PSA Exam: Clinical Pharmacology

pharmacological treatment for urge urinary incontinence? - urge incontinence: urgent desire - stress incontinence: leakage upon coughing/any increased abdominal pressure

*ANTICHOLINERGICS*: any muscarinic antagonist: do NOT use if patient has myasthenia gravis. drug examples - *oxybutynin* - *tolterodine* remember anticholinergic effects: dilated pupils, blurred vision, vasodilation/flushing, hyperthermia, dry skin, dry mouth, tachycardia, constipation, urinary retention, memory impairment, confusion, drowsiness, hallucinations. *DULOXETINE*: do not use with stress incontinence.

asthma therapy

*B2 AGONISTS e.g. salbutamol, terbutaline* - usual dose for adults given via inhaler (100 micrograms/puff) 2 puffs via a spacer device PRN up to 4 times a day. - via O2 driven nebuliser 2.5-5mg (dose dependent on the FEF) every 10-15 mins - overuse may lead to *tremors, anxiety and headaches*. Arrhythmias can also occur because of the risk of *hypokalaemia*. Remember dealing with that difficult patient who consistently became agitated with anxiety; the more nebs he used, the worse it got. *ICS e.g. beclometasone* - should also be taken in a spacer - common low dose: 200-400 micrograms 12-hourly; increased if necessary up to 800 micrograms 12-hourly, dose to be adjusted as necessary. note: a steroid card is given those who have been treated for longer than 3 weeks. It is a reminder that whatever the case, the steroids must be weaned and not immediately stopped. Be warned about oral candidiasis: if the patient is immunosuppressed, they may develop a sore throat and white plaques in oral cavity

generalised anxiety disorder

1) first line: SSRI: particularly sertraline 2) second line: offer another SSRI e.g. escitalopram or a SNRI such as venlafaxine 3) third line: pregabalin NOTE: in anxiety, when giving an SSRI/SNRI, we must start with low doses (compared with depression) for the first few weeks and titrate up to often higher doses compared with depression. Continue for at least a year after remission of symptoms (as opposed to in depression which is 6 months). It would be OK to prescribe zopiclone with an SSRI if the patient's anxiety is terrible and keeping them up at night.

best drugs for indigestion? pain or discomfort in your upper abdomen (dyspepsia) or burning pain behind the breastbone i.e. heartburn

antacids!! for immediate relief *- MAGNESIUM CARBONATE*: suitable antacid which provides quick relief. Prescribe 10 mL PO, 8-hourly, dose to be taken with water. *- ALUMINIUM HYDROXIDE* *- CO-MAGALDROX* *- MAGNESIUM TRISILICATE* others: PPIs, H2 receptor antagonists e.g. ranitidine: but they do not provide immediate relief.

- they are effective - discontinuation symptoms (physical/psychological discomfort) occur within 72 hours of discontinuation or rapid dose reduction. They must be taken every day and for at least 6 months once symptoms resolve (at least a year if being given for anxiety). - there is no risk of addiction, tolerance or dependence - they are not tranquilisers If poor response to antidepressant 1) change or increase dose after 3-4 weeks 2) combine 2 antidepressants 3) augment with lithium 4) augment with an antipsychotic 5) consider combining antidepressants with CBT (cognitive behavioural therapy) and refer to psychiatrist.

antidepressants: the rules:

63 year old woman is admitted for pneumonia. PMH: epilepsy (taking phenobarbital), hyperthyroidism which is treated with carbimazole and lymphoma that has just been treated with her last cycle of chemotherapy. On bloods: WBC: 1.2 (ref 4-11) Neu: 0.2 (ref 2-8) Lymph: 0.8 (ref 1-4.8) temp 37.8, HR 80, RR 14, BP 135/80, 98% sats appropriate management?

this is a clear indication of NEUTROPAENIC SEPSIS which is very severe. Appropriate therapy includes: *- tazosin + gentamycin IV*: popular antibiotic regime for neutropaenic sepsis - give paracetamol: she is slightly pyretic - stop the cause e.g methotrexate, trimethoprim, phenytoin, carbamazepine, barbiturates, antipsychotics (e.g. clozapine). She is taking carbimazole!! Methotrexate should ONLY be given *ONCE WEEKLY* since side effects (n/v, diarrhoea, rash) can occur if given more regularly. FBC must be monitored every 1-2 weeks to monitor if patient develops neutropaenia. Sulphasalazine, which is commonly co-prescribed with methotrexate for the treatment of RA and is also indicated in inflammatory bowel disease

emergency treatment: poisoning

traditional medicines from other cultures, may be a source of lead or other heavy metals recognise s/s: CNS depression, low BP, - calcium disodium edetate used to treat lead poisoning

calcium channel blockers

two types: *the antiarrhythmics*: diltiazem and verapamil *dihydropyridines*: nifedipine, amlodipine: - first line in hypertension for >55yr old caucasians and any Black/African or Caribbean regardless of age. - stable angina: for coronary vasospasm: best drug to use is nitroglycerin (GTN) either the sublingual spray (2 sprays) or sublingual tablet (0.3-1mg) for quick relief. A/E - headaches, dizziness, orthostatic hypotension: due to brain artery dilatation - flushing (redness): capillary dilatation *- FLUID RETENTION*: known to cause peripheral oedema: all the calcium channel blockers so be wary in any patient with pulmonary oedema - * ☣ GUM HYPERTROPHY*: has been known to occur with amlodipine - ♡ with diltiazem and verapamil: bradycardia, AV node block.

NSAIDs - indications - contraindications - warnings and adverse effects

useful medication for - *HEADACHES AND MIGRAINES*: use naproxen: its the best NSAID generally and carries the lowest cardiovascular risk. Ibuprofen also recommended for migraines - *SPORTS INJURIES*: sprains and strains: use ibuprofen - aches/pains from *ARTHRITIS*: rheumatological disorders e.g, RA, SLE, psoriatic arthritis, etc. If osteoarthritis is severe enough. - *ACUTE GOUT*: use a really potent NSAID: indomethacin. Naproxen (although weak) is best used over stronger NSAIDs: you must weigh this along with contraindications - pain relief from *KIDNEY STONES* (renal colic): better to use NSAIDs (IM diclofenac maybe best for quick relief) than opioids. Opioids just carry that higher risk of vomiting and constipation. *- POST-OP PAIN*: naproxen most recommended Contraindications "NSAID" mnemonic ☞ *N*URSING and PREGNANCY: particularly 3rd trimester ☞ *N*O URINE: this is a relative contraindication: they can precipitate AKI especially in the elderly, those with chronic renal failure and those taking also ACE-i/ARBs or diuretics. ☞ ♡ *S*YSTOLIC HF: class II-IV: because NSAIDs may promote fluid retention ☞ *A*STHMA (bronchoconstriction), angioedema, allergy ☞ *I*NDIGESTION: since these drugs provoke nausea, vomiting, dyspepsia, peptic ulcers, perforations of the upper gastrointestinal tract, and gastrointestinal bleeding. Anything related to the GI particularly *PUD* or any bleeding. For the elderly: supplement with a PPI to reduce GI symptoms. Ibuprofen carries the lowest risk of GI bleeds. Note: for IBD patients; NSAIDs may precipitate exacerbations. ☞ *D*RUGS: - particularly anticoagulants, aspirin and other blood thinners --> leads to increased bleeding. - do not use (especially diclofenac) in conjunction with ACE-i, ARBs and diuretics especially in the elderly due to the likelihood of AKI development. ⛔ Note: CELCOXIB and DICLOFENAC are now CONTRAINDICATED for people with - ischaemic heart disease - peripheral arterial disease - cerebrovascular disease - congestive heart failure Use with caution in: - ⚠ renal failure: they can provoke RTA - THE ELDERLY: increased risk of serious adverse effects such as ⚠ *GI BLEEDING* ⚠ and perforation, which may be fatal. Supplement NSAID with a PPI always. Ibuprofen is probably the most ideal drug as it carries a low risk of GI side effects. *- ⚠ IBD: can precipitate exacerbations* - some drugs e.g. naproxen can cause photosensitivity what's the advantage and disadvantage of selective COX2 inhibitors (only celecoxib) over the non-selective types? - advantage: they don't inhibit platelet aggregation and prolong bleeding time so there is a lesser risk of dyspepsia s/s or GI bleeding - disadvantage: ⚠ increases the risk of MI and stroke!! :-(

AKI precipitating drugs

PRERENAL: all about volume loss: think about medications that do this: *- diuretics*!! RENAL: main cause for RTA *- NSAIDs*!!! *- ACE inhibitors*!!! - antibiotics: particularly outdated *tetracyclines*, *aminoglycosides* (*gentamycin*) and *vancomycin* *- lithium*: used for bipolar disease *- radiological contrast* *- chemotherapy* POST-RENAL: no drugs can cause this

oral contraceptives - preparations - in the event of a 'missed' pill

Preparations: (many available, these are a few examples) *Monophasic standard strength (21-day preparations)*: you take 21 'active' pills and nothing for the next 7 days. The course is then repeated. Examples: Yasmin, Microgynon 30®. *Monophasic standard strength (28-day 'Every day' preparations)*: you take 21 'active' pills and 7 dummy pills ------------------------------------------------------------------------------------ IN THE EVENT OF A MISSED PILL *If you miss one pill* If you've missed one pill anywhere in the pack or started a new pack one day late you're still protected against pregnancy. You don't need to use any extra contraception. - take the pill you missed immediately (even if this means taking two pill in a day) - continue taking the rest of the pack as normal. - take your seven-day break or dummy pills as normal, then start a new pack. *If you miss two or more pills* - if you've missed two or more pills anywhere in the pack or started a new pack two or more days late your protection against pregnancy may be affected. - take the pill you missed immediately (even if this means taking two pill in a day) - leave any earlier missed pills. (so if you've missed 3 pills don't take 3 in a day to catch up.) - continue taking the rest of the pack as normal - if you have sexual intercourse use extra contraception (such as condoms) for the next seven days after missing the pill. When you should start your next pack after missing two or more pills depends on the number of pills left in the current pack. - If there are seven or more pills left in the pack: finish the pack, take your seven day break or inactive pills as normal, then start a new pack. - If there are fewer than seven pills left in the pack: finish the pack, then start a new pack the day after you finish the old one. (Therefore missing out the seven day break or not taking your inactive pills.) If you miss two or more pills in the first week of a pack and you've had unprotected sex within the last seven days, you may need emergency contraception. The critical time for loss of contraceptive protection is when a pill is omitted at the beginning or end of a cycle (which lengthens the pill-free interval). *Same rules but just said a different way* If a woman forgets to take a pill, it should be taken as soon as she remembers, and the next one taken at the normal time (even if this means taking 2 pills together). - a missed pill is one that is 24 or more hours late (unless taking Qlaira® or Zoely® in their case >12 hours) - if a woman misses only one pill, she should take an active pill as soon as she remembers and then resume normal pill-taking - if a woman misses 2 or more pills (especially from the first 7 in a packet), she may not be protected. She should take an active pill as soon as she remembers and then resume normal pill-taking. In addition, she must either abstain from sex or use an additional method of contraception such as a condom for the next 7 days. If these 7 days run beyond the end of the packet, the next packet should be started at once, omitting the pill-free interval (or, in the case of everyday (ED) pills, omitting the 7 inactive tablets). - if 2 or more combined oral contraceptive tablets are missed from the FIRST 7 TABLETS in a packet and unprotected intercourse has occurred since finishing the last packet: take emergency contraception. remember: after at least 7 pills have been taken consecutively during a cycle, there is no need for emergency contraception. - the pill-free interval should be omitted if doses are missed in the week that precedes this (i.e. during days 15-21).

