mmol/L
bms should be less than what after meals (for pts on insulin)
<9mmol/L
should you omit your insulin doses when you’re sick?
NO.
does IV insulin have to be diluted in sodium chloride?
yes.
e.g. 50 units actrapid in 50ml 0.9% Nacl
how do suphonylureas work?
increase insulin secretion (need functional beta cells, best in early stages of t2dm)
name two key side effects of suphonylureas
hypoglycaemia
weight gain
name 2 suphonylureas
gliclazide, tolbutamide
why should you withold metformin for 48hrs in pts undergoing iodine contrast imaging?
risk of acute renal failure
what blood test annually on metformin?
U&E - eGFR is important
jean’s having terrible vomiting on metformin. what should you do?
reduce dose
or use modified release
how does metformin work?
increases tissues sensitivity to insulin
jean’s having terrible vomiting on metformin. what should you do?
reduce dose
or use modified release
how does metformin work?
increases tissues sensitivity to insulin
does metformin requires the presence of endogenous insulin to function?
yes. if no beta cells no point.
what kind of drug is liraglutide?
GLP-1 analogue
GLP1 analogues only rlly give in combo when other options failed. who do u only give liraglutide to?
in pts w t2dm and established cardiovascular disease or BMI >35
(CV benefit)
jean’s having terrible vomiting on metformin. what should you do?
reduce dose
or use modified release
what long term effects can pioglitazone have?
osteoporosis, HF
does metformin requires the presence of endogenous insulin to function?
yes. if no beta cells no point.
what kind of drug is liraglutide?
GLP-1 analogue
subcut injectable
what kind of drug is canagliflozin
sodium glucose co-transporter 2 inhibitors
what should be considered if a person taking metformin presents with megaloblastic anaemia?
can cause b12 deficiency
what is first line drug treatment in t2dm person ?
● Metformin →add another drug→ triple therapy→ insulin
why is metformin useful in PCOS?
increases insulin sensitivity
HbA1c target when just lifestyle/ metformin?
<48
HbA1c target when two or more diabetes drugs prescribed?
<53
which 3 drugs might you usually add if metformin not working
DPP4 inhibitor
suphonylurea
pioglitazone
what should be considered if a person taking metformin presents with megaloblastic anaemia?
can cause b12 deficiency
what is first line drug treatment in t2dm person ?
● Metformin →add another drug→ triple therapy→ insulin
why is metformin useful in PCOS?
increases insulin sensitivity
HbA1c target when no hypo risk is management (e.g. lifestyle, metformin)?
<48
HbA1c target when two or more diabetes drugs prescribed?
<53
which 3 drugs might you usually add if metformin not working
DPP4 inhibitor
suphonylurea
pioglitazone
give an example of a DPP4 inhibitor
sitagliptin
what kind of drug is sitagliptin
DPP4 inhibitor
as well as hypertension, steroid induced DM, thinskin/easy bruising, name some other SEs of steroids
moon face w plethoric cheeks steroid induced cataracts buffalo hump striae steroid induced psychosis
does prednisolone put you at high risk of severe chickenpox?
yes
if treatment w prednisolone is long term, what should you consider presciribng with it?
bisphosphonates
how should you take alendronic acid?
on an empty stomach 30 mins before breakfast, with whole glass of water, stood upright
name a common SE of bisphosphonates
GI disturbance
name 3 imporrrrtantSEs of bisphosphonates
osteonecrosis of jaw
oesophagitis
atypical stress fractures
name 3 situations in which u should avoid bsiphosphonates
preg
hypoCa
oes strictures
should you avoid live vaccines on methotrexate?
yes
whats the risk that can happen if co-prescribing trimethoprim and methotrexate?
pancytopenia
azathioprine and allopurinol. is that ok
not ok
does azathioprine increase risk of skin ca?
yes
