Therapeutic drug monitoring & High risk drugs Flashcards
What is the difference between HYPERglyceamia and HYPOglyceamia symptoms?
HYOGLYCEAMIA:
Dizzy, head hurts, shaky, hungry, cannot see or think straight, sweaty
HYPERGLYCEAMIA:
Dry mouth, need water, lots of weeing, wetting bed, stomach painblood glucose concentration ishigh so fluid moves out of cells into circulation due to osmosis so you get dehydration
What is an ionotrope? What is a positive and what is a negative ionotrope?
Drug that alters force or energy of heart contractions
Positive ionotrope (e.g. Digoxin, Amiodarone): ↑ force of contractions of heart, (decompensateHF, shock (severe hypotension)+ heart attack as they get blood pumping again! NB: these do not increase rate, digoxin decreases rate, just increase force of contraction. Digoxin used as rate control in AF, Amiodarone used as Rhythm.
Negative ionotropes: ↓ force of contractions of heart, (Hypertension to bring BP down + Angina) I.e. Rate limiting CCB’s, cardio-selectivebeta blockers e.g. bisoprolol, carvedilol, metoprolol, some anti-arrhythmics such asflecainide
What is the desired serum concentration of Digoxin?
1 - 2 mcg / L
What is the difference between bradycardia and tachycardia? What is the the classified pulse rate for these?
Bradycardia: slow heart rate: pulse under 60 bpmTachycardia: fast heart rate: pulse over 100 bpm
What are the symptoms of DIGOXIN toxicity? (i.e. levels over 2 mcg/ L)
Gastro: Nausea & vomiting, Abdominal pain, Anorexia (weight loss)
Cardiac: Bradycardia (HR under 60 bpm), Arrythmias (irregular heart beat)
Mental: Delirium (confusion), Visual disturbance- blurred, seeing yellow, blind spots
Digoxin needs close monitoring. It slows the heart rate, but increases the force of contraction. We need to monitor the heart rate: When should we be worried?
If it falls <60 BPM (i.e. bradycardic)
We need to monitor the plasma concentration of Digoxin closely. When should levels be taken?
> 6 HOURS after a dose given
Digoxin toxicity can be fatal. What electrolyte imbalance can precipitate digoxin toxicity?
HYPOKALEAMIA: We manage this by giving K+ sparing diuretics (e.g. spironolactone) and K+ supplements.
Hypomagnesaemia
Hypocalcaemia
How is digoxin excreted? Therefore what do we need to monitor and decrease dose if impaired?
Renally excreted, decrease dose if patient has renal impairment
What is digoxin used in?
Most use in persistent & permanent Atrial Fibrilation
RATE control
Has a role in Heart Failure
Role in Atrial flutters
Amiodarone is used in the rhythm control of AF.
Digoxin is used as rate control
interaction between these 2 drugs?
Amiodarone INCREASES Cp of digoxin
= ENZYME inhibitor but not one of P450’s class (so not part of SICKFACES)
Digoxin dose decreased by 50% if given with Amiodarone
Digoxin is metabolised by the CYP450 enzyme system, primarily 2C19. It therefore has many interactions. Can you think of any drugs that increase its concentration?
Macrolides: Erythromycin, Clarythromycin, Azithromycin
Ciclosporin
Itraconazole
Amiodarone (but not through CYP)
Rifampicin and St Johns Wort are both CYP450 enzyme inducers. What TDM drug do they reduce the concentration of?
Digoxin
Why does Digoxin interact with Diuretics?
~ Diuretics (Loop & thiazide/ thiazide- like) may cause HYPOKALEAMIA
~ Digoxin toxicity precipitated by HYPOkaleamia
SO careful with these
K sparing diuretics Okay:Amiloride/ Triamterene/Spironolactone (this can increase [Digoxin]), Eplerenon
What drugs other than diuretics can interact with digoxin due to their Hypokaleamic effects?
Amphotericin (Antifungal!)
Can you think why ACE inhibitors and NSAID’s interact with digoxin?