The patient above has started to stabilise from replacement/resuscitation fluids. We can now examine him more thoroughly and calculate what and how much fluid he requires: HISTORY: any vomiting, diarrhoea, bleeding, sweating/fever? --> fluid loss EXAMINATION: - HR, BP and urine output are most important - any presence of postural hypotension? note: if patient is oliguric (<30 ml/hour) be sure its not due to obstruction of the urethra. *Ensure the bladder is not palpable on physical exam!!* - others: capillary refill and jugular venous pressure - check the patient is not fluid overloaded with presence of pulmonary, peripheral oedema or increased JVP. - check NEWS score, fluid balance charts and weight changes BLOODS: FBC, urea, creatinine and electrolytes: important to know this before prescribing fluids In the end, it comes to your attention that the patient is nil by mouth and cannot take oral rehydration therapy. What type of IV fluids should you give?

Prepare a prescription for *MAINTENANCE IV fluids over a 24 hour period* in those unable to maintain adequate oral intake or NPO e.g. those with bowel obstruction or perioperative. Note: those with bowel obstruction require higher fluids than normal. ♔ DAILY REQUIREMENT RULES FOR MAINTENANCE IV FLUIDS OVER 24 HOURS ♔ ✔ 25-30 ml/kg/day of water and ✔ approximately 1 mmol/kg/day of potassium, sodium and chloride and ✔ approximately 50-100 g/day of glucose to limit starvation ketosis. these daily requirement must also take into account how much the patient is eating/drinking as well as any loss from vomiting, diarrhoea, bleeding, sweating, fever, etc. Now check of your fluids: which one should you use based on your calculations and data. Which has the most suitable amount of electrolytes/glucose to give to the patient? ♕ Key Rules ♕ - max for adults: 3 litres IV fluid/24hrs (8 hourly) - max for elderly: 2 litres IV fluid/24hrs (12 hourly) - adequate electrolytes are provided in 1 litre of 0.9% saline and in 2 litres of 5% dextrose. - if potassium required: prescribe IV 40mmol KCL/24hr unless contraindicated. Infusion rate should be NO MORE THAN 10mmol/hour. Remember that this happens in almost all cases in patients NBM with healthy functioning kidneys because they are constantly filtering out potassium. Check for the causes for hyperkalaemia with "DREAD" mnemonic causes for hyperkalaemia ✗ *D*rugs: ACE-i, ARBs, K+ sparing diuretics, heparin, ✗ *R*enal failure: so be sure to check function ✗ *E*ndocrine: Addison's disease ✗ *A*rtefact: pseudohyperkalaemia ✗ *D*KA and hyperglycaemia

beta lactam adverse effects?

*- hypersensitivity 10% develop an allergy*: maculopapular rash, fever, joint swelling, bronchospasm - *rarely anaphylaxis*: sudden dyspnoea and hypotension *- GI disturbances*: nausea, vomiting, diarrhoea. With ampicillin: consider pseudomembranous colitis *- ATN*: mainly methicillin: AKI: especially in conjunction with other renally damaging drugs. *ϟϟ Seizures* in patients with poor renal function *- haemolytic anaemia*: look for jaundice *- hyperkalaemia*: arrhythmias

medications that promote constipation

*- opiates*: e.g. codeine, morphine, tramadol *- antidepressants*: particularly TCAs which are neuropathic pain relievers *- antipsychotics* e.g. chlorpromazine, haloperidol, olanzapine, clozapine *- chronic laxative use* *- iron supplements* *- calcium channel blockers*

controlled drugs?

*- strong opioids* e.g. morphine, diamorphine, codeine, pethidine, fentanyl, alfentanil, remifentanil, methadone *- amphetamine like agents* e.g. methylphenidate *- cocaine* (local anaesthetic) stored in a locked cupboard by law requires yellow form to be filled out. Remember the CDP forms you were given more the two suppository meds

drugs to avoid in children?

*- tetracycline*: irreversible staining of bones and teeth because of its chelating properties *- aspirin*: Reye's syndrome *- antidepressants*: can increase the risk of suicide... NICE recommends psychological therapy first in mod/severe depression.. but if it fails then fluoexetine (prozac) 10 mg daily, is best used. - others: consult the BNF

medications that promote fluid retention?

*- NSAIDs* *- prolonged steroids* *- antihistamines*: remember also that cyclizine is an antiemetic antihistamine *- calcium channel blockers*: e.g. diltiazem, verapamil, nifedipine, amlodipine *- insulin* if you notice peripheral oedema: is it unilateral or bilateral. If unilateral, is it acute or chronic. If bilateral is it pitting/non-pitting? these meds will cause bilateral pitting oedema. What else causes this? - CHF - chronic kidney disease - liver disease: due to hypoalbuminaemia - malnutrition/malabsorption syndromes: causes of hypoalbuminaemia

what are the effects of enzyme inducers and inhibitors

*- enzyme inducers*: result in increased metabolism of affected drugs and thus reduced activity of them e.g. warfarin --> lower INR --> thicker blood. *- enzyme inhibitors*: result in reduced metabolism of affected drugs and thus creates exaggerated drug responses as more of the affected drug remains available to exert its effect like warfarin -> higher INR --> thinner blood

ϟϟ antiepileptic drugs ϟϟ

*BDZ: first line* - paramedic treatment for status epilepticus: LORAZEPAM - status epilepticus: diazepam, clonazepam - not recommended for use in pregnancy *PHENYTOIN* - 2nd line therapy: for status epilepticus Warnings - P450 INDUCER "*P*CBRAS" - do not use in pregnancy A/E: there are many: - CNS: headache, dizziness, nausea, vomiting, drowsiness, insomnia, transient nervousness, tremour, seizures, paraesthesia - CNS specific: ataxia, nystagmus - GI: constipation, anorexia - coarsening of facial appearance - HIRSUTISM - ACNE - *OSTEOMALACIA* - ☣ *GINGIVAL HYPERPLASIA* - ☢ *BLOOD DISORDERS!!!* ☢ (including megaloblastic anaemia, leucopenia, thrombocytopenia, and aplastic anaemia), *Barbiturates: PHENOBARBITAL* - 3rd line therapy for ϟϟ status epilepticus A/E: - dependence - confusion and aggression particularly in the elderly upon withdrawal *- CNS DEPRESSION*: respiratory depression --> death. Do not give to any alcohol abusers *- AGRANULOCYTOSIS* Cautions: - P450 INDUCER - contraindicated in pregnancy - withdrawal s/s: anxiety, insomnia - many more see above *CARBAMAZEPINE* - can cause teratogenic effects and can lead to haemorrhagic disease of the newborn so do *not* use in pregnancy - Monotherapy of focal seizures - Monotherapy of primary and secondary generalised tonic-clonic seizures Warnings - P450 inducer "P*C*BRAS" - withdraw immediately in acute liver disease A/E - CNS: headache, dizziness, nausea, vomiting, drowsiness, insomnia, transient nervousness, tremour, seizures, paraesthesia - *hyponatraemia* due to precipitation of SIADH - ☢ *BLOOD DISORDERS!!!* ☢ (including megaloblastic anaemia, leucopenia, thrombocytopenia, and aplastic anaemia) - withdraw immediately if acute liver failure occurs *SODIUM VALPROATE* - first line therapy in general tonic clonic seizures (<5 minutes: meaning not status epilepticus) - acute pancreatitis is a known side effect!! *LAMOTRIGINE* ツ - 2nd line therapy for generalised tonic clonic seizures <5 minutes - the newest antiepileptic drug ☄ safest antiepileptic to use in pregnancy *GABAPENTIN* - many symptoms: consult the BNF - also great for neuropathic pain

