Year 3 Flashcards
IV Fluid Therapy
What are crystalloid and colloid fluid solutions?
*LOB: Define crystalloid and colloid fluid solutions and give examples of each
Crystalloid
Sodium Chloride
Ringers Lactate
Hartmanns
Hypertonic Saline
Colloid
Albumin
Hydroxyethyl starch
Gelatin
IV Fluid Therapy
Colloids: Gelatin, Albumin
M comparatively large, osmotically active molecules which do not readily cross semipermeable membranes, so their osmotic effect should ‘hold’ the infused volume in the intravascular compartment. and therefore increase circulating fluid
I To expand circulating volume in states of impaired tissue perfusion (including shock). However, compound sodium lactate and sodium chloride 0.9% are preferred.
C caution is required in heart failure, due to the risk of worsening cardiac output, and renal impairment, monitor fluid balance closely to avoid volume overload.
R IV Infusion
A promotes oedema. may increase LVent filling reducing cardiac output and precipitating pulmonary oedema.
Gelatins may cause hypersensitivity reactions, including anaphylaxis—another reason to prefer crystalloids, which are non-allergenic.
In managing a severely ill patient requiring large-volume fluid therapy, it is a good idea to use warmed fluids if possible, to avoid causing hypothermia.
IV Fluid Therapy
Compound sodium lactate (Hartmann’s solution)
M electrolyte composition approximates serum: 1 L contains Na+ 131 mmol, Cl– 111 mmol, K+ 5 mmol, Ca2+ 2 mmol, and lactate 29mmol. Lactate generates bicarbonate. As compound sodium lactate contains sodium in a concentration similar to extracellular fluid, the infused volume is largely retained in the extracellular water compartment
I To provide sodium and water for people unable to meet their water and electrolyte requirements orally (or by enteral tube). To expand circulating volume in states of impaired tissue perfusion (including shock). This may be done as a ‘fluid challenge’,
C Exercise caution during rapid infusion of IV fluid in patients with heart failure, due to the risk of pulmonary oedema. In renal impairment, monitor fluid balance closely to avoid overload. Conventional advice is to avoid compound sodium lactate in severe liver disease because of reduced capacity to metabolise lactate.
R The maximum rate of infusion using a pump is usually too slow for an effective fluid challenge.
A sodium in interstitium promotes oedema, may worsen cardiac output. Compound sodium lactate should not be mixed or infused with ceftriaxone, as may cause precipitation.
Can be used as your ‘standard’ sodium-based crystalloid solution.but cannot be used for potassium replacement
IV Fluid Therapy
Glucose (dextrose) - glucose 5%, 10%, 20% and 50%
M glucose content ensures it is initially isotonic with serum, so that it does not induce osmotic lysis of cells in the immediate vicinity of infusion. Glucose is rapidly taken up by cells and metabolised, leaving ‘free’ (hypotonic) water that distributes across all body water compartments
I To provide water for people unable to meet their water requirements orally (or by enteral tube), Severe hypoglycaemia, As a substrate fluid for IV insulin infusions., With insulin to treat hyperkalaemia. Reconstitution and dilution of drugs administered by injection or infusion.
C Giving IV glucose in thiamine deficiency can cause Wernicke’s encephalopathy. Administering hypotonic fluid in hyponatraemia may precipitate hyponatraemic encephalopathy.
R It is preferable, though, to use an infusion pump to control the rate and volume precisely.
The typical adult maintenance requirement for water is 25–30 mL/kg/day, some of which may be provided with a sodium-containing fluid (e.g. compound sodium lactate or sodium chloride 0.9%, to provide the daily sodium requirement) and the rest made up with glucose 5%
A Glucose 50% is highly irritant to veins and may cause local pain, phlebitis and thrombosis.
IV Fluid Therapy
Potassium, intravenous - potassium chloride (as an additive)
M In people unable to tolerate dietary intake, who are instead receiving their sodium and water requirement by IV infusion, potassium may be provided intravenously. For best effect,** IV potassium** is given with sodium chloride rather than glucose. This is because infusion of negatively charged Cl– ions promotes retention of K+ in the serum, whereas glucose may promote insulin release with resultant stimulation of Na+/K+-ATPase, shifting potassium into cells.
I Prevention of potassium depletion in people unable to meet their electrolyte requirements orally AND Treatment of established potassium depletion and hypokalaemia. (< 2.5 mmol/L), symptomatic or associated with electrocardiogram (ECG) changes.
C overcorrection leading to hyperkalaemia and a resultant risk of arrhythmias, irritant to veins
R infused no higher than 10 mmol/hr, due to the risks of venous irritation and cardiac toxicity.
AIV potassium has an additive effect with other potassium-elevating drugs, including oral potassium, aldosterone antagonists, potassium-sparing diuretics, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin-receptor blockers.
For example, if you need to prescribe 10 mmol potassium in 500 mL of 0.9% sodium chloride, you might specify this as the total amount of potassium chloride in the bag (10 mmol), the concentration per litre (20 mmol/L) or the concentration as a percentage (0.15%). Which you use will depend on the requirements of the prescribing interface.
IV Fluid Therapy
Sodium chloride - sodium chloride 0.9%, sodium chloride 0.45%
M If you take in more sodium (like from a saline solution), the volume of ECF increases. a 0.9% sodium chloride solution has a sodium concentration similar to that of ECF, so when you receive this solution, the ECF increases by about the same amount as the volume of the solution given.
I To provide sodium and water for people unable to meet their water and electrolyte requirements orally, To expand circulating volume in states of impaired tissue perfusion (including shock, Reconstitution and dilution of drugs administered by injection or infusion.
C Caution is required with rapid IV infusions in heart failure, due to the risk of pulmonary oedema. The concentration of chloride in sodium chloride 0.9% (154 mmol/L) is significantly higher than that of ECF (about 100 mmol/L). This may cause hyperchloraemia which, in turn, promotes acidaemia.
R
A When reconstituting drugs, it is important to check its compatibility with the diluent. For example, amiodarone is incompatible with sodium chloride. Refer to local policies and product information.
When estimating maintenance fluid requirement, a simple rule of thumb is to infuse fluid at an hourly rate (in mL/hr) equal to body weight. This will provide 24 mL/kg/day of water, which is close to the 25–30 mL/kg/day recommended in guidelines. For example, for a 75-kg adult, you might prescribe sodium chloride 0.9% (1 × 500 mL bag) and glucose 5% (2 × 1 L bags), each infused at 75 mL/hr.
Sulfonylureas
Gliclazide, glimepride, glipizide
Statins
Atorvastatin, simvastatin, rosuvastatin, pravastatin
Hypertension: for first- or second-line treatment of hypertension, to reduce the risk of stroke, myocardial infarction, and death from cardiovascular disease.
➋ Chronic heart failure: for first-line treatment of all stages of heart failure, to improve symptoms and prognosis.
➌ Secondary prevention of major adverse cardiovascular events in people with ischaemic heart disease, cerebrovascular disease or peripheral vascular disease.
➍ Diabetic nephropathy and chronic kidney disease (CKD) with proteinuria: to reduce proteinuria and progression of nephropathy.
Mechanisms of action
ARBs have similar effects to angiotensin-converting enzyme (ACE) inhibitors, but instead of inhibiting the conversion of angiotensin I to angiotensin II, ARBs block the action of angiotensin II on the angiotensin type 1 (AT1) receptor. Angiotensin II is a vasoconstrictor and stimulates aldosterone secretion. Blocking its action reduces peripheral vascular resistance (afterload), which lowers blood pressure. It particularly dilates the efferent glomerular arteriole, which reduces intraglomerular pressure and slows the progression of CKD. Reducing aldosterone concentration promotes sodium and water excretion. This can help to reduce venous return (preload), which has a beneficial effect in heart failure.
ARBs can cause hypotension (particularly after the first dose), hyperkalaemia, and renal failure. The mechanism is the same as for ACE inhibitors. Renal artery stenosis presents a particular risk, as constriction of the efferent glomerular arteriole is required to maintain glomerular filtration. ARBs are less likely than ACE inhibitors to cause cough and angioedema, as they do not inhibit ACE, so do not affect bradykinin metabolism. They may therefore preferred in Black people of African or Caribbean origin, who are at higher risk of angioedema.
Methotrexate
Methotrexate
Methatrexate
M: inhibits dihydrofolate reductase which converts dietary folate to FH4 for DNA and protein synthesis. Actively dividing cells are particularly sensitive
Anti- inflammatory and immunosuppressive effects at a lesser value than anti-mitotic via G protein coupled receptors due to increased adenosine release.
I: for inflammatory disorders and for neoplastic disorders.
C: Tetarogenic, Aspirin, nsaid, pencillin, PPI, The risk of neutropenia is increased if methotrexate is combined with clozapine.
A: Mucosal damage, bone marrow suppression, toxicity from inadvertent daily administration. Folinic acid rescues normal cells from methotrexate
Why is Methotrexate intrethecal?
Methotrexate is a chemotherapy drug that is used to treat certain types of cancer and leukaemia. When given intrathecally, it prevents leukaemia cells entering the cerebrospinal fluid (CSF) around the spine and brain.
Metformin
Metformin
Type 2 diabetes, as the first-choice medication for control of blood glucose, used alone or in combination with other oral hypoglycaemic drugs (e.g. sulphonylureas, dipeptidylpeptidase-4 (DPP-4) inhibitors, sodium–glucose co-transporter 2 inhibitors) or insulin.
Metformin (a biguanide) lowers blood glucose primarily by reducing hepatic glucose output (glycogenolysis and gluconeogenesis) and, to a lesser extent, increasing glucose uptake and utilisation by skeletal muscle. It does not stimulate insulin secretion and therefore does not cause hypoglycaemia. The cellular mechanisms are complex, involving activation of adenosine monophosphate-activated protein kinase (AMP kinase). This is a cellular metabolic sensor, activation of which has diverse effects on cell functions. Its effects on glucose metabolism can be accompanied by other metabolic changes, notably modest weight loss, which can be a desirable side effect (see CLINICAL TIP).
Important adverse effects
Metformin commonly causes GI upset, including nausea, vomiting, taste disturbance, anorexia, and diarrhoea. Lactic acidosis has been associated very rarely with metformin use, although the evidence for this is largely derived from case reports. There is no strong evidence of an increased risk in general, but metformin may be a contributory factor in people who develop an intercurrent illness that causes metformin accumulation (e.g. renal impairment), increased lactate production (e.g. sepsis, hypoxia) or reduced lactate metabolism (e.g. liver failure).
Diuretics, thiazide and thiazide-like
Bendroflumethiazide, indapamide, chlortalidone
Thiazide diuretics (e.g. bendroflumethiazide) and thiazide-like diuretics (e.g. indapamide, chlortalidone) differ chemically but have similar effects and clinical uses. We refer to them here collectively as ‘thiazides’. Thiazides inhibit the Na+/Cl− co-transporter in the distal convoluted tubule of the nephron. This prevents reabsorption of sodium and its osmotically associated water. The resulting diuresis causes an initial fall in extracellular fluid volume. Over time, compensatory changes (e.g. activation of the renin–angiotensin system) tend to reverse this, at least in part. The longer-term antihypertensive effect may be mediated by vasodilation, the mechanism of which is incompletely understood.
HTN: Bendro, Chloratalidone
Take in morning so effect maximal in day
Corticosteroids, systemic
Dexamethasone, prednisolone, hydrocortisone
Dexamethasone
M: inding to glucocorticoid receptors in the cytoplasm of a cell, which then translocates to the nucleus.
I: Suppression of inflammatory and allergic disorders, local inflammation, short term inflammation, macular oedema, mild croup, congenital adrenal hyperplasia, overnight dexa supression test, adjunctive Tx of sus[ct bact MCD C: For all corticosteroids (systemic) Avoid live virus vaccines in those receiving immunosuppressive doses (serum antibody response diminished); systemic infection (unless specific therapy given)
Contra-indications, further information
With intra-articular use or intradermal use or intralesional use:
For further information on contra-indications associated with intra-articular, intradermal and intralesional preparations, consult product literature.
Contra-indicationsFor dexamethasone
With intravitreal use
Active ocular herpes simplex (in adults); active or suspected ocular infection (in adults); active or suspected periocular infection (in adults); rupture of the posterior lens capsule in patients with aphakia, iris or transscleral fixated intra-ocular lens or anterior chamber intra-ocular lens (in adults); uncontrolled advanced glaucoma (in adults)
A:Anxiety; behaviour abnormal; cataract subcapsular; cognitive impairment; Cushing's syndrome; electrolyte imbalance; fatigue; fluid retention; gastrointestinal discomfort; headache; healing impaired; hirsutism; hypertension; increased risk of infection; menstrual cycle irregularities; mood altered; nausea; osteoporosis; peptic ulcer; psychotic disorder; skin reactions; sleep disorders; weight increased
Calcium channel blockers
Amlodipine, felodipine, nifedipine, diltiazem, verapamil
Taken orally, CCB have a half life of 35-50 hours. They are prescribed for HTN, Angina, supraventricular arrythmia.
M: Calcium-channel blockers (less correctly called ‘calcium-antagonists’) interfere with the inward displacement of calcium ions through the slow channels of active cell membranes. They influence the myocardial cells, the cells within the specialised conducting system of the heart, and the cells of vascular smooth muscle. Thus, myocardial contractility may be reduced, the formation and propagation of electrical impulses within the heart may be depressed, and coronary or systemic vascular tone may be diminished.
I: Amlodipine HTN, Angina Dilitazem, Supraventricular arrhtymia Verapamil
C: Cardiogenic shock; significant aortic stenosis; unstable angina
R: Orally, only verapamil is IV option (arrythmia), MR shouldnt be crushed
A:Abdominal pain; dizziness; drowsiness; flushing; headache; nausea; palpitations; peripheral oedema; skin reactions; tachycardia; vomiting
Overdose
Features of calcium-channel blocker poisoning include nausea, vomiting, dizziness, agitation, confusion, and coma in severe poisoning. Metabolic acidosis and hyperglycaemia may occur. In overdose, the dihydropyridine calcium-channel blockers cause severe hypotension secondary to profound peripheral vasodilatation. For details on the management of poisoning, see Calcium-channel blockers, under Emergency treatment of poisoning.
Antihistamines (H1-receptor antagonists)
Cetirizine, fexofenadine, loratadine, chlorphenamine
Mechanism of Action (M):
H1 antihistamines block H1 receptors on cells, preventing histamine from binding and exerting its effects. This reduces allergic symptoms such as itching, swelling, and vasodilation, commonly seen in allergic rhinitis, conjunctivitis, and urticaria.