Remember digoxin excreted renally + caution in kidney impairment
==> ACE inhibitors & NSAID’s can both decrease kidney function + precipitate digoxin toxicity
What happens if a CCB is administered to someone on Digoxin?
conc of digoxin ⬆ by:
Diltiazem
Nicardepine
Nifedipine
Verapamil
(also ⬆ risk of AV BLOCK & bradycardia)
What are the signs of Lithium toxicity?
GI disturbance warning signs: V, D
Mostly CNS effects:
Fine Tremor then coarse tremor
Involuntary movement (ataxia)
Involuntary eye movement (Nystagmus)
Blurred vision
Thirst- due to hypernatreamia?
Severe toxicity (level over 2 mmol/L):
Convulsions
Coma
Renal failuire
Lithium can cause problems in some of our organs. What are these, what would be the signs if their function had altered?
Kidney - monitor renal function
Sign of decline: Polyuria, Polydipsia
Thyroid- usually hypothyroidism
Signs: unexplained fatigue
Benign intracranial hypertension (high BP in brain)
Signs: persistent headache, visual disturbance
You know the target range for lithium is 0.4 - 1.0 mmol/L.What is the target in acute episodes of mania?
0.8 - 1.0 mmol/ L- upper end of range!
What three drugs do you legally have to provide a patient alert card with?
LithiumSteroidsAnticoagulant
Lithium interacts with ACE inhibitors/ ARB’s/NSAIDS
What is this interaction?
ACE inhibitors / ARB’s & NSAIDs = decrease renal perfusion
=> Lithium excreted by Kidneys => Lithium levels risk= lithium toxicity
Why does Lithium interact with the Diuretics (loop, thiazide AND potassium-sparing)?
Diuretics = cause electrolyte disturbance
=> Hyponatreamia
=> Lithium levels influenced by sodium levels- lithium toxicity
Which antibiotic could possibly cause Lithium toxcity/ levels to rise?
Metronidazole
Please note increased risk of neurotoxicity when Lithium given with
~ methyldopa, phenytoin, carbamazepine & rate limiting CCB’s (diltiazem & verapamil)
increased risk of EPSE’s when Lithium given with antipsychotics
What type of seizures can phenytoin be used in?
Focal
Tonic- clonic
Myoclonic
=> But not first/ 2nd line in any. Its use is fizzling out.All types of seizure but Absent!
Desired therapeutic range for Phenytoin?Why is it so important to monitor phenytoin levels?
10 - 20 mg/ L = 40- 80 micromol/L
Non-linear relationship between dose + plasma conc: small change in dose= big change in conc
What are the symptoms of Phenytoin toxicity?
CNS:
Nystagmus (involuntary eye movement)
Ataxia (involuntary body movement)
Slurred speech
Confusion
suicidal thoughts
HYPERGLYCEAMIA
Double vision (diplopia)
blurred vision
: Similar to Lithium toxicity: remember differentials (hyperglyceamia, no convulsions)
Phenytoin related to SKIN & BLOOD disorders
What does the patient need to look out for?
Skin- look out for RASH
Phenytoin also causes:
HIRSUTISM (excess hair growth)
gingival hypertrophy (enlarged gums)
acne
Blood disorder: Fever, sore throat, mouth ulcers, bruising, bleeding
With phenytoin, we should monitor ECG & BP with IV use.Should also monitor _____ function, especially in elderly
LIVER
Phenytoin hepatically metabolised: Caution in Hepatic impairment
What is the desired range of Theophylline levels?
10 - 20 mg/ L
55 - 110 micromol/ L
(mg/ L= same as phenyotin! & digoxin is 1 - 2 mcg/ L so similar! and you know Lithium!)
