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PSA > Top 100 Drugs > Flashcards

Top 100 Drugs Flashcards

1
Q

what are 2 examples of 5 alpha-reductase inhibitors?

A

finaseteride
dutasteride

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2
Q

what drug class is finasteride?

A

5 alpha-reductase inhibitor

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3
Q

what are 2 indications for 5 alpha reductase inhibitors?

A

BPH causing LUTS
Androgenetic alopecia - male patterned baldness

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4
Q

what is the MOA of 5 alpha reductase inhibitors?

A

inhibits intracellular enzyme 5-alpha-reductase which converts testosterone to the more active dihydrotestosterone, stimulating prostatic growth

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5
Q

how long does it take 5-alpha-reductase inhibitors to work?

A

up to 6 months

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6
Q

what are 5 adverse effects of 5-alpha-reductase inhibitors?

A

Impotence
Reduced libido
breast tenderness and gynaecomastia
BREAST CANCER
SUICIDAL THOUGHTS
hair growth

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7
Q

what are the warnings needed with 5-alpha-reductase inhibitors?

A

NEVER in women - can cause genital birth defects in male foetuses

avoid contact with women of childbearing potential including with SEMEN

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8
Q

what is the starting dose of finasteride given for BPH?

A

5mg OD PO
review after 3-6 mon for efficacy then every 6-12 mon

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9
Q

what is the dose of dutasteride for BPH?

A

500 micrograms OD PO

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10
Q

what is the dose of finasteride for male patterned baldness?

A

10mg OD PO

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11
Q

what is the monitoring for 5-alpha reductase inhibitors?

A

review after 3-6 mon for efficacy then every 6-12 mon

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12
Q

what are 2 examples of Acetylcholinesterase inhibitors?

A

donepezil
rivastigimine

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13
Q

what are 2 indications for Acetylcholinesterase inhibitors?

A

mild to moderate Alzheimers
Mild to moderate dementia in parkinsons - rivastigimine

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14
Q

what is the MOA of Acetylcholinesterase inhibitors?

A

Ach is needed for memory and learning. Acetylcholinesterase inhibitors inhibit the breakdown of Acetylcholine in the CNS => increasing the availability of acetylcholine allowing for improved cognitive function and slower decline though this is not universal

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15
Q

what drug class is rivastigimine?

A

Acetylcholinesterase inhibitors

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16
Q

what drug class is donepezil?

A

Acetylcholinesterase inhibitors

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17
Q

what is the most common adverse effect to Acetylcholinesterase inhibitors?

A

GI upset

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18
Q

What can Acetylcholinesterase inhibitors cause in asthma and COPD?

A

Bronchospasm

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19
Q

what are 3 peripheral side effects of Acetylcholinesterase inhibitors?

A

Peptic ulcers and bleeding
Bradycardia
Heart block

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20
Q

what are 4 central cholinergic side effects of Acetylcholinesterase inhibitors?

A

hallucinations
altered/aggressive behaviour
extrapyramidal symptoms
neuroleptic malignant syndrome

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21
Q

what are 2 life threatening side effects of Acetylcholinesterase inhibitors?

A

neuroleptic malignant syndrome
Bronchospasm in asthma/COPD

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22
Q

what are 2 contraindications to Acetylcholinesterase inhibitors?

A

Sick sinus syndrome
heart block

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23
Q

what are 4 cautions in Acetylcholinesterase inhibitors?

A

Asthma
COPD
Peptic ulcers
Parkinsons - rivastigimine may worsen tremor

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24
Q

what are 2 medications that interact with Acetylcholinesterase inhibitors to increase risk of peptic ulcers?

A

NSAIDS
Systemic corticosteroids

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25
Q

what medications should be used with caution alongside Acetylcholinesterase inhibitors due to increased risk of neuroleptic malignant syndrome?

A

antipsychotics

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26
Q

what medications should be used with caution alongside Acetylcholinesterase inhibitors due to risk of Brady/heart block?

A

beta blockers

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27
Q

what medications can worsen cognitive decline so should not be used with Acetylcholinesterase inhibitors?

A

anticholinergics - antimuscarinics, tricyclic antidepressants

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28
Q

what are 5 medications that should be used with caution with Acetylcholinesterase inhibitors?

A

NSAIDs
Systemic corticosteroids
Antipsychotics
beta blockers
anticholinergics

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29
Q

what is the usual starting dose for donepezil?

A

5mg OD

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30
Q

what is the usual starting dose for rivastigimine?

A

1.5mg every 12 hours

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31
Q

when should donepezil be taken?

A

at night

may cause vivid dreams, in which case take in morning

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32
Q

which Acetylcholinesterase inhibitors is available as a patch?

A

rivastigimine

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33
Q

what is the monitoring for Acetylcholinesterase inhibitors?

A

review for adverse effects at 2-4 weeks
review for efficacy at 3 months - only continue if effective

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34
Q

what are 2 examples of aldosterone antagonists?

A

Spironolactone
Eplerenone - only licensed for CHF

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35
Q

What are 3 indications for aldosterone antagonists?

A

1 - Ascites and oedema due to liver cirrhosis - Spiro 1’
2 - CHF - Spiro 3’ in addition to Beta blocker and ACEi
3 - primary hyperaldosteronism

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36
Q

what is aldosterone?

A

Mineralocorticoids produced in glomerulosa of adrenal cortex and acts on mineralocorticoid receptors in distal tubule of kidney to increase activity of luminal epithelial sodium channel causing increased sodium and water retention and increased potassium excretion

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37
Q

what is the MOA of aldosterone antagonists?

A

Competitively inhibit mineralocorticoid receptors to decrease activity of luminal epithelial sodium channels causing increased sodium and water excretion and increased potassium retention

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38
Q

what are 4 adverse effects of aldosterone antagonists?

A

Hyperkalaemia
Gynaecomastia - SPIRO
Liver impairment and jaundice
Steven Johnsons syndrome - SPIRO

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39
Q

what are 5 signs of hyperkalaemia on ECG?

A

peaked T wave - tall tented
flattened P wave
prolonged PR interval
ST depression
prolonged QRS duration (broad QRS complexes)

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40
Q

what are 4 symptoms of hyperkalaemia?

A

muscle weakness
arrhythmia
cardiac arrest
nausea

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41
Q

what are 3 contraindications to aldosterone antagonists?

A

Renal impairment
Hyperkalaemia
adrenal insufficiency

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42
Q

what is one caution to aldosterone antagonists?

A

should be avoided in pregnancy and breast feeding - can cross placenta

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43
Q

what are 2 medications that should be used with caution with aldosterone antagonists?

A

ACEI and ARBs - also increase risk of hyperkalaemia

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44
Q

what is one medication hat should not be taken with aldosterone antagonists?

A

potassium

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45
Q

what is a typical starting dose for Spironolactone in CHF and resistant HTN?

A

25mg OD PO

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46
Q

what is a typical starting dose for spironolactone in ascites or nephrotic syndrome?

A

100mg OD PO

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47
Q

when should spironolactone be taken?

A

with food

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48
Q

what are 2 things patients should be told when starting on Spironolactone (or other aldosterone antagonists)?

A

May cause gynaecomastia/impotence
Need to come back for potassium monitoring

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49
Q

what monitoring is needed for aldosterone antagonists?

A

For safety - U+E (K+ and Creatinine) - 1 week after initiation and after any dose increase

monthly for first 3 months

then every 3 months for 1 year

then every 6 months

Also monitor for efficacy

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50
Q

what are 3 examples of antacids?

A

sodium bicarbonate
calcium carbonate
magnesium carbonate

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51
Q

what are 2 indications for antacids/alginates?

A

GORD
Dyspepsia

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52
Q

what is the MOA of alginates?

A

increase viscosity of stomach contents and lead to floating ‘raft’ seperating stomach contents from oesophagus

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53
Q

what is the MOA of antacids?

A

buffer stomach acid

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54
Q

what are 2 adverse effects of antacids?

A

magnesium salts - diarrhoea
Sodium salts - constipation

most compound alginates have few side effects

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55
Q

when should alginates/antacids be used with caution?

A

hyperkalaemia/fluid overload - e.g renal impairment

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56
Q

what interactions are there with alginates/antacids? (8)

A

Can reduce serum conc of:
- ACEI
- Bisphosphonates
- PPIs
- Digoxin
- Levothyroxine
- ABx - Tetracyclines, cephalosporins, ciprofloxacin

Can increase excretion of:
- aspirin
- lithium

Should leave 2 hours between interactive medications

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57
Q

what should alginates not be used with as cause too thick stomach contents?

A

thickened infant formula

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58
Q

how are alginates/antacids usually available as?

A

liquid or chewable tablets

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59
Q

what are 4 lifestyle measures to reduce GORD?