Indication (I):
Allergic rhinitis
Urticaria (hives)
Allergic conjunctivitis
Anaphylaxis (as part of combination therapy)
Other allergic conditions causing itching or swelling
Contraindication (C):
Severe liver impairment (for some antihistamines)
Use with caution in patients with glaucoma, prostate hypertrophy, or urinary retention
Cetirizine: Contraindicated in patients with severe renal impairment
Risk Factors (R):
Elderly (increased risk of sedation and confusion)
Use with other sedative medications
Patients with cardiovascular disease
Renal or hepatic impairment
Adverse Reactions (A):
Sedation (especially with first-generation antihistamines like chlorphenamine)
Drowsiness (common in first-generation; less so in newer agents like cetirizine, loratadine, and fexofenadine)
Dry mouth, blurred vision, and urinary retention (anticholinergic effects, more prominent with first-generation drugs)
Gastrointestinal discomfort, headache, dizziness
Cetirizine:
Less sedating than first-generation antihistamines but can cause mild drowsiness in some.
Requires dose adjustment in renal impairment.
Fexofenadine:
Non-sedating, making it a good choice for daytime use.
Generally has fewer interactions with other medications.
Loratadine:
Non-sedating and well-tolerated, often chosen for once-daily dosing.
Safe for most patients with mild liver or renal impairment but may require dose adjustment.
Chlorphenamine:
A first-generation antihistamine, causing more sedation and anticholinergic effects.
Used in more severe allergic reactions like anaphylaxis but typically avoided for regular allergy management due to sedation.
Cetirizine:
Useful for allergic rhinitis and urticaria, especially when mild drowsiness is not an issue or nighttime use is preferred.
Can be used for chronic allergies with some degree of renal function monitoring.
Fexofenadine:
Ideal for patients needing a non-sedating antihistamine, particularly for daytime management of hay fever or chronic urticaria.
Suitable for individuals with active lifestyles or driving needs.
Loratadine:
Good choice for once-daily use in allergic rhinitis or hives with minimal side effects.
Useful for patients requiring long-term allergy management without sedation.
Chlorphenamine:
Reserved for acute, severe allergic reactions (e.g., in anaphylaxis alongside adrenaline).
May also be used at night when sedation is desired or not problematic, but generally avoided for regular, daily allergy management.
Angiotensin-converting enzyme (ACE) inhibitors :
Ramipril, lisinopril, perindopril
Mechanism of Action (M):
ACE inhibitors block the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This leads to vasodilation, reduced blood pressure, and decreased aldosterone secretion, which reduces sodium and water retention, improving heart function.
Indication (I):
Hypertension (first-line treatment)
Heart failure (adjunct treatment)
Post-myocardial infarction (to improve survival and reduce heart failure risk)
Diabetic nephropathy (renal protective effects)
Chronic kidney disease (to reduce proteinuria)
Contraindication (C):
History of angioedema
Use with aliskiren in patients with diabetes or low eGFR
Pregnancy (due to risk of fetal harm)
Severe renal impairment without dose adjustments
Risk Factors (R):
Elderly (due to risk of hypotension, especially postural)
Renal impairment (increased risk of hyperkalemia and renal dysfunction)
Patients on diuretics or low-sodium diets (risk of first-dose hypotension)
Collagen vascular disease (increased risk of agranulocytosis)
Adverse Reactions (A):
Dry cough (due to bradykinin accumulation)
Hyperkalemia (especially in renal impairment or with potassium-sparing drugs)
Hypotension, especially after the first dose
Angioedema (can occur at any time during treatment)
Renal dysfunction (worsening of kidney function in some patients)
Fatigue, dizziness, headache
Differences Between Ramipril, Lisinopril, and Perindopril
Ramipril:
Often preferred for its once-daily dosing and longer half-life.
Indicated for a broad range of conditions, including hypertension, heart failure, and post-MI management.
Requires dose adjustment in renal impairment and elderly patients.
Lisinopril:
A longer-acting ACE inhibitor, usually taken once daily.
Commonly prescribed for hypertension, heart failure, and post-MI treatment.
Its fixed dosing for most renal impairment cases makes it a popular choice, but caution is advised in severe renal impairment.
Perindopril:
Has a longer half-life and is often prescribed for once-daily use.
Particularly useful in hypertension and chronic heart failure management.
Dose adjustments are required for renal impairment; it is also effective in patients at risk of ischemic heart disease.
When to Prescribe Each:
Ramipril:
A good first-line option for hypertension and heart failure.
Useful post-myocardial infarction for long-term cardiovascular protection.
Consider in patients who need a once-daily ACE inhibitor with a favorable renal protection profile.
Lisinopril:
Ideal for hypertension management, particularly when straightforward dosing and long-term therapy are needed.
Suitable for heart failure and post-MI patients, especially in those who tolerate the initial dose well.
Preferred when monitoring for renal impairment is straightforward.
Perindopril:
Best suited for patients with cardiovascular risk, particularly for hypertension and chronic heart failure.
Beneficial in ischemic heart disease and for patients requiring long-term vascular protection.
Use with caution in those with significant renal impairment, adjusting the dose as needed.
Angiotensin receptor blockers
Losartan, candesartan, irbesartan
Hypertension: for first- or second-line treatment of hypertension, to reduce the risk of stroke, myocardial infarction, and death from cardiovascular disease.
➋ Chronic heart failure: for first-line treatment of all stages of heart failure, to improve symptoms and prognosis.
➌ Secondary prevention of major adverse cardiovascular events in people with ischaemic heart disease, cerebrovascular disease or peripheral vascular disease.
➍ Diabetic nephropathy and chronic kidney disease (CKD) with proteinuria: to reduce proteinuria and progression of nephropathy.
Mechanisms of action
ARBs have similar effects to angiotensin-converting enzyme (ACE) inhibitors, but instead of inhibiting the conversion of angiotensin I to angiotensin II, ARBs block the action of angiotensin II on the angiotensin type 1 (AT1) receptor. Angiotensin II is a vasoconstrictor and stimulates aldosterone secretion. Blocking its action reduces peripheral vascular resistance (afterload), which lowers blood pressure. It particularly dilates the efferent glomerular arteriole, which reduces intraglomerular pressure and slows the progression of CKD. Reducing aldosterone concentration promotes sodium and water excretion. This can help to reduce venous return (preload), which has a beneficial effect in heart failure.
ARBs can cause hypotension (particularly after the first dose), hyperkalaemia, and renal failure. The mechanism is the same as for ACE inhibitors. Renal artery stenosis presents a particular risk, as constriction of the efferent glomerular arteriole is required to maintain glomerular filtration. ARBs are less likely than ACE inhibitors to cause cough and angioedema, as they do not inhibit ACE, so do not affect bradykinin metabolism. They may therefore preferred in Black people of African or Caribbean origin, who are at higher risk of angioedema.
Emergency drugs
Adrenaline
M potent agonist of the α1-, α2-, β1- and β2 adrenoceptors
bronchodilatation and suppresses inflammatory mediator release from mast cells, ; increases in heart rate, force of contraction, and myocardial excitability; vasoconstriction of vessels supplying skin, mucosa, and abdominal viscera
I Cardiac arrest (IV), Anaphylaxis (IM), Croup (nebuliser), Local vasoconstriction during endoscopy to control bleeding or premixd with local anaesthetics to increase effect
C may also precipitate angina, myocardial infarction, and arrhythmias, Co-administration with ▲ β-blockers may induce widespread vasoconstriction
R IV, IM, Nebuliser
A adrenaline-induced hypertension. It may cause anxiety, tremor, headache, and palpitations
In children with croup (laryngotracheitis), nebulised adrenaline is an unlicensed but widely recommended treatment for those whose condition has not responded adequately to a systemic corticosteroid.
Paracetamol
Paracetamol
M reduces the availability of oxidised COX-2, interfering in the prostaglandin synthesis pathway, interferes with transmission of pain signals between the spinal cord and higher centre. Reduces prostaglandin E2 (PGE2) concentrations in the thermoregulatory region of the hypothalamus, reducing fever.
I first-line analgesic for most forms of acute and chronic pain, AND an antipyretic that can reduce fever
C reduced in people at increased risk of liver toxicity, either because of increased NAPQI production chronic excessive alcohol use, inducing metabolising enzymes) or reduced glutathione stores (malnutrition, low body weight, severe hepatic impairment)
R PO as tablets, caplets, capsules, soluble tablets, and oral suspension. IV paracetamol solution may be infused neat over 15minutes or diluted in 0.9% sodium chloride or 5% glucose solution before administration, depending on the product.
A overdose, paracetamol causes liver failure as NAPQI accumulation causes hepatocellular necrosis, CYP inducers, e.g. phenytoin and carbamazepine, increase the rate of NAPQI production and therefore the risk of liver damage in paracetamol toxicity.
Cocodamol or co-dydramol contain paracetamol. DONT double dose
Alpha-blockers
Alpha-blockers : Tamsulosin, doxazosin, alfuzosin
Doxazosin is licensed both for benign prostatic enlargement and hypertension
Tamsulosin for benign prostatic enlargement only
M: are highly selective for α1-adrenoceptors found mainly in smooth muscle, including in blood vessels and the urinary tract (the bladder neck and prostate in particular). Stimulation induces contraction; blockade induces relaxation
causes vasodilation and a fall in blood pressure (BP) and reduces resistance to urine outflow from the bladder.
I a first-line medical option to improve lower urinary tract symptoms (LUTS) in benign prostatic enlargement, AND as an add-on treatment in resistant hypertension,
C avoid in existing postural hypotension. Omit existing anti hypertensive drugs. Ideally α-blocker treatment should be stabilised before starting a PDE-5inhibitor.
R PO advised bedtime.
A postural hypotension, dizziness, and syncope.
PDE-5inhibitor may be given (sildenafil) as those with BPH may experience erectile dysfunction.
Penicillins, antipseudomonal
Penicillins, antipseudomonal : Piperacillin with tazobactam (e.g. Tazocin®)
M broad spectrum of activity against a wide range of Gram-positive and Gram-negative bacteria (notably including Pseudomonas spp.) and anaerobes via β-lactamase inhibitor, high affinity to penicillin-binding proteins
I severe infections, Lower respiratory tract infection. Urinary tract infection, Intraabdominal infection, Skin and soft tissue infection.
Cpenicillin allergy, moderate/severe renal impairment.
R a powder to be reconstituted in 10mL sterile water or 0.9% sodium chloride. This is diluted further in 50–150mL of 0.9% sodium chloride or 5% glucose for IV infusion.
A GI upset is common, Less frequently, antibiotic-associated colitis occurs, hypersensitivity may occur
piperacillin–tazobactam contains about 11mmol Na+ and is infused in 50–150mL fluid (which may contain more sodium). Take this into account when determining the need for supplementary fluid and electrolyte therapy, particularly in people with heart failure or oedema.
Penicillins, narrow-spectrum
Penicillins, narrow-spectrum : Flucloxacillin, benzylpenicillin, phenoxymethylpenicillin
M Inhibit enzymes responsible for cross linking the peptidoglycans in bacterial cell wall - cell swells, cell lysis
P have beta lactam ring
ISTAPHOCOOCAL, Skin and soft tissue
Ostemyelitis and septic arthritis, Other infection - endo carditis
C Reduce dose renal failure
Allergy
Previous hepatotocxity
Reduce renal excretion of methotrexate - caution
A GI
Effects of allergy
Liver toxcity
Central nervous system toxcitity
Penicillins, broad-spectrum
Penicillins, broad-spectrum : Co-amoxiclav, amoxicillin
M inhibit enzymes responsible for cross-linking peptidoglycans, weakens the bacterial cell wall, reducing its ability to maintain an osmotic gradient, causing cell swelling, lysis, and death. Penicillins contain a β-lactam ring, which is responsible for their bactericidal
I Amoxicillin- including sinusitis, otitis media, community-acquired pneumonia, and urinary tract infection (UTI), and to eradicate Helicobacter pylori.
Co-amoxiclav is a common choice for severe, resistant, and hospital-acquired infections, including pneumonia, UTI, intraabdominal infection, cellulitis, and bone and joint infection.
C severe allergy to a β-lactam antibiotic, young people with a sore throat, as they can cause a rash with glandular fever, C. difficile infection, and in those with a history of penicillin-associated liver injury
R severe infection IV administration at a high dose, moderate orally at a lower dose
Available as capsules, tablets, and oral suspensions. Co-amoxiclav suspension may cause dental staining. IV preparations may be given by slow injection or infusion.
A GI upset is common, Less frequently, antibiotic-associated colitis occurs, hypersensitivity may occur. Acute liver injury (cholestatic jaundice or hepatitis) may develop during or shortly after co-amoxiclav
inactivated by bacterial penicillinases, and resistance is increasingly prevalent.
Opioids
Opioids : Strong (morphine, oxycodone); weak/moderate (codeine, dihydrocodeine, tramadol)
M agonism of opioid µ (mu) receptors in the central nervous system (CNS). leading to reduced neuronal excitability and pain transmission. BUT blunts response to hypoxia and hypercapnia, reduces respiratory drive and breathlessness.
I Acute pain, chronic pain if other analgesics are insufficient, breathlessness in palliative care, acute pulmonary oedema
C Avoid co-prescription with other sedating drugs including benzodiazepine and tricyclic antidepressants. Avoid in hepatic and renal failure and in older people. Do not give in respiratory failure other than palliative care.
R IV for rapid effect. A typical initial prescription is morphine 2–10mg IV, tailored to pain, age, and other individual factors. A common choice for mild pain is codeine (e.g. 30mg orally 4-hrly)
A Respiratory depression, euphoria, detachment, neurological depression, nausea, vomitting, pupillary constriction, constipation (reduced motility), itching (histamine release)
opioid withdrawal are the opposite of the clinical effects of opioids: anxiety, pain, and breathlessness increase; the pupils dilate; and the skin is cool and dry with piloerection (‘cold turkey’).
Anaesthetics, general
Anaesthetics, general : Propofol, thiopental, sevoflurane, nitrous oxide, ketamine
M Enhance the inhibitory action of γ-aminobutyric acid (GABA), particularly via GABAA receptor activation, and/or antagonise excitatory N-methyl-D-aspartate (NMDA) and nicotinic cholinergic receptors. This decreases cortical and thalamic activity, leading to varying degrees of unconsciousness, analgesia, and muscle relaxation
I induce reversible unconsciousness, (e.g. propofol) may be used at sub-anaesthetic doses to reduce discomfort from procedures that do not require full general anaesthesia, or as an infusion to improve tolerability of invasive ventilation in critical illness (sedation).