Phenytoin is an interesting drug when it comes to interactions as it itself enzyme inducer, but its levels effected by other enzyme inducers/ inhibitors. It can (effectively) induce its own metabolism.This weird effect displayed by its varied interactions with anti-fungals. Ketoconazole and Fluconazole are both Part of SICKFACES and are enzyme inhibitors…
However,Phenytoins own levels INCREASED by fluconazole & miconazole= phenytoin TOXICTY
Phenytoin itself INCREASES levels of Ketoconazole and itraconazole
What is the interaction between PHENYTOIN and AMIODARONE?
Amiodarone inhibits metabolism of Phenytoin !!
Phenytoin concentration increases
Phenytoin is metabolised by CYP450 enzymes. Some of the enzyme inhibitors can therefore increase [Phenytoin]. Which ones?
I soniazidC imetidineF luconazoleC hloramphenicolE rythromycinS ulfamethoxazoleC iprofloxaxinO meprazoleM etronidazole
What electrolyte disturbance can Theophylline cause?
Hypokaleamia
~ Patients may also be on salbutamol
(SABA) for their asthma- can also cause hypokaleamia
Severe asthma patients- monitor K+ as may alsobe on corticosteroids- can cause hypokaleamia
Diuretics- hypokaleamia
Monitor plasma Potassium in severe asthma/ with theophylline therapy
What is Theophylline? How does it work?
Xanthine
Same family as Caffeine.. broncho dilator
Theophylline is used in Chronic Asthma Therapy only, usually orally as an MR prep.When is Theophylline used in Asthma therapy?
Can be used at step 3 or 4 of asthma pathway
Step 3: as add-on therapy to ICS/ LABA
Step 4: As a regular bronchodilator (6 week trial)
Signs of Theophylline toxicity?Hint: same family as caffeine
- Vomiting
- Restlessness
- Agitation
- Dilated Pupils
- Sinus tachycardia (palpitations)
- Hyperglyceamia
- Severe HYPOKALEAMIA
- Hallucinations
Severe toxicity: convulsions, arrhythmias, throwing up blood
How do we treat theophylline toxicity?
Treatment:
Repeated activated charcoal, odansetron for vomitting, potassium chloride
Short acting beta-blocker (e.g. Esmolol) may reverse severe tachycardia, hypokalemaia and hyperglyceamia
The plasma concentration of theophylline is increased in ….3…. conditions?
Heart Failure
Hepatic impairment
RespiratoryViral infections
==> So watch out for signs of toxicity (plasma conc >20mg/ L)
What 2 social activities can DECREASE theophylline levels?
SMOKING
Alcohol consumption
Why is it important to ensure the same BRAND of theophylline is maintained?
Rate of absorption from different modified release preparations can change between brandsThe brands have different dosing regimesBrands: Uniphyllin Continus®, Slo-phyllin®, Nuelin SA®
How can Slo-phyllin (theophylline) capsules be taken?
Swallow whole with water OR granules can be sprinkled onto yoghurt/ soft food and swallowed without chewing
How is theophylline metabolised?
HEPATICALLYtherefore <strong>reduce dose</strong> in liver impairment!
What are the 3 E’s that Theophylline should be used in caution with?
Epilepsy- reduced seizure threshold (Hence interaction with Quinolones!)
Elderly-Increased plasma theophylline conc- maybe due to reduced Liver function?
Elevated BP-Hypertension, also hyperthyroidism
Theraputic range of Carbamazepine?
4 - 12 mg / L
Gentamicin- multiple daily dose regimen- one hour peak serum concentration?And for endocarditis?
NB: For once-daily: consult local guidelines
5 - 10 mg / L
Endocarditis: 3 - 5 mg/ L
Gentamicin-pre-dose trough concentration?And for endocarditis?
< 2 mg/ L
Endocarditis: < 1 mg/ L
For Vancomycin monitoring, we just take Pre-dose Trough levels.What should this be?Different for endocarditis?When should this be taken?
Trough level: 10 - 15 mg/ L
Endocarditis: Aim higher for Vancomycin (its lower for Gentamicin): 15- 20 mg/L~~~ Take this after 3rd or 4th dose if renal function normal, 30 MINUTES before next dose is due
When should plasma theophylline concentration be measured after starting oral treatment?How many hours after a dose should a blood sample be taken?