Diabetic medication; what are they? their side effects

*Biguanides (e.g. metformin)*; - enhances glucose uptake in the liver - first line in overweight patients. If patient has a normal BMI <25 or is underweight, prescribe sulphonylureas first! - A/E: *GI side effects*: particularly *WEIGHT LOSS*, ⚠️*VITB12 DEFICIENCY*⚠️ (macrocytic anaemia) so beware of patients with neurological symptoms. - *contraindicated if high creatinine or if renal failure eGFR <30*: why? it promotes *☢ LACTIC ACIDOSIS ☢* - beware taking with renal, liver, lung disease and cardiac failure meds: drug interactions - Dose: initially 500mg OD *WITH FOOD*: increased every 10-15 days, max. 2g OD with evening meal; if control not achieved, use 1g 12-hourly with meals, and if control still not achieved change to standard-release tablets *Sulphonylureas (e.g. gliclazide* or older gen: *tolbutamide*) dose: gliclazide 40mg OD taken *IN THE MORNING WITH BREAKFAST!!*. Do not take at night because it can encourage overnight hypoglycaemia. - stimulates β cells (insulin release) - used first line if patient is normal or underweight. Check BMI - usually added with metformin as second line - A/E: * ⚠ HYPOGLYCAEMIA ⚠* (so make sure not to miss meals!!), *WEIGHT GAIN*, GI side effects Warnings: - *P450 INDUCERS* - avoid in severe renal and liver insufficiency - try to avoid in pregnancy (neonatal hypoglycaemia risk), - contraindicated in DKA REMEMBER most people has glucose levels in their blood of between *4 to 6 mmol/L*. In diabetics, we want to obviously keep it below 11.1mmol/l (random) or <7 (fasting). Less than 3mmol/l would mean hypoglycaemia *Thiazolidinediones* TZDs (glitazones) - make cells more sensitive to insulin/reduce insulin resistance in fat and muscles - 2nd line after metformin + sulphonylureas. - A/E: *weight gain, raised LDL*, *♡ ⚠ HEART FAILURE ⚠ ♡* (especially if taken with insulin) and other cardiovascular problems, there is a also a slight risk of: *⚠ BLADDER CANCER ⚠*: patients should be advised to report promptly any haematuria, dysuria, or urinary urgency during treatment!! - rosiglitazone is off the market!! terrible drug. Pioglitazone is the only TZD available *DPP4-Inhibitors* (gliptins e.g. sitagliptin) - stop degradation of incretin hormones in the intestine that help stimulate glucose dependent insulin secretion - first choice after metformin and sulphonylureas if patient refuses or cannot use insulin. - A/E: mild: *GI* (nausea, diarrhoea, stomach pain), *flu-like symptoms*, *skin rash*. Increasing risk of * ⚠ PANCREATITIS ⚠*. *Alpha-glycosidase inhibitors* e.g. acarbose - block enzymes that help digest starches and thus delay intestinal carb absorption, gastric emptying and thus postprandial glucose levels. - 3rd line therapy. - A/E: GI: flatulence, soft stools, diarrhoea (may need to reduce dose or withdraw), abdominal distention and pain; rarely, nausea, abnormal liver function tests and skin reactions; very rarely ileus, oedema, jaundice, and hepatitis - contraindicated in: inflammatory bowel disease, predisposition to partial intestinal obstruction; hernia, previous abdominal surgery *Incretin Mimetics* - e.g. exendatide, liraglutide - subcutaneously given - improve glucose dependent insulin secretion - reduce food intake - slow down gastric emptying - reduce glucagon secretion - promote beta cell proliferation. A/E: *⚠ increased risk of PANCREATIC CANCER ⚠* *SGLT2 inhibitors* (canagliflozin, dapagliflozin, empagliflozin): - act on the kidneys and reduce glucose reabsorption thus increasing urinary glucose excretion - serious and potentially life-threatening cases of *⚠ DIABETIC KETOACIDOSIS ⚠* have been reported

oral candidiasis/oral thrush

*CLINICAL PICTURE* sore mouth and throat, erythematous soft palate with white plaques visible on the mucosal surfaces of the mouth *CAUSES* - course of *broad spectrum antibiotics* e.g. amoxicillin, particularly over a long period or at a high dose - *inhaled corticosteroid* e.g. beclometasone medication for asthma - wearing *dentures* (false teeth), particularly if they don't fit properly - having *poor oral hygiene*, having a *dry mouth* - *smoking* - *chemotherapy or radiotherapy* to treat cancer Babies, young children and elderly people are at a particularly high risk of developing oral thrush, as are people with certain underlying conditions, including - diabetes - iron or vitamin B12 deficiency - an underactive thyroid (hypothyroidism) - HIV. *TREATMENT* - topical antifungals e.g. MICONAZOLE or NYSTATIN are first line for oral candidiasis

insulin sliding scale (VRIII)

*Definition* also known as VRIII, is a system used in the hospitals (particularly surgical ward) to gain more control over glucose levels using IV glucose than the regular treatment that the patient may be on. *Monitoring:* Bedside capillary glucose levels are measured every 4-6 hours and the ideal goal is to maintain capillary blood glucose levels between 6-10 mmol/L. *Preparation:* - if patient is already on a basal long acting insulin e.g. glargine or detemir, then KEEP THEM on this insulin but every other anti-diabetic medication should be stopped. - make sure IV line is set up. Make up a syringe to 50mls with 50 units Actrapid® (draw up in the specific insulin syringe) and 49.5mls of 0.9% sodium chloride solution. - the Insulin solution must be administered via a syringe pump alongside the substrate infusion. *Restarting back to normal* - the insulin should be re-introduced either before breakfast or before the evening meal so do not change to subcutaneous insulin at any other time. - the VRIII should be maintained for 30 to 60 minutes after the subcutaneous insulin has been given to avoid DKA Slide scale: - sensitive: those with type I DM or renal failure - resistant: those with DM II, corticosteroids or has sepsis

medication that you can use to treat acute diarrhoea

*LOPERAMIDE HYDROCHLORIDE*: for symptomatic relief in uncomplicated acute diarrhoea - common side effects: dizziness; flatulence; headache; nausea these drugs are mainly used when the side effects of other medications promote constipation. do not treat diarrhoea directly if the cause is known. Treat the cause e.g. AAD: treat with metronidazole 400mg 8-hourly for 10 days.

Emergency contraception

*ORAL LEVONORGESTREL* is effective *if taken within 72 hours (3 days)* of unprotected intercourse and may also be used between 72 and 96 hours after unprotected intercourse [unlicensed use], but efficacy decreases with time. *ULIPRISTAL ACETATE*, a progesterone receptor modulator, is effective *if taken within 5 days* of unprotected intercourse. *INTRAUTERINE COPPER DEVICE* can be inserted *up to 5 days* after unprotected intercourse and it is more effective than oral levonorgestrel for emergency contraception. - sexually transmitted infections should be tested for and insertion of the device should usually be covered by antibacterial prophylaxis (e.g. azithromycin). - if intercourse has occurred more than 5 days previously, the device can still be inserted up to 5 days after the earliest likely calculated ovulation (i.e. within the minimum period before implantation), regardless of the number of episodes of unprotected intercourse earlier in the cycle.

analgesics.

*PARACETAMOL*: - usually 1g PO 6-hourly max (for adults). - in children, the dose will be different. *CO-CODAMOL* - either 30/500 PO or 8/500 PO 2 tablets 6-hourly - co = codeine: so take note of constipation note in Scunthorpe, they do not supply this and require us to prescribe paracetamol and codeine separately. *NSAIDs* - indicated for headaches/migraines, arthritis, sprains/strains, acute gout or renal colic - remember "NSAID" mnemonic for adverse effects and contraindications *OPIOIDS*: *- codeine 30-60 mg 6-hourly (QDS) PO*: this is the weakest opioid and is the most beneficial after paracetamol/NSAID however carries the constipation effect. *- tramadol* would be next in line: it is stronger than codeine: unfortunately *hallucinations/agitation* particularly in the elderly are more common stronger ones include: *- morphine*: do not give in patients with renal impairment *- fentanyl*: this is metabolised via the liver so is safer to give in renal impairment. *- methadone* (all three good for severe long term pain) remember that *CNS depression and thus respiratory depression* may occur. Do ABCDEs if patient is uncooperative after prescription of morphine and give *NALOXONE 150 MICROGRAMS IV* if so. Look for: ☢ *comatose/drowsy* ☢ *pinpoint pupils* ☢ *constipation* ☢ *urinary retention* especially postop ☢ *vomiting*. *AMITRIPTYLINE*: an antidepressant that is also great for neuropathic pain. As a TCA, remember the three C's. ☢ *Cardiac arrhythmias* ☢ *Convulsions* ☢ *Cholinergic block*: dilated pupils, blurred vision, vasodilation/flushing, hyperthermia, dry skin, dry mouth, tachycardia, constipation, urinary retention, memory impairment, confusion, drowsiness, hallucinations. *GABAPENTIN, PREGABALIN*: for neuropathic pain - has CNS sedation effects: drowsiness is common *TENS*: transcutaneous electrical nerve stimulation: - used most often to treat muscle, joint, or bone problems that occur with illnesses such as osteoarthritis or fibromyalgia, or for conditions such as low back pain, neck pain, tendinitis, or bursitis. - people have also used TENS to treat acute pain, such as labor pain, and long-lasting (chronic) pain, such as cancer pain. - although TENS may help relieve pain for some people, its effectiveness has not been proved.

anticoagulants medication - warfarin - heparin

*WARFARIN* vitamin K antagonist used to prevent embolism occurring by antagonising thrombus growth. indications - TIAs for prevention of embolus formation causing an ischaemic stroke - prophylaxis after insertion of prosthetic heart valve - prophylaxis of embolisation formation in atrial fibrillation if CHADS2VAS2 score is >2. - prophylaxis against DVT - treatment of PE after patient has stabilized and INR levels normalized for 5 days after heparin administration. cautions: conditions in which risk of bleeding is increased: - history of GI bleeding, peptic ulcer - recent surgery - recent ischaemic stroke - bacterial endocarditis (use only if warfarin otherwise indicated) - uncontrolled hypertension - concomitant use of drugs that increase risk of bleeding (e.g. NSAIDs and any P450 inhibitors); avoid cranberry juice but also statins. contraindicated: - pregnancy - haemorrhagic stroke - recent ischaemic stroke note: for most conditions (AF, DVT and PE) an INR of 2.5 is aimed for. For recurrent venous thromboembolism or in patients with mechanical prosthetic valves, a higher INR of 3.5 is targeted. monitoring - at the beginning of treatment, warfarin does need to be monitored *weekly* in order to reach the correct INR. - with time and as INR has stabilised, we can switch this to *monthly* checkups *Heparin* - can be either unfractioned LMWH or fractionated which requires monitoring all LMWH are usually given in the evening for nursing convenience and they all do the same thing but the cheapest on the market is: *DALTEPARIN*. - for example, if an 80kg patient is to be treated for PE: a prescription would correlate with the BNF and be written like 'dalteparin 15,000 units s/c ONCE DAILY' with the date, time, your printed name and signature on the the 'once only medicine' prescription. - usual thromboprophylaxis dose in medical/non-surgical patients is 5000 units s/c once daily *ENOXAPARIN* - usual dose in medical/non-surgical patients is 40 mg s/c once daily. - in the event of very low eGFR <30 and/or patients under 50kg, this drug must be dose-adjusted to prevent excessive anticoagulation *TINZAPARIN* - what we use in the current trust - usually given once in the late afternoon -------------------------------------------------------------- INDICATIONS: - thromboprophylaxis: subcutaneous injection, 5000 units s/c 24-hourly. This is usually given routinely in the hospitals unless contraindicated. - in patients with DVT, PE, unstable angina or acute peripheral arterial occlusion, we prescribe an IV loading dose of 5000 units or 75 units/kg, followed by continuous intravenous infusion of 18 units/kg/hour WARNINGS/SIDE EFFECTS - hypersensitivity - bleeding via HIT - hyperkalaemia - osteoporosis (risk lower with LMWH) - alopecia with long-term use - you must reduce the dose with hepatic and renal impairments. CONTRAINDICATIONS: most likely checked on admission: *- GFR<20* *- bleeding*: e.g. after major trauma, recent ischaemic or haemorrhagic stroke (for at least 2 months), thrombocytopaenia, recent surgery to eye or nervous system, haemophilia *- hypersensitivity* to either unfractionated or low molecular weight heparin *- acute bacterial endocarditis* *- spinal or epidural anaesthesia* with treatment doses of unfractionated or LMWH