A

eat smaller meals more often
stop smoking
avoid food triggers - fatty, spicy
raise head of bed

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60
Q

what are 4 GORD red flags?

A

bleeding
vomiting
dysphagia
wt loss

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61
Q

what are 5 medications that may cause dyspepsia?

A

NSAIDs
antimuscarinics
aspirin
bisphosphonates
corticosteroids

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62
Q

what are 3 indications of allopurinol?

A

1 - gout prevention
2- prevention of uric acid and calcium oxalate renal stones
3 - prevent hyperuricaemia and tumour lysis syndrome in chemo

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63
Q

when is allopurinol used in gout prevention?

A

2+ attacks a year
OR joint damage
OR renal impairment

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64
Q

what is the MOA of allopurinol?

A

xanthine oxidase inhibitor

xanthine oxidase metabolises xanthine (from purines) to uric acid

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65
Q

what is second line to allopurinol?

A

febuxostat

non-purine xanthase oxidase inhibitor

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66
Q

what are 5 adverse effects of allopurinol?

A

May trigger gout attack on initiation
Skin rash
- Steven’s johnson syndrome/TEN
Allopurinol hypersensitivity syndrome

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67
Q

what are 3 contraindications to allopurinol?

A

acute gout attack (can continue but do not start treatment)
Recurrent skin rash
Severe hypersensitivity

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68
Q

what are 2 cautions for use of allopurinol?

A

renal impairment
hepatic impairment

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69
Q

Co-prescription of allopurinol and what medication increases risk of toxic levels of the drug due to it being metabolised by xanthine oxidase?

A

azathioprine

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70
Q

Co-prescription of allopurinol and what 2 medications causes increased risk of hypersensitivity reaction?

A

ACEi
thiazides

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71
Q

Co-prescription of allopurinol and what medication causes increased risk of skin rash?

A

Amoxicillin

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72
Q

what is the starting dose of allopurinol for gout?

A

100mg OD PO

titrate up to 200-600mg in 1/2 divided doses

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73
Q

what should be co-prescribed with allopurinol?

A

NSAIDs or Colchicine to prevent acute attack in first month/till uric acid levels stabalise

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74
Q

how should allopurinol be taken?

A

After meals
Maintain good hydration - 2-3L/day

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75
Q

what is the monitoring of allopurinol?

A

Uric acid levels after 4 weeks from starting/dose change

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76
Q

what uric acid level is aimed for in gout?

A

<300 umol/L

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77
Q

what are 3 medication that can trigger gout?

A

Increase serum uric acid conc:
-Thiazide diuretics
-Loop diuretics

Decrease uric acid excretion:
-Aspirin

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78
Q

What are 3 examples of alpha blockers?

A

Tamsulosin
Doxazosin
alfuzosin

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79
Q

what are 2 indications of alpha blockers?

A

1 - To improve LUTS in BPH
2 - resistant HTN - 4th line after ACEI, CCB and thiazide diuretic

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80
Q

what is the MOA of alpha blockers?

A

Highly selective inhibitors of alpha1-adrenoreceptors causing smooth muscle relaxation in both blood vessels and urinary vessels

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81
Q

what are 3 adverse effects of alpha blockers?

A

Dizziness
syncope
Postural hypotension

Due to effect on vascular smooth muscle

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82
Q

who should not be given alpha blockers?

A

people with postural hypotension

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83
Q

what is an important consideration when starting alpha blockers?

A

May need to omit dose of antihypertensive or Beta-blocker to prevent 1st dose postural hypotension

Also may need to advise on risk of hypotension in combination with phosphodiesterase-5 inhibitors (sildenafil)

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84
Q

which alpha blocker is licenced for both BPH and HTN?

A

Doxazocin

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85
Q

which alpha blocker is licenced in BPH only?

A

Tamsulosin

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86
Q

what is the dose of doxazocin for HTN?

A

1mg OD and then increase after 1/2 weeks to 2mg then to response up to max of 16mg OD

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87
Q

what is the dose of doxazocin for BPH?

A

1mg OD and titrate 1/2 weekly to response up to max of 16mg OD

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88
Q

what is the dose of tamsulosin?

A

400micrograms OD

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89
Q

when should alpha blockers be taken?

A

At night due to effect on BP

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90
Q

What are 3 examples of aminoglycosides?

A

gentamicin
amikacin
neomycin

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91
Q

what type of bacteria do aminoglycosides treat?

A

gram negative aerobes

including pseudomonas aeruginosa

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92
Q

what are 5 indications for aminoglycosides?

A

1 - Sepsis
2 - Pyelonephritis - NOT 1st line
3 - Intrabdominal infections - diver with metro and co-amox
4 - Endocarditis
5 - Otitis externa - neomycin

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93
Q

what is the spectrum of activity of aminoglycosides?

A

treat gram negative aerobes, staph and mycobacteria

NO ACTIVITY AGAINST - strep and anaerobes - often used in combo with penicillin and metronidazole

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94
Q

what is the MOA of aminoglycosides?

A

Bind irreversibly to bacterial ribosomes and inhibit protein synthesis

Enter cells through oxygen-dependent transport systems so only work in aerobes and staph

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95
Q

what are 2 adverse effects of aminoglycosides?

A

ototoxicity
nephrotoxicity

Accumulate in tubular epithelial cells and cochlear and vestibular hair cells

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96
Q

what are 4 cases where aminoglycosides can be used but with caution?

A

Neonates
Elderly
Renal impairment
Myasthenia Gravis - can impair neuromuscular transmission

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97
Q

what 2 medications increase risk of ototoxicity in aminoglycosides?

A

loop diuretics
glycopeptide antibiotics - vancomycin, teicoplanin, etc

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98
Q

what 4 medications increase the risk of nephrotoxicity in aminoglycosides?

A

loop diuretics
glycopeptide antibiotics - vancomycin, teicoplanin, etc
Cephalosporins - cephalexin, ceftriaxone
NSAIDs

Other nephrotoxic drugs

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99
Q

How are aminoglycosides administered?

A

Parenterally as NOT absorbed by gut

Usually OD IV over 30 minutes - given every 24 hours but can be up to 48 hourly in renal impairment

can be given locally

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100
Q

what need to be measured before administering aminoglycosides?

A

renal function

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101
Q

what monitoring is needed for aminoglycosides?

A

Trough levels taken 18-24 hours after dose or mid interval concentration taken 6-14 hours after dose to determine whether it is safe to give the next dose and when

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102
Q

what is the safe trough level of gentamicin?

A

<1 mg/mL

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103
Q

How do you calculate adjusted body weight?

A

[ideal body weight] + 0.4x [actual body weight] - [ideal body weight]

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104
Q

what weight is used to calculate aminoglycosides doses?

A

adjusted body weight

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105
Q

what are 2 aminosalicylates?

A

Mesalazine
Sulfasalazine

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106
Q

what are 2 indications for aminosalicylates?

A

1 - For mild-moderate UC - Mesalazine 1ST LINE - Sulfasalazine can also be used

2 - For RhA - Sulfasalazine - DMARD

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107
Q

What is the MOA of aminosalicyclates?

A

release 5-aminosalicylic acid - exat MOA unknown but thought to have local anti-inflammatory and immunosuppressive properties

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108
Q

what are 6 side effects of aminosalicyclates?

A

GI upset - most common - more with sulfasalazine
Headache
Blood abnormalities - leukopenia, thrombocytopenia
renal impairment
oligospermia
hypersensitivity reaction

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109
Q

what medication are aminosalicyclates related to?

A

ASPIRIN

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110
Q

who cannon take aminosalicyclates?

A

people with Aspirin allergies as also a salicylate

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111
Q

what are 2 medications that may interact with aminosalicyclates?

A

PPIs - may cause premature capsule breakdown
Lactulose - may cause delayed capsule breakdown

in tablets with pH sensitive coating

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112
Q

what is the prescription for aminosalicyclates in mild/moderate UC?

A

1st line - Mesalazine enema/suppository every 12/24 hours for 4-6 weeks to induce remission

can also be taken orally if preferred

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113
Q

what monitoring should be done with aminosalicyclates?

A

Mesalazine - renal function
Sulfasalazine - FBC and LFTs

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114
Q

what is amiodarone used for?

A

AF
Atrial flutter
supraventricular tachycardia
ventricular tachycardia
refractory ventricular fibrillation

usually not 1st line

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115
Q

What is the MOA of amiodarone?

A

effects myocardial cells including blockading sodium, calcium and potassium channels
Also Antagonises alpha and beta adrenergic receptors

Reduces spontaneous depolarisation and increases refractor period

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116
Q

What are 6 long term side effects of amiodarone?

A

Pneumonitis
Bradycardia
AV block
Hepatitis
Skin - photosensitivity and grey discolouration
Thyroid abnormalities - due to iodine content

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117
Q

What is amiodarone’s half life like?

A

long - 25 to 100 days

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118
Q

What is a short term side effect of IV amiodarone?