5 days after starting
Take blood sample 4 - 6 hours after oral dose of Modified release preparation
Why is it important for prescribers to specify the brand of aminophyllin or theophylline MR tablets?What can be done for smokers on aminophylline?
The rate of absorption from MR preparations can differ between brandsSpecific brand of aminophylline (phyllocontin continus) forte tablets are for smokers (smoking induces metabolism of aminophylline/ theophylline)
What are the side effects of Theophylline?
Diarrhoea
Convulsions- lowers seizure threshold
Arrythmias
Headache
Insomnia
Vomitting
We know that <strong>sodium</strong> effects Lithium levels. How does it effect lithium levels?!
Lithium will follow sodiums movement:So if plasma sodium is low, renal reabsorption of sodium occurs (as the sodium ions move from high to low concentration) and<strong> lithium follows</strong>, so lithium levels RISE- <strong>lithium toxicity</strong>If plasma sodium is high: more sodium excreted/ less reabsorption- lithium follows and lithium level decreases- <strong>subtherapeutic</strong><em><strong>This is why we say keep your salt intake stable- dont increase or decrease it!</strong></em>
What is Carbimazole used for?
HyperthyroidismReport any sore throat, ulcers, fever, malaise, bleeding with Carbimazole
What is the difference between:<em>Agranulocytosis</em><em>Thrombocytopenia</em><em>Blood Dyscrasias</em>
<em>Agranulocytosis: </em><strong>WBC’s go down; sore throat, fever, malaise all symptoms</strong><em>Thrombocytopenia: </em><strong>Platelets go down: blood very thin: unexplained bleeding/ bruising. Can be from Heparins</strong><em>Blood Dyscrasias:</em><strong>Entire blood profile goes down; symptoms of both of the above, this is why we report both sets of symptoms with some drugs</strong>
What is the loading dose of Amiodarone?
200mg TDS for 7 days200mg BDfor 7 daysThen 200mg OD from there on (maintenance)<span><strong>Why load? Long half life (50 days)means it would take ages to reach therapeutic levels. Also meansinteractions can still occur months after stopping.</strong></span>
Symptoms of Aspirin Overdose (5)
Tinnitus Hyperventilation Deafness Vasodilation Sweating
Why is rifampicin considered High Risk do you think?(Rifampicin is one of the TB drugs)
Many <strong>interactions</strong>- as it is an enzyme Inducer, it induces ALL of the CYP enzymes: decreases efficacy of COC’s<strong>HEPATOTOXIC</strong>: Monitor LFTs, counsel on liver toxicity signs,stop if:<strong>Persistent Nausea<br></br>Vomiting<br></br>Malaise<br></br>Jaundice</strong><em>Also colours urine/ body fluids/ soft contact lenses red/ orange</em>
What monitoring is needed with Rifampicin?
LFT’s before starting- continue to monitor if on prolonged therapyRenal function before startingFBC if on prolonged therapy
Which class of antibiotics do we need to use with caution in EPILEPTICS?
<strong>Quinolones</strong>-Ciprofloxacin, LevofloxacinThese lower seizure threshold!<em>Particularly if used with theophylline</em>
Why do we need to check albumin levels with warfarin?
Warfarin is highly protein bound to albumin- if this is low there may be issues transporting it round the bodyneed to monitor both renal and liver function with warfarin
People stable on warfarin- how often is INR checked?
Every 3 monthsUnless changes in clinical status occur e.g. diarrhoeaand vomitting
What (quite unpleasant)side effects are associated with Amiodarone use, what signs should patients look out for? (7)
Nausea and vomitting and taste disurbance<u>Thyroid function</u>- <strong>Hypo and Hyperthyroidism through action of IODINE in the drug</strong><u>Phototoxic skin reactions</u>: burning sensation, erythema, slate grey skin discolouration<u>Pulmonary toxicity-</u><strong><u> </u>persisitent SOB/ Cough</strong><u>Tremor-</u> peripheral neuropathy- numbness in hands and fee<u>t</u><u>Corneal microdepositis in eyes</u>- dazzled by headlights- common SE: <em>this is reversibleonce drug stopped</em><u>Liver toxicity: </u>Jaundice
What is the half life of amiodarone
approx 40-50 days
What 5 things needmonitoring at baselinewith Amiodarone?