drugs for TB and their side effects

1) 4 months of PIRE - pyrazinamide: joint/muscle pain, gout, hepatotoxic - isoniaZid: think "Z" for electricity/neurological issues: peripheral neuritis, vitamin B6 deficiency, ϟϟ seizures, hepatotoxicity, rashes, skin eruptions. *P450 INHIBITOR* thus increases the effects of other drugs like warfarin - rifampicin: red/orange urine, sweat and tears, rash, flu-like symptoms. *P450 INDUCER* thus reduces effects of other drugs like warfarin. - ethambutol: reduced visual acuity, red/green colour blindness, gout, rash, fever 2) 2 months of IR

which drugs have a narrow therapeutic index?

*digoxin*:. CARDIAC -☟hyp*O*kalaemia: be aware of: ⚠️ hepatic encephalopathy and coma ⚠️ -☟hyp*O*magnesaemia: can precipitate into convulsions. -☝hyp*ER*calcaemia -> bones, stones, groans and psychological moans. Be wary also of the risk increase of valve calcification - complete SA node bock - more arrhythmias NON-CARDIAC - GI: n/v, diarrhoea - CNS: depression, disorientation - visual: blurred yellow-green vision - hyperestrogenism: gynecomastia *theophylline* *lithium*: therapeutic serum-lithium concentrations are within the range of 0.4-1mmol/l. If >2 then we could have: - early tremour - intermediate: fatigue - late: arrhythmias, ϟϟseizures, coma, renal failure, diabetes insipidus note: serum levels can be raised if used in conjunction with ACE-inhibitors, NSAIDs and renal failure, especially in the elderly. *phenytoin* - GUM HYPERTROPHY - ataxia, nystagmus, peripheral neuropathy - teratogenic - megaloblastic anaemia *antibiotics*: gentamycin, vancomycin - ♫ OTOTOXICITY ♫ - ☢ NEPHROTOXICITY ☢ if evidence of toxicity regardless of drug levels, then there are three approaches to make: (A) stop drug and/or find alternative (B) supportive measures (IV fluids) (C) give antidote if one available

examples of drugs that induce and inhibit enzyme activity in the liver?

*inducers*: "PCBRAS" note: mostly CNS drugs - phenytoin - carbamazepine - barbiturates e.g. phenobarbital - rifampicin - alcohol (chronic excess) - sulphonylUREAS (anti-diabetic) Note: conveniently: the "PC B" drugs above cause agranulocytosis and other blood dyscrasias. *inhibitors*: "AO*T*D*E*VI*C*E*S*" note: all the class of *antibiotics* are here - *A*llopurinol, *A*miodarone - omeprazole *- tetracyclines* - disulfiram (used to treat chronic alcoholism) *- erythromycin*, *clarithromycin*: macrolides - valproate - isoniazid *- ciprofloxacin*: 2nd gen fluoroquinolone - ethanol *- sulphonAMIDES* (antibiotics) these inhibitors will increase the effects of drugs e.g. warfarin: blood will be thinner, INR will be higher and the risk of bleeding is higher.

DRUGS MONITORING the 'Drug Monitoring" section consists of 8 questions with a total of 16 marks out of 200. - it appears using the NICE.org.uk website is better and more up to date. Select this option then select "CKS" from the options on the right. Then search for your drug of interest. - if question asks for the most *immediate/quick* monitoring method for treatment: always say the clinical symptoms before test results - question may ask monitoring *within a time frame* e.g. "within 12 hours" so take this into account. For example, you'd obviously not use CXR to assess the treatment for pneumonia within 12 hours. - be aware of NOMOGRAMS, particularly for paracetamol and gentamycin - be careful e.g. with immunosuppressants, the question will ask you how often you perform certain tests either (a) before starting treatment (b) initial monitoring frequency just after starting treatment (c) after dosage has stabilised.

*oxygen* - too much oxygen therapy can lead to respiratory alkalosis so ABGs must be measured. - early quick measures include RR & PaO2 *asthma therapy* - clinical features: lower RR, HR - PaO2: fastest measure to see if the initial drugs are working - PEFR measured every 15-30 minutes in emergencies: best used in the first 12 hours of treatment - ABG is severe asthma exacerbation: the most efficient method. *IV theophylline/aminophylline* - if we wanted to measure the EFFICACY: measure PaO2 or ABG to see if improving (after asthma/COPD exacerbation) - if we wanted to assess TOXICITY: measure serum levels after 18 hours: note that tachycardia is an indicator of toxicity and so serum levels may need to be taken sooner if this was to occur. *blood transfusions, fluid replacement therapy* - assess BP, HR and urine output - signs of peripheral and pulmonary oedema (dyspnoea, orthopnoea, PND). *ANTIBIOTICS*: particularly gentamycin and vancomycin - remember these drugs are highly nephrotoxic and ototoxic - important to measure serum levels before prescribing a new dose of the drug for *pneumonia*: the best options to adequately assess response to antibiotics include: - in acute setting: ABG, pulse oximetry or if those are not available, measure CRP (acute phase protein) and/or RR: - crepitations in the lungs would take several days to resolve - CXR: can take up to 6 weeks to clear: useful to monitoring but not in the acute setting. *THYROID MEDICATION* Carbimazole - *FBC* must be monitored due to the low risk but most dangerous risk of ⚠️ AGRANULOCYTOSIS. Inform patient to report any sign of infection such as sore throat or fever. Levothyroxine: - taken once daily, preferably at least 30 minutes before breakfast - *TSH* measured 2-3 months later ✔ if <0.5: lower the dose by minimally ✔ if 0.5-1: keep same dose ✔ if >1: increase dose minimally - *symptomatic relief* is the ultimate aim of thyroid replacement therapy and fatigue, drowsiness and subtle cognitive impairment are sensitive markers of suboptimal treatment. *anti-diabetic medication* - metformin: check *BMI (only use if overweight) and eGFR is >20* before prescribing - sulphonylureas: check *BMI* (for normal/underweight) and most importantly *baseline glucose* levels *ANTICOAGULANTS* *warfarin!* - check *INR* 2-3 target levels (unless they have a prosthetic valve, in that case 3.5 - caution for enzyme inducers (PCBRAS) and inhibitors (AOTDEVICES) - vitamin K (oral/IV) will help reverse the effects. - FFP or (the more expensive, prothrombin complex) is added to the regime if significant bleeding and INR>8 *heparin* - know that you use protamine IV to reverse the effects *STATINS* ☢ HEPATOTOXICITY: statins require monitoring of *transaminases* - before starting treatment (baseline) - 3 months after starting treatment - 12 months after starting treatment ☢ MYOSITIS [aka RHABDOMYOLYSIS]: warn patients to report immediately any muscle pain, especially in the shoulders, thighs or lower back - check *CK levels* and if suspected, stop the statin. ☢ they can also increase the concentration of warfarin and shouldn't be taken with grapejuice as this increases the toxicity of the statin *ACE INHIBITORS* - measure *U&E* at baseline and after every dose change because of the risk of hyperkalaemia, hyponatraemia and in some cases, AKI *ARBs* - renal function should be measured 1-2 weeks after starting an angiotensin II receptor blocker. *DIGOXIN* - *serum creatinine* is an important measurement to monitor during treatment since the drug is renally excreted - measure *plasma digoxin concentration levels* 8-10 days after prescribing and only if toxicity or inadequate effect is suspected or when the dose is being changed. - serum for therapeutic levels should be measured 6-12 hours after the last dose *LITHIUM*: - serum concentrations 0.4-1mmol/l - hyponatraemia, ACE-i, ARBs, diuretics can also increase lithium levels - monitor serum lithium levels, thyroid and renal function *ANTIPSYCHOTICS* - before prescribing, always check *fasting blood glucose* since ⚠️ HYPERGLYCAEMIA and diabetes can occur in these patients prescribed antipsychotics particularly olanzapine - *baseline ECG* only done in those with cardiovascular disease of associated risk factors. Be sure the QT inverval is not prolonged. These drugs are contraindicated in cardiac disease: ♡CARDIOTOXIC - AGRANULOCYTOSIS: monitor *leucocyte and differential blood counts*: Neutropenia and potentially fatal agranulocytosis reported --> bone marrow suppression and be wary of neutropaenic sepsis *ANTIEPILEPTICS* - phenytoin, carbamazepine and phenobarbital can cause agranulocytosis so measure FBC Note: the usual total plasma-phenytoin concentration for optimum response is 10-20 mg/litre. - sodium valproate: monitor *liver function* before (baseline) therapy and during first 6 months especially in patients most at risk. *ORAL CONTRACEPTIVES* - if a patient comes in requesting prescription of the combined pill then cardiovascular related factors should be measured. *BP* is the fastest and easiest measurement undertaken in the GP practice. *AMIODARONE* - a *baseline CXR* must be performed before commencing therapy due to the risk of pulmonary fibrosis - *TSH, T3 and T4* all must be measured during treatment - *serum transaminases* should be measured during treatment - note there is no effect on renal function *IMMUNOSUPPRESANTS (DMARDs)*: *Methotrexate* - this drug is given ONCE-WEEKLY: it is not uncommon to find an error in this on prescriptions and it would prove fatal if so ☢ FATAL BLOOD DYSCRASIAS: - *monitor FBC, LFT and renal function tests* every fortnight until stable (usually at 6 weeks) - once doses are stable, monitoring is required monthly for 1 year. - after 1 year of dosage stabilisation, monitor every 2-3 months after. - inform patient to report any sore throat, fever or unexplained bruising immediately after using this drug. Infections might be suggestive of bone marrow failure. *Azathioprine* • monitor FBC and LFT weekly for the first month. Thereafter reduce frequency of monitoring to at least every 3 months. • U&E every 6 months (since immunosuppressants are not very renal friendly) *Hydroxychloroquine* - requires annual eye screening *Ciclosporin* - baseline lipids. Once stable, periodic. - fortnightly renal function. Once stable, monthy monitoring - monthly FBC and LFT. Once stable, every 3 monthly monitoring

You are about to anaesthetise an ABG puncture site. How many mg in 1ml of 1% lidocaine solution is required?

*remember 1% = 1g/100ml* so convert the grams to mg 1% = 1000mg/100ml 1000mg/100ml = 10mg/ml

dose required: 0.5mg of adrenaline in 1:1000 solution. What is the required volume?

*remember 1:1000 = 1g/1000ml* convert this so 1:1000 = 1000mg/1000ml 0.5/1000mg x 1000ml = 0.5ml required

Third test (intermediate) feedback - treatment for chlamydia in one dose? - treatment for suspected PE - combined oral contraceptive and patients missing their pill(s) - see below for a more in depth discussion - digoxin drug monitoring

- "write a prescription for ONE drug that will treat her chlamydia infection when *given as a single dose*". It says 'given as a single dose' so a drug is required here that requires no maintenance. Doxycycline is first line but requires maintenance. The best answer is *azithromycin 1 g oral once only*. - you wrote the prescription for prophylaxis for PE/DVT rather than the treatment of PE (even if just suspected), use the patient's weight and write the correct *TREATMENT dose*. Furthermore, always adjust dose based on their renal function and if they have cardiovascular compromise. - drug monitoring: digoxin has *linear kinetics*. Any change in dosage will lead to a proportionate change in serum concentration. For example halving the dose from 250 to 125 micrograms should lead to a serum drug concentration from 2.8 to 1.4 nmol/L. - data interpretation: digoxin causes nausea and this patient has it despite his bloods now being normal after reducing the dose to 125 micrograms. His serum digoxin levels are 1.8 nmol/L (1.0-2.0). This may be within range but he still has nausea. The best thing to do would be to half the dose to 62.5 micrograms.

Advice after taking the first PSA test on website

- STATINS: although simvastatin is cheap, *atorvastatin* is considered the best for primary prevention in cardiovascular disease. Atorvastatin and other statins can also be taken anytime during the day unlike simvastatin which requires nightly dosing!!! If you choose simvastatin, then you must write 'once daily *AT BEDTIME*' since statins are more effective in the evenings HOWEVER, atorvastatin and other statins can be taken *AT ANY TIME* during the day. Also, 20-40mg is best used in this case. - IV FLUIDS: you need to make the correct choice given the patient circumstances; NBM/cannot tolerate oral rehydration, their hydration status, electrolyte and glucose levels.

drugs that can cause/worsen urinary incontinence

- alcohol, caffeine - ACE inhibitors, calcium channel blockers, diuretics - antihistamines - alpha blockers: e.g. doxazosin, prazosin. These relax the urinary sphincter and urethra. They are useful for the treatment of BPH - antidepressants - antipsychotics - sedatives: worsen urge incontinence

paracetamol overdose situations

- always ask when and what time the overdose occurred and the time when serum paracetamol levels were taken. - use the nomogram: ♦ on the x-axis, count the hours between OD occurred and when the serum sample was taken and compare with ♦ on the y-axis: use the serum paracetamol level. if ABOVE the treatment line (or just below): indicates severe liver damage so treat with *IV acetylcysteine*. Because the efficacy of acetylcysteine declines rapidly eight hours after ingestion of paracetamol, acetylcysteine should be administered immediately to patients who present *8 to 24 hours after taking an acute overdose*, even if the plasma-paracetamol concentration is not yet available; acetylcysteine can be discontinued if the plasma-paracetamol concentration is later reported to be below the treatment line on the treatment nomogram, provided that the patient is asymptomatic and liver function tests, serum creatinine and international normalised ratio (INR) are normal. note: gastric lavage only effective within an hour of ingestion. Gastric lavage and activated charcoal also present a risk of aspiration in those who have taken CNS such as alcohol.

Third paper - know your anticholinergic drugs and their effects: dilated pupils, blurred vision, vasodilation/flushing, hyperthermia, dry skin, dry mouth, tachycardia, constipation, urinary retention, memory impairment, confusion, drowsiness, hallucinations. - an interesting case where the patient has cirrhosis but requires analgesics for some pain somewhere else. The standard paracetamol dosage must be reduced in patients with chronic liver disease to avoid further hepatotoxicity. - permethrin 5% dermal cream is used as first-line treatment for scabies and is given as two applications, 7 days apart. Permethrin has been found to be the most effective topical treatment for scabies. - anticoagulants/antiplatelet combo will show up as a potentially serious drug interaction. The circumstances where you may combine an anticoagulant with an antiplatelet include: (i) patients who have had an acute coronary syndrome (ACS) within the previous year, (ii) patients having a bare metal stent, and (iii) patients having a heart valve replacement. - plasma HIV RNA should be measured in all patients at baseline and regularly during therapy since it is the most reliable indicator of response to antiretroviral therapy (ART)

- be wary that *paracetamol doses vary in children* so look it up in the BNF if you choose this as your choice of analgesic and the case involves a child! - you got the correct IV fluid for maintenance and thought about his age and thought you needed 2 litres/day thus being 500ml/6 hours. What you got wrong is that the *patient has CHF!! and in these patients, you need to give a total of 1.5 litres, that being 500ml/8 hours*. Remember, NEVER SAY 250ml in the volume section because this is just too small of a bag and will require too much changing. - ciclosporin is an immunosuppressant used to help prevent organ transplants as well as treatment for other conditions that are affected by the body's immune system: all of which have to be severe: Crohn's disease, UC, RA, atopic dermatitis, plaque psoriasis. It is known for high BP and renal impairment. - drugs that should be prescribed using their proprietary names? well... the brand names, just select the ones that require monitoring e.g. aminophylline or cyclosporin. - traditional medicines from other cultures, may be a source of lead or other heavy metals leading to poisoning. You must be aware of these since they are becoming increasingly popular. - "select the most appropriate monitoring option to identify important *adverse effects* of drug A": when you get this kind of question: look it up under 'monitoring' section of the BNF. If the question asks about *therapeutic effect*: then use your knowledge.

loop and thiazide diuretics: uses and side effects

- loop e.g. furosemide, bumetanide - thiazide e.g. hydrochlorothiazide, indapamide, etc note: these diuretics are best given in the *MORNING* due to subsequent diuresis e.g. of a prescription - Drug: FUROSEMIDE - Dose: 20mg (20mg-1.5g max). It is best for the elderly to start an initial dose at the lowest - Route: PO (can also be given IM, IV) - Frequency: ONCE-DAILY IN THE MORNING - Circle a time in the morning - loops diuretics are *first line in pulmonary oedema* to reduce fluid overload - loops diuretics are *first line in ACUTE heart failure* to reduce fluid overload - both used for *chronic renal disease*: to reduce fluid overload - thiazide diuretics are second line for hypertension: *in patients >55yr old or African/Carribeans of any age who cannot tolerate calcium channel blockers or have a high risk of heart failure*. - used in conjunction with ACE-i/ARBs for congestive heart failure - used in conjunction with K+ sparing diuretics sometimes if hypokalaemia present both have the same adverse effects -☟hyp*O*kalaemia: may precipitate: ⚠️ hepatic encephalopathy and coma ⚠️ -☟hyp*O*natraemia -☟hyp*O*magnesaemia larger molecules shall not escape!! -☝hyp*ER*glycaemia (be wary of diabetics) -☝hyp*ER*lipidaemia -☝hyp*ER*uricaemia (very rarely) --> gout frequency unknown - *GOUT* - hypersensitivity reaction - urinary retention - thiazides can cause gynecomastia -☀ PHOTOSENSITIVE RASH ☀ - ♫♫ OTOTOXICITY ♫♫ - BLOOD DISORDERS: bone marrow suppression Contraindicated in - severe renal failure Warnings * ⛔ DO NOT USE ANY DIURETICS IN PREGNANCY ⛔*

medication that promote urinary retention?

- opioids - anticholinergics (eg, antipsychotic drugs, antidepressant agents, anticholinergic respiratory agents, detrusor relaxants), - general anaesthetics, - alpha-adrenoceptor agonists, - benzodiazepines (e.g. diazepam), - NSAIDs (e.g. ibuprofen), - calcium-channel blockers, - antihistamines - alcohol.

drugs that promote urinary retention?

- opioids: especially in early post-op period - anticholinergics (eg, antipsychotic drugs, antidepressant agents particularly TCAs, anticholinergic respiratory agents, detrusor relaxants), - general anaesthetics, - alpha-adrenoceptor agonists - benzodiazepines (e.g. diazepam), - NSAIDs (e.g. ibuprofen), - calcium-channel blockers, - antihistamines - alcohol.

Common abbreviations - PR - PO - INH - STAT - OD - OM - ON - BD - TDS - QDS - units - PRN

- per rectum - orally - inhaled - immediately - once a day/24hr - every night - twice a day/12hr - three times a day/8hr - units - as required

PReS CR IBER mnemonic

- ✮ ⓟATIENT details: name, DOB, hospital number, date of admission and consultant - ✮ ⓡEACTION to drug: ALLERGIES! - ✮ ⓢIGN the front of the chart. Give your name and todays date and bleep number if requested - ☆ *ⓒ*ONTRAINDICATIONS to each drug?: know co-morbidities and which ones are P450 enzyme inducers/inhibitors - ☆ DRUG, DOSE, *ⓡ*OUTE, FORM & FREQUENCY e.g. dalteparin *15,000 units, s/c, once daily* - ۞ ⓘV FLUIDS required?: resuscitation or maintenance fluids - ۞ ⓑLOOD CLOT PROPHYLAXIS required? - ۞ ANTIⓔMETICS required? - ۞ ⓡelief from PAIN required?

*----------------------------------------------------------------------* *!!!!!!!!!!!!!!!! DRUG DOSE CALCULATIONS !!!!!!!!!!!!!!!* *----------------------------------------------------------------------* 1) What is 1% solution? 2) What is 1 in 1000 solution 3) What is 1 in 10,000 solution 4) What is an IV pump set to?

1) 1 GRAM in 100 MILLILITRES 2) 1g in 1000ml 3) 1g in 10,000ml 4) in ML/HOUR Remember: these are the common questions - calculate the *volume* of a solution that will give the correct dose - expressing a required dose as a *percentage* - the *dose (g/mg/mcg or even units)* that is given to a patient from a set of data - *dose and a dosing interval* from a normogram/chart - IV infusion *rates* (possibly) in ml/hour

calculate the volume required for: 1. prescription of metronidazole 120mg. Ampule contains 200mg in 5ml 2. prescription of diazepam 500mcg with ampules of 2mg in 5ml 3. prescription of spironolactone 7mg with ampules of 25mg in 5ml

1) 120mg/200mg x 5ml = 3ml required of the ampule 2) convert your prescription to mg so 500mcg = 0.5mg now: 0.5mg/2mg x 5ml = 1.25ml required from the ampule 3) 7mg/25mg x 5ml = 1.4ml required

RULES to the management of warfarin if: 1) INR is <6 and no bleeding 2) INR is between 6-8 and no bleeding 3) INR is >8 and no bleeding 4) INR is raised >3 with minor bleeding 5) the patient is hypotensive or bleeding into a confined space such as the brain or eye? 6) INR 6.1 and patient with minor bleeding? 7) INR 7.4 and no bleeding? 8) INR 8.6 and major bleeding? always ask yourself why the INR is raised. Is it maybe because a P450 enzyme inhibitor "AOT DEVICES" such as erythromycin has been administered Intravenous vitamin K can halve the INR within 6 hours. Oral vitamin K may take up to 24 hours for full effect but is more practical for patients without significant bleeding symptoms.

1) reduce warfarin dose 2) omit warfarin for 2 days, then reduce the dose 3) omit warfarin and give 1-5mg *ORAL* vitamin K (*PHYTOMENADIONE*) 4) omit warfarin and give *IV* vitamin K (also known as phytomenadione. 5) several things - stop warfarin - administer 5-10mg IV vitamin K - give FFP or the more expensive option: prothrombin complex (e.g. Berliplex) note: vitamin K - if there is minor or major bleeding: give IV vitamin K regardless of how high the INR is. - if there is no bleeding and INR is <8, there is no need for vitamin K. - if INR>8 with no bleeding: give vitamin K in oral form. 6) omit warfarin for 2 days and give vitamin K IV (we give IV vitamin K to anyone with minor or major bleeding with any raised INR). Then find out cause (P450 enzyme inhibitor maybe?) 7) omit warfarin for 2 days and then reduce the dose. Note that *vitamin K is NOT required* since there is no bleeding. Then find out cause (P450 enzyme inhibitor maybe?) 8) with major bleeding, we must administer FFP or the prothrombin complex (berliplex) - stop warfarin - administer 5-10mg IV vitamin K - give FFP or the more expensive option of prothrombin complex (e.g. Berliplex) - find out cause for raised INR (P450 enzyme inhibitor maybe?)

digoxin 1) main use? 2) toxicities

1) symptomatic HF with AF because it slows down conduction through the AV node. Overall effect: increased cardiac output while reducing the HR. 2) toxicities: it has a narrow therapeutic index :-( *CARDIAC* -☟hyp*O*kalaemia: be aware of: ⚠️ hepatic encephalopathy and coma ⚠️ -☟hyp*O*magnesaemia -☝hyp*ER*calcaemia -> bones, stones, groans and psychological moans. Be wary also of the risk of valve calcification increase - complete SA node block - more arrhythmias *NON-CARDIAC* - GI: n/v, diarrhoea - CNS: depression, disorientation - visual: blurred yellow-green vision - hyperestrogenism: gynecomastia

dilution calculations 1) I have a stock solution of 100mg/ml. How can i prepare 2mg/ml from this? 2) I have an ampule of 20mg/1ml and I need to prepare 1 mg/ml from this. How to do this? 3) I have an ampule of 20mg/2ml and I need to prepare 1mg/ml. How do I make up this concentration? 4) I have made up a 1mg/ml solution (20mg in 20ml) from an ampule of 20mg/2ml and I need to use that to make a working solution of 5mg/ml.

1) you want to dilute this to a volume 50x because 100/2 = 50. So take the stock solution and dilute to 50ml. Add 1ml of stock to 49ml of solvent. 2) you need to dilute the ampule this by a factor of 20. Add 1ml of the ampule solution to 19ml of solvent to make up 20ml in total 3) you need to dilute the ampule: 18ml of NS to 2ml of the ampule in a 20ml syringe

A 24-year-old man requires sutures for extensive lacerations to the face and chest. Lidocaine hydrochloride 1% with adrenaline (epinephrine) 1:200,000 is used to provide local anaesthesia before suturing, and a total of 13 mL is injected SC around the wound. How much adrenaline (in micrograms) has been administered?

1:200000 = 1 gram in 200,000ml = 1000mg in 200,000ml = 1000000mcg in 200,000ml = 10mcg in 2ml 13ml/2ml x 10mcg = 65 MICROGRAMS

A 60-year-old woman with chronic renal impairment is to be given alfacalcidol 1 microgram orally daily. Alfacalcidol is available as capsules each containing 250 nanograms. How many capsules of alfacalcidol should she be given daily?

1mcg = 1000ng 1000ng/250ng = 4 capsules daily

a basic IV fluid regime for a small elderly person who is not septic

500 ml of normal saline with 20 mmol KCl over 6 hours 500 ml of normal saline with 20 mmol KCl over 6 hours 500ml of 5% dextrose with 20mmol KCl over 6 hours 500ml of 5% dextrose with 20mmol KCl over 6 hours

drugs that cause blood disorders?

AGRANULOCYTOSIS: deficiency of granulocytes: low levels of neutrophils, eosinophils and/or basophils: *- ϟϟ phenytoin*: antiepileptic medication for grand mal seizures *- ϟϟ carbamazepine*: antiepileptic medication - *ϟϟ barbiturates*: antiepileptic medication *- clozapine*: 2nd generation antipsychotic (neuroleptic) but consider that it may occur in all the antipsychotics *- colchicine*: for acute gout; short-term prophylaxis during initial therapy with allopurinol *- carbimazole*: antithyroid medication. Also PTU Note: remember 'PC B' are the first two drugs on enzyme inducers "PCBRAS". HAEMOLYTIC ANAEMIA - penicillins MACROCYTIC ANAEMIA - folate antagonists: methotrexate, trimethorpim - B12 deficiency: metformin - pancytopaenia: phenytoin, carbamazepine THROMBOCYTOPAENIA - NSAIDs - heparin: HIT - antibiotics: penicillin, sulphonamides, linezolid - quinidine (antiprotozoal) - antihistamines: ranitidine - furosemide - RA medication: penicillamine - gold, used to treat arthritis

Jaundice patient what drugs can raise serum bilirubin, ALP levels and GGT levels.

ALP indicates post-hepatic failure primarily from bile flow obstruction. Raised GGT confirms this could be from *reduced intrahepatic excretion* as opposed to extrahepatic obstruction. We should think about *CHOLESTASIS* (bile flow obstruction) if drug induced, this can be due to: - penicillins: co-amoxiclav, flucloxacillin - nitrofurantoin - steroids - sulphonylureas - statins remember the case with the elderly lady who had significantly raised AST and GGT but ALT was OK. She was completely asymptomatic. Was on simvastatin 40mg ON: possible cause? We did U/S abdomen which showed 'inspissated bile' i.e. thickened bile

you need to give 300mg paracetamol to a 14 year old child. The suspension contains 120mg in 5ml. What volume of suspension do you give?

As a rule, the volume needed is equal to *What you want* * -------------------------- X volume you got* *what you've got* what you want always come first before you what you get ... in real life generally :-/ so make sure the units are the same first (mg) secondly 300/120 X 5ml = 12.5ml