A

Hypotension

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119
Q

When should amiodarone be avoided? (3)

A

Severe Hypotension
heart block
active thyroid disease

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120
Q

What are 3 medications that amiodarone increases plasma concentrations of ?

A

Digoxin
Diltiazem
Verapamil

Dose should be halved if starting amiodarone

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121
Q

What food should be avoided with amiodarone?

A

Grapefruit juice

Down regulates cytochrome P450 3A4 increasing amiodarone exposure

Long half life so should be avoided after exposure

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122
Q

When is amiodarone given in ALS?

A

In cardiac arrest with VF OR pulseless VT

Give immediately after 3rd shock

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123
Q

What is the dose of amiodarone given in ALS?

A

300mg IV

Followed by 20ml 0.9% saline or 5% glucose flush

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124
Q

what is a complication of peripheral administration of amiodarone?

A

phlebitis

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125
Q

How is amiodarone usually administered?

A

through central line

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126
Q

What should always be done when administering amiodarone?

A

continuous cardiac monitoring

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127
Q

what is the monitoring for long term amiodarone?

A

Renal, liver and thyroid monitoring baseline and 6 monthly
Baseline CXR

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128
Q

What are 3 examples of local anaesthetics?

A

lidocaine
Bupivacaine
levobupivacaine

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129
Q

what are 3 indications for local anaesthetics?

A

Surface anaesthesia
SC local anaesthesia
Regional anaesthesia - spinal/epidural

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130
Q

For what non-anaesthetic purpose can lidocaine be used?

A

2nd line for ventricular tachycardia

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131
Q

what is the MOA of local anaesthetics?

A

reversibly inhibit voltage gated sodium channels on plasma membranes

Prevents initiation and propagation of action potentials in neurones

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132
Q

What property of lidocaine makes it good for topical anaesthesia?

A

readily absorbed through epithelia and has rapid onset

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133
Q

what local anaesthetic is good for blocks and epidurals?

A

bupivacaine

high affinity to binding sites and long duration

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134
Q

what is the most common side effect of local anaesthetics?

A

stinging at injection site

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135
Q

what are 6 effects of IV administration of local anaesthetics?

A

drowsiness
restlessness
tremor
seizures
Hypotension
arrhythmia

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136
Q

what are 5 complications of local anaesthetics for blocks/epidruals?

A

infection
bleeding
higher than intended anaesthetic level
Hypotension and bradycardia - blockage of sympathetic fibres
weakness/paralysis

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137
Q

what are 2 cases in which local anaesthetics should be used with caution?

A

Hepatic impairment
cardiac failure

metabolised hepatically and reliant on hepatic blood flow

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138
Q

what medication can be given with local anaesthetics to prolong their effect?

A

Vasoconstrictors - adrenaline

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139
Q

what local anaesthetic is usually used for SC local anaesthesia and what dose?

A

1% (10mg/ml) solution of lidocaine hydrochloride up to a max dose of 3mg/kg or 200mg (whatever is lower)

If combined with adrenaline can go up to 7mg/kg or 500mg

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140
Q

what is the brand name of topical anaesthetic cream?

A

Emla 5%

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141
Q

What are 3 examples of angiotensin receptor blockers (ARBs)?

A

losartan
candesartan
irbesartan

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142
Q

what are 4 indications for ACEI/ARBs?

A

1 - hypertension - 1st/2nd line
2 - heart failure
3 - secondary prevention of cardiac events
4 - diabetic nephropathy and CKD with proteinuria

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143
Q

what is the MOA of ARBs?

A

blocks action of angiotensin II on angiotensin type I receptor

angiotensin II causes vasoconstriction so blocking it’s effect leads to vasodilation including of the efferent arteriole in the kidney reducing pressures. Also reduces amount of aldosterone secreted leading to increased sodium and water excretion which is beneficial in heart failure

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144
Q

what are 3 adverse effects of ARBs?

A

hyperkalaemia
hypotension
renal failure - in renal artery stenosis due to inadequate filtration pressures

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145
Q

what are 2 cases where ACEI/ARBs should be avoided?

A

Renal artery stenosis
AKI

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146
Q

what are 3 cases where ACEI/ARBs should only be used with caution?

A

Pregnancy
breast feeding
CKD - use lower doses and monitor closely

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147
Q

what are 4 medications that ARBs shouldn’t be prescribed with?

A

Potassium supplements
aldosterone antagonists
potassium sparing diuretics
NSAIDs - due to nephrotoxicity risk

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148
Q

what is the usual starting dose for losartan in heart failure?

A

12.5mg OD

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149
Q

what is the usual starting dose for losartan HTN and as secondary prevention?

A

50mg OD

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150
Q

what is the max dose of losartan?

A

100mg

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151
Q

what is the safety monitoring for ARBs?

A

take baseline U+Es and renal function then take at 1-2 weeks and after dose adjustment

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152
Q

at what GFR or creatinine should ACEI/ARBs be stopped?

A

If serum creatinin conc rises >30%
If GFR falls >25%

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153
Q

at what serum potassium level should ACEI/ARBs be reduced and at what level should they be stopped?

A

reduce at 5 mmol/L
STOP at 6 mmol/L

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154
Q

what are 3 examples of Angiotensin converting enzyme inhibitors (ACEI)

A

ramipril
lisinopril
peridopril

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155
Q

what is the MOA of ACEI?

A

inhibit action of angiotensin converting enzyme reducing the conversion of angiotensin I to angiotensin II

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156
Q

what are 6 adverse reactions to ACEIs?

A

hypotension
hyperkalaemia
renal failure
dry cough
angioedema
anaphylaxis

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157
Q

what is a common starting dose for ramipril in heart failure?

A

1,25mg od

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158
Q

what is a common starting dose for ramipril in HTN?

A

2.5mg OD

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159
Q

what is the max dose for ramipril?

A

10mg

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160
Q

What are 4 examples of selective serotonin reuptake inhibitors (SSRIs)?

A

Sertraline
Fluoxetine
Citalopram
Escitalopram

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161
Q

what are 3 indications for SSRIS?

A

depression - 1st line in moderate/severe and 2nd after CBT in mild
Panic disorder/PTSD/Social anxiety
OCD

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162
Q

What is the MOA of SSRIs?

A

inhibit neuronal uptake of 5-hydroxytraptamine (5-HT)from the synaptic cleft

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163
Q

what are 9 side effects of SSRIs?

A

GI upset
appetite/weight change
hypersensitivity reaction
Hyponatraemia
Suicidal thoughts/behaviour in first few weeks
lowered seizure threshold
Prolonged QT - citalopram
increase bleeding risk
serotonin syndrome

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164
Q

what are 4 side effects of SSRI withdrawal?

A

GI disturbance
neurological symptoms - zaps
flu-like symptoms
sleep disturbance

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165
Q

which SSRI causes long QT?

A

citalopram

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166
Q

when are 4 times SSRIs should be used with caution?

A

Hepatic impairment
young people - children - limited efficacy
epilepsy
peptic ulcer disease

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167
Q

what medications interact with SSRIs?

A

monoamine oxidase inhibitors
serotonergic drugs - triptans, tramadol
Bleeding risk - aspirin, nsaids, anticoagulants - also gastroprotection
Drugs that prolong QT (antipsychotics) and citalopram

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168
Q

what is the typical starting dose for sertraline?

A

50mg OD

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169
Q

what is the typical starting dose for citalopram?

A

20mg OD

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170
Q

does citalopram have higher bioavailability in tablets or drops? what is the dosage difference?

A

DROPS!

20mg tablets equivalent to 16mg drops

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171
Q

what is the monitoring of SSRIs?

A

review after 1-2 weeks
maintain dose for 6-8 weeks before changing
continue therapy till at least 6 months after symptoms have gone

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172
Q

what SSRI can be stopped suddenly due to longer half life?

A

fluoxetine

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173
Q

how should SSRIs be stopped?

A

slowly over 4 weeks reducing dose or frequency

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174
Q

what 2 SSRIs shouldn’t be prescribed with tamoxifen?

A

paroxetine
fluoxetine

as they inhibit CYP2D6

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175
Q

what drug class are duloxetine and venlofaxine?

A

serotonin noradrenaline reuptake inhibitors (SNRIs)

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176
Q

what drug class is mertazipine?

A

tetracyclic antidepressant

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177
Q

what SNRI can be used for diabetic neuropathy?

A

duloxetine

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178
Q

what is mirtazapine indicated for?

A

depression

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179
Q

what are venlefaxine and duloxetine indicated for?

A

Depression
Generalised anxiety disorder
diabetic neuropathy - duloxetine

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180
Q

what is the MOA of mirtazapine (tetracyclic antidepressant)?