<strong>LFT’s-</strong> Hepatotoxicity a risk<strong>THYROID FUNCTION-</strong> hyper/hypothyroidism<strong>Serum Potassium!!!!</strong> before starting<strong>Chest X-ray-</strong> pulmonary toxicity<strong>ECG with IV use</strong><em><strong>LFT’s and TFT’s need monitoring after 6 months too!</strong></em>
What is Amiodarone used for?
Treatment of<strong>Both supraventricular and ventricularArrhythmias</strong><strong>Ventricular fibrilation, ventricular tachycardia</strong>Usually used when other drugs failed as quite a nasty drug<em><strong>Rhythm control as part of pharmacological cardioversion in AF</strong></em>
Methotrexate inhibits dihydrofolate reductase and therefore reduces folate in the body. What drug has to be given with methotrexate as supplementation to prevent its nasty side effects, and when?
For prevention of methotrexate induced horrible side effects in Chron’s/ RA:<strong>Folic acid 5mg ONCE WEEKLY- dose to be taken on a DIFFERENT DAY to methotrexate</strong>
Methotrexate may lead to blood disorders (most significantly neutropenia and increased infection risk)through BONE MARROW SUPPRESSION. Its anti- folate propertied may explain how it suppresses bone marrow…
Bone marrow is where the body creates new cells. Cell division requires folate in order to occur.Since folate deficiency limits cell division, erythropoiesis, production ofred blood cells, WBC, neutrophils etc is suppressed in the bone marrow when methotrexate is taken as it is anti- folate. This is the <strong>same story as with Trimethoprim</strong>/ Co- trimoxazole and <strong>Phenytoin</strong>as these are also anti-folate- Avoid use together!Production of RBC’s beinghindered also leads tomegaloblastic anemia, which is characterized by large immature red blood cells that cannot divide.
What monitoring does Methotrexate require?
<strong>Renal function</strong><strong>LFT’s</strong><strong>FBC</strong> (due to blood disorder risk)<strong><em>These should be 1-2 weekly until dose stabilised then 2-3 monthly thereafter</em></strong>Exclude pregnancy- pregnancy test before starting?<em>Avoid in <strong>hepatic impairment </strong>and reduce dose in <strong>renal impairment </strong>unless severe- then avoid.</em>
What is Methotrexate used for?
Main use in:Rhumatoid ArthritisSevere Chron’s (Inflammatory Bowel Disease)Severe PsoriasisIt is cytotoxic- stops cell division- part of chemotherapy
What are the Methotrexate warning signs
<strong>Blood disorder</strong>: Bone marrow suppression- sore throat, ulcers, fever, rash<strong>Liver toxicity-</strong> N&V, abdominal pain,dark urine,Jaundice<strong>Gastro-intestinal toxcitiy</strong>: stomatitis, GI upset (sore mouth first symptom)<strong>Pulmonary Toxicity</strong>- persistentSOB, cough<strong>PREGNANCY & Breastfeeding</strong>- its anti-folate so avoid!!- <em><strong>contraception needed during treatment and for 3 months after stopping</strong></em><em><strong>WITHDRAW TREATMENT IF ANY OF THESE OCCUR</strong></em>
What OTC med’s can increase the risk of Methotrexate toxicity?
<u><strong>NSAIDS/ ASPIRIN !!</strong></u><br></br>Reduce methotrexate excretion in kidney<strong>As do penicillins!</strong>
A patient comes in complaining of mouth sores, they think it may be cold sores. After further questioning you find out they are on Methotrexate. What do you do?