antidepressants adverse effects & warnings

Note: *generally, ⚠ ALL ANTIDEPRESSANTS ARE CONTRAINDICATED IN PREGNANCY* ⚠ TCAs however are still being studied. Check the BNF ------------------------------------------------------------------------- SSRIs e.g. fluoxetine (prozac), paroxetine, sertraline, citalopram. first line for - generalised anxiety disorder: sertraline is NICE recommended because its incredibly cost-effective. - depression route and dose: e.g. fluoxetine 20-60mg OD e.g. sertraline 50mg OD it can take up to 6 months to see any improvement in symptoms. The earliest symptom you may see is hypersensitivity or suicidal thoughts so this must be checked frequently on the next visit (within a week after giving for the first time). Sertraline is the best SSRI available. It is first line in depressants patients with a previous MI and are taking aspirin. Give it with omeprazole to reduce the risk of a GI bleed. Adverse Effects - GI: nausea, vomiting, dyspepsia, abdominal pain, diarrhoea, constipation, BLEEDING!! - weight gain. - dry mouth - hypersensitivity reaction - sexual dysfunction - ☀ *PHOTOSENSITIVITY* ☀ - ☠ *SUICIDAL BEHAVIOUR*: particularly children/adolescence. You must see the patient again within a week of prescribing and then monitored weekly within the first month. - withdrawal symptoms: mainly GI. The drug should be stopped gradually and not abruptly. contraindications - ⛔ do not use with MAOIs (can precipitate ⚠ *SEROTONERGIC SYNDROME* ⚠) - ⛔ do not give with any aspirin, NSAIDs or anticoagulants as they increase risk of GI bleed). Be wary of rheumatological patients - do not give with tramadol - citalopram is contraindicated in patients with known prolonged QT interval - contraindicated in pregnancy What is serotonergic syndrome? *- neuromuscular hyperactivity* (such as tremor, hyperreflexia, clonus, myoclonus, rigidity) *- autonomic dysfunction* (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea) *- altered mental state* (agitation, confusion, mania). ------------------------------------------------- SNRIs e.g. venlafaxine - sexual dysfunction - GI: nausea, constipation - sleep disorders - dry mouth - sweating - contraindicated in liver and renal failure - contraindicated in pregnancy - ♡ associated with high risk of *CARDIAC ARRHYTHMIAS* and *UNCONTROLLED HYPERTENSION* ------------------------------------------------- TCAs e.g. amitriptyline, clomipramine, etc: these drugs are superb for neuropathic pain e.g. 'shooting pain in the back' and also for migraines route and dose e.g. amitriptyline - for neuropathic pain and migraine prophylaxis: initially 10 mg ON, gradually increased if necessary to 75 mg daily - for depression: initially 75mg (ELDERLY and ADOLESCENTS 30-75 mg) daily in divided doses or as a single dose at bedtime increased gradually as necessary to 150-200 mg A/E include: - ♡ *CARDIAC ARRHYTHMIAS* ♡: thus caution in those with cardiovascular problems - *CHOLINERGIC BLOCK*: see below - ϟϟ *CONVULSIONS* ϟϟ - withdrawal s/s: include influenza-like symptoms Contraindications - with cardiac problems (particularly arrhythmias), - manic phase of bipolar disease - acute porphyria remember the mnemonic for anticholinergic medication: dilated pupils, blurred vision, vasodilation/flushing, hyperthermia, dry skin, dry mouth, tachycardia, constipation, urinary retention, memory impairment, confusion, drowsiness, hallucinations. ------------------------------------------------- MAOI e.g. selegiline (irreversible) or moclobemide (reversible). Many problems with these medications. Only really prescribed by specialist. - *AVOID WITH TYRAMINE CONTAINING FOODS* e.g. cheese, chocolate, beer and wine - do not take with SSRIs as it may precipitate ☠ serotonergic syndrome ☠ - avoid in hepatic failure - avoid in pregnancy A/E *- HYPERTENSIVE CRISIS* - sleep problems - tremour, agitation - headaches - dry mouth ----------OTHERS------------ offered when SSRIs are not ideal. The below drugs are good as they do not increase the risk of developing GI bleed or sexual dysfunction. *- MIRTAZAPINE*: unfortunately though, it associated with both short term and long term weight gain and significant day time drowsiness. *- AGOMELATINE*

IV fluid types

CRYSTALLOID solutions: IV fluids containing varying concentrations of electrolytes. *- 0.9% saline*: commonly used for resuscitation. *- Hartmann's solution* *- 5% dextrose solution*: COLLOID solutions (unpopular nowadays) - IV fluids containing large proteins and molecules that tend to stay within the vascular space (blood vessels) but in practice they have little effect compared to crystalloid. - they are used for resuscitation particularly in those who have had MAJOR TRAUMA AND HYPOTENSIVE in order to keep fluids in the intravascular space for a longer period of time. - an example would be *gelofusine*. BLOOD AND BLOOD PRODUCTS: need to be ordered from the transfusion lab - pRBC - PLT - FFP

treatment for typical pneumonia

Community acquired - *amoxicillin* 500 mg/8hr (TDS) PO for 5 days if community acquired - if moderate: *amoxicillin* + *clarithromycin 500mg BD* OR *fluoroquinolone* Hospital acquired - ABCDEs: particularly *oxygen* if severely dyspnoeic - in the hospital: *co-amoxiclav 1.2g/8hr IV*: first line in the BNF if infection developed within 5 days of admission. Severe and with symptoms of diarrhoea from first line antibiotic treatment: - *taszosin 4.5g 8-hourly*

Rules of prescription writing?

ONLINE BNF: https://www.medicinescomplete.com/mc/bnf/current/index.htm Consult the local pharmacy if you ever have problems *---------☝ ☝ ☝---- RULES ----☝ ☝ ☝---------* - write with black pen and in CAPITALS for drug, dose, route, form and frequency - use generic name for drug - do not write out the dose if there are decimal points e.g. 0.5mg should be written as 500mcg. Convert units if this has to be done! - the words MICROGRAMS, NANOGRAMS and UNITS must *never* be abbreviated - do not use abbreviations for frequency e.g. OD. Write out ONCE DAILY or 6-HOURLY, etc unless its a GP prescription. Write it out normally e.g. "four times a day in the evening/at bedtime/in the morning", etc. - generic drug name e.g. diclofenac - dose - route - frequency of administration - date started - circle the times the drug should be given - record any specific instructions e.g. with food - sign the entry with name and bleep number

corticosteroid side effects

Corticosteroids - remember mnemonic "CUSH(x3)ING(x3)OID" *C*entral obesity, moon face, buffalo hump, cataracts, comedones (acne) *U*lcers: due to inhibition of the gastric epithlial renewal process *S*kin: purple striae, thinning, bruising, petechiae *H*ypertension, *H*yperglycaemia, *H*ypercholesteraemia *I*nfertility (due to hypogonadism - loss of libido, menstrual irregularities, hirsutism, gynecomastia, testicular atrophy, muscle weakness) *N*ecrosis, avascular necrosis of the femoral head --> hip fractures *G*rowth retardation, *G*lycosuria, *G*ynecomastia *O*steoporosis *I*mmunosuppression - susceptible to infections *D*iabetes, *D*epression/mania ✔ the longer the patient has been on steroids, the more gradual the reduction of steroids needs to be. Therapy *for longer than 2 weeks can lead to adrenal suppression*. - Withdrawal reactions include *Addisonian crisis (hypotension, dehydration, hyperkalaemia, hyponatraemia)*, arthralgia, conjunctivitis, mood change, rhinitis, skin rashes (itchy nodules or acne) and weight loss. ✔ *'sick day' rules* indicate that those on long term steroids must have their daily dose *DOUBLED* on days of sickness e.g. from sepsis or just before surgery (from stress)

medication to treat constipation

DO NOT USE LAXATIVES IN BOWEL OBSTRUCTION - *SENNA* 2 tablets ORAL nightly contraindicated in colitis or when there is cramping!! - *BISACODYL* 5-10mg ORAL nightly contraindicated in colitis or when there is cramping!! - *LACTULOSE* contraindicated when there is bloating

HMG-CoA reductase inhibitors (statins): side effects, contraindications, interactions

HMG-CoA reductase inhibitors (statins): indications, side effects, contraindications, interactions HMG-CoA: Indications - ♡ secondary prevention for cardiovascular disease "AⓢAB" - ♡ post-MI "AⓢAB": 'aspirin, *STATIN*, ACE-i, beta blocker' ⚠ Side effects ⚠: ☢ *HEPATOTOXICITY*: statins require monitoring of transaminases. *Only stop statin treatment if 3x the normal limit* - before starting treatment - 3 months after starting treatment - 12 months after starting treatment ☢ *MYOSITIS* [aka RHABDOMYOLYSIS]: warn patients to report immediately any muscle pain, especially in the shoulders, thighs or lower back - check *CK levels* and if suspected, stop the statin. ☢ *P450 INHIBITORS*: they will increase the effect of other drugs so stop temporarily if a patient is on warfarin or on any other P450 inhibitor drugs BNF says: if muscular symptoms or raised CK occur during treatment, other possible causes (e.g. rigorous physical activity, hypothyroidism, infection, recent trauma, and drug or alcohol addiction) should be excluded before statin therapy is implicated. When a statin is suspected to be the cause of myopathy, and creatine kinase concentration is markedly elevated (more than 5 times upper limit of normal), or if muscular symptoms are severe, treatment should be discontinued. Contraindications: - *G*irl during pregnancy/ Growing children Interactions: - *C*oumarin (*statins may INCREASE the effects of anticoagulants*) --> higher risk of bleeding - grapefruit juice: statin effect increases - antidepressants - cyclosporin - quinolones - sulphonylureas

protein pump inhibitors

INDICATIONS - H.pylori eradication in combination with amoxicillin and clarithromycin - prevention and treatment of gastric/duodenal ulcers - GORD - acid reflux in the long term - major peptic ulcer bleeding following endoscopic treatment CAUTIONS/SIDE EFFECTS - GI: abdominal pain, altered bowel movements, etc - GI: may increase the risk of C.diff infection - can increase the risk of fractures (especially in elderly) with long term use MONITORING - measurement of serum-magnesium concentrations should be considered before and during prolonged treatment

lithium - indications? - what must you think about when starting a patient on lithium therapy? - lithium blood concentration levels? the therapeutic index concentration and levels with serious toxicity - what do do if you've taken too much?