A

antagonises inhibitory pre-synaptic alpha adrenoreceptors. Increases availability of monoamines for neurotransmission

fewer antimuscarinic side effects than tricyclics

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181
Q

what are side effects of SNRIs and mirtazapine?

A

GI upset
dry mouth
neurological effects - headache, insomnia, abnormal dreams
hyponatraemia
serotonin syndrome

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182
Q

which SNRI can cause long Q-T?

A

Venlafaxine

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183
Q

what is a serious side effect of mirtazapine?

A

bone marrow suppression

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184
Q

what SNRI is associated with greater risk of withdrawal symptoms?

A

venlafaxine

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185
Q

in what 4 cases should SNRIs/Mirtazapine be used with cation?

A

Older people
renal impairment
hepatic impairment
arrythmias

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186
Q

what medications shouldn’t be used with SNRIs/Mirtazapine?

A

other antidepressants

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187
Q

what is the typical starting dose for duloxetine in neuropathic pain?

A

60mg OD

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188
Q

When should mirtazapine be taken?

A

at night as can be sedating

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189
Q

what are 3 tricyclic antidepressants?

A

amitriptyline
nortriptyline
lofepramine

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190
Q

what class of medication is trazodone?

A

serotonin-antagonist-and-reuptake-inhibitor

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191
Q

what are 4 indications of tricyclic antidepressants?

A

depression
neuropathic pain
IBS - 2nd line after antispasmodic (antimuscarinic or mebeverine)
Migraine prophylaxis - Amitryptiline - 3rd line

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192
Q

what is the MOA of tricyclic antidepressants?

A

inhibit neuronal uptake of 5-hydroxytriptamine (serotonin) and noradrenaline

Block muscarininc, adrenergic, dopamine and histamine receptors

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193
Q

what are 12 side effects of tricyclic antidepressants?

A

Dry mouth
constipation
urinary retention
cognitive impairment
sedation
hypotension
arrhythmias - long QT
breast changed
extrapyramidal symptoms - tremor, dyskinesia
sexual dysfunction

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194
Q

what are 6 patients that tricyclic antidepressants should be used with caution in?

A

Older people
epilepsy
cardiovascular disease
constipation
glaucoma
prostate enlargement

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195
Q

what medications should tricyclic antidepressants NOT be given with?

A

monoamine oxidase inhibitors - increase risk of hypertension, hyperthermia and serotonin syndrom

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196
Q

what is the typical starting dose of amitriptyline in neuropathic pain?

A

10mg OD at night

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197
Q

what formulations are tricyclic antidepressants available as?

A

tablets and oral solution

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198
Q

when should tricyclic antidepressants be taken?

A

at night due to drowsiness

199
Q

what kind of medication are dopamine D2 receptor antagonists?

A

Antiemetics

200
Q

what are 3 examples of dopamine D2 receptor antagonists?

A

metoclopramide
prochlorperazine
domperidone

201
Q

what cause of nausea are dopamine D2 receptor antagonists especially good at dealing with?

A

reduced gut motility

202
Q

What is the MOA of D2 receptor antagonists?

A

triggering of vomiting centre in medulla which receives inputs from the chemoreceptor trigger zone (CTZ), the vagus nerve, vestibular system and higher centres. Dopamine D2 receptor is the main receptor in the chemoreceptor trigger zone which senses emetogenic substances. Dopamine also leads to gut relaxation and reduced motility. Therefore antagonism of dopamine receptors leads to increased gut motility and reduced triggering of CTZ.

203
Q

what are the 2 different types of D2 receptor antagonists?

A

Benzamides - metoclopramide, domperidone
phenothiazines - prochlorperazine

204
Q

what is the most common side effect of D2 receptor antagonists?

205
Q

which 2 D2 receptor antagonists can cause extrapyramidal side effects?

A

metoclopramide
Prochlorperazine

Cross BBB

206
Q

Which D2 receptor antagonists doesn’t cause extrapyramidal side effects and why?

A

Domperidone

Doesn’t cross BBB

207
Q

which D2 receptor antagonists can cause drowsiness?

A

prochlorperazine

208
Q

which D2 receptor antagonists can cause long QT and arrhythmias?

A

domperidone

209
Q

which D2 receptor antagonists can be used in parkinsons?

A

Domperidone - doesn’t cross BBB

210
Q

what conditions are all D2 receptor antagonists contraindicated in due to their prokinetic nature?

A

Bowel obstruction and perforation

211
Q

who should metoclopramide be avoided in?

A

Neonates always!

Children and young adults

212
Q

what condition should metoclopramide and prochlorperazine be avoided in?

A

PARKINSONS (and Lewy body dementia)

213
Q

when is domperidone contraindicated?

A

severe hepatic impairment
cardiac conduction defects
children <12 years
Weight <35kg

214
Q

what are 5 medications that inhibit cytochrome P450 enzymes?

A

amiodarone
Diltiazem
Macrolides - erythromycin, clarithromycin
fluconazole
protease inhibitors

215
Q

what are 6 examples of medications that increase QT interval?

A

D2 receptor antagonists
Antipsychotics
SSRIs
Quinine
Amiodarone
Macrolides

216
Q

what are 4 types of medications that shouldn’t be prescribed with D2 receptor antagonists?

A

Antipsychotics
Dopaminergic agents for parkinson’s - cancel each other out
Drugs that prolong QT
Drugs than inhibit cytochrome P450

217
Q

what is the maximum duration of D2 receptor antagonists?

218
Q

what is the stating dose for metoclopramide and domperidone?

A

10mg 8 hourly (TDS) PO if >60kg

500 micrograms <60kg

219
Q

what is the dosing for IM and IV metoclopramide?

A

same as oral

give IVs slowly over 3 mins

220
Q

what are 3 examples of Histamine H1 receptor antagonists used as antiemetics?

A

Cyclizine
Promethazine
Cinnarazine

221
Q

what are Histamine H1 receptor antagonists used for in antiemesis?

A

prophylaxis of nausea and vomiting especially motion sickness and vertigo

222
Q

what is the MOA of Histamine H1 receptor antagonists in antiemesis?

A

Histamine and muscarinic Ach are used in communication between vomiting centre and vestibular system so antagonism of histamine receptors inhibits nausea

223
Q

what are 3 side effects of Histamine H1 receptor antagonists as antiemetics?

A

Drowsiness
Anticholinergic - dry mouth and throat, urinary retention, constipation, confusion
Tachycardia - after IV injection

224
Q

what are 2 contraindications to Histamine H1 receptor antagonists used as antiemetics?

A

Prostatic enlargement - due to anticholinergic effect
Hepatic encephalopathy - due to drowsiness

225
Q

what are 2 medication classes that interact with Histamine H1 receptor antagonists?

A

sedatives - benzos, opioids - may increase drowsiness
Anticholinergics - ipratropium, tiotropium

226
Q

what is a typical prescription of cyclizine for nausea?

A

50mg 8 hourly PRN

227
Q

what is the dosing for cyclizine IM and IV?

A

same as oral

228
Q

How should iv cyclizine be administered?

A

slowly over 2 minutes

229
Q

what are 2 examples of 5HT3 (serotonin) receptor antagonists?

A

Ondansetron
Granisetron

230
Q

what are 5HT3 (serotonin) receptor antagonists used for?

A

nausea and vomiting particularly with chemo and general anaesthetics

231
Q

what is the MOA of 5HT3 (serotonin) receptor antagonists?

A

There are 5HT3 receptors in chemoreceptor trigger zone which are stimulated by emetogenic substances in bloodstream. 5HT (serotonin) is a key neurotransmitter in gut which stimulates vagus nerve to activate vomiting centre. Blockade of these pathways reduces nausea.

Not effective in motion sickness as no involvement in vestibular system

232
Q

what are 3 common side effects of 5HT3 (serotonin) receptor antagonists?

A

Constipation
Headache
Flushing

233
Q

At what dose may ondansetron prolong QT?

234
Q

what can ondasetron cause in pregnancy?

A

congenital defects - cleft lip and palate, heart defects

235
Q

what are 2 contraindications to 5HT3 (serotonin) receptor antagonists?

A

Pregnancy - congenital defects
Long QT

236
Q

what medications shouldn’t be prescribed with 5HT3 (serotonin) receptor antagonists?

A

Those than prolong QT

SSRIs
Antipsychotics
Quinine
D2 receptor antagonists (antiemetics - metoclopramide)

237
Q

what is the typical starting dose of ondansetron?

A

4-8mg 12 hourly oral or IV

dosage depends on indication - usually higher for chemo induced nausea

238
Q

what are 3 examples of antifungals?

A

nystatin
clotrimazole
fluconizole

239
Q

what is the MOA of antifungals?

A

target ergosterol on fungal cell membranes either by binding to it and creating a polar pore (nystatin) or by inhibiting ergosterol synthesis (clotrimazole, fluconizole)

240
Q

what are 6 side effects of fluconazole?