<em><strong>Advise they seek medical attention ASAP</strong></em>Mouth sores may be a sign of stomatitis (inflammation of mouth) which is the first sign of <strong>Gastro-intestinal toxicity associated with Methotrexate!</strong>
A patient asks for some Lozenges as they are experiencing a very sore throat. You find out they are on Methotrexate. What do you do?
<em><strong>Seek medical attention ASAP</strong></em>Sore throat is most common side of blood disorders with Methotrexate
Patients can sometimes overdose on Methotrexate as they get confused that it is Just once weekly dosing. What are the symptoms? what is methotrexate toxicity treated with?
Renal impairmentLiver impairmentHeadache, seizures, coma<strong>Treatment: FOLINIC ACID</strong>- rescues normalcells from methotrexate effects
What happens when Baclofen (used for pain of muscle spasms in palliative care/ trauma) issuddenly withdrawn? What if itis given with ACE inhibitors or Beta blockers?
Suddenly withdrawn: hyperactivity, hyperthermia, hallucinations, convulsionsEnhanced Hypotensive effects with ACEi/ Beta blockers
Which NOAC is contra-indicated in patients with a Prosthetic valve?
DABIGATRAN
which OTC medication can affect the absoprtion of anti epileptics
ORLISTAT (Alli)
What needs monitoring with Vancomycin (4)?
<p><strong>Full blood count</strong>: can cause both LOW PLATELETS and LOW NEUTROPHILS (Neutropenia)</p>
<p><strong>Renal function-</strong> Nephrotoxic- Urinalysis, CrCl used for dosing</p>
<p><strong>Hearing function </strong>in the elderly</p>
<p><strong>Plasma concentration</strong></p>
What needs monitoring with Gentamicin?
<p>Renal function</p>
<p>Hearing function</p>
<p>Plasma concentration</p>
<p><span>NB: differs to vancomycin as do not need to monitor FBC- does not cause neutropenia/ low platelets</span></p>
Which antihypertensive drugs require the SAME BRAND to be maintained?
<strong>Diltiazem</strong><strong>Nefedipine</strong>(Both CCB’s)
Which CCB <strong>cannot be used </strong>in both Supraventricular and Ventricular arrhythmias?
<u><strong>VERAPAMIL</strong></u>Used for Supraventricular only<u><strong>Ve</strong></u>rapamil NOT to be used in <u><strong>Ve</strong></u>ntricular Arrhythmias
Ciclosporin (an immunosuppressant drug) has many interactions. This is because it is toxic to many organs, so any drug effecting each of those organs will be contra-indicated with ciclosporin use. What toxicitys can it cause (5)?
<strong>Neurotoxicity</strong> (CNS- tremor, convulsions, encephalopathy)<strong>Liver toxicity</strong> (jaundice, N&V, abdo pain, dark urine)<strong>Nephrotoxicity</strong> (kidney)<strong>Blood toxicity/ disorders</strong> (fever, sore throat, ulcers, bleeding)<strong>Hypertension- </strong>BP needs monitoring regularly<b>Patient should report any of these signs</b>
What type of vaccines are Ciclosporin and Tacrolimus Contra-indicated with?
Live vaccinesLive vaccines can, in some situations, cause severe or fatal infections in <strong>immunosuppressed individuals</strong> due to extensive replication of the vaccine strain that the immune system cannot fight off.<strong>Same goes with high dose corticosteroids: these can suppress the immune system so avoid live vaccines</strong>
What should patients on corticosteroids be told with regards to <strong>chickenpox/ measels?</strong>
If they have not have these before, avoid any exposure to anyone with these as they can contract very severe forms of these if they do.
Why is an eye exam needed with corticosteroid use?
Risk of eye problems:Glaucoma- look for intraocular pressureCorneal thinning
What drugs can increase the risk of someone developing <strong>gout </strong>(build up of uric acid)?