INDICATIONS - prophylaxis and treatment of ☻ MANIA, hypomania and depression in bipolar disorder (manic-depressive disorder) - prophylaxis and treatment of recurrent unipolar depression - treatment of aggressive or self-harming behaviour. THINGS TO THINK ABOUT: - the drug has a *narrow therapeutic index* and thus its concentrations must be monitored - serum concentrations of lithium must be monitored on a *sample taken 12 hours after* the last dose - routine serum lithium monitoring must be performed *WEEKLY after initiation* and after each dose change until the concentrations are stable and then *every 3 months thereafter* - the full prophylactic effect of lithium may not occur for 6-12 months after the initiation of therapy. Olanzapine or valproate (given alone or as adjunctive therapy with lithium) are alternative prophylactic treatments in patients who experience frequent relapses or continued functional impairment. - lithium toxicity is *MADE WORSE BY SODIUM DEPLETION*, therefore concurrent use of diuretics (particularly thiazides) is hazardous and should be avoided. ACE-inhibitors and NSAIDs also reduce lithium excretion and thus increase toxicity. - long-term use of lithium has been associated with ⚠ *5x RISK OF HYPOTHYROIDISM* and ⚠ *MILD COGNITIVE & MEMORY IMPAIRMENT* so monitor thyroid function every 6 months (more often if there is evidence of deterioration). ⚠ *RENAL FUNCTION MUST be monitored* at baseline and every 6 months thereafter (more often if there is evidence of deterioration or if the patient has other risk factors, such as starting ACE inhibitors, NSAIDs, or diuretics which precipitate AKI. - the need for continued therapy should be assessed regularly and patients should be maintained on lithium after 3-5 years only if benefit persists. BLOOD CONCENTRATIONS - therapeutic serum-lithium concentrations are within the range of *0.4-1mmol/l*; - concentrations >2mmol/l are usually associated with serious toxicity: symptoms include: ♦ early: tremour ♦ intermediate: tiredness ♦ late: arrhythmias, seizures, coma, ataxia, dysarthria, nystagmus and RENAL impairment and diabetes inspidus. TREATMENT IN OVERDOSE - in mild acute overdosage cases without features of toxicity: all that is necessary is to take measures to *increase urine output* (e.g. by increasing fluid intake with IV 0.9 NaCl but AVOID DIURETICS). - if adverse effects (CNS: tremour, ataxia, dysarthria, nystagmus, convulsions and RENAL impairment are present, *haemodialysis* may be required. - emergency cases: *gastric lavage* may be considered if it can be performed within 1 hour of ingesting significant quantities of lithium. *Whole-bowel irrigation* should be considered for significant ingestion, but advice should be sought from the National Poisons Information Service.

antipsychotics (neuroleptics)

In the short term they are used to calm disturbed patients whatever the underlying psychopathology, which may be schizophrenia, brain damage, mania, toxic delirium, or agitated depression. Antipsychotic drugs are used to alleviate severe anxiety but this too should be a short-term measure. Two groups exist: *Traditional* (mainly dopamine antagonists) - e.g. chlorpromazine, haloperidol: - these have a high potential for EPS (extrapyramidal symptoms). - better used for positive symptoms of schizophrenia (delusions, hallucinations, agitations). ☠ ☠ EXTRAPYRAMIDAL S/S ☠ ☠: antidopaminergic effects *- parkinsonian symptoms* (including tremor), which may occur more commonly in adults or the elderly and may appear gradually; *- dystonia*: spasms and contractions may either be sustained or may come and go. Dyskinesia, which occur more commonly in children or young adults and appear after only a few doses. If acute dystonia occurs, prescribe IM or IV administration of procyclidine which has antimuscarinic actions to counteract antidopaminergic effects *- akathisia (restlessness)*, which characteristically occurs after large initial doses and may resemble an exacerbation of the condition being treated; *- tardive dyskinesia* (rhythmic, involuntary movements of tongue, face, and jaw), which usually develops on long-term therapy or with high dosage, but it may develop on short-term treatment with low doses—short-lived tardive dyskinesia may occur after withdrawal of the drug. *Nontraditional* - e.g. clozapine, olanzapine, risperidone - these have a much lower potential for EPS. - better used for the negative s/s of schizophrenia (social withdrawal, blunted emotions, ambivalence) ------------------------------------------------- ⚠ WARNINGS ⚠ *-↓ ↓ ↓ AGRANULOCYTOSIS* ↓ ↓ ↓: monitor leucocyte and differential blood counts: Neutropenia and potentially fatal agranulocytosis reported --> bone marrow suppression and be wary of neutropaenic sepsis *-♡ FATAL MYOCARDITIS ♡* (most commonly in first 2 months) *-♡ CARDIOMYOPATHY ♡* *- DIABETES AND HYPERGLYCAEMIA* Contraindications - cardiac disease - avoid in Parkinsons disease - it is recommended to avoid in the elderly due to the *increased risk of cerebrovascular disease* and increased mortality. - contraindicated in comatose states Weirdly, if someone is smoking, this is encouraged to avoid clozapine toxicity.

trimethoprim: indications, side effects and contraindications

Indications: UTIs and respiratory tract infections. Side effects *- FOLATE ANTAGNOIST*: can cause megaloblastic anaemia, bone marrow toxicity and thus pancytopenia. Remember: do not include this with any other folate antagonist e.g. methotrexate. They can also cause ☠ *NEUTROPAENIC SEPSIS* ☠. Folate antagonists are also CONTRAINDICATED IN PREGNANCY *- GI disturbances* *- acute porphyrias* contraindicated in: *- pregnancy*: because it is a folate antagonist *- ☢ BLOOD DYSCRASIAS ☢*: any blood disorder *- NEUTROPAENIC SEPSIS*

Feedback after the 2nd PSA test on the website PRESCRIBING - for IV fluids question: always assess hydration status, U&E and glucose levels. Then decide based on this if the patient needs resusc or just maintenance with total volume depending on their age in the process. PRESCRIPTION REVIEW - know the clinical appearance of oral candidiasis (sore mouth and throat, erythematous soft palate with white plaques visible on the mucosal surfaces of the mouth). Know the the risk factors: immunosuppression from steroids particularly inhaled ones (beclomethasone) in this case. - tamsulosin is an alpha1 blocker used to improve urination in men with an enlarged prostate. Like all alpha-blockers, it tends to reduce blood pressure causing OH. - if a patient is vomiting, you wouldn't give oral medication nor would you give a third line for n/v (ondansetron). The first line choice, even in pregnancy is cyclizine and give it in its IM form if the patient is still vomiting. COMMUNICATING INFO: an easy section to master - simvastatin can cause muscle aches but these should not require discontinuation if they are mild": this is true... the answer is a little wordy but your utmost concentration is required. ADVERSE DRUG REACTIONS - hypoglycaemia: what to do? ♦ if not severe and can tolerate oral intake: give *10-20mg of glucose* e.g. lucozade, coke, chocolate bar. ♦ if severe (unconsciousness, seizures, or altered mental status): give *1 mg IM glucagon (0.5mg in children)* when at home or IV access cannot be achieved quickly enough ♦ if severe (unconsciousness, seizures, or altered mental status): give *IV 20% glucose* may be given into a large vein through a large-gauge needle. 10% is an alternative but larger volumes are needed. Do not give 50%! - clinical symptoms are the fastest method to monitor if a drug is working or not... assess this before tests. DATA INTERPRETATION - in the event of DKA: initial management should be IV rehydration and an *IV infusion of a short-acting insulin at around 0.1 units/kg/hr*.

Prescribing: question asked you to 'treat the CAUSE of the diarrhoea' not the diarrhoea itself. If a patient is having antibiotic-associated diarrhoea, treat with metronidazole (500 mg oral three times a day) or vancomycin orally!! If you need to treat acute diarrhoea without knowing the cause or the questions asks you to prescribe for 'symptom relief' then think about laxatives! - for the IV fluids question: you prescribed 0.9% NaCl which is correct for a dehydrated patient but you gave maintenance (1 litre over 8 hours) instead of the required RESUSC fluid (500ml over 15 minutes) challenge needed in a patient who is clearly dehydrated and NBM. - even if they're showing hypokalaemia in U&E, you should NEVER administer KCL with normal saline in a resusc fluid because the rate is too fast!! Potassium is only safe at 10 mmol/hour so giving 20mmol/15 minutes is 80mmol/hour and that is NOTTTT GOODD!!! - resuscitate with a crystalloid if their sodium is in the range 130-154 mmol/l.. so they can be slightly hyponatraemic or hypernatraemic: it wouldn't matter: normal saline would still be safe. - topical antifungals e.g. miconazole or nystatin are first line for oral candidiasis: recognise this clinical situation!!

ACE inhibitors: examples, indications, adverse effects, contraindications, interactions?

Prescription example *- Drug*: ENALAPRIL *- Dose*: 2.5mg *- Route*: PO *- Frequency*: *ONCE NIGHTLY* (taken at night because they can cause orthostatic hypotension). *- Start Date*: today's date *- Circle a time*: e.g. 18:00 *- Today's date, time and sign + print your name* on the prescription form. Indications: *- hypertension*: first line in <55yr old caucasians *- hypertension and fluid overload caused by chronic renal failure*: but it's good to reduce the dose in case of hyperkalaemia *- post-MI*: reduces ischaemic events, mortality and hospital admissions. "AS*Ⓐ*B" *- congestive heart failure*: to reduce volume overload but remember they're not first line *- diabetic nephropathy*: slow down the progression to CKD. Urine albumin to creatinine ratio (ACR) is measured every year in diabetics to assess the risk of development to CKD A.E and contraindications. Use mnemonic "CAPTOPRIL" - *C*ough that is dry - *A*ngioedema: months later - *P*otassium excess ⚠️ arrhythmias ⚠️ - *T*aste changes - *O*rthostatic hypotension (remember the peri-arrest in elderly care; patient unconscious due to low BP so we gave IV fluids and reduced his ramipril dosage). - *P*regnancy contraindicated unless essential. Switch to labetolol for hypertension. - *R*enal artery stenosis (bilateral). Chronic *R*enal failure? warning: hyperkalaemia and other side effects more common; the dose may need to be reduced. - AK*I*: if used in conjunction with drugs like NSAIDs, lithium, methicillin, etc (see below) or if in the elderly. *Check U&E after 1-2 weeks* of initiation if there are s/s of AKI - *L*iver toxicity: should be discontinued if marked elevation of hepatic enzymes or jaundice occur. Avoid the following if possible, or monitor frequently: *- NSAIDs* - increased risk of renal failure. *- Heparin, potassium-saving diuretics or potassium supplements, cyclosporin, and epoetin* - increased risk of hyperkalaemia. *- Lithium* - increased serum levels of lithium.

your consultant has asked you to designate a patient 'NBM" in order to prepare her for emergency surgery tomorrow morning. What kind of drugs must you check for and which should be stopped/require alternative?

What does NBM mean: *Clear fluids (water/squash)* - none in 2 hours prior to surgery (except for 30mL to administer medication). *Food (includes milk)* - none in the 6 hours prior to surgery. *Medicines* - regular medication should be administered up to 1 hour prior to surgery with 30mLs of water unless they need to be withheld. Drugs to withhold/change: ♦ *ACE inhibitors* (enalapril, ramipril, perindopril, captopril) ♦ *ARBs* (candesartan, losartan) - both these drugs may drop the BP during an anaesthetic. - anaesthetists may request that these drugs are given before surgery but this will be requested on an individual basis. Withhold unless requested. ♦ *All diuretics* (furosemide, bumetanide, bendroflumethiazