Workbooks Flashcards
Medications that require dose adjustment or stopping with renal dysfunction
NSAIDs, opiates, neuropathic pain meds
H2 antagonists
Most immunosuppressants
LMWH, DOACs
Most Abx, most antivirals, most antifungals
ACE-i, ARB, BB, mineralcorticoid antagonists
Digoxin, hydralazine, most statins, fibrates
Most SNRIs
Amisulpride, lithium
Benzos, z-drugs
Most anti-epileptics (but not those for status epilepticus)
Metfromin, -gliptins, -flozins, exenetide Propylthiouracil
NSAIDs, colchicine, allopurinol, febuxostat
Bisphosphonates
What medication should women of childbearing potential avoid handling?
Finasteride (used for BPH in men)
List some atypical and typical antipsychotics
What drugs are risks for acute dystonic reactions
- antipsychotics (esp haloperidol)
- metoclopramide
- domperidone [but doesnt cross BBB?]
- cyclizine
CI / caution with heart failure
[6]
- NSAIDs and COX2 inhibitors
- Midodrine (used for orthostatic hypotension)
- Pioglitazone
- Moxonidine
- Verapamil (other CCBs also caution in acute heart failure)
- Several immunosuppressive monoclonal antibodies
Caution drugs with PMH of Gout
- Diuretics
- Pyrazinamide [used to treat TB]
- Nicotinic acid
- (Allopurinol and febuxosin in acute gout)
- Many chemotherapy agents can result in hyperuricaemia, but this is not a contraindication, but need appropriate management
How to search for which drugs out of a list are most likely to increase risk of QT prolongation
BNF:
QT prolongation AND ( drug1 OR drug2 OR drug3)
Caution (none CI) with PMH of psoriasis as may exacerbate condition
[3]
- beta-blockers
- lithium salts
- chloroquine
How to search for which 2 drugs out of a list of drugs has the highest potential to worsen symptoms of myasthenia gravis?
BNF Search:
myasthenia AND (drug OR drug OR drug OR drug)
- you don’t want ‘indications and dose’ in this context as these medications are USED to treat the conditio
- you are looking for ‘cautions’, ‘SE’s or ‘contraindications’
Caution (none CI) with PMH of myasthenia gravis as may exacerbate condition
- Tetracyclines, macrolides, quinolones (higher risk IV)
- Sedating medications including Z-drugs, benzodiazepines, antipsychotics, opiates
- Local anaethetics (particularly nerve blocks)
- Beta-blockers
Drugs which may cause hypokalaemia
- Hypokalaemia
- Diuretics
- IV Antifungals (esp. amphotericin)
- Cisplatin
- Glucocorticoids / mineralocorticoids (typically only if excess)
- Beta2-agonists
- (Rarely) aminoglycosides such as gentamicin and amikacin
- Many others…
Drugs which may cause hyperkalaemia
- ACEi, ARB, spiro/eplerenone/amiloride
- Heparin and LMWH
- Tolvaptam [used in SIADH]
- Co-trimoxazole
Drugs that have risk of hypomagnesaemia as a SE
- Thiazide / thiazide-like diuretics
- Loop diuretics
- Proton pump inhibitors (usually within 1st year of treatment)
- Exchange resins (e.g. calcium resonium)
- Ciclosporin
- IV bisphosphonates (e.g. during treatment of hypercalcaemia)
- IV Antifungals
- IV Aminoglycosides
Drugs which have SE risk of hypoglycaemia
- Insulin
- Sulfonylureas
- Other anti-diabetic drugs still have the risk, but lower
- GLP-1 activators (e.g. exenetide)
- SGLT2 inhibitors (e.g. canagiflozin)
- DPP4 inhibitors (e.g. sitaglitpin)
- Pioglitazone
- (Not metformin)
- Other RARE causes
Drugs which have SE risk of hyperglycaemia or worsen diabetic control
- NOTE: These medications are NOT CONTRAINDICATED in diabetes, just needs better management/control
- Steroids
- Antipsychotic drugs
- Thiazide and thiazide-like diuretics
- (Loop diuretics less likely)
- Beta-blockers
- Tacrolimus
Drugs which could cause increased serum cholesterol / TG
- Systemic steroids
- Diuretics (thiazide and loop)
- Most antipsychotics
- Cyclosporine (and less frequently tacrolimus)
- Most HIV medications
- SGLT2 inhibitors (-flozins)
Drugs with risk of hypertension as a SE
- NOTE: These medications are NOT CONTRAINDICATED in hypertension, just needs better management/control
- NSAIDs
- Glucocorticoids
- Mineralocorticoids (but usually as treatment for hypotension/insufficiency)
- Combined oral contraceptives
- Mirabegron
- Clozapine
- Venlafaxine / tricyclic antidepressants
- Monoamine oxidase inhibtiors
- Selegiline
- Cyclosporine / tacrolimus / rapamycin
- Many other rarer contributing medications
Drugs with a risk of the SE of falls
Drugs that increase the overall risk of falls (and the baseline risk has many other factors)
- Benzodiazepines, Z-drugs
- Antidepressants (especially TCAs and SNRIs, less so SSRIs)
- Monoamine oxidase inhibitors
- Most antipychotics
- Opiates
- Most antihypertensives (especially alpha-blockers [e.g. doxazosin], diuretics, centrally acting antihypertensives)
- Some anti-Parkinson’s medications (e.g. selegiline, ropinirole)
- (Less commonly) some antiepileptics
- In theory, those that cause hypoglycaemia
Drugs with increased risk of worsening osteoporosis
- steroids
- PPIs at high doses can increase risk of fractures, esp in elderly over long courses
- Long-term androgen supression (e.g. LHRH agonists such as buserelin, goserelin for prostate cancer)
- There are other rarer causes (including methotrexate)
Drugs with the SE of increased risk of urinary retention / incontinence
(alpha blockers e.g. doxazosin ARE NOT anticholinergics, things like oxybutinin is)
Drugs which increase risk of constipation
- Opioids
- Oral iron
- Some calcium channel blockers
- Anti-psychotics
- Some diuretics (if dehydration)
- Anti-diarrhoeals
- Some antacids (aluminium-containing)
- Anti-muscarinics (even inhaled)
- Ondansetron
- Phosphate-binders
- Exchange resins
- Some anti-Parkinson’s medications
- Some anti-epileptics
- Many others!
Drugs which increase risk of diarrhoea
- Laxatives
- Antibiotics
- Some antacids (magnesium-containing)
- Alpha-glucosidase inhibitors (Acarbose)
- Lipase inhibitors (orlistat)
- Cholinesterase inhibitors (e.g. rivastigmine)
- Colchicine
- Many others!
- Can also relate to lactose- or sorbitol-content of the medications
How to check for interactions on medicines complete
Drugs
Type in your whole lsit of medications e.g. (aspirin clopidogrel simvastatin amlodipine salbutamol clarithromycin prednisolone)
Click interactions
Monitoring required for antipsychotics
FBCs, U&E, LFT, lipids, blood glucose, BP
Prolactin
Physical health (and CV risk) monitorning, QTc monitoring
Important SEs antipsychotics
& Common SEs
Important side effects
–Blood dyscrasias / agranulocytosis
–QT prolongation, arrythmias
–Worsening diabetes
–Worsening Parkinson’s disease
–Neuroleptic malignant syndrome
Common side effects
–Drowsiness, constipation, urinary retention, dry mouth, hypotension
–Weight gain
–Galactorrhoea, gynaecomastia, sexual dysfunction
DONT STOP THE MEDICATION ABRUPTLY
Drugs with photosensitivity
(where pts must avoid significant exposure to sunlight)
& where can this info be found?
Isotretinoin
Doxycycline (& other tetracyclines) - look at medicinal forms, its on the label info
Amiodarone
What are labels? give some examples
Communicating info about lithium
Patients should be aware of (and report) symptoms of potential toxicity
–visual disturbance, persistent headaches
–increased urination, muscle weakness, tremors, confusion or drowsiness
Patients should be aware of (and report) potential causes of dehydration
–E.g. vomiting, diarrhoea, profuse sweating with fevers
–To keep well hydrated
–Risk of toxicity with diuretics
Will need monitoring of blood tests
–Lithium, TFTs, U+Es, bone profile
Avoid if possible in pregnancy (but not absolute contraindication)
Should not stop treatment abruptly without medical advice
Communicating info Metformin
Patient should be aware that:
–Dehydration (e.g. with diarrhoea, vomiting, infections) risks severe side effects (lactic acidosis) : so must stop taking M if get DorV
–Gastro-intestinal side-effects are common. However, a slow increase in dose may improve tolerability
Method of use
–Take with or just after food
–Start with low starter dose
–Likely to require higher doses in the future
–(Modified release tablets not to be crushed)
Monitoring
–Renal function (as it will influence dosing / stopping)
Sick day rules (general)
- which drugs to consider stopping if unwell?
If unwell, (e.g. vomiting, diarrhoea, fevers, sweats), consider stopping the following:
–Metformin (not insulin! – see later)
–ACEi / ARBs / diuretics
–NSAIDs
(“DAMN” medications)
Sick day rules - Type 1 DM
- Never omit insulin (may need increased – local guidance usually provided)
- Maintain adequate (sugar-free) fluid intake
- Maintain regular carbohydrate intake – if unable to take solids, in liquid carbohydrate format
- Consider anti-emetic if nauseated
- Consider oral electrolyte replacement in diarrhoea
- If prolonged inability to keep down fluids (e.g. >4hrs), then likely needs hospital admission
- Increased blood glucose monitoring (e.g. 4hr-ly, and even more frequently if >moderate ketones)
- Ketone testing 2-4 hrly
- If persistently elevated, or elevated while low blood glucose – may need hospital admission
- Diabetic specialist nurse should provide individualised plan
Type 2 DM Sick Day rules
- Patients on oral medication only, not including sulphonylureas
- Continue with medication as normal (except metformin if prolonged D/V)
- Encourage adequate fluid and diet intake
- Consider providing an oral electrolyte replacement
- Patients taking Sulphonylureas
- Minimum of daily self-blood glucose monitoring
- Advice should be provided regarding the increased risk of hypoglycaemia and reinforce the importance of taking some form of regular carbohydrate
- Seek advice if blood glucose persistently elevated (e.g. > 17)
- Patients taking insulin therapy
- Never omit insulin (if regular prescription)
- Emphasis on the importance of regular carbohydrate intake
- Minimum twice-daily self-blood glucose monitoring
- Seek advice if blood glucose persistently elevated (e.g. > 17)
- Diabetic specialist nurse should provide individualised plan
(long-term) steroids communicating info to pt
Sick day rules:
–Likely need to increase dose if unwell or undergoing surgery
Method of use:
–Do not stop steroids abruptly
–Usually taken in morning (reduce nocturnal side effects)
–Taken with or just after food
–Should carry steroid card
Serious side effects:
–Increased risk of psychological side effects
–Increased risk of infections
(not necessarily CI in pregnancy)
How best to find communicating info advice
e.g. for prednisolone
In “Treatment cessation”
and “patient and carer advice”
Peri-operative prescribing
what does it depend on?
what are the common drugs involved?
[where to find this info?]
Elective, emergency, NBM
- antiplatelets/anticoagulants
- diabetic meds: oral, insulin
- steroids
- anti-hypertensives
- oral contraception/HRT
[Surgery & long-term medication]
Give some “typical” advice for peri-operative prescribing for the some of the main important drugs
Advice to patients starting on antidepressants
[6]
- To be vigilant for worsening depressive symptoms and suicidal ideas, and to seek help promptly if they are concerned
- It usually takes 2–4 weeks for symptoms to improve
- Antidepressants should not be stopped suddenly due to potential for withdrawal symptoms
- Antidepressants should be taken for at least 6 months after they have recovered, to reduce the risk of relapse
- Antidepressants are not addictive
- Some antidepressants potentially have sedating effects greatest in the first month, and may affect the person’s ability to drive.
HRT communicating information:
- Formulations
- which type
- oestrogen / progestogen?
- Contraception
When to stop HRT? (same as combined hormone contraceptives)
HRT absolute and relative contraindications
Absolute contraindications
–Undiagnosed vaginal bleeding
–Severe liver disease
–Pregnancy
–Coronary artery disease
–Endometrial cancer
–Recent DVT or stroke
Relative contraindications
–Migraine headaches
–Personal history of breast cancer
–Personal history of ovarian cancer
–Venous thrombosis
–History of uterine fibroids
–Atypical ductal hyperplasia of the breast
–Active gallbladder disease (cholangitis, cholecystitis)
What are the risks associated with HRT?
& where to find more info on HRT on BNF?
“Sex hormones” page
What do you need to know how to find regarding contraception?
What is the generic name for the COCP?
What is the generic name for Protestogen only pill?
–How to start
–What to do with missed dose
–Monitoring
–Reasons to stop immediately
–Contraindication
–Interactions
–Peri-operative period
- Stop for combined pill
- Can continue for progestogen only pill
Ethinylestradiol with desogestrel
Levonorgestrel
Notes on azathioprine [2] and methotrexate [7], and general immunosuppressants [1]
Azathioprine
- Should be warned to report immediately any signs or symptoms of bone marrow suppression e.g. inexplicable bruising or bleeding, infection
- There is a risk of hypersensitivity reactions, which calls for immediate withdrawal
Methotrexate
- Weekly dosing
- Requires folic acid also weekly on a separate day to methotrexate
- Should be warned to report immediately any signs or symptoms of bone marrow suppression e.g. inexplicable bruising or bleeding, infection
- Should be warned to report if stomatitis develops (may be first sign of gastro-intestinal toxicity)
- Should be warned to report to seek medical attention if dyspnoea, cough or fever (risk of pneumonitis)
- Contraception recommended for both women and men for at least 3 months after treatment
- Patients should be advised to avoid self-medication with over-the-counter aspirin or ibuprofen
In general
Requires regular blood monitoring (esp. FBC, LFT)
Which medications have certain contraception requirements for males?
Methotrexate
Cyclophosphamide and many other strong IS
Some chemotherapy
(some antifungals and some antivirals)
Communicating info advice for Anti-diabetic medications
Communicating information for patients on antiepileptic medications
what is PaCO2 normal range?
5.1 - 5.6 kPa
What groups is low-concentration (controlled conc) O2 therapy reserved for?
patients at risk of hypercapnic respiratory failure, which is more likely in those with:
- COPD
- advanced cystic fibrosis;
- severe non-cystic fibrosis bronchiectasis;
- severe kyphoscoliosis or severe ankylosing spondylitis;
- severe lung scarring caused by tuberculosis;
- musculoskeletal disorders with respiratory weakness, especially if on home ventilation;
- opioids OD, benzodiazepines, or other drugs causing respiratory depression.
Until blood gases can be measured, initial oxygen should be given using a controlled concentration of 24% or 28%, titrated towards a target oxygen saturation of 88–92% or the level specified on the patient’s oxygen alert card if available.
The aim is to provide the patient with enough oxygen to achieve an acceptable arterial oxygen tension without worsening carbon dioxide retention and respiratory acidosis.
Patients with COPD and other at-risk conditions who have had an episode of hypercapnic respiratory failure, should be given a 24% or 28% Venturi mask and an oxygen alert card endorsed with the oxygen saturations required during previous exacerbations. Patients and their carers should be instructed to show the card to emergency healthcare providers in the event of an exacerbation.
Statins monitoring summary
Antimicrobial choice based on MC&S
how to look up allergy and cross-sensitivity for an Abx?
Look on drug & allergy and cross-sensitivity
e.g. avoid if history of immediate hypersensitivity reaction to beta-lactam antibacterials
Describe how the twice daily mix insulin and the basal-bolus therapy look in terms of time of day they cover
Describe which dose in the TWICE-DAILY MIX-INSULIN is the main influence on different blood glucoses throughout the day
Describe which dose in the BASAL-BOLUS THERPY is the main influence on different blood glucoses throughout the day
what pt groups should quinolones be avoided in?
long QT
Adjusting insulin - general principles
Which insulin to adjust depends on timing of hypo/hyperglycaemia
–Typical target of 4-10 mmol/L
Ideally review pattern over 48 hours (might not always be possible)
Typically adjustments by 10% of dose (varies with experience), e.g.
–Reducing from 24 units à new dose 22 units
–Increasing from 16 units à new dose 18 units
Adjusting insulin - general principles (do NOTs)
Do not prescribed stat doses of rapid acting insulin to ‘correct’ hyperglycaemia
–Can precipitate hypoglycaemia.
–Needs clinical experience
Do not change the total daily dose of insulin into one night-time dose
–Dangerous
Do not specify changes in calorific content of meals
Adjusting insulin - biphasic insulin
Adjusting insulin - basal-bolus
Monitoring requirements / parameters for the different anticogulants
e.g. Warfarin, LMWH, unfractionated heparin infusion, DOAC, fondaparinux
Rx neuroleptic malignant syndrome
& Px
starts within days of starting antipsychotic:
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion
Ix: raised CK
Rx: fluids, stop antipsychotic, dantrolene
how to find the ratio of a drug e.g/ if it says its 1 in 10,000
BNF medicinal forms
- 1-in-1 = 1 g/mL
- 1-in-1000 = 1g/1000mL
- 1-in-10000 = 1g/10000mL
percentages of drugs
Conversions
- 100% = 1 g/mL
- 1% = 1g/100mL
- (Or however you prefer to remember)
•
•But if you cannot remember on the day, the BNF sometimes has a conversion for the specific drug
.
How to prescribe fluids
Pt with 1 day of vomiting, has NG tube in. What fluids? currently NBM
obs normal
slightly hypokalaemic, eGFR as dropped, urea is high
what fluid to give, ONE
ANSWER: dabigatran (direct thrombin inhibitor), metrofmin and naproxen
KEY MESSAGE – Need to recognise the difference between medications that:
Require dose adjustments / cessation with reduced renal function
- The aim of this question
- E.g. metformin, NSAID in this question
May cause a reduction in renal function
•See below
Both of the above
HIGHEST RISK OF NEPHROTOXICITY:
- Diuretics, especially loop diuretics
- ACEi/ARBs/mineralocorticoid antagonists
- NSAIDs
drug for respiratory secretions in palliative care
Hyoscine hydrobromide
man A&E, 40 tablets of PCM 1hr ago… what to do?
Activated charcol 50mg PO
BNF: “poisoning, emergecny treatment”
Monitoring for enoxaparin
Anti-factor Xa assay
D.
REGULAR dose
60mg x2/day = 120mg/24hr
AS REQUIRED dose
7.5mls of morphine solution 10mg/5ml = 15mg/dose
Four doses in 24hours = 60mg morphine/24hrs.
Therefore total 180 mg morphine /24 hours
Dosing for breakthrough pain is typically 1/6th f the total daily dose = 30mg morphine sulfate orally
(D) Oral morphine sulfate (aka oramorph) is appropriate formulation
- no indication for intravenous (C) as still no evidence cannot drink
- nasal (A) may be reserved for those who cannot take oral meds
- should be immediately active for breakthrough pain, so not modified release (B)
- tramadol (E) would be insufficient, particularly at that dose
Best way to measure the benefits of IV GTN used for angina
Pain score
Managing specific SEs of antipsychotics
Extrapyramidal symptoms (esp. first generation antipsychotics, e.g. haloperidol, chlorperazine)
- Parkinsonian symptoms
- Acute dystonia managed with procyclidine 10mg IV (or IM if no IV access)
- Procyclidine also useful for acute dystonic reactions to metoclopramide
Neuroleptic malignant syndrome
- Hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with pallor, tachycardia, labile blood pressure, sweating, and urinary incontinence
- Discontinuation of the antipsychotic drug is essential because there is no proven effective treatment
- But bromocriptine and dantrolene have been used
When to use which anticoagulant?
Penicillin allergies and cross-sensitivity
Calculations (+- rounding?)
- (Q17) Most syringe drivers can be as precise as 0.1mL/hr
- (Q18) Precision for other volumes is dependent on overall volume
- In the case of question 18, would be reasonable to be 7.5mL
- Paediatric volumes are less likely to be rounded
- Tablet doses in mg more likely to be rounded
- E.g. 350.5mg à 350mg
what are the daily fluid requirements
25-30 mol/kg/day
1mmol/kg/day each of K, Na and Cl
~ 50-100g of glucose per day to limit starvation ketosis
what istthe maximum rate of KCl infusion
10 mmol / hr