<p><strong>Diuretics</strong>– clears excess fluid out of body butthe remaining fluid is more concentrated;increases the risk of developing the crystals that causegout</p>
<p>Beta-blockersand ACE inhibitors</p>
<p>low-dose aspirin– used to reduce the risk ofblood clots</p>
<p>niacin–used to treat high cholesterol</p>
<p>ciclosporin– used to treat conditions such aspsoriasis</p>
What are the symptoms of gout?What are the dietary risk factors of gout?
<p>Build up of uric acid causing:</p>
<p>suddenattack ofsevere painin one or morejoints, typically big toe.</p>
<p>joint feeling hot and very tender,swellingin and around the affected joint</p>
<p><strong>Dietary risk factors:</strong>high in meat and seafood and high in beverages sweetened with fructosepromotes higher levels of uric acid, also alcohol.</p>
<p><strong>Phospohorus can help cure gout:</strong>Banana is a rich source of phosphorus.</p>
What is the main symptom of Hypokaleamia?What drugs can cause hypokaleamia?
<strong>Ventricular Arrhythmias</strong><strong>(Hyperkaleamia can also cause arrhythmias!)</strong>Thiazide, thiazide-like and Loop diureticsSotalolSalbutamolAmisulpirideAtomoxetine (used for ADHD)
Can you inject potassium chloride 20% w/v straight?
No- must be diluted first with sodium chloride 0.9%<br></br>Must be given by slow infusionMonitor ECG- rapid infusion would be toxic to heart and arrhythmias occurNeed to the patient is weeing enough- contraindicated in anuria (absence of urination) as potassium would build up
What could black stools or coffee groung vomit be suggestive of with NSAIDs? What about Iron deficient aneamia?
GI bleeding
<p>What are the following indicative of with NSAID therapy?</p>
<p>Unexplained weight loss</p>
<p>difficulty swallowing</p>
<p>nausea or vomiting</p>
<p>bloating</p>
<p>burping or acid reflux- recent onset dyspepsia</p>
Peptic ulcer
What could swollen ankles indicated with NSAID therapy?
Kidney failure
Which NSAID is now contra-indicated in patients with a cardiac disease history/ risk of CV disease?
<strong>Diclofenac</strong>The new treatment advice applies to systemic formulations (ie, tablets, capsules, suppositories, and injection available both on prescription and via a pharmacy, P); it does not apply to topical (ie, gel or cream) formulations of diclofenac.
What electrolyte disturbance could NSAIDs effectively cause?
NSAIDs can <strong>damage </strong>the <strong>kidneys </strong>(AKI)This can in turn lead to <strong>HYPERKALEAMIA</strong>
A dose increase for an <strong>opioid </strong>should be no more than __% of the last dose
No more than <strong>50%</strong>Due to risk of overdose
Aside from their use in pain, what else can strong Opioids be used for?
Relief of breathlessness in palliative careRelief of breathlessness and anxiety in acute pulmonary oedema (alongside oxygen, furosemide, nitrates)- Myocardial infarctionBut do not give them in respiratory failure!Suprising when they can cause respiratory depression! This is because they reduce cardiac work and oxygen demand- hence their use in Myocardial Infarction.
What side effects opioids have on skin?
They cause <strong>histamine </strong>release- this can cause <strong>ITCHING </strong>and <strong>urticaria </strong>(hives/ nettle rash), also sweating
Biliary colicis atype of pain related to gallbladder that occurs when gallstone obstructs cystic duct & gallbladder contracts. Should we use opioids for this pain?
No- opioids can worsen the pain due to sphincter spasm
How is chronic pain usually managed with strong opioids?
Oral route first:Start with immediate release solution (Oramorph)
~ Then once optimal dose found- switch to MR (MST Continus- administered BD [12 hourly])
For breakthrough pain = immediate release (Oramorph) morphine at dose of 1/6 usual.
Why must codeine/ dihydrocodeine never be given via the IV route?
Can cause severe reaction similar to anaphylaxis (but not allergy based)
Which opioid should be avoided in epileptics?