C enhances other drugs that supress conciousness and cardiorespiratory drive.
R Intravenous anaesthetics include propofol, thiopental, and ketamine, while inhalational anaesthetics include volatile liquids (e.g. sevoflurane) and simple gases (nitrous oxide)
IV anaesthetics are given by bolus injection to induce anaesthesia, and infusion to maintain anaesthesia (or sub-anaesthetic sedation)
A Supression of airway reflexes and respiratory drive, bradycardia, vasodlation, hypotension (ketamine hypertension), nausea and vomiting, propofol may cause pain on injection.
Anaesthetics, local
Anaesthetics, local : Lidocaine, bupivacaine, levobupivacaine
M reversibly inhibit voltage-gated sodium channels, prevents initiation and propagation of action potentials
I Surface anaethesia such as urinary catheterisation and venepuncture, local anaesthesia for suturing and lumbar puncture, regional anaesthesia/analgesia such as epidural, lidocaine second line for ventricular tachycardia
C Liver disease, cardiac failure (due to liver blood flow), duration of action can be overtly increased with vasoconstrictor (adrenaline)
R Urinary catheter- Instilagel. Subcuntaneous 1%- 3mg/kg, topical creams, plasters. NEVER IV
A stinging during administration, other affects are uncommon when care to avoid OD or IV administration. If OD- drowsiness, restlessness, tremor fits, hypotension, arrhythmia
Administer the local anaesthetic early, then complete any other preparatory work for your procedure. Wait 5minutes before testing the effect.
Antimuscarinics, genitourinary uses
Antimuscarinics, genitourinary uses : Solifenacin, oxybutynin, tolterodine
M bind to muscarinic receptors as competitive inhibitor of acetylcholine. promoting bladder relaxation increasing bladder capacity. May reduce urinary frequency, urgency, urge incontinence. Work in overactive bladder at antagnosim at M3 receptor.
I urinary frequency urgency and urge incontinence in overactive bladder, if bladder training doesnt work
C Adverse with other antimuscarinics like tricyclic antidepressants, UTI, dementia (cognitive effect), caution in those at risk of intraocular pressure, caution with arrhythmia risk and urinary retention
R Immediate-release antimuscarinics should be taken at roughly equal intervals, with or without food. MR forms should be taken at a similar time each day and swallowed whole, not chewed.
Oxybutinin available as a patch.
A dry mouth, tachycardia, constipation, blurred vision, urinary retention may occur if there is bladder outflow obstruction. Oxybutiynin congnitive effects as ccrosses BBB acting at M1.
chewing gum good for dry mouth symptoms
Direct oral anticoagulants
Direct oral anticoagulants : Apixaban, rivaroxaban, edoxaban, dabigatran
M DOACs act on the final common pathway of the coagulation cascade: Factor X, Thrombin and Fibrin.
Dabigatran directly inhibits thrombin and the “xa” inhibit Factor Xa. And thus prevent fibrin formation.
I VTE for Tx and recurrence, Atrial Fibrilation to prevent stroke and systemic embolism in non-valvular AF associated with a risk factor
C Avoid in active clinically significant bleeding and those with risk of bleeding such as ulceration, cancer, recent surgery. Eliminates via CYP450 so reduce dose/ alternatives in those with hepatic and renal disease. Avoid in pregnancy and breastfeeding.
The anticoagulant effect is increased by macrolides, protease inhibitors, and fluconazole and decreased by rifampicin and phenytoin.
R PO. Rivaroxaban with food. Dabigatran cannot be crushed but ‘xa’ can.
A Bleeding including greater risk of GI bleeds (less intercranial risk than warfarin), anaemia, GI upset, dizziness, elevate liver enzymes.
In emergencies, dabigatran can be reversed with idarucizumab (a humanised monoclonal antibody fragment that binds to dabigatran and its metabolites). Apixaban and rivaroxaban can be reversed with andexanet alfa (a recombinant, modified form of human factor Xa that acts as a ‘decoy receptor’ for factor Xa inhibitors).
5 alpha reductase inhibitors
5 alpha reductase inhibitors: Finasteride, dutasteride
M Reduce size of prostate gland by inhibiting conversion of testosterone to dihydrotesterone but can take months for clinical difference to be seen. Hence second line
I Benign prostatic hyperplasia
Second line treatment after alpha blockers
C Pregnancy
R PO
A Impotence, Reduced libido, Gynaecomastia, Can be used to help male pattern baldness as adrogen inhibition can help hair growth
Nitrofuratoin
Nitrofuratoin
M Metabolised in bacterial cells by nitrofuran reductase
Damages the bacterial DNA and cause cell death
Active against - E coli (g -ve) and staphcoc (g +ve)
I Uncomplicated UTI first line treatment
Because:
Effective against most com uti patho
Reaches therapeutic conc in urine through rental excretion
Most bactericidal in acidic conditions - aka urine
C Pregnancy, Babies < 3 mo, Renal impairement as impaired excretion increase tox and reduce effectivity Caution with long term use
A GI upset
Hypersensitivity
Chronic pul reactions
Hepatisis and peripheral neuropathy in long term
Babies - haemolytic anaemia
Phosphodiesterase (type 5) inhibitors :
Phosphodiesterase (type 5) inhibitors : Sildenafil, tadalafil, vardenafil
M Phosphodiesterase inhibitor selective for type 5 This is mainly found in the SM of the corpus cavernosum of penis and arteries of lungs
I Erectile dysfunction, Primary pulmonary hypertension
CIf vasodilation is risky aka, Recent stroke, ACS, significant CVD, Severe renal or hepatic impairment, dont give or lower the dose
ARelated to the fact its a vasodilator
Flushing, Headaches, Dizzyness, nasal congestion
More serious, Hypotension, tachy, palpilations
If erection fails to subside - medical attention needed to prevent damage
Antiemetics, dopamine D2-receptor antagonists
Antiemetics, dopamine D2-receptor antagonists : Metoclopramide, prochlorperazine, domperidone
M D2 receptors in the main receptor in the ctz. Dop also relaxes stomach and lower esophagus and inhibs gastoduodenal effects
I Prophyaxis and treatment of nausea in many things but particulary reduced gut motilty
C Gastrointenintal obstructions
Perforation
Extrapyraminal side effects more common in under 25 so avoid
Dont combine with anti psycotics or dopmergic agents (park treatment)
A Diarrhoea
Extra pyrmindal sydrome
Acute dystonic reaction
Antiemetics, histamine H1-receptor antagonists
Antiemetics, histamine H1-receptor antagonists : Cyclizine, promethazine, cinnarizine
MH1 found in vomiting centre and in its comms with vestibular system
I Proph and treatment of nausea and vomiting particaully in motion sickness and vertigo
C Hepatic encephalopathy
Avoid patient suseptiable to anticholeric side effect aka men with prostatic hypertrophy
Sedation more if also on other sedative drugs
Anticholergic effects more pronounced in patients taking antimusc, bronch dilators
A Drowsiness
Dry throat and mouth
Tachy
Palpitations
Antiemetics, serotonin 5-HT3-receptor antagonists
Antiemetics, serotonin 5-HT3-receptor antagonists : Ondansetron, granisetron
M High density of 5ht in ctz and seratonin is key NT released by gut in response to emetogenic stimulation
I Nausea and vom, in context of GA and chemo
C May prolong qt so just be caution
Avoid taking with other drugs that prolong qt - antipsycotic, ssri
A Rare but constipation, diarrhoea, and headache
Benzodiazepines
Benzodiazepines : Diazepam, midazolam, lorazepam, chlordiazepoxide
M Targets γ-aminobutyric acid type A (GABAA) receptor in the brain. (Main inhibitory neurotransmitter) changes structure to facilitate binding odf GABA. Depressant effect on the synaptic transmission
reduced anxiety, sleepiness, sedation, and anticonvulsive effects.
I First line epilepsy and alcohol withdrawal. Sedation in palliatie care and inteventional procedures. Short term anxiety incl procedures.
C additive to those of other sedating drugs, including alcohol and opioids. CYP inhibitors (e.g. amiodarone, diltiazem, macrolides, fluconazole, protease inhibitors) may increase their effects.
R Oromucosal, IV,
A dose-dependent drowsiness, sedation, and coma. There is relatively little cardiorespiratory depression in benzodiazepine overdose (in contrast to opioid overdose), but loss of airway reflexes can lead to airway obstruction and death. If used repeatedly for more than a few weeks, a state of dependence
*Dont give Flumazenil- antagonist but can cause seizures that you cant fix becuase you block benzo receptor. *
Monoclonal antibodies
Monoclonal antibodies : Infliximab, adalimumab, denosumab, rituximab, omalizumab
MInfliximab & Adalimumab: Target TNF-α to reduce inflammation in autoimmune diseases.
Denosumab: Inhibits RANKL, reducing bone resorption by inhibiting osteoclast activity.
Rituximab: Binds to CD20 on B cells, leading to B-cell depletion.
Omalizumab: Binds IgE, reducing allergic responses.
IInfliximab & Adalimumab: Used in autoimmune diseases (e.g., rheumatoid arthritis, Crohn’s disease, psoriasis).
Denosumab: Treats osteoporosis, bone metastases, and hypercalcemia of malignancy.
Rituximab: Indicated for non-Hodgkin lymphoma, chronic lymphocytic leukemia, and some autoimmune conditions.
Omalizumab: Treats allergic asthma and chronic urticaria not controlled by antihistamines.
CAll: Avoid in active infections due to immunosuppressive effects.
Denosumab: Contraindicated in hypocalcemia.
Omalizumab: Contraindicated in patients with a history of severe hypersensitivity to the drug.
R Infliximab & Rituximab: IV infusion.
Adalimumab, Denosumab, & Omalizumab: Subcutaneous (SC) injection.
A Common: Infections (increased risk for all due to immunosuppression).
Infliximab & Adalimumab: Infusion or injection reactions, headache, nausea.
Denosumab: Hypocalcemia, osteonecrosis of the jaw, musculoskeletal pain.
Rituximab: Infusion reactions, cytopenias, risk of progressive multifocal leukoencephalopathy (PML).
Omalizumab: Injection site reactions, headache, rare risk of anaphylaxis.
Corticosteroids, inhaled: Beclomethasone, fluticasone, budesonide
Beclomethasone, fluticasone, budesonide
M interact with receptors in the cytoplasm- pro inflammatory IL, cytokines, chemokines are downregulated whilst antiinflammatory proteins are upregulated.
I: Asthma airway inflammation and shortterm control where B2 agonist is insufficient
C In COPD risk of pneumonia. Risk of paradoxical bronchospasm w wheezing. Systemic corticosteroid has adrenal suppression, osteoporosis and in children growth stunting.
If prescribed Cyp P450 inhibitors, inhibits inhaled corticosteroid metabolism (systemic symptoms)
R Metered-dose Inhaler (MDI) or dry powder inhaler (DPI). Beclamethasone ‘extrafine; is 3.5 times more potent than a standard inhaler, Fluticasone proprionate is 2 times more potent that budesonide
A changes in taste sensation and voice, oral candidiasis.
Corticosteroids, nasal: Beclometasone, mometasone, fluticasone.
Beclometasone, mometasone, fluticasone
Mhave antiinflammatory and vasoconstriction effects. in rhinitis this reduces mucosal inflammation, oedema and secretions.
I Prevention and tx of seasonal or perennial allergic rhinitis where antihistamines are insufficient, first line tx to shrink nasal polyps
C local adverse effects such as nasal irritation, epistaxis, pharyngisitis and change in sense of smell and taste. Occular adverse effects are rare. Systemic adverse effects are less common with mometasone and fluticasone as lesser bioavailability
R Nasal Spray with fixed drug per spray. starting dose 100mcg, once daily for mometasone and fluticasone or 12-hrly for beclometasone
A. DO NOT use in coexisting nasal infection, nasal trauma or surgery, avoid in Pulmonary TB
Corticosteroids, topical: Hydrocortisol, betamethasone, clobetasone
Hydrocortisol, betamethasone, clobetasone
M in skin suppresses inflammation during flares and reduces recurrence but not curative.
I Inflammatory skin conditions incl eczema and psoriasis to tx disease flares or control chronic disease where emollients alone are ineffective
Cdo not use in untreated bacterial, fungal or viral infection as this can worsen spread. Avoid for potent for use on face, genitals and axillae where the skin is thin or flexural
R potent (e.g. hydrocortisone 0.1%–2.5%), moderately potent (e.g. betamethasone valerate 0.025%) potent (e.g. betamethasone valerate 0.1%) or very potent (e.g. clobetasol propionate 0.05%).
A usually limited to site of application- skin thinning, striae, telangiectasia, contact dermatitis, worsening/spreading untreated infection. On face they can cause perioral dermatitis or acne. Withdrawal can occur with skin flare.
Emollients increase efficacy of topical corticosteroids so may allow a lower-potency drug to be used reducing adverse effects. Seperate application by 15 minuets to allow for absorption
Think as finger tip unit- 5mm tube should cover palms and fingers of both hands.
Corticosteroids, systemic: dexamethasone, prednisolone, hydrocortisone.
Dexamethasone, prednisolone, hydrocortisone.
M bind to cytosolic glucocorticoid receptors to regulate gene expression. modifies immune response. Upreg antiinfl. genes and downreg pro-infl. genes
I allergic or inflammatory disorders, anaphylaxis, exacerbations of asthma or COPD; suppression of AutoIx disease; reduce tissure damage in response to infection- bacterial meningitis, COVID19; some cancers or to reduce tumour associated swelling; hormone replacement in adrenal insufficiency or hypopituitarism.
C prescribe with caution in people with infection and children (suppress growth). Caution with NSAIDS as can increase risk of peptic ulceration and GI bleeding. Can increase hypokalaemia when used with B2 agonists, loop or thiazide diuretics. Efficacy can be reduced with cP450 inducers.
R Once-daily corticosteroid treatment should be taken in the morning, to mimic the natural circadian rhythm and reduce insomnia. antiinflammatory activity of hydrocortisone 100mg is approximately equivalent to prednisolone 25mg and dexamethasone 4mg. If PO inappropriate (ibd, anaphylaxis) IV hydrocortisone may be used.