A

GI upset
headache
increased liver enzymes
hypersensitivity and anaphylaxis
severe hepatotoxicity
prolonged QT and arrythmias

241
Q

what are 4 contraindications to fluconazole?

A

Liver disease
QT prolongation
Renal impairment - requires dose reduction
Pregnancy - can cause foetal malformation

242
Q

what medications does fluconazole interact with?

A

inhibits cytochrome p450 so increases concentration of anything metabolised through this pathway
- carbamezapine
- phenytoin
- Warfarin
- diazepam
- simvastatin
- sulphonureas

may reduce activity of colpidogrel as prodrug is metabolised through liver

Do not prescribe with medications that prolong QT

243
Q

what is the dose of nystatin for oral thrush?

A

100 000 units - 1mL - oral suspension dropped into the mouth QDS for 7 days

244
Q

what is the dosage for clotrimazole cream?

A

1% (1g in 100g)
Applied BD/TDS for 1-2 weeks

245
Q

what is the dose for fluconazole in vaginal thrush?

A

150mg orally once

246
Q

what is the dose of fluconazole for other infections?

A

50mg OD for 1-2 weeks

247
Q

when should oral nystatin be administered?

A

After food

248
Q

what are 4 H1-receptor antagonists used as amtihistamines?

A

certifizine
fexofenadine
loratadine
chlorphenamine

249
Q

what are 3 indications for H1-receptor antagonists (antihistamines)?

A

1st line for tx of allergies particularly hayfever
for pruritus and urticaria
For skin symptoms in anaphylaxis

250
Q

what is the MOA of H1-receptor antagonists ?

A

Block H1 receptor and therefore blocking the effects of histamine.

Histamine is release from storage granules in mast cells in response to antigens binding to IgE on the cell surface

251
Q

which antihistamines causes sedation?

A

1st generation - chlorphenamine

252
Q

which antihistamines don’t cross BBB?

A

fexofenadine
certirizine
loratadine

Do not cause drowsiness

253
Q

In what condition are chlorphenamine antihistamines contraindicated?

A

severe liver disease due to risk of hepatic encephalopathy

254
Q

what is the dose of certirizine?

A

10mg tablet once daily

255
Q

what is the dose of chlorphenamine?

A

4mg tablets
2mg/5ml solution

every 4-6 hours

256
Q

what is the dose of loratidine?

A

10mg tablets once daily

257
Q

what are 4 examples of antimuscarinics used as bronchodilators?

A

tiotropium
umeclidinium
glycopyrronium
ipraropium

258
Q

what are 2 respiratory uses of antimuscarinics?

A

COPD for acute breathlessness

Acute severe asthma and 3rd line in chronic management

259
Q

what is the MOA of antimuscarinics?

A

competitively inhibit muscarinic receptors in place of acetylcholine

cause increase HR and conduction, reduced smooth muscle tone (GI, GU, Resp), reduce respiratory secretions, relax pupillary and cilliary muscles preventing accomodation

260
Q

what are 5 adverse effects of antimuscarinics?

A

dry mouth, cough and hoarse voice
Tachycardia
constipation
urinary retention
blurred vision
Drowsiness and confusion

Less likely to have adverse effects when inhaled than with systemic use

261
Q

what are 4 contraindications to antimuscarinics?

A

angle-closure glaucoma - can cause dangerous rise in orbital pressure
Arrythmias
Urinary retention and BPH
Older age and dementia

262
Q

what type of antimuscarinic is ipratropium?

A

short acting

263
Q

what dose of ipratropium is prescribed in stable COPD?

A

50micrograms every 6 hours via INH

264
Q

what dose of ipratropium if prescribed in acute asthma/COPD exacerbations?

A

500micrograms nebulised every 4-6 hours as require - max dose 2mg

265
Q

what antimuscarinic is used for muscle spasms in IBS?

A

hyoscine butylbromide

266
Q

what medication is second line for muscle spasm in IBS?

A

meverine - may be better tolerated than hyoscine butylbromide

267
Q

what antimuscarinics are used for reducing resp secretions in palliative care?

A

hyoscine butylbromide
Glycopyrronium bromide

268
Q

what antimuscarinics are used for treatment of bradycardia?

A

Atropine
Glycopyrronium bromide

269
Q

what medication can antimuscarinics interact with?

A

increased side effects when used in combination with medications with antimuscrinic side effects like TRICYCLIC ANTIDEPRESSANTS

270
Q

what antimuscarinic and at what dose is usually given for bradycardia?

A

Atropine IV 500 micrograms every 5 mins up to max of 3mg

glycopyronium can also be given but is less readily available

271
Q

what antimuscarinic is usually given or IBS and at what dose?

A

hyoscine butylbromide (buscapan) 10mg 8 hourly

272
Q

what are 3 examples of antimuscarinics used for overactive bladder syndrome?

A

solifenacin
Oxybutynin
tolterodine

273
Q

which antimuscarinic used for overactive bladder crossess the BBB and therefore causes confusion?

A

oxybutynin

274
Q

what is the 1st line management for overactive bladder?

A

Bladder retraining
avoid caffeine
weight loss

275
Q

what would a typical prescription for overactive bladder be?

A

tolterodine 2mg PO every 12 hours

276
Q

how long can antimuscarinics used for overactive bladder take to work?

A

At least 4 weeks

277
Q

What are 4 examples of anti-platelet medications?

A

Clopidogrel
Ticagrelor
Parasugrel
Aspirin

278
Q

what are 3 indications for anti-platelets?

A

1 - Treatment of ACS
2 - Secondary prevention of major adverse cardiovascular event
3 - Prevention of stent occlusion

279
Q

what class of medication are clopidogrel, ticagrelor and parasugrel?

A

ADP-receptor antagonists

280
Q

what is the MOA of non-aspirin anti-platelets (e.g. clopidogrel)?

A

prevent platelet aggregation by irreversibly (clopidogrel and parasugrel) or reversibly (ticagrelor) binding to adenosine diphosphate (ADP) receptors on the surface of platelets

281
Q

what are 3 adverse effects of non-aspirin antiplatelets?

A

Bleeding
GI upset - dyspepsia, pain, diarrhoea
Thrombocytopenia rarely

282
Q

what are 4 contraindications to non-aspirin antiplatets?

A

bleeding - absolute contraindication
Elective surgery in next 7/52
renal impairment
hepatic impairment - especially with impaired clotting

283
Q

co-prescribing non-aspirin antiplatelets with which 3 medication types increases bleeding risk?

A

anticoagulants
antiplatelets - aspirin
NSAIDs

284
Q

what medications interact with clopidogrel?

A

any cytochrome P450 inhibitors reduce metabolism from prodrug

omeprazole
ciprofloxacin
erythromycin
antifungals
some SSRIs
Grapefruit juice

285
Q

what PPIs are safe to use with clopidogrel?

A

lansoprazole
pantoprazole

286
Q

what preparation is clopidogrel available as?

287
Q

what is the loading dose of clopidogrel?

A

300mg once

288
Q

what is the maintenance dose of clopidogrel?

A

75mg OD PO

289
Q

how long should antiplatelets be given after a drug eluting stent is placed?

A

12 months - to reduce risk of stent thrombosis

290
Q

How long are dual antiplatelets given after CV event or stroke?

A

12 months

then continue aspirin and stop ADP-receptor antagonist in CVD and vice versa in stroke

291
Q

what is the MOA of Apirin?

A

irreversibly inhibits cyclooxygenase (COX) to reduce synthesis of the pro-aggregatory factor thrombane from arachidonic acid, reducing platelet aggregation

as irreversibly bound > lasts for lifetime of platelet 7-10 days

292
Q

what are 4 side effects of aspirin?

A

GI upset
peptic ulceration and haemorrhage
Hypersensitivity and bronchospasm
Tinnitus - in high doses

293
Q

what are the symptoms of aspirin (salicylate) overdose?

A

Hyperventilation
hearing changes
metabolic acidosis
confusion
cardiovascular collapse
respiratory arrest

294
Q

what are 5 contraindications to aspirin?

A

Children <16 - Reye’s syndrome
Pregnancy in 3rd trimester - may precipitate premature closing od ductus arteriosus
Aspirin/NSAID hypersensitivity
Peptic ulceration
Gout - can trigger attack

295
Q

what formulations of aspirin are available?

A

oral or rectal

296
Q

what is the loading dose of aspirin?

A

300mg once

297
Q

what is the usual dose of aspirin?

A

75mg OD PO

298
Q

what is the maximum daily dose of aspirin?

299
Q

when should gastroprotection be considered in aspirin therapy?

A

> 65 years
comorbidities - diabetes, CVD
previous gastric ulcer
concurrent therapy with other gastric irritant medications - prednisolone, NSAIDs

300
Q

How should aspirin be taken?

A

after food

301
Q

what are 3 examples of typical (1st gen) antipsychotics?