Tramadol: it lowers seizure threshold
Avoid with other drugs that lower seizure threshold: SSRIs, TCAs, quinolones, theophylline
What is heaviness in the centre of the chest likely to indicate?
Heart attack
How should oral antiplatelets be administered?
With or just after food (to protect stomach)
Except for Dipyridamole
30 to 60 mins before food
Why is Tacrolimus such a high risk drug? What can it cause?Hint: Similar to Ciclosporin. Both toxic to many organs
Neurotoxicity (CNS)- tremor, headache
Nephrotoxicity
Eye disorders (ciclosporin not toxic to eyes)
Blood disorders- report fever, sore throat, ulcers etc
Skin disorders- rash
Hyperglycaemia
Liver toxicity
What dietary substances should patients on Tacrolimus / Ciclosporin avoid?
Avoid diet high in K (as these can BOTH cause Hyperkaleamia
Avoid grapefruit juice- Increases plasma concentrations of these as its enzyme inhibitor
What drugs can cause Hyperkaleamia?
Ace inhibitors/ ARBs/K K-sparing diuretics (spironolactone + eplerenone)/Ciclosporin / Tacrolimus (immunosuppressants)NSAIDs
What do we use to treat hyperkaleamia?
~ Calcium gluconate
~ priority = stabilise heart: do not want it to arrest due to fatal cardiac arrhythmias
~ Then sort out hyperkaleamis: IV insulin / salbutamol as temporary measures to drive K+ back into cells
~ If its severe- use Heamodialysis
Why not use diuretics, as these cause hypokaleamia too?- as diuretics will effect fluid balance. do not want to put any more strain on heart.
<p>What should a patient do if they miss a warfarin dose?</p>
Do not double up!If later that evening- take dose. If next day- skip dose
Why are beta blockers used with caution in diabetes?
Can mask hypoglyceamia:beta blockers blunt of adrenalin: if someone becomes hypoglycemia adrenalin doesnt kick in and they dont get warning symptoms. Sweating= only symptom that still shows.Canalso prevent adrenalin from stimulating liver to make glucose, and therefore may make hypoglycemia more severe
Why are beta blockers cautioned in asthma and COPD?
Risk of bronchospasm
If absolutely need one: choose cardio selective BB like Bisoprolol
Why do we get a dry cough with Ace inhibitors and not ARB’s?
ARB’s do not increase bradykinin levels, because they do not inhibit ACE
Why are NSAID’s cautioned in asthma, what can they cause?
Bronchospasm- does not happen to every asthmatic.
Which diuretics can exacerbate diabetes?
Thiazides (most likely)
Loop diuretics
Due to hyperglyceamia side effect!
What do we need to monitor with diurectic use?
Electrolytes:Na +K +Mg +Renal function
Uric acid levels (risk of gout)
Hyperglyceamia- can exacerbate diabetes
Hypotension- BP lowering effects
When do we use simvastatin at max dose of 10mg?
With fibrate use in combo: massive risk of myopathy+ Bezafibrate+ Ciprfibrate
Do not use gemfibrozil at all- risk of
Rhabdomylosis too great
Which oral antidiabetic carries least risk of Hypoglyceamia?
Metformin
What vitamin deficiency can Metformin cause?
Vitamin B12 (cobalamin)
Symptoms of deficiency: neuropathy (numbness, pain, or tingling in hands or feet)
Anaemia- extreme tiredness (fatigue)
lack of energy (lethargy)
breathlessness
pale skin
ACE inhibitors have some protective & some negative effects on Kidneys. When are they contra- indicated?
Bilateral
Renal artery stenosis - make it progress into renal failure
Less effect on Unilateral renal artery stenosis
Best to avoid in patients with known or suspected RENOVASCULAR disease
Max daily dose of Codeine?
How long must intervals between doses be?Max number of days OTC?
240mg daily
6 hour intervals
3 days OTC
What drug causes ‘Purple glove syndrome’ skin diseasein which extremities becomeswollen, discoloured & painful
Phenytoin if given IV