A immunosuppresion risk of infection. metabolic effects of diabetes mellitus and osteoporosis. Increased catbaolism causes proximal muscle weakness and skin thinning. Mood and behavioural changes include insomnia, confusion, psychosis. Hypertension, hypokalaemia, oedema can result from mineralocorticoid actions.
Can suppress ACTH in prolonged tx this can cause adrenal atrophy. If then, corticosteroid is removed, adrenal crisis with CVS collapse may occur.
Can reduce immune response to vaccine.
β2-agonists: Salbutamol, formoterol, salmeterol, indaceterol.
salbutamol, formoterol, salmeterol, indacaterol
M B2 found in s.m of bronchi gut uterus and blood vessels. Stimulation leads to smooth muscle relaxation and bronchodilation. ALSO stimulates Na/K-ATPase pumps on cell membranes can be adverse or benefit as hyperkalaemia treatment
I Asthma (SABA) to relieve bronchospasm LABA added to Inhaled cortiocosteroids. COPD SABA relieves breathlessness and exercise limitation. If SABA inefficient, combine LABA or inhaled cortiocosteroid.
C LABA should only be used in asthma if inhaled corticosteroid part of therapy as LABA without is associated with increased asthma deaths. Caution in CVS disease as tachycardia may provoke angina or arrhythmia especially at high dose.
R inhaled as aerosol metered-dose or dry powder inhalers. In hospital tx regular nebulised therapy is used acutely. Inhalation via spacer also appropriate.
A tachycardia, palpitation, anxiety, tremor, headache. Hypokalaemia and elevated serum lactate at high doses. Promotes glycofenolysis so may cause hyperflycaemia. LABA can cause muscle cramps.
Spacers also reduce oropharyngeal deposition and therefore oral adverse effects.
Dipeptidylpeptidase-4 inhibitors: sitagliptin, linagliptin, alogliptin
sitagliptin, linagliptin, alogliptin
M Incretins such as GLP1 and GIP are released by the intestine throughout the day. Incretins are rapidly inactivated by hyrolysis by the enzymes DPP4. DPP4 inhibitors lower blood glucose by preventing incretin degradation and increasing plasma concentrations of their active forms. Actions are glucose dependents.
Less likely to cause hypoglycaemia than sulphonylurea.
IT2 diabetes,options for combination therapy with metformin if blood glucose not adequateky controlled or monotherapy if metformin is contraindicated/not tolerated.
C contra in people with hypersensitivity to the drug class. DO NOT use in tx of T1 diabetes or ketoacidosis. DO NOT use in pregnancy or breastfeeding. Caution in age > 80 and those with Hx of pancreatitis. Dose reduction advised in moderate to severe renal impairment. Saxagliptin avoid in hepatic impairment. Hypoglycaemia risk increased with coprescription of other antihyperglycaemics.
R PO t.d.s or fixed dose with metformin combination to time with metformin doses.
A GI upset, headache, nasopharyngitis, peripheral oedema. Hypoglycaemia can occur. Small risk of acute pancreatitis so stop drug if persistent abdo pain.
The efficacy of DPP-4 inhibitors is reduced by drugs that elevate blood glucose, e.g. prednisolone, thiazide, and loop diuretics.
no evidence that they reduce the risk of vascular complications.
Carbamazepine
Carbamazepine
M: inhibits neuronal sodium channels, stabilising resting membrane potentials
I seizure prophylaxis in epilepsy, trigeminal neuralgia
C absence and myoclonic seizures, tetarogenic (neural tube defect), Steven Johnson syndrome risk in Han CHinese and Thai origin, Hepatic, renal, cardiac disease, CYP inhibitors, other antiepileptic, antipsychotics, tramadol
R PO, PR, low dose increased gradually
A GI upset, neurological effect incl dizziness and ataxiam oedema, hyponatraemia, hypersensitivity
Digoxin : Digoxin
Digoxin
M negatively chronotropic (reduces HR) and positively inotropic (increases contractile folce), increases vagal tone in AF
In HF, inhibits Na+/K+ ATPase pumps to increase contractile force of myocytes
I AF to reduce ventricular rate, in severe HF, may be added if Tx not efficient
C Loop and thiazide, Amiodarone, CCB, spironolactone and quinine can increase toxicity
Second degree Heart block, intermittant block, ventricular arrhytmia, lower dose in renal failure
R PO, IV
A bradycardia, GI upset, rash, dizziness, visual disturbance
Is
Foxglove- has a tight therapuetic margin
Non-steroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors :
Ibuprofen, diclofenac, naproxen (NSAIDs); etoricoxib (COX-2 inhibitor)
M inhibit prostaglandin synthesis from arachidonic acid by inhibiting cyclo-oxygenase (COX). COX-2 is expressed in response to inflammatory stimuli. It stimulates production of prostaglandins that cause inflammation and pain
I As needed for mild moderate pain and fever
Regular treatment for pain due to inflammation incl RA, severe OA, acute gout
C contraindicated in ✖ severe renal impairment, ✖ heart failure, ✖ liver failure and known ✖ NSAID hypersensitivity. They should be avoided in ▲ peptic ulcer disease ▲ cardiovascular disease and milder forms of ▲ renal impairment.
R PO, Gel, Suppositories, Injectible
A Diclofenac suppository only hospital as BP drop
GI toxicity, renal impairment, and major adverse cardiovascular events
renal impairment. Other adverse effects include hypersensitivity reactions, e.g. bronchospasm and angioedema, and fluid retention
therapeutic benefits of NSAIDs are principally mediated by COX-2 inhibition, and adverse effects by COX-1 inhibition
Acetylcholinesterase inhibitors :Donepezil, rivastigmine, pyridostigmine
Donepezil, rivastigmine,
M inhibits the cholinesterase enzymes that break down acetylcholine in the CNA and increases availability for neurotransmission
I mild to mod alzheimers, mild to mod parkinsons (rivastigimine)
C use with caution in asthma and COPD and those risk of peptic ulcers, AVOID in heart block or sick sinus,
NSAIDs and ▲ systemic corticosteroids may increase the risk of peptic ulceration. Use alongside ▲ antipsychotics may increase the risk of neuroleptic malignant syndrome.
R Tablets, capsules, liquids, Rivastifmine as a patch. Donepezil should be taken at night (vivid dreams may occur)
A GI upset (increased cholinergic activity), those with asthma or COPD may experience bronchospasm, peptic ulcers, bleeding, bradycardia, heart block, hallucinations and altered aggressive behaviour.
Small risk of extrapyramidal symptoms and neuroleptic malignant syndrome
Acetylcholinesterase inhibitors :Donepezil, rivastigmine, pyridostigmine
pyridostigmine
M an acetylcholinesterase inhibitor. cant cross BBB
I Myasthenia gravis, underactive bladder, with atropine to reverse neuromuscular blocking medication, off-labels POTS
Ccontraindicated in cases of mechanical intestinal or urinary obstruction and should be used with caution in patients with bronchial asthma
R PO, IV
A Sweating, Diarrhea, Nausea, Vomiting, Abdominal cramps, Increased salivation, Tearing
Increased bronchial secretions, Constricted pupils, Facial flushing due to vasodilation, Erectile dysfunction
Acetylcysteine and carbocisteine : Carbocisteine, acetylcysteine
Carbocisteine, acetylcysteine
M Replenishes the glutathoine which clears NAPQI,
with mucus it breaks disulfide bonds and reduces mucus viscocity
I IV acetylcysteine is the antidote for paracetamol
Oral carbocisteine and acetylcysteine as mucolytics
C Peptic ulcer disease, consider paracetamol poisioning use even if previous anaphylactoid reaction (check with superior)
R Acetylcysteine is diluted in glucose 5% for IV infusion.
Oral carbocisteine is available as capsules or oral solution
A anaphylactoid in IV after paracetamol poisoning, NOT Anaphylaxis, GI upset, GI bleeding, bronchospasm (use bronchodilator first)
Expensive BUT acetylcysteine is also available as eye drops (artificial tears). It reduces the viscosity and tenacity of mucus in the eye and is of potential benefit in the treatment of dry eye syndromes.
Aldosterone antagonists : Spironolactone, eplerenone
Spironolactone, eplerenone
M mineralocorticoid receptors in the distal tubules of the kidney to increase the activity of luminal epithelial sodium (Na+) channels (ENaC) inhibit the effect of aldosterone by competitive inhibition at mineralocorticoid receptors. This increases sodium and water excretion and potassium retention
I Ascites and oedema, chronic HF, primary hyperaldosteronism
eplerenone is licensed for the treatment of heart failure only
C ✖ severe renal impairment, ✖ hyperkalaemia, and ✖ adrenal insufficiency, avoid in pregnant and lactating.
combination of an aldosterone antagonist with other ▲ potassium-elevating drugs, including ▲ ACE inhibitors and ▲ angiotensin receptor blockers (ARBs), increases the risk of hyperkalaemia.
R Taken with food, PO
A hyperkalaemia, gynaecomastia, liver impariment and jaundice. Spironolactone is a cuase of SJS
Allopurinol : Allopurinol
Allopurinol
M inhibits xanthine oxidase. Xanthine oxidase metabolises xanthine (produced from purines) to uric acid
I prevent recurrent attacks of gout, prevent uric acid and calcium oxalate renal stones, prevent hyperuricaemia dn tumour lysis syndrome in chemo
C should not be started during an ✖ acute attack of gout, Recurrent skin rash or signs of more ✖ severe hypersensitivity to allopurinol are contraindications to therapy, ▲ renal impairment or ▲ hepatic impairment.
R PO, after meals with good hydration
A can trigger a gout attack, but can be reduced with NSAID or cholchine during initiation
Skin rash- SJS or TENS risk
Allopurinol hypersensitivity syndrome is rare
Co-prescription of allopurinol with ▲ angiotensin-converting enzyme (ACE) inhibitors or thiazides increases the risk of hypersensitivity reactions,
Ocular lubricants (artificial tears) : Hypromellose, carbomers, liquid a
Hypromellose, carbomers, liquid and white soft paraffin
M soothing effect, help protect eye from abrasive damage. Usually an electrolyte with a viscocity agent like cellulose polymer.
I First-line dry eyes, including keratoconjunctovitis sicca, Sjögrens
C Preservative-free products are preferable for long-term or frequent application (more than four times daily), to avoid adverse reactions to the preservative.
R liquid- hypromellose; Gels - carbomers, Oitnments- liquid paraffin (last longer but with blurred vision)
A Stinging, Blurring, if not preservative free may cause local inflammatory reaction
Eye care is therefore an essential component of good-quality intensive care. Prescription of an ocular lubricant, e.g. hypromellose 0.3%, 1drop per eye 4-hrly, should be considered for all patients with impaired consciousness (including due to sedation).
Oestrogens & progestogens
ethinylestradiol, estradiol (oestrogens) levonorgestrel, desogestrel (progestogens)
M to suppress LH/FSH release and hence ovulation. In symtpom relief, they can eleviate vaginal dryness, vasomotor instability. Offers reduced menstrual pain and improvements in acne
I Hormonal contraception AND Hormone replacement therapy,
C ✖ breast cancer, should be avoided with personal or family Hx of VTE, thrombogenic mutation or risks for CVD
Cytochrome P450 inducers (e.g. rifampicin, carbamazepine) may reduce contraceptive efficacy
R PO/ If a COC pill is started within the first 6days of the woman’s cycle, no additional contraception is needed. Beyond this, a barrier method should be used or sex avoided for the first 7days
A may cause irrefular bleeding, mood change, NO WEIGHT GAIN, doubles risk of VTE but risk is low,
POP do not increase risk of VTE or CVD
Continuous or extended use of the COC pill (i.e. without pill-free intervals) is unlicensed for most brands, but is safe and effective
Potassium, oral : Potassium bicarbonate, potassium chloride
Potassium bicarbonate, potassium chloride
M Clinical effects are usually not apparent until the serum potassium falls below 3mmol/L (normal range 3.5–5.0mmol/L)
Potassium supplementation results simply in increased potassium excretion and only minimal effect on serum concentration therefore MUST start potassium sparing diuretic or similar
I Prevention and Tx of potassium depletion and hypokalaemia. Addition of potassium sparing diuretic is preferred. IV KCl is preferred in initial severe hypokalaemia
C contraindicated in ✖ hyperkalaemia and take care when risk of ▲ renal impairment. Contra with drugs that increaese potassium incl ACEi NSAID etc.
R Effervescent tablets (e.g. Sando-K®) are stirred in about half a glassful of water for administration.
A Unpalatable, may inadvertently increase intake.
Prostaglandin analogue and carbonic anhydrase inhibitor eye drops
Latanoprost (prostaglandin analogue); brinzolamide (carbonic anhydrase inhibitor)
M Prostaglandin F2α analogues act via prostaglandin receptors to increase expression of matrix metalloproteinases, reducing resistance to aqueous humour outflow
carbonic anhydrase inhibitors reduce aqueous humour production.
I first line to lower intraocular pressure in open-angle glaucome and ocular hypertension. Preferred over β blockers as less side effects.
C Caution is lens is absent and with those at risk of iritis uveitis or macular oedema
R eye drops (best in evening, remove contact lenses)
A Local eye discomfort and blurred vision. Prostaglandin cause conjunctival reddening and change in eye colour (1/3 people)
Advice that may be given for all eye drops is that it is helpful to gently compress the medial canthus (the nasal ‘corner’) of the eye for about 1minute, immediately after instilling the drop. This reduces drainage through the lacrimal duct, lowering systemic absorption of the drug.
Prostaglandins and analogues : Dinoprostone, misoprostol, alprostadil, i
Dinoprostone, misoprostol, alprostadil, iloprost
M
* PGE2 synthesised in uterine mucosa and stimulated contraction and thins the cervix,
* PGE1 in sm muscle stimulates cAMP and vasodilation/relaxation except in the penis with erection
* PGI2 has vasodilatory effects
I Induction of labour (dinoprostone), Erectile Dysfunction (alprostadil), Termination of pregnancy (Misoprostol), Vasodilator in Pulmonary HTN, and PVD (iloprost)
C Induction of labour with dinoprostone should not be attempted if there are ✖ risk factors for difficult delivery
prostaglandins should be used with caution in people with ▲ severe cardiac disease. Iloprost contra in bleeding risk and DOACs and warfarin
R
* Dinoprostone is administered as a gel, pessary or vaginal tablet.
* Alprostadil is prescribed for urethral application. Misoprostol and iloprost are used in specialist practice
A
* Dinoprostone may cause uterine hyperstimulation increase the risk of uterine rupture.
* Alprostadil may cause prolonged painful erections (priapism) that can lead to tissue ischaemia.
* Iloprost may cause problematic hypotension when given systemically.
* Prostaglandins may cause nausea and vomiting from stimulation of gastro-intestinal smooth muscle.
misoprostol is an alternative for people who cannot tolerate PPIs.
Proton pump inhibitors : Omeprazole, lansoprazole, esomeprazole
Omeprazole, lansoprazole, esomeprazole
M They act by irreversibly inhibiting H+/K+-ATPase in gastric parietal cells and supresses gastric acid production nearly completely
I Prevention of peptic ulcer disease, incl NSAID, Tx of GORD and dyspepsia incl Barretts, eradicated H Pylori (w/ Abx)
C may mask symptoms of gastric and oes cancer and ulcer disease w H Pylori. PPI can increase risk of fracture so caution in risk of osteoporosis
Warning with Clopidogrel as may reduce effect of antiplatelet
R Oral PPI with food, a.m. IV slow injection or infusion
A GI upset, headache, may increase C diff colitis risk. Hypomagnesaemia if long term -> caution for neuromuscular symptoms and arrhythmias.
PPIs should preferably be withheld for 2weeks before testing. This is because they increase the chance of a false-negative result
Emergency drugs : Adenosine
Adenosine
M Agonist of adenosine receptors. Increases refractoriness (resistance) in the AV node temporarily allowing circiut to resume at the SA node (Cardioversion)
10 second half life
I Diagnostic and therapeutic for Supraventricular tachycardia SVT (if shock present, prefer electrical cardioversion)
C contraindicated in ✖ hypotension, ✖ coronary ischaemia or ✖ decompensated heart failure. May induce bronchospasm in susceptible individuals, so should be avoided in ✖ asthma and ▲ COPD. Use lower dose in heart transplant pat.
▲ Dipyridamole, an antiplatelet agent, blocks cellular uptake of adenosine
R large-bore cannula (e.g. 18 G [green] or bigger), sited as proximally as possible (e.g. in the antecubital fossa). Rapid injection, followed with Sodium chloride flush. Seen on ECG 10-15 seconds.
A can induce bradycardia and even asystole and feeling of impending doom and breathlessness
Emergency drugs : Alteplase, streptokinase
Alteplase, streptokinase
(Top 100: Fibrinolytic)
M catalyse conversion of plasminogen to plasminogen and dissolve fibrinous clots.
I acute iscahemic stroke within 4.5 hours, in ST elevation acute coronary syndrome within 12 hours, for massive PE
C factors that predispose to ✖ bleeding, bleeding disorders, severe hypertension. In acute stroke, ✖ intracranial haemorrhage. ✖ Previous streptokinase treatment is a contraindication to repeat dosing (Abs)
Risk of haemorrhage is increased in people taking anticoagulants and antiplatelet
R high-dependency area, powder reconstituted with sterile water as injuction of IV infusion with 0.9% NaCl
A nausea, vomitting, bruising, hypotension
STOP if bleeding, allergic reaction, cardiogenic shock and cardiac arrest.
Emergency drugs : Naloxone
Naloxone
M binds to opioid (especially μ) receptors as competitive antagonist. Little effect if opioid not present.
I Acute treatment of opioid toxicity associated with respiratory or neurological depression.
C caution should be exercised in people with ▲ opioid dependence as could cause opioid withdrawal. Lower doses should be used in ▲ palliative care to reduce the risk of complete reversal of analgesia.
R pre filled syringe or IV, IM, SC, intranasally
A Withdrawal may be significant: presents with pain (if the opioid was being taken for its analgesic effect), restlessness, nausea and vomiting, dilated pupils, and cold, dry skin with piloerection (‘cold turkey’).
Emergency drugs : Oxygen
Oxygen
M Supplemental oxygen therapy increases PO2 in alveolar gas (PAO2), driving more rapid diffusion of oxygen into blood.
I acute hypoxaemia, and chronic hypoxaemia, accelerate reabsorption of pleural gas in pneumothorax, reduce carboxyhaemoglobin in CO poisoning
C chronic type 2 respiratory failure (shut off carbonic drive)
A discomfort of the mark,
Emergency: Oxygen
Administering Oxygen
- Reservoir Marks (continuous, 15L/min)
- Venturi (blends air)
- Nasal cannulae (24-50% O2 at 2-6 L/min)
- Humidified high-flow (warmed can provide high FiO2)
Oxygen therapy should always be guided by a written prescription, except in emergencies when it may be administered first and prescribed later.
Alginates and antacids
Alginic acid compound preparations, sodium bicarbonate
M Antacids buffer stomach acids, alginates increase viscocity of stomach contents preventing reflux
I GORD heartburn symptom relief; dyspepsia short term indigestion
C Caution if containing Na and K in hyperkalaemia, fluid overload, renal failure
Can interact with ACEi, some Abx, bisphosphonates, digoxin, levothyroxin, PPI and can increase excretion of aspirin and lithium
R PO or chewable tablets, Taken following meals, for infants oral powder can be mixed with feeds or waters BUT NOT thickened infant milk
A Magnesium salts can cause diarrhoea, whereas aluminium salts can cause constipation.
Z-drugs : Zopliclone, zolpidem
Zopliclone, zolpidem
M Similar to benzodiazepines, GABA (a) receptor with allosteric modulation to increase GABA binding. Depressent effect including sleepiness.
I Short term treatment of insomnia which is debilitating or distressing
C caution in older people as more sensitve to neuro effect, AVOID ✖ obstructive sleep apnoea, ✖ respiratory muscle weakness or ✖ respiratory depression
Enhances antihistamines and benzodiazepine so avoid or warning.
R PO tablets or capsules
A Daytime sleepiness, rebound insomnia, neuro incl headache, confusion, nightmares and rarely amnesia.
Zopiclone can cause taste disturbance where zolpidem causes Gi upset.
Prolonged use leads (4weeks) to dependence and withdrawal incl headache, muscle pain, anirty
not useful anticonvulsants, as they cannot be given by injection.
Warfarin : Warfarin
Warfarin
M Clotting factors 2,7,10 (vit K reliant) are prevented from forming through vitamin k epoxide reductase inhibition.
I treat and prevent VTE recurrence (DOACS preferred), prevent arterial abolism from AF, prevent arterial embolisn from mechanical heart valves.
C ontraindicated if there is ✖ active bleeding, avoided in the first trimester of ✖ pregnancy due to teratogenicity
Interacts with CYP inducers and CYP inhibitros so caution on administration.
R PO at 18:00 daily
A Bleeding
effect of warfarin can be reversed with phytomenadione (vitamin K1)
Vitamins : Folic acid, thiamine, hydroxocobalamin, phytomenadione
Folic Acid
M
Facilitates cell proliferation, possibly aiding neural tube closure by supporting normal cell division during early pregnancy.
I:
Prevention of neural tube defects in pregnancy.
Treatment of megaloblastic anaemia due to folate deficiency.
C:
Avoid sole replacement in combined vitamin B12 and folate deficiency to prevent worsening of neurological damage.
R
Oral (400 micrograms daily preconception/first trimester; 5 mg daily for high-risk pregnancies or folate deficiency anaemia).
A
Rarely toxic.
Vitamins : Folic acid, thiamine, hydroxocobalamin, phytomenadione
hydroxocobalamin
MCobalamin is a cofactor in DNA synthesis and myelin production, critical for red blood cell formation and neurological function.
IMegaloblastic anaemia due to vitamin B12 deficiency.
Subacute combined degeneration of the cord.
CEnsure folate is replaced concurrently in combined deficiencies to avoid neurological progression.
RIM (e.g., hydroxocobalamin for initial treatment).
Oral (e.g., cyanocobalamin in cases of mild deficiency without malabsorption).
ARarely toxic.
Vitamins : Folic acid, thiamine, hydroxocobalamin, phytomenadione
Phytomenadione
MRestores vitamin K-dependent clotting factor synthesis, reversing warfarin’s effects and preventing vitamin K deficiency bleeding.
IProphylaxis of vitamin K deficiency bleeding in neonates.
Reversal of over-warfarinisation.
CLess effective in severe liver disease due to impaired clotting factor synthesis.
RIM (e.g., 1 mg in neonates).
IV (e.g., 10 mg for major bleeding).
Oral (e.g., low doses for mild over-warfarinisation).
ARare risk of anaphylaxis with IV administration.
Valproate (valproic acid) : Sodium valproate, valproic acid
Sodium valproate, valproic acid
M Increases activity of GAD to increase GABA, inhibits VGNaC. Reduces neuronal excitability, supressing seizure discharge and propagation
I seizure prophylaxis in epilepsy, selected cases of established convulsive status epilepticus that hasnt responded to benzodiazepine, bipolar disorder, prevent frequent migraine attacks
C valproate should be avoided in ✖ girls and women who could become pregnant particularly around the time of ✖ conception and in the ✖ first trimester of pregnancy. Avoided in ▲ hepatic impairment and dose reduction is required in ▲ severe renal impairment.
Inhibits hepatic enzymes so avoid lamotrigine and CYP drugs such as warfarin and carbapenems
R enteric-coated tablets, capsules, granules, and oral solutions
A GI upset, neurological and psychiatric effects incl tremor, ataxia, behavioural disruebances, thrombocytopenia and incredible liver enzymes.
The efficacy of antiepileptic drugs is reduced by ▲ drugs that lower the seizure threshold (e.g. antipsychotics, tramadol).
Trimethoprim : Trimethoprim, co-trimoxazole
Trimethoprim, co-trimoxazole
M Should be broad activity (E Coli) but is limited by resistance. Combinational with sulfamethoxaole (co-trimoxazole) extends activity to fungus pneumocystis jirovecii
Inhibits bacterial folate synthesis, with sulfamethoxazole inhibiting another part of the same pathway.
I first line for acute lower UTI, prevention of recurrent UTI. Option for acne vulgaris and prostatitis. co-trimoxazole for precention of pneymocytis pneumonia in immune compromised.
C DO NOT USE in first trimester as is a folate antagonist, use with caution in folate deficiency and renal impaitment. Neonates, older people and HIV more suscpetible to adverse effects
▲ potassium-elevating drugs (e.g. aldosterone antagonists, ACE inhibitors, ARBs) predisposes to hyperkalaemia.
R PO tablets and suspension, IV must be diluted in NaCl 0.9 or Gluc 5 over 60-90 min.
A GI upset and skin rash. Can impair haematopoiesis with megaloblastic anaemia, leukopenia and thrombocytopaenia. Can cause hyperkalamia.
Tranexamic acid : Tranexamic acid
Tranexamic acid
M antifibrolynitic that binds to plasma inhibiting activation of plasmin. Promote haemotasis.
I Second line treatment for menorrhagia, for epistasis, in major trauma to reduce mortality and postpartum haemorrhage in addition to other drugs
CAvoid in people with a history of seizures and VTE disease. Avoided in DIC. Investigate for abnormal menstrual bleeding first.
Can increase the risk of thromboembolism when combined with other drugs that have an increased risk risk such as COC
R Tablet or injection. In trauma IV
AGI upset, rash with IV use. Rare effects include DVT PE seizures and visual disturbances.
Thyroid hormones : Levothyroxine, liothyronine
Levothyroxine, liothyronine
M Levothyroxine is synthetic T4, liothyronine is synthetic T3. Levothyroxine is preferred For long-term years, as liothyronine has a small short life and quick onset (trauma use)
IPrimary hypothyroidism, hypothyroidism secondary to hypopituitarism
C Excessive doses give symptoms of hyperthyroidism. In people with coronary artery disease cautiously monitor as risk of cardiac ischaemia. In hypopituitarism Treat with corticosteroids first to avoid Addisonian crisis
R PO, tablet
A GI upset palpitations, arrhythmia angina tremor, restlessness, insomnia. weight loss is expected.
Tetracyclines and glycylcyclines :
Doxycycline, lymecycline (tetracyclines); tigecycline (glycylcycline)
M Ford spectrum with activity against both g + and g -. Resistance is common but less problematic for Tigecycline.
Inhibit bacterial protein synthesis binds to ribosomal 30 S so is bacteriostatic
I Acne Bulgars, lower respiratory tract infections including infective exacerbation of COPD and pneumonia chlamydia infection including PID infection such as typhoid malaria and Lyme disease. Severe skin soft tissue and abdominal infections when other options are limited.
C Avoid in pregnancy breastfeeding and children under 12 years of age as binds to bone and teeth. caution in renal impairment
R PO, but Tigecycline available as IV infusion
AGI upset But with a lower risk of CDiff infection than other broad spectrum. Oesophageal ulceration and dysphasia, photosynthesis activity, discolouration and all hyperplasia of tooth enamel in children. Rare effects include hepatotoxicity and interocranial hypertension.
Aminoglycoside : Gentamicin, amikacin, neomycin
Gentamicin, amikacin, neomycin
M Find irreversibly to bacterial ribosomes 30 S subunit and inhibits protein synthesis. Streptococci and anaerobic bacteria do not have the transport system required and so are aminoglycoside resistant.
G -ve negative aerobic bacteria
I Sepsis, pyelonephritis and complicated UTI, intra abdominal infection, endocarditis, topical neomycin an option for otitis externa
C ddose adjust to prevent renal, cochlear, and vestibular damage, particularly in ▲ neonates, ▲ older people and those with ▲ renal impairment. can impair neuromuscular transmission
R IVI and parenterally (no gut absorption)
A Nephrotoxicity and ototoxicity,
Aminoglycosides have a narrow therapeutic index, meaning that there is little ‘safety margin’ between the clinically effective dose and the toxic dose. One means of tailoring the dose to the individual is to base it on body weight
Aminosalicylates : Mesalazine, sulfasalazine
Mesalazine, sulfasalazine
M In UC, releases 5- amino salicylic acid which is anti-inflammatory and immunosuppressive to act on the gut.
I First line option for mild moderator UC, Sulfasalazine Is option for rheumatoid arthritis used with a DMARD
C contraindicated with aspirin hypersensitivity
R Enema or suppository As first line or oral formulation may be used
A Mesalazine generally causes fewer side effects than sulfasalazine. GI upset, headache. RARE leukaemia thrombocytopenia and renal impairment. Reversible oligospermia. Hypersensitivity reactions.
Drugs which adapt pH such as PPI and lactulose may affect medications with pH sensitive coating
Amiodarone : Amiodarone
Amiodarone
M Many effects on myocardial cells including blockade of sodium, calcium and potassium channels and antagonism of alpha and beta adrenergic receptors.
This reduces automaticity, slows conduction velocity and increases resistance to depolarisation (refractoriness) Including at the AV node. Can help convert and maintain sinus rhythm.
I Atrial fibrillation, atrial flutter, supraventricular tachycardia, ventricular tachycardia, refractory ventricular fibrillation
C avoided in ▲ severe hypotension, ▲ heart block, and ▲ active thyroid disease.
Avoid/ rethink doses in digoxin, diltiazem, verapamil. Reduce grape juice bracket CP450 3A4
R IV bolus
A Hypertension, pneumonitis, bradycardia, AV block, hepatitis, photosynthesis activity and grey discolouration to skin. Thyroid abnormalities (contains iodine).
in cardiac arrest, in which it is given for VF or pulseless VT immediately after the third shock in the Advanced Life Support (ALS) algorithm. The dose is 300mg IV, followed by 20mL of 0.9% sodium chloride or 5% glucose as a flush.
Antidepressants, selective serotonin reuptake inhibitors
Sertraline, citalopram, fluoxetine, escitalopram
M Inhibits reuptake of 5HT increasing its availability
I First line for moderate to severe depression and in mild depression. Panic disorder, OCD.
C Caution on epilepsy and peptic ulcer disease. Caution in young people as increased risk of self harm and suicidal thoughts. Caution in people with hepatic impairment
Do not give with monoamine oxidise inhibitors and other serotonergic drugs. Bleeding risk is increased if taken with anticoagulant aspirin or NSAID, do not use with drugs that prolong the QT interval
R Tablets and oral drops
A GI upset, appetite changes, weight changes and hypersensitivity reactions. Hyponatraemia in older people, suicidal thoughts and behaviour, may lower seizure threshold, prolonged QT interval, increase risk of bleeding.
Sudden withdrawal can cause GI upset neurological and flu like symptoms and sleep disturbance
Fluoxetine interacts with tamoxifen
Antidepressants, tetracyclic and serotonin-noradrenaline reuptake inhibi
Venlafaxine, mirtazapine, duloxetine
M Venlafaxine and duloxetine are a serotonin–noradrenaline reuptake inhibitors (SNRIs), Mirtazapine is a tetracyclic antidepressant
Increases availability of mono means which improves mood.
Tricyclic antidepressants can also be an antagonist of histamine and muscarinic receptors
I Major depression if SSRI ineffective, generalised anxiety disorder ( venlafaxine duloxetine) And diabetic neuropathy (duloxetine)
C Reduce dose in hepatic and renal impairment. Avoid duloxetine and severe renal impairment. Caution with venlafaxine in people at risk of arrhythmias.
Can interact with SSRI
R PO, Mirtazapine should be taken at night to mitigate (or benefit from) its sedative effects.
A GI upset, dry mouth, neurological effects including headache. Less common: hyponatraemia, serotonin syndrome. Suicidal fault and behaviour may increase. Then affecting prolonged QT interval. Sudden drug withdrawal can cause GI upset neurological and flu like symptoms Mitrazepine may cause bone marrow suppression.
Counterintuitively, some evidence suggests that mirtazapine’s sedative effects are less severe at higher doses. This may be because at low dose its (sedating) antihistamine effect predominates, while at higher doses this is counteracted by increased monoaminergic effect
Antidepressants, tricyclics and related drugs : Amitriptyline, trazodone
Amitriptyline, trazodone, nortriptyline, lofepramine
M Tricyclic antidepressants inhibit re-uptake of 5HT and no adrenaline from the synaptic cleft. They also block macaronic histamine alpha-adrenergic and dopamine receptors (extensive adverse effects).
I Second line treatment for moderate to severe depression where SSRIs are ineffective, neuropathic pain, IBS, amitriptyline to prevent frequent migraine and attacks
C Caution required an older people and those with epilepsy of CVS disease. Antimuscarinic affects me worse and constipation, glaucoma and prostatic enlargement.
Do not give with monoamine oxidase inhibitor
R Tablet or oral solution
A Blockage of anti-muscular and a receptors causes dry mouth, constipation, urinary retention, blurred vision and can exacerbate cognitive impairment.
Blockage of histamine and uric receptors cause a sedation and hypertension
This can also cause cardiac adverse effects, including prolongation of the QT and QRS duration. In the brain seizures hallucinations in mania
Blockage of dopamine receptors can cause breast changes sexual dysfunction and rarely extrapyramidal symptoms (tremor, dyskinesia)
Tricyclic antidepressants are dangerous and overdose and sudden withdrawal can cause GI upset neurological and flu like symptoms
Antifungal drugs : Nystatin, clotrimazole, fluconazole
Nystatin, clotrimazole, fluconazole
M Ergosterol is only on fungal cell membranes and is a target. polyene antifungals (nystatin) binds to ergosterol creating a pore so ions leak out. Clotrimazole and Triazole antifungals inhibit ergosterol synthesis impairing the cell membrane.
I Treatment of local fungal infections include an or referring, vagina or skin. Systemic treatment of invasive or disseminated fungal infections (specialist).
CFluconazole should be prescribed with caution and liver disease and cutie interval prolongation. A dose reduction is required in moderate renal impairment. Avoid in pregnancy.
Fluconazole inhabits P4 50 caution with carbamazepine, warfarin, diazepam, simvastatin, sulphonylureas
R Topical, PO, IV
A Local irritation for creams, PO with GI upset, headache, increase in liver enzymes, hypersensitivity. Rare includes severe hepatic toxicity, prolonged QT interval, severe hypersensitivity.
Antimuscarinics, bronchodilators : Tiotropium, umeclidinium, glycopyrron
Tiotropium, umeclidinium, glycopyrronium (LAMA), ipratropium (SAMA)
M Find some muscarinic receptors acting as a competitive inhibitor of acetylcholine. Increases heart rate and conduction (M2), reduces smooth muscle tone in respiratory tract, gut and urinary tract (M3), and reduces secretions from glands in the respiratory tract and gut (M1, M3). In the eye causing relaxation of the pupillary constrictor and celery muscles (M3).
Inhaled antimuscarinic relieve airway obstruction in COPD and asthma
I In COPD LAMA, an acute severe asthma SAMA and LAMA if control is insufficient with ICS
C Use with caution and people susceptible to angle closure glaucoma, at risk of arrhythmias, urinary retention. Interactions are unproblematic.
R Inhaled medication
A Dry mouth is common. Inhalation may irritate respiratory tract with cough or horse voice. Can cause tachycardia, constipation, retention, blurred vision. Inhaled therapy Delivers lower dose to systemic circulation
Antimuscarinics, cardiovascular and GI uses : Hyoscine butylbromide, atr
Hyoscine butylbromide, atropine, glycopyrronium
M Find muscular receptors acting as competitive inhibitors of acetyl:
I Atropine and glycopyrronium our first line options in the management of severe bradycardia,
first line for irritable bowel syndrome and in palliative care to prevent respiratory secretions
C No contra indications for life-threatening bradycardia. Caution should be excised in angle closure glaucoma, avoid in arrhythmia risk. May causes urinary retention in BPH.
R IV, PO, SC
A Can cause tachycardia, dry mouth, constipation. Urinary retention by blocking the Truse muscle, blurred vision due to oculus effects. M1 in the brain has central effects including drowsiness and confusion.
Hyoscine butylbromide, glycopyrronium Are less lipid soluble and so have less brain effects
Take care not to confuse hyoscine butylbromide and hyoscine hydrobromide.
Antiplatelet drugs, ADP-receptor antagonists : Clopidogrel, ticagrelor,
Clopidogrel, ticagrelor, prasugrel
M ADP receptor antagonist prevent platelet aggregation by binding irreversibly to ADP receptors on the surface of platelets
I Acute coronary syndrome treatment, prevent coronary artery stent occlusion, secondary prevention of major adverse cardiovascular events
C Should not be prescribed for people with active bleeding may need to be stopped before elective surgery. Caution in renal and hepatic impairment.
Clopidogrel is a pro drug and is affected by CYP inhibitors. Choice of PPI is important as may inhibit Clopidogrel
Prescription with other anti-drugs anticoagulants and NSAID can increase bleeding risk
R PO
A Most common effect is bleeding. GI upset, dyspepsia, Abdo pain, diarrhoea is also common. Rare thrombocytopenia.
Antiplatelet drugs, aspirin : Aspirin
Aspirin
M Irreversibly inhibits COX to reduce production of thromboxane and reduces platelet aggregation. Lifetime 7-10 days.
I Tx ACS and acute ischaemic stroke, secondary prevention of major CVS events, at high dose for mile to moderate pain and fever
C Risk of Reyes under 16 y.o, avoid in aspirin hypersensitivity, avoid in 3rd trimester (premature closure of ductus arteriosus). Caution in peptic ulcer disease and gout.
Acts synergistically w other antiplatelets- caution in dosing for at risk groups
R PO, PR
A GI upset, peptic ulceration and haemorrhage, hypersensitivity incl bronchospasm. In regular high dose can cause tinnitus. Overdose is life-threatening.
In the UK, aspirin is not recommended or licensed for use in primary prevention of cardiovascular disease (i.e. in people who have not previously had an event). The reason is that large-scale, randomised controlled trials and meta-analyses have found that the absolute risk of major adverse cardiovascular events in this group is low (around 1/500), and the benefits of preventing a proportion of these with aspirin are offset by the increased risk of serious bleeding (around 1/1000).
Antipsychotics, first-generation (typical) : Haloperidol, chlorpromazine
Haloperidol, chlorpromazine, flupentixol
M block post synaptic D2 receptors. Acts on the Mesolimbic(main mode)/mesocortical, nigrostriatal and tuberohypophyseal pathways (accounts for side effects too)
Acts on D2 in the CTZ to reduce nauea and vomitting. All are sedative to an effect.
I Rapid tranquilisation, schizophrenia (where 2nd gen problematic), bipolar disorder, nausea and vomiting (incl palliative care)
C Older people are sensitive to antipsychotics, avoid in dementia (risk of death and stroke), avoid in parkinsons (extrapyramidal effect)
Long list of contra drugs including prolong QT interval.
R PO, IM, IV Haloperidol (acute effects, specialist use only)
A Extraoyramidal effects (nigrostirtiatal) incl acute dystonic reactions, akathisia, neurolepticmalignant syndrome. Tardive duskinesia is a late adverse effect (months or years). Drowsiness, hypotension, QT prolongation, arrhythmia, erectile dysfunction. Hyperprolactinaemia (tuberohypophyseal blockade)(incl menstrual change and breast pain)
Antipsychotics, second-generation (atypical) :
Quetiapine, olanzapine, risperidone, clozapine
M Same as first line BUT second-generation antipsychotics have greater activity at other receptors (particularly 5-HT2A antagonism), and a characteristic of ‘looser’ binding to D2 receptors (in the case of clozapine and quetiapine). This may explain why they have a lower risk of extrapyramidal symptoms.
I Schizophrenia, especially where extrapyramidal side effects prevent use of first gen. Bipolar disorder
C caution in CVS disease, clozapine must not be used in severe heart disease or nuetropenia Hx
R PO, IM
A extrapyramidal effect (less common), metabolic disturbances, weight gain, DM, lipid changes. Can prolong QT and arrhythmia. Risperidone acts on tuberohypophyseal pathway with prolactin secretion - breast symptoms and sexual dysfunction. Clozapine can cause neutrophil deficiency (agranulocytosis) in 1%
Antiviral drugs, aciclovir : Aciclovir
Aciclovir
M HSV 1 &2 have DsDNA which has a HSVDNA polymerase. Aciclovir inhibits the herpes-DNApolymerase.
I Tx of herpesvirus infections, HSV and VCZ, supression of reccurent herpes simplex attacks
C crosses placenta and breast milk so caution in pregnancy and breastfeeding. Caution in severe renal impariment
Renal function should be monitored when prescribed with drugs that increase nephrotoxicity risk
R PO, IV
A headache, dizziness, GI upset, skin rash, IV can cause phlebitis.
Aciclovir is relatively water insoluble. During high-dose IV therapy, delivery of a high concentration of aciclovir into the renal tubules can cause precipitation, leading to crystal-induced acute renal failure
Antiviral drugs, other
Oseltamivir, nirmatrelvir, tenofovir, efavirenz, atazanavir
M
* oseltamivir and zanamivir inhibit neuraminidases, viral surface enzymes important for entry into and release from host cells.
* molnupiravir and remdesivir are nucleotide analogues that block viral RNA synthesis,
* nirmatrelvir (with ritonavir) is a protease inhibitor that inhibits viral replication.
* nucleoside/nucleotide (e.g. emtricitabine, tenofovir) and non-nucleoside (e.g. efavirenz) reverse transcriptase inhibitors (NRTIs and NNRTIs, respectively)
* Protease inhibitors (e.g. atazanavir) inhibit the enzyme which cleaves inert polyproteins into structural and functional viral proteins
I acute tx of viral incl influenza, SARS-CoV-2, PrEP, PEP, chronic tx to supress viral load in Hep B, c, HIV inf.
C increased bronchospasm risk with inhaled zanamvir in asthma and copd. NNRTI and protease inhibitor are contra in acute porphyria. Cuation with QT prolongation.
R PO, inhaled,
A GI upset, skin reactions, dizziness, and sleep problems. Inhaled zanamivir may cause bronchospasm. Immune-mediated effects include hypersensitivity. Long-term treatment can cause dyslipidaemia, hyperglycaemia, hypertension, and weight gain, increasing cardiovascular risk.
Calcium and vitamin D : Colecalciferol, alfacalcidol, calcium carbonate,
calcium carbonate, calcium gluconate
M Muscle, nerve, and bone function, Blood clotting
Calcium homeostasis is primarily regulated by:
Parathyroid hormone and vitamin D, which:
Increase intestinal calcium absorption
Enhance renal calcium reabsorption
Promote bone resorption
Impaired phosphate excretion and reduced vitamin D activation cause:
Hyperphosphataemia
Hypocalcaemia
Calcium raises myocardial threshold potential, reducing excitability and arrhythmia risk (does not lower potassium)
I Osteoporosis for calcium balance, CKD to tx and prevent 2’ hyperparathyroidism and renal osteodystrophy, severe hyperkalaemia, calcium in hypocalcaemia, vit d in vit d deficiency
C. Also reduces the absorption of many drugs, including iron, bisphosphonates, tetracyclines, and levothyroxine avoid in hypercalcaemia
R PO calcium salt dissolves in stomach, calcium gluconate IV
A may cause dyspepsia and constipation. When administered IV for the treatment of hyperkalaemia, calcium gluconate can cause hypotension and local tissue injury if subcut
Administered IV, calcium must not be allowed to mix with ✖ sodium bicarbonate due to the risk of precipitation.