A

Haloperidol
chlorpromazine
Flupentixol

302
Q

what are 4 indications for typical antipsychotics?

A

Rapid tranquillisation
Schizophrenia - especially when metabolic side effects of atypicals are problematic
Bipolar - particularly acutely
Nausea and vomiting - palliative particularly

303
Q

what is the MOA of typical antipsychotics?

A

block post synaptic dopamine (D2) receptors in 3 pathways - mesolimbic, nigrostriatal, tuberohypophyseal

304
Q

blockade of which neural pathway causes exrapyramidal side effects by antipsychotics?

A

nigrostriatal pathway - connects substantia nigra to corpus striatum in basal ganglia

305
Q

what are 4 extrapyramidal side effects?

A

acute dystonia - involuntary contractions
Akathisia - restlessness
Neuroleptic malignant syndrome
Tardive dyskinesia - automatisms e.g. lip smacking

306
Q

what are 6 side effects of typical antipsychotics?

A

Extrapyramidal side effects
Long QT > Arrhythmias
Drowsiness
hypotension
erectile dysfunction
hyperprolactinaemia

307
Q

what are 3 symptoms of hyperprolactinaemia?

A

galactorrhoea
menstrual disturbance
breast pain

308
Q

what are 3 cautions in using typical antipsychotics?

A

older age
Dementia
parkinsons disease

309
Q

what medications interact with typical antipsychotics?

A

MANY!!

Any that prolong QT - amiodarone, macrolides

310
Q

what is the starting dose for haloperidol in agitation in the elderly?

A

500 micrograms IM or PO

311
Q

what is the dose of haloperidol in agitation for adults?

A

1-10mg IM or PO

312
Q

what monitoring is needed for typical antipsychotics?

A

prolactin at baseline, 6 months and yearly

baseline ECG

313
Q

what medication can be used for intractable hiccups in palliative care?

A

chlorpromazine 25mg TDS

314
Q

what are 4 examples of atypical antipsychotics?

A

quetiapine
olanzapine
risperidone
clozapine

315
Q

what are 2 indications for atypical antipsychotics?

A

Schizophrenia - especially if had extrapyramidal side effects on typicals
Bipolar - particularly acutely

316
Q

what is the difference in the MOA between typical and atypical antipsychotics?

A

atypicals work on same pathways but also affect 5HT2 receptors and bind more losely to D2 receptors meaning there are fewer side effects and are better at treating treatment resistant schizophrenia

317
Q

what 3 side effects are less common in atypical antipsychotics?

A

drowsiness
cognitive impairement
extrapyramidal side effects

318
Q

what are 4 side effects of atypical antipsychotics?

A

Extrapyramidal side effects - less common
Metabolic side effects - more common
long QT > Arrhythmias
Breast symptoms

319
Q

what atypical antipsychotic often causes breast symptoms?

A

risperidone

320
Q

what atypical antipsychotic often causes metabolic disturbance?

A

olanzapine

321
Q

what are 2 rare side effects of clozapine?

A

agranulocytosis - low neutrophils
myocarditis

322
Q

what are 3 metabolic disturbances common with atypical antipsychotics?

A

diabetes mellitus
weight gain
lipid changes

323
Q

what are 2 contraindications to clozapine?

A

neutropenia
severe heart disease

324
Q

when should atypical antipsychotics be used with caution?

A

cardiovascular disease

325
Q

what are 2 medications that atypical antipsychotics should not be prescribed with?

A

D2 receptor antagonists - antiemetics
drugs that prolong QT
Other sedating drugs

326
Q

How should atypical antipsychotics be taken?

A

at same time every day - if make drowsy, take at night

327
Q

what monitoring should be done for atypical antipsychotics?

A

prolactin baseline, 6 months, yearly
Weight, lipid profile, fasting blood glucose baseline, 3 monthly, yearly

328
Q

what extra monitoring is needed for clozapine?

A

FBC weekly for 18 weeks, then 2/52 for 1 year then monthly

329
Q

what lifestyle factor can alter clozapine metabolism?

A

Smoking increases metabolism&raquo_space; stopping smoking can cause rise in clozapine levels

330
Q

what are 2 indications for aciclovir?

A

Treatment of herpes virus infections including HSV and VZV

Suppression of recurrent herpes simplex attacks happening more that 6x per year

331
Q

what kind of viruses are herpes viruses?

A

DNA

Includes HSV1, HSV2 and VZV

332
Q

what is the MOA of aciclovir?

A

enters herpes infected cells and inhibits herpes specific DNA polymerase stopping further replication

333
Q

what are 6 side effects of aciclovir?

A

headache
dizziness
GI upset
rash
phlebitis - if IV
AKI - can precipitate in renal tubules, minimise risk by infusing slowly into well hydrated patient

334
Q

what are 3 cautions for aciclovir?

A

pregnancy
breast feeding
severe renal impairment - renally excreted

335
Q

what are 2 interactions for aciclovir?

A

can increase plasma conc of aminophylline and thenophylline

other nephrotoxic drugs - NSAIDs, methotrexate, antibiotics - aminoglycosides, cephalosporins, trimeth, vacomycin

336
Q

what is the dose of aciclovir for oral or genital HSV outbreaks?

A

200mg 5x per day PO

337
Q

what is the dose of aciclovir for suppression of recurrent disease?

A

400mg every 12 hours PO

338
Q

what is the dose of aciclovir in herpes simplex encephalitis?

A

10mg/kg IV 8 hourly

for 14-21 days

339
Q

what is the dose of aciclovir for VZV treatment?

A

800mg 5x per day for 7 days

340
Q

what blood need to be monitored for safety in IV aciclovir?

A

renal function

341
Q

what are 4 bits of self care advice for cold sores and genital herpes?

A

stay hydrated
topical analgesia
barrier preparations
OTC analgesia

342
Q

what are 5 examples of antivirals?

A

Oseltamivir
nirmatrelavir
tenofovir
efaverezn
atanazavir

343
Q

what are 3 indications for antivirals?

A

Treatment of viral infections - e.g. COVID
PrEP or PEP
Treatment to suppress load of hep A/B or HIV

344
Q

what are 4 side effects of all antivirals?

A

Dizziness
GI upset
Sleep problems
Skin reactions

345
Q

what is a side effect of inhaled zanamivir?

A

bronchospasm

346
Q

what are 4 adverse effects of long term antivirals?

A

dyslipidaemia
hyperglycaemia
hypertension
weight gain

^^CVD risk factors

347
Q

what are 4 adverse immune mediated effects of antivirals?

A

hypersensitivity reaction
hepatitis
blood diseases
severe cutaneous reactions

348
Q

what is the MOA of oseltamivir and zanamivir?

A

inhibit neuroamidases - surface enzymes needed for viral entry and exit of host cells

349
Q

what is the MOA of molnuparvir and remdesivir?

A

nucleotide analoges that block viral RNA synthesis

350
Q

what are 2 examples of antiretrovirals?

A

emtricitibine
tenofovir
efavirenz

351
Q

what is the MOA of antiretrovirals?

A

non/nucleoside reverse transcriptase inhibitors => inhbit synthesis of DNA from viral RNA

352
Q

non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors are contraindicated in what 2 conditions?

A

acute porphoria
QT prolongation

353
Q

what is the dose of antiviral for influenza in adults?

A

oseltamivir 75mg po

zanamivir 10mg IHR

BD for 5 days for treatment
OD for 10 days for prophylaxis

354
Q

what antigen can be tested for to reduce risk of hypersensitivity reaction to abacavir in those who carry it?

A

human leukocyte antigen

355
Q

what ar 4 examples of benzodiazepines?

A

chlorodiazepoxide
lorazopam
midazolam
diazepam

356
Q

what are 4 indications for benzodiazepines?

A

status epilepticus - 1st line
alcohol withdrawal reactions - 1st line
Sedation in palliative care, procedures or rapid tranquilization
Short term treatment of anxiety of insomnia

357
Q

what is the MOA of benzodiazepines?

A

change shape of GABA receptors to facilitate binding and increase resistance to depolarisation of cells. Causes widespread depression of synaptic transmission leading to clinical effects of anti-anxiety, seizure cessation, sedation and sleepiness

358
Q

How does alcohol affect GABA?

A

alcohol also increases binding of gaba and increased resistance to depolarisation leading to tolerance. When alcohol is abruptly withdrawn there is a decrease in GABA binding and therefore an increase in neuronal excitability leading to symptoms of alcohol withdrawal

359
Q

what are 4 adverse effects of benzodiazepines?

A

drowsiness, sedation, coma
overdose - resp depression (less than opioids) and death due to loss of airway reflexes
Dependance
withdrawal effects

360
Q

what is the best choice of benzo in liver failure?

A

lorazepam - less dependant on liver for elimination

361
Q

what are 4 conditions to be cautious with when prescribing benzodiazepines?

A

the elderly - may need reduced dose
Respiratory impairement
Neuromuscular disease
Liver failure

363
Q

using benzodiazepines with what medications may increase their effects?

A

cytochrome P450 inhibitors - amiodarone, macrolides, diltiazem, fluconizole, protease inhibitors

366
Q

what medication(s) and what dose is usually given for stopping a seizure?

A

lorazepam 4mg IV

Diazepam 10mg IV

Midazolam 10mg buccally

367
Q

what are 3 choices of benzodiazepines in alcohol withdrawal?

A

chlordiazepoxide - usually
Lorazepam
Diazepam

368
Q

what benzodiazepine is preferred for procedural sedation?

A

midazolam as short acting

369
Q

what is the antagonist to benzodiazepines?

A

Flumazenil

not usually used as can precipitate seizures

370
Q

what are 4 examples of beta-agonists?

A

Salbutamol
Salmeterol
Formeterol
Indacaterol

371
Q

what are 2 indications for beta agonists?

A

Asthma
COPD

372
Q

what is the MOA of beta-agonists?

A

acts on beta receptors in smooth muscle of bronchi, gut, uterus and blood vessels leading to smooth muscle relaxation and bronchodilation

Also cause increased action of ATPase which shifts K+ into intracellular compartment causing hypokalaemia - beneficial in Tx of hyperkalaemia

373
Q

what are 9 side effects of beta-agonists?

A

Fine tremor
tachycardia
palpitations
anxiety
headache
Hypokalaemia
Raised lactate
hyperglycaemia
muscle cramps - LABAs

374
Q

what should always be prescribed with a LABA?

375
Q

when should there be caution in prescribing beta-agonists?

A

in CVD as tachycardias may lead to tachyarrhythmias

376
Q

what is a usual PRN prescription for salbutamol?

A

100-200 micrograms IHR PRN

377
Q

what is the usual nebulised prescription of salbutamol?

A

2.5 mg nebulised 4 hourly

378
Q

How long before LABA therapy can be ‘stepped down’?

379
Q

what are 2 medications that when used with beta-agonists can increase risk of hypokalaemia?

A

thenophylline
corticosteroids

380
Q

what are 5 examples of beta blockers?

A

Atenolol
Bisoprolol
Propanolol
Metoprolol
Carvedilol

381
Q

what are 7 indications for beta blockers?

A

ischaemic heart disease - improves outcomes in angina and ACS
Heart failure - improves prognosis
AF - reduces ventricular rhythm and increases time spent in sinus
SVT - to restore sinus rhythm
Resistant HTN - 4th line
Prophylaxis of migraine
Thyrotoxicosis - for symtoms

382
Q

what is the MOA of beta blockers?

A

act on beta1 adrenoreceptors to decrease heart rate and contractility

383
Q

what are 7 side effects of beta blockers?

A

cold peripheries
fatigue
headache
GI upset
sleep disturbance
nightmares
impotence

384
Q

what are 3 contraindications to beta blockers?

A

asthma
heart block
hypotension

385
Q

what are 2 conditions to be cautious when prescribing beta blockers in?

A

Heart failure - start slowly and titrate
hepatic failure - may need dose reduction

386
Q

what medication should not be used with beta blockers?

A

non-dihydropyridine calcium channel blockers - verapamil, diltiazem

may cause heart failure, bradycardia, asystole

387
Q

when may IV beta blockers be needed?

A

SVT and AF - when quick action is needed

388
Q

what advice should be given to those with heart failure being prescribed a beta blocker?

A

symptoms may initially get worse - seek medical advice is this occurs

389
Q

what HR should be aimed for with beta blockers in IHD?

390
Q

what measurement can be useful in initiation of beta blockers in heart failure?

A

daily weights for accumulation of fluids

391
Q

How should beta blockers be stopped?

A

slowly over 2 weeks

abrupt withdrawal can lead to increased risk of Myocardial ischaemia

392
Q

what are 4 examples of bisphosphonates?

A

alendronic acid
risendronate
disodium pamidronate
Zolendronic acid

393
Q

what are 4 indications for bisphosphonates?

A

osteoporosis prevention - alendronic acid or risendronate 1st line

Hypercalcaemia due to malignancy - zolendronic acid and pamidronate

Bone mets - myeloma and breast Ca - reduce risk of pathological fracture

Paget’s disease of the bone

394
Q

what is the MOA of bisphosphonates?

A

reduce bone turn over by inhibiting osteoclast activity and promoting apoptosis

395
Q

what are 4 side effects of bisphosphonates?

A

Osteonecrosis of jaw - more common with IV
oesophagitis
hypophosphataemia
atypical femoral fractures

396
Q

How are bisphosphonates excreted?

397
Q

what are 3 contraindications to bisphosphonates?

A

severe renal impairment
hypocalcaemia - check levels before commencing
upper GI disorders

398
Q

what are 2 cautions in prescribing bisphosphonates?

A

smokers - increased risk of osteonecrosis of jaw
dental disease

399
Q

what are 3 things that bisphosphonates interact with?

A

calcium salts including in milk
antacids
iron salts

should not be taken with any of these

400
Q

who can take a weekly dose of bisphosphonate?

401
Q

what is the usual dose of alendronic acid for osteoporosis?

A

10mg OD PO or 70mg once weekly PO

once weekly only in women

402
Q

How long may it take for bisphosphonates to lower calcium levels in hypercalcaemia?

A

up to 1 week/10 days

403
Q

How should bisphosphonates be taken orally?

A

Swallowed whole at least 30 minutes before breakfast or any other medications and taken with plenty of water
The patient should remain upright for at least 30 minutes after taking them

404
Q

what advice needs to be given to people taking bisphosphonates?

A

Indication
Advice on how to take
symptoms of osophagaetis
Advise to see dentist
Advice on dosing especially in once weekly preparations

405
Q

what needs to be monitored in bisphosphonates?

A

DEXA every 3-5 years
side effect monitoring
Blood for calcium levels

406
Q

what are 2 vitamin D formulations?

A

colecalciferol
alfacalcidol

407
Q

what are 2 types of calcium tablets?

A

calcium carbonate
calcium gluconate

408
Q

what are 4 indications for calcium and vitamin D?

A

osteoporosis

CKD - for secondary hyperparathyroidism and renal osteodystrophy

Severe Hyperkalaemia - to prevent life threatening arrythmia

Hypocalcaemia - <1.9, or symptomatic

Vitamin D deficiency prevention and treatment

409
Q

what are 5 symptoms of hypocalcaemia?

A

tetany - involuntary muscle contractions
seizure
parasthaesia
confusion
stiff, achy muscles

410
Q

How does vitamin D help to absorption of calcium?

A

stimulating intestinal calcium and phosphorus absorption
stimulates bone calcium mobilization, increases renal reabsorption of calcium in the distal tubule

411
Q

what are 2 side effects of oral calcium?

A

dyspepsia
constipation

412
Q

what are 2 side effects of IV calcium gluconate?

A

tissue damage if accidentally given SC
Hypotension with rapid administration

413
Q

what are 4 medications that oral calcium decreases absorption of?

A

Iron
bisphosphonates
levothyroxine
tetracyclines (doxy)

414
Q

what is one medication that should not be mixed IV with calcium?

A

sodium bicarb - can cause precipitation

415
Q

what is a usual dose of calcium in osteoporosis?

A

1 -1.2 g OD PO

416
Q

what is the usual dose of vitamin D in osteoporosis?

A

400-800 units OD PO

417
Q

what are the 2 different types of vitamin D?

A

D2 - from plant sources
D3 - from animal fats

418
Q

what is the dose of calcium in severe hyperkalaemia?

A

30 ml calcium gluconate 10% for slow IV injection

419
Q

How far apart should calcium and interacting medications be taken?

A

4 hours apart

420
Q

what are 3 foods that could interact with calcium tablets and how far apart should they be eaten?

A

spinach
whole cereals
bananas

2 hours apart

421
Q

what is the monitoring required for calcium administration?

A

ECG monitoring if IV
Serum calcium levels at regular intervals

422
Q

how much stronger is calcium gluconate compared to calcium carbonate?

A

3X more calcium

423
Q

what is the loading dose of vitamin d in deficiency?

A

50 000 units for 6 weeks

424
Q

what are 5 examples of calcium channel blockers?

A

amlodipine
finodipine
nifedipine
diltiazem
verapamil

425
Q

what are 3 indications of calcium channel blockers?

A

Tx of HTN
Angina control in IHD
Diltiazem and verapamil only - Rhythm control for supraventricular arrhythmias

426
Q

what is the MOA of calcium channel blockers?

A

decrease calcium ion entry into vascular and cardiac cells reducing intracellular calcium concentration which causes relaxation and vasodilation in arterial smooth muscle

reduce cardiac contractility in heart by suppressing cardiac conduction through AV node => reduces myocardial demand => reduces angina

427
Q

what type of calcium channel blockers are more selective for the heart?

A

non-dihydropyridines - verapamil (most cardio-selective), diltiazem

428
Q

what type of calcium channel blockers are more selective for the vessels?

A

dihydropyridines - amlodipine, felodipine

429
Q

what are 4 common side effects of amlodipine and nifedipine?

A

ankle swelling
flushing
headache
palpitations

430
Q

what are 4 side effects of verapamil?

A

constipation
bradycardia
heart block
heart failure

431
Q

what is the side effect profile of diltiazem?

A

can have all calcium channel blocker side effects

ankle swelling, flushing, headache, palpitations, constipation, bradycardia, heart block and heart failure

432
Q

what are 2 conditions where verapamil and diltiazem should be used with caution?

A

impaired L ventricular function
Heart block/Av node delay

433
Q

what are 2 contraindications to amlodipine and nifedipine?

A

unstable angina - vasodilation causes reflex increase in HR => increases angina
severe aortic stenosis - can cause collapse

434
Q

what medication should non-dihydropyridine calcium channel blockers be prescribed with?

A

Beta blockers - both negatively inotropic

435
Q

what is the only calcium channel blockers that can be given IV?

436
Q

how should modified release calcium channel blockers be prescribed?

A

with the brand name as bioequivalence differs

437
Q

what is a standard dose of amlodipine for HTN?

A

5-10mg PO OD

438
Q

what is a standard dose of MR diltiazem for angina?

A

90mg PO 12 hourly

439
Q

what is the dose of verapamil for supraventricular arrhythmias?

A

40-120mg PO 8 hourly

440
Q

what should be communicated with the patient when prescribing calcium channel blockers?

A

indication
measures to reduce other CVD risk factors
common side effects - ankle swelling

441
Q

what are 2 indications for carbamezpine?

A

Seizures - 2nd line in focal
Trigeminal neuralgia

442
Q

what is the MOA of carbamezapine?

A

not fully known

inhibits neuronal sodium channels stabilising resting membrane potentials and inhibiting repeated firing

443
Q

what are 6 side effects of carbamezpine?

A

GI upset
neurological effects - dizzy, ataxia
oedema
hyponatraemia
skin rashes
hypersenitivity reactions and SJS/TEN

444
Q

what genetic component is associated with carbamezpine and Steven johnson syndrome and what population is most affected?

A

HLA B-1502 allele

Han Chinese and Thai people

445
Q

what can carbamezapine cause in pregnancy?

A

neural tube defects
cardiac and urinary tract abnormalities
cleft palate

446
Q

what are 3 conditions to use carbamezapine with caution in?

A

hepatic, renal or cardiac disease

increased risk of toxicity

447
Q

what medications does carbamezapine interact with?

A

is a cytochrome P450 INDUCER

reduces - warfarin, oestrogen, progesterones - metabolised by CYP450

carbamezpine conc is increased by CYP450 INHIBITORS - as also metabolised by CYP450

efficacy reduced by drugs that lower seizure threshold - antipsychotics, tramadol

interacts with other antiepileptics

448
Q

how can carbamezapine be administered?

A

oral or rectal

449
Q

what is the max dose of carbamezapine?

A

1.6g per day in divided doses

450
Q

what is the usual starting dose of carbamezapine?

A

100-200mg OD PO

increase gradually to tolerance

451
Q

what symptoms should patients started on carbamezapine be warned of?

A

signs of hypersensitivity
skin rashes, bruising, bleeding
high temperature, mouth ulcers - blood toxicity
reduced appetitie, abdo pain - liver toxicity
CONTRACEPTION

452
Q

what is the driving advice for focal seizure epilepsy?

A

12 months seizure free or 6 months after withdrawal/change of medication

453
Q

what are 3 cephalosporins?

A

cefalexin
ceftriaxone
cefuroxime

454
Q

what are 2 carbopenems?

A

meropenem
ertapenem

455
Q

what are oral cephalosporins used for?

A

2nd/3rd line in UTI and pneumonia/other resp tract infection (epiglotitis)

456
Q

what are IV cephalosporins and carbopenems used for?

A

Very severe/complicated infections or antibiotic resistant infections

457
Q

what is the activity of cephalosporins and carbopenems?

A

broad spectrum
increasing generations of cephalosporins increase activity against gram negatives

458
Q

what is the MOA of cephalosporins and carbopenems?

A

contain BETA LACTAM RING
inhibit enzymes responsible for cross linking of peptidoglycan walls which weakens bacterial cell wall

459
Q

what are 4 side effects of cephalosporins and carbopenems?

A

GI upset
C.Diff and antibiotic associated collitis
Hypersensitivity reaction - not concern for mild penicillin allergies
seizures

460
Q

what are 2 cautions for cephalosporins and carbopenems?

A

renal impairment - requires dose reduction
at risk of C. DIff - older

461
Q

what are 2 interactions for cephalosporins and carbopenems?

A

Enhance effect of warfarin - kill normal gut flora that synthesise vit K

Carbapenems - reduce plasma conc and efficacy of valporate

462
Q

what is the usual adult dose of cephalosporin for bacterial meningitis?

A

Ceftriaxone 4mg IV OD

463
Q

what is ertapenem?

A

a carbopenem that is administered once daily

464
Q

what are the formulations of meropenem?

465
Q

what are the formulations of cephalosporins?

A

oral - suspension, tablet, capsule
IV/IM injection

466
Q

what are 2 indications for general anaesthetic agents?

A

general anaesthesia
sedation

467
Q

what are 3 IV general anaesthetics?

A

propofol
thiopental
ketamine

468
Q

what are 2 inhaled general anaesthetic agents?

A

sevoflurane
nitrous oxide

469
Q

what is the general MOA of general anaesthetics?

A

lipid soluble molecules that disrupt neuronal cell membranes especially potassium channels either directly or indirectly though disrupting crystallin lipids that surround them

Either enhance action of GABA (inhibitory neurotransmitter) or decrease action of NMDA (excitatory neurotransmittter) or nichotinic cholinergic receptors

470
Q

what is one key side effect of propofol?

A

pain on injection

471
Q

what are 3 common side effects of general anaesthetics?

A

bradycardia
Hypotension
vasodilations

472
Q

which general anaesthetics does not cause brady, hypotension and vasodilation?

A

Ketamine - may cause hypertension and tachy

473
Q

what is a common post operative side effect of general anaesthetics?

A

nausea and vomiting

474
Q

what classification system is often used for anaesthetic ris§k?

A

american society of anaesthesiologists classification

475
Q

what medications do general anaesthetics enhance the effect of?

A

other medications that reduce consciousness and cardiorespiratory function - benzos, opioids

476
Q

what monitoring is needed with general anaesthetics?

A

BP
HR
RR
sats
Temp
ECG
End tidal CO2 - capnograph

477
Q

what is the MOA of chloramphenicol?

A

Binds to ribosomes therefore inhibiting protein synthesis

bacteriostatic and can be bacteriocidal

478
Q

what are 3 side effects of topical chloramphenicol?

A

stinging
burning
itching

479
Q

what are 4 side effects of systemic chloramphenicol?

A

Dose related bone marrow suppression
Aplastic anaemia
Grey baby syndrome - neonates cannot alway metabolise
optical and peripheral neuritis

480
Q

what are 5 contraindications to chloramphenicol?

A

Hypersensitivity
Bone marrow disorder
3rd trimester pregnancy
Breastfeeding
< 2 years

481
Q

what is 1 caution in systemic chloramphenicol use?

A

hepatic impairement

482
Q

what are 2 thing to communicate with patients having chloramphenicol eye drops?

A

may blur vision and do not drive is vision blurred
Avoid use of contact lenses

483
Q

ho long should a course of chloramphenicol eye drop be?

A

48 hours after healing

484
Q

what is the spectrum of clindamycin?

A

gram positive aerobes and anaerobes

485
Q

what is the MOA of clindamycin?

A

binds to ribosomes and prevents protein synthesis

486
Q

what are 6 side effects of clindamycin?

A

diarrhoea
Abdo pain
rashes and SJS
Abnormal liver enzymes
Antibiotic related colitis - C. diff

487
Q

what is 1 contraindication to clindamycin?

A

acute porphyria

488
Q

what is 1 condition to use clindamycin with caution in?

489
Q

what is one interaction with clindamycin?

A

can increase effect of neuromuscular blocking drugs => delays postoperative recovery

490
Q

what dose of topical clindamycin is used in acne?

A

1/2% once a day applied thinly

491
Q

how should clindamycin be administered IV?

A

diluted in 5% glucose or normal saline and given over 10-60mins

492
Q

what is the length of clindamycin course in acne?

A

6 months minimum

PSA (9 decks)

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