Beta-blockers : Bisoprolol, atenolol, propranolol, metoprolol, carvedilo
Bisoprolol, atenolol, propranolol, metoprolol, carvedilol
M Via β1-adrenoreceptors, which are located mainly in the heart, β-blockers reduce force of cardiac contraction and speed of conduction. In AF, it reduces ventricular rate by prolonging the refractory period of the atrioventricular (AV) node. In thyrotoxicosis, they offset the effect of β-adrenoreceptor upregulation, which causes symptoms such as tremor and palpitations.
I IHD to improve angina and acs, chronic HF to improve prognosis, AF reduce ventricular rate, SVT restore sinus, resistant hypertension, prophylaxis of migraine, thyrotoxicosis
C ✖ asthma, β-blockers can cause life-threatening bronchospasm and should be avoided. ▲ heart failure, β-blockers should be started at a low dose and increased slowly. contraindicated in ✖ heart block and severe ✖ hypotension
must not be used with ✖ non-dihydropyridine calcium channel blockers
R PO,IV
A Fatigue, cold extremities, headache, and GI upset are common. β-blockers can also cause sleep disturbance, nightmares, and impotence.
Calcium and vitamin D : Colecalciferol, alfacalcidol, calcium carbonate,
Colecalciferol, alfacalcidol
Bisphosphonates : Alendronic acid, risedronate, disodium pamidronate, zo
Alendronic acid, risedronate, disodium pamidronate, zoledronic acid
M Redue bone turnover by inhibiting osteoclasts, also inhibits osteoclasts and promote apoptosis
I Alendronic acid and risedronate sodium are first line for osteoporotic fragility fractures
Pamidronate and zoledronic acid are used in severe hyperclacaemia of malignancy
Myeloma and breast cacncer with bone mets
First line in metbaolically active pagets disease
C Avoid in severe renal impairement, contra in hypocalaemia. PO contra in active upper GI disorders, CARE in smokers and people witg major dental disease as risk of jaw osteonerosis
absorption is reduced if taken with calcium salts (including milk), as well as antacids and iron salts
R PO, IV slow
A oesophagitis, hypophosphataemia. Osteonecrosis of teh jaw liekly wiht high dose IV therapy. Atypical femoral fracture in long-term Tx
Cephalosporins and carbapenems : Cefuroxime, ceftriaxone, cefalexin, mer
Cefuroxime, ceftriaxone, cefalexin, meropenem, ertapenem
M Broad spectrum Cephalosporins and carbapenems are naturally more resistant to β-lactamases than penicillins. Inhibit enzymes responsible for cross-linking peptidoglycans in bacterial cell walls
I PO 2nd and 3rd line for UTI, pneumonia and other RTI.
Parenteral for severe, complicated or Abx resistant infections.
C Caution in those at risk of C Diff, elderly and hospital. Allergy of β lactam. Reduce dose in renal impairment
Enhance the anticoagulant effect of warfarin by killing flora for Vit K.
R PO, IV
A GI upset ommon. Disrupt of flora -> C Diff overgrowth with toxin and Abx associated olitis. Hypersensitivity reaction. Rarely in parenteral, cause seizures.
Chloramphenicol : Chloramphenicol
Chloramphenicol
M Broad spectrum binds to bacterial ribosomes inhibiting protein synthesis= bacteriostatic.
I Bacterial conjunctivitis eye drops or ointment, ear drops for otitis externa.
C contraindicated in people with previous ✖ hypersensitivity reactions or a personal or family history of ✖ bone marrow disorders.
Systemic chloramphenicol is contraindicated in the ✖ third trimester of pregnancy, ✖ breastfeeding, and ✖ children < 2years because of the risk of grey baby syndrome
R Optic and Otic drops (different formula do not mix)
A Stinging, burning, itching, Dose-related bone marrow suppression is more likely with high-dose therapy, Systemic- aplastic anaemia is rare. Grey baby syndrome. Optic and peripheral neuritis.
Systemic (oral or IV) chloramphenicol is rarely used due to toxicity. In the UK, it is restricted to the treatment of life-threatening infection (Haemophilus influenzae) and typhoid fever (Salmonella spp.).
Clindamycin : Clindamycin
Clindamycin
M Gram positive aerobes.
binds to bacterial ribosomes and inhibits the early stages of bacterial protein synthesis. bacteriostatic
I topical for acne vulgaris and vaginal for bacterial vaginosis, PO or parenteral for cellulitis, osteomyelitis, septic arthritis, intraabdo inf. Tx plasmodium falciparum malaria w quinine
C Hx of hypersensitivity to clindamycin, caution in IBS, avoid in acute porphyria
Enhanes neuromuscular blockers
R PO, PV, IM,IV
A diarrhoea, abdo pain, skin rash, abdnormal liver enzymes, Abx associated collitis, RARE- blood dyscrasias, SJS, DRESS
useful option where penicillin is contraindicated by allergy, as there is no cross-sensitivity between these drug classes
Diuretics, loop : Furosemide, bumetanide
Furosemide, bumetanide
M Ascending limb inhibit Na+/K+/2Cl− co-transporter.
I relief of breathlessness in acute pulmonary oedema, Tx of fluid overload in CHF, Tx of fluid overload in other oedmatous states eg) renal disease, liver failure.
C Lithium increased due to reduced excretion and risk of digoxin toxicity. Increase ototoxicity and nephrotoxicity of aminoglycosides
Contra in severe hypovolaemia and dehydration. Caution in hypokalameia, hyponatraemia and risk of hepatic encephalopathy. Worsens gout
R PO, IV
ADeydration and hypotension, low electrolyte states. At high doses can effect endolymph w hearing loss and tinnitus
Dopaminergic drugs for Parkinson’s disease
Levodopa (as co-careldopa, co-beneldopa), ropinirole, pramipexol
M Treatment seeks to increase dopaminergic stimulation to the striatum. D2 doesnt cross BBB so LDopa precursor enters via membrane transporter. Ropinirole and pramipexol are relatively selective agonists for the D2 receptor,
I Improve motor sympx in Parkison’s Disease. Levodopa is preferred if motor sympx impacting QOL.
Options for Secondary parkinsonism
C Caution in older people and those with existing cognitive or psychiatric disease due to risk of confusion and hallucinations. Caution in CVD as risk of hypotension
R PO Modified release for on-off effect
A Nausea and hypotension, sleepiness confusion and hallucinations Dyskinesias more problematic with levodopa and wearing off effect.
Emollients :
Liquid paraffin, white soft paraffin
M replace water content in dry skin by reducing water loss
I dry or scaling skin disorders- emollient can be used in combo w topical corticosteroids for eczema. Can reduce dryness and cracking in psoriasis
C paraffin-based emollients are a significant fire hazard.
when using more than one topical product, applications should be separated in time
R Topical. semi-solid creams (50% oil, 50% water), semi-liquid lotions (less oil, more water) or ointments (80% oil, 20% water)
A greasiness of the skin Emollient ointments can exacerbate acne vulgaris and folliculitis by blocking pores
Gabapentinoids : Pregabalin, gabapentin
Pregabalin, gabapentin
M Related to γ-aminobutyric acid (GABA), the major inhibitory neurotransmitter in the brain but DO NOT BIND. ? inhibition of pre-synaptic VGCaC neocortex and hippocampus.
I Neuropathic pain, prevention of focal seizures, GAD
C doses should be reduced in ▲ renal impairment. identify risk factors for ▲ substance misuse.
sedative effects of gabapentinoids may be enhanced when combined with other ▲ sedating drug
R PO
A drowsiness, impaired concentration, dizziness, and ataxia, Weight gain, recognised as drugs of misuse and dependency
Gabapentin may cause false-positive results for detection of protein on urine dipstick testing
Glycopeptide antibiotics : Vancomycin, teicoplanin
Vancomycin, teicoplanin
M relatively narrow spectrum of activity against Gram-positive bacteria
inhibit growth and cross-linking of peptidoglycan chain= bacteriocidal
I complicated skin and soft tissue, bone and joint infections, infective endocarditis, Vancomycin is a first-line treatment for Clostridioides difficile colitis.
C caution in people with ▲ immune-mediated hypersensitivity, risk in ▲ hearing impairment. ▲ reduced renal function, including ▲ neonates and ▲ older adults, are at increased risk of nephrotoxicity.
Ototoxicity and/or nephrotoxicity when prescribed with other drugs that cause these effects, particularly ▲ loop diuretics, ▲ aminoglycosides, ▲ NSAIDs, and ▲ ciclosporin
R parenterally, vancomycin PO
A Pain and thrombophlebitis from vancomycin infusion are common. vancomycin flushing syndrome. cause nephrotoxicity and ototoxicity
Rare: blood dyscrasias (neutropenia, thrombocytopenia) and severe cutaneous adverse reactions.
H2-receptor antagonists : Ranitidine, cimetidine, famotidine
Ranitidine, cimetidine, famotidine
M reduce gastric acid secretion via H2 receptor antagonists, but cannot completely suppress gastric acid production
I Peptic ulcer disease where PPI inadequate. GORD and Dyspepsia where PPI inadequate
C Dose reduced in renal impaired, Can mask GORDor ulcer diseasde.
Inhibits cyp P450 so interacts with ▲ aminophylline/theophylline, ▲ amiodarone, ▲ citalopram, ▲ phenytoin, ▲ quinine, and ▲ warfarin
R PO w food
A Side effects are usually mild and include bowel disturbance (diarrhoea or, less often, constipation), headache, and dizziness.
At the time of writing, ranitidine is unavailable due to safety concerns as products have been found to contain low levels of an impurity called N-nitrosodimethylamine, a substance that could cause cancer
Heparins and fondaparinux :
Enoxaparin, dalteparin, fondaparinux, unfractionated heparin
M . Antithrombin inactivates clotting factors, particularly factors IIa (thrombin) and Xa, providing a natural break to the clotting process. Heparins and fondaparinux enhance the anticoagulant effect of antithrombin
unfractionated heparin (UFH) promotes inactivation of both factors IIa and Xa, whereas LMWH is more specific for factor Xa
I LMWH (preferred) prevention of VTE. acute coronary syndrome (ACS) to reduce clot progression.
C ▲ clotting disorders and ▲ severe uncontrolled hypertension. withheld immediately before and after ▲ invasive procedure. ▲ renal impairment, LMWH and fondaparinux accumulate
R SC, IV
A haemorrhage, Bruising, Hyperkalaemia occurs occasionally, due to an effect on adrenal aldosterone secretion. RARE: (heparin-induced thrombocytopenia (HIT) less likely with LMWH than UFH
Hormone antagonists and agonists used in breast and prostate cancer :
Letrozole, tamoxifen, anastrozole (breast); bicalutamide, goserelin (prostate)
M
* Tamoxifen is a selective oestrogen receptor modulator
* Anastrozole and letrozole are aromatase inhibitors
* 90-percent of prostate cancers will respond to hormone therapies that suppress androgens
* Androgen receptor inhibitors like bicalutamide directly block androgen
I Tamoxifen, anastrozole, and letrozole are used in estrogen (oestrogen)-receptor positive (ER-positive) breast cancer, as an adjuvant (after surgery)
Leuprorelin, bicalutamide, and goserelin are used in prostate cancer,
C Tamoxifen is contraindicated in ✖ pregnancy and ✖ breastfeeding. Aromatase inhibitors should not be used in ✖ pre-menopausal women
Initial overstimulation of LH production by goserelin and leuprorelin may stimulate tumour growth
R Tamoxifen, bicalutamide, and aromatase inhibitors PO. GnRH analogues may be formulated as implants or suspension for injection SC or IM
A are symptoms of oestrogen depletion (e.g. vaginal dryness, hot flushes, loss of bone density)
Tamoxifen increases the risk of venous thromboembolism and endometrial cancer.
agranulocytosis and liver failure. Antiandrogen therapy may lead to hair loss, gynaecomastia, and mood disturbance.
Tamoxifen inhibits a cytochrome P450 enzyme (CYP2C9) responsible for metabolising ✖ warfarin, increasing the risk of bleeding. The selective serotonin reuptake inhibitors (SSRIs) ✖ fluoxetine, and ✖ paroxetine inhibit hepatic activation of tamoxifen
Insulin :
Insulin aspart, insulin glargine, biphasic insulin, soluble insulin
M functions similarly to endogenous insulin
Insulin also activates Na+/K+-ATPase, driving K+ into cells, and reducing serum K+ concentrations
I insulin replacement in type 1 diabetes, and control of blood glucose in type 2 diabetes
IV, in the Tx of diabetic emergencies such as diabetic ketoacidosis and hyperosmolar hyperglycaemic state, and for peri-operative glycaemic control
Tx Hyperkalaemia, with IV glucose.
C ▲ renal impairment, insulin clearance is reduced, so there is an increased risk of hypoglycaemia. therapy with systemic corticosteroids increases insulin requirements.
R SC or smart pumps
A hypoglycaemia, insulin can cause fat overgrowth (lipohypertrophy),
Iron : Ferrous sulfate, ferrous fumarate
IRON
M: replenish iron for erythropoesis. Is absorbed best in Fe2+ state in duodenum and jejenum. Vit C increases absorption. Transferrin transports
I: Iron deficiency anaemia, prophylaxis.
C: Reduce absoprtion of levothyroxine and bisphosphonates.
May exacerbate bowel symptoms in intestinal disease. Caution in atopic predisposition for anaphylaxis risk
R: IV or PO. IV so correction and in end-stage renal disease w/ erythropoeitin
A:GI upset, incl nausea, epigastric pain, constipation, diarrhoea. Black stool
Ferrous sulfate 200mg contains 65mg elemental iron.
Ferrous Fumarate 200mg contains 60mg of Iron
Iron : Ferrous sulfate, ferrous fumarate
Ferrinject
Ferinject 50 mg iron/mL dispersion for injection/infusion.
One mL of dispersion contains ferric carboxymaltose corresponding to 50 mg iron.
– there is a clinical need to deliver iron rapidly.
Iron deficiency occurring in the first trimester of pregnancy can in many cases be treated with oral iron. Treatment with Ferinject should be confined to the second and third trimester if the benefit is judged to outweigh the potential risk for both the mother and the foetus.
Lamotrigine : Lamotrigine
Lamotrigine
M: Voltage sensitive neuronal Na+ channels producing Na+ influx. Impedes repetitive neuronal firing.
I: seizure prophylaxis in epilepsy. First line monotherapy or add on in focal seizures and generalised tonic-clonic
For bipolar depression
C
* avoid in people with a prior history of ▲ hypersensitivity to other antiepileptic drugs.
* metabolised by hepatic glucuronidation, so dosage reduction in ▲ hepatic impairment.
* Drugs that induce glucuronidation include ▲ carbamazepine, ▲ phenytoin, ▲ oestrogens, ▲ rifampicin, and ▲ protease inhibitors
* Glucuronidation is inhibited by ▲ valproate, causing lamotrigine concentration to rise
R: PO standard swallow w water whole but chewable/ dispersible forms too.
A: headache, drowsiness, irritability, blurred vision, dizziness, and GI upset. A minority develop a skin rash within a few weeks
Lamotrigine appears to be unique among agents used in bipolar disorder, in that it effectively treats depressive symptoms but does not increase the risk of a switch to mania.
Laxatives, oral : Macrogol 3350, lactulose; senna, docusate sodium
Macrogol 3350
Lactulose
M Osmotic laxatives substances remain in gut lumen to move water in to lumen and stimulate peristalsis
- macrogol 3350 is a non-absorbable polymer of ethylene glycol
- Lactulose has a useful additional effect of reducing ammonia absorption by increasing gut transit rate and acidifying the stool
I: Constipation, bowel prep for surgery/endoscopy. Hepatic encephalopathy (lactulose reduce ammonia)
C contraindicated in ✖ intestinal obstruction as there is a risk of perforation.
R Oral solutions can be taken as they are or diluted in another liquid; powdered forms are dissolved in water. Macrogols must not be administered with feeds that contain a starch-based thickener
A Flatulence, abdominal cramps, diarrhoea, and nausea
Laxatives, oral : Macrogol 3350, lactulose; senna, docusate sodium
senna
docusate sodium
M
* increase water and electrolyte secretion from the colonic mucosa, thereby increasing the volume of colonic content and stimulating peristalsis.
* direct pro-peristaltic action,
* bacterial metabolism of senna in the intestine produces metabolites that have a direct action on the enteric nervous system, stimulating peristalsis.
I: Constipation
C contraindicated in ✖ intestinal obstruction as there is a risk of perforation.
R Oral solutions can be taken as they are or diluted in another liquid; powdered forms are dissolved in water.
A Flatulence, abdominal cramps, diarrhoea, and nausea
Laxatives, rectal : Glycerol, sodium citrate, phosphates
Glycerol, sodium citrate, phosphates
M
* glycerol is osmotic laxative with lubricant and faecal dotening effects with mild irritant effect on rectal mucosa with stimulates peristalsis.
I: Constipation, faecal impaction, bowel preparation, hepatic encephalopathy (lactulose)
C Phosphates enemas can cause significant fluid shifts, so should be used with caution in ▲ heart failure, ▲ ascites and when ▲ electrolyte disturbances are present.
R Enemas and suppositories are generally used when there is constipation complicated by faecal impaction
A Flatulence, abdominal cramps, diarrhoea, and nausea.
* Enemas in particular can be uncomfortable because of the relatively large volume that must be instilled into the rectum.
* Phosphates enemas can cause pain, volume depletion (leading to hypotension), and electrolyte disturbances, including hyperphosphataemia and hyper- or hypokalaemia.
Leukotriene receptor antagonists : Montelukast, zafirlukast
Montelukast, zafirlukast
M: In asthma, LT produced by mast cells and eosinophils active receptor CysLT1 -> inflammation and bronchoconstriction. BLOCKS the CysLT1 so dampens inflammatory cascade.
I Add on for chronic asthma, allergic chinitis in those who have asthma and nasal symptoms have not responded to antihistamines etc.
C Drugs that induce the cytochrome P450 enzymes that metabolise montelukast can cause a reduction in plasma levels
R PO
A Headache, abdominal pain, and GI upset. Neuropsychiatric reactions, including sleep disturbance, depression, and agitation occur in up to 1 in 100 of those taking montelukast.
Macrolides : Clarithromycin, azithromycin, erythromycin
Clarithromycin, azithromycin, erythromycin
M
* broad spectrum of activity against Gram-positive and some Gram-negative organisms
* inhibit bacterial protein synthesis
* bacteriostatic
I resp, skin, soft tissue infectio when penicillin contraindicated. Added to penicillin in severe pneumonia to cover atypical, Eradication of h pylori
C
* ✖ macrolide hypersensitivity,
* Caution in ▲ severe hepatic impairment, and doses should be reduced in ▲ severe renal impairment.
* Erythromycin and clarithromycin (but not azithromycin) inhibit cytochrome P450 (CYP) enzymes so caution for warfarin.
* Also caution ▲ drugs that prolong the QT interval or cause arrhythmias,
R PO or IV (dilute in large water) NEVER IV bolus or IM (irritant)
A , causing nausea, vomiting, abdominal pain, and diarrhoea. IV thrombophlebitis
Metronidazole : Metronidazole
Metronidazole
M
* anaerobic bacteria and protozoa
* passive diffusion, generates nitroso free radicals, binds to DNA, damage
I: oropharyngeal Gram-negative anaerobes, including dental infections, infected human/animal bites and aspiration pneumonia. Eradicate Hpylori, Intraabdominal inf and PID, protozoa incl trichomonal vaginal inf and giardiasis, C diff if IV
C inhibitory effect on CYP enzymes, reducing metabolism of warfarin
dose should be reduced in ▲ severe liver disease.
Avoid alcohol as inhibits acetaldehyde dehydrogenase.
R PO preferred but IV for severe, PR is available. Can be topical for bacteria vaginosis etc.
A GI upset (such as nausea, vomiting, metallic taste) and immediate and delayed hypersensitivity reaction
High dose: peripheral and optic neuropathy, seizures, and encephalopathy.
Nitrates : Glyceryl trinitrate, isosorbide mononitrate
Glyceryl trinitrate, isosorbide mononitrate
M NO increases cyclic guanosine monophosphate (cGMP) synthesis and reduces intracellular Ca2+ in vascular smooth muscle cells, causing them to relax and ARTERIAL VASOCILATION. Reduces preload.
I short- ACS acute angina. long- prophylaxis of angina where Bblocker. CCB are insufficient. IV for ACS, pulmonary oedema, and hypertensive emergencies
C ✖ severe aortic stenosis, Nitrates should be avoided in ✖ hypotension. ✖ phosphodiesterase (PDE) inhibitors (e.g. sildenafil) as acts on metabolising cGMP
R GTN spray, IV infusion, immediate release tablets.
A flushing, headaches, light-headedness, and hypotension
Quinine : Quinine sulfate
Quinine sulfate
M
* Cramp: reducing the excitability of the motor end plate in response to acetylcholine stimulation.
* Malaria: detox cant occur so haem monomers accumulate, impairing membrane integrity and killing the parasites in the schizont stage
I Nocturnal leg cramps, first line for malaria P. falciparum
C caution in people with existing ▲ hearing or visual loss. It is teratogenic, so should not be used in the ▲ first trimester of pregnancy, avoid in G6PD deficiency (haemolysis)
R PO, IV slow infusion,
A tinnitus, deafness and blindness (which may be permanent), GI upset, and hypersensitivity reactions. Quinine prolongs the QT
Quinolones : Ciprofloxacin, levofloxacin, ofloxacin, moxifloxacin
Ciprofloxacin, levofloxacin, ofloxacin, moxifloxacin
M
* Broad spectrum G- and G+
* Ciprofloxacin= Pseudomonas aeruginosa
* Moxi and Levo enhanced G+ activity
* inhibiting DNA synthesis
I: UTI (G-), Severe gastroenteritis (shigella, campylobacter), LRTI incl IECOPD, Pneumonia
C calcium, iron, antacids reduce absorption and efficacy
Ciprofloxacin inhibits certain cytochrome P450 (CYP) enzymes, increasing risk of toxicity
▲ drugs that prolong the QT interval
Co-prescription of ▲ NSAIDs increases the risk of seizures
▲ prednisolone increases the risk of tendon rupture
R PO and IV (over 60min)
A GI upset and immediate- and delayed-type hypersensitivity, Clostridioides difficile colitis
Racetams : Levetiracetam, brivaracetam
Levetiracetam, brivaracetam
M: synaptic vesicle protein 2A (SV2A) expressed in excitatory and inhibitory synases. inhibits synchronised epileptiform burst firing and reduces propagation of seizure activity.
I Seizure prophylaxis in epilepsy.
Levetiracetam is increasingly the preferred option for treating established convulsive status epilepticus, following inadequate response to a benzodiazepine.
C ▲ renal impairment. ▲ hepatic impairment. Brivaracetam has potential to interact with cytochrome P450 inducers
R PO, IV (15 min)
A Drowsiness (affecting about 10%), weakness, dizziness, and headache are the most common adverse effects. Mood disturbance. Suicidal ideation and serious hypersensitivity reactions have been reported rarely.
Serotonin 5-HT1-receptor agonists (triptans) : Sumatriptan, zolmitriptan
Sumatriptan, zolmitriptan
M Triptans are thought to act by inhibiting neurotransmission in the peripheral trigeminal nerve and in the trigeminocervical complex (via 5-HT1B and 5-HT1D receptors) and constricting cranial blood vessels (via 5-HT1B receptors).
I In acute migraines to reduce duration and symptoms.
C Vasoconstriction: ✖ ischaemic heart disease, ✖ cerebrovascular disease, ✖ peripheral vascular disease, and ✖ uncontrolled hypertension. Triptans should also not be used in ✖ hemiplegic migraine or ✖ migraine with brainstem aura. may increase the risk of serotonin toxicity and serotonin syndrome when given in combination with other serotonergic drugs
R Tablets, nasal spray
Achest and throat discomfort, angina and myocardial infarction due to coronary vasospasm, nausea and vomiting, tiredness, dizziness, and transient high blood pressur
Vaccines and immunoglobulins : Vaccines, normal immunoglobulin, tetanus
Vaccines
M Stimulate an adaptive immune response by exposing the immune system to an antigen, leading to memory cell formation for future protection.
I: Prevention of infectious diseases (e.g., MMR, DTP, HPV, influenza).
C: Severe allergic reaction (anaphylaxis) to a previous dose or component, immunocompromised states for live vaccines, pregnancy for certain live vaccines (e.g., MMR, varicella).
R: Intramuscular (e.g., DTP, HPV), subcutaneous (e.g., MMR, varicella), oral (e.g., rotavirus), intranasal (e.g., live attenuated influenza vaccine).
A: Local site reactions (pain, swelling, redness), fever, mild systemic symptoms, rare serious reactions (e.g., anaphylaxis, Guillain-Barré syndrome).
Vaccines and immunoglobulins : Vaccines, normal immunoglobulin, tetanus
Normal Immunoglobulin (Human Immunoglobulin, IVIG)
M Provides passive immunity by supplying pre-formed antibodies that neutralize pathogens or modulate immune function.
I: Immune deficiency disorders (e.g., primary immunodeficiency, hypogammaglobulinemia), autoimmune conditions (e.g., Kawasaki disease, immune thrombocytopenic purpura), post-exposure prophylaxis (e.g., hepatitis A, measles in immunocompromised patients).
C: IgA deficiency with anti-IgA antibodies (risk of anaphylaxis), hypersensitivity to human immunoglobulin.
RIntravenous (IV) or subcutaneous (SC).
AHeadache, fever, chills, infusion-related reactions, thromboembolic events, hemolysis, renal impairment.
Vaccines and immunoglobulins : Vaccines, normal immunoglobulin, tetanus
Tetanus Immunoglobulin (TIG)
M: Provides passive immunity by neutralizing tetanus toxin, preventing disease progression.
I: Post-exposure prophylaxis for tetanus-prone wounds (e.g., deep, contaminated wounds in unvaccinated or incompletely vaccinated individuals).
C: Hypersensitivity to human immunoglobulin, IgA deficiency with anti-IgA antibodies.
R: Intramuscular (IM).
A: Local injection site reactions, fever, rare anaphylaxis.
Sodium-glucose co-transporter 2 inhibitors :
Empagliflozin, dapagliflozin, canagliflozin
M selectively and reversibly inhibit the sodium–glucose co-transporter 2 (SGLT2) in the proximal convoluted tubule of the nephron. SGLT2 inhibition impairs glucose reabsorption in the nephron, increasing renal excretion of glucose (glycosuria) and treating hyperglycaemia
I T2DM, symptomatic chronic inadequately controlled HFrEF, CKD w albuminuria w ACEi/ARB
C withheld during ▲ intercurrent illness that causes or presents a risk of ✖ volume depletion or hypotension. augment the effects of other glucose-lowering drug
R Canagliflozin and dapagliflozin are formulated as tablets.
A Osmotic diuresis can cause thirst and, in the context of intercurrent illness, increase the risk of hypovolaemia and electrolyte disturbance
Increased risk of UTI and genital infection.
Rare ketoacidosis w normal glucose (mainly T1DM)
Side Effects of Antifungals
Azoles: Hepatotoxicity, QT prolongation, drug interactions.
Echinocandins: Generally well tolerated, rare liver toxicity.
Polyenes (Amphotericin B): Nephrotoxicity, electrolyte disturbances (hypokalemia, hypomagnesemia).
Terbinafine: GI upset, liver toxicity (monitor LFTs).
PBL
Procyclidine
M Anticholinergic; blocks muscarinic receptors in the CNS, reducing cholinergic activity.
I Parkinson’s disease, drug-induced extrapyramidal symptoms (e.g., from antipsychotics).
C: Narrow-angle glaucoma, urinary retention, GI obstruction.
R: Oral, IM.
A: Dry mouth, blurred vision, urinary retention, confusion, tachycardia, raised intraocular pressure.
PBL
Apriprazole
MPartial agonist at D2 and 5-HT1A receptors, antagonist at 5-HT2A receptors.
I: Schizophrenia, bipolar disorder, adjunct in major depressive disorder.
C: Hypersensitivity, caution in elderly with dementia (↑ stroke risk), liver impairment
R: Oral, IM (long-acting depot available).
A Akathisia, weight gain, insomnia, nausea, headache, QT prolongation (rare). PARKINSONISM
Vaccines
Which Vaccines are Live attenuated?
Vaccines
Which vaccines are subunit?
Vaccines
Which vaccines are conjugated?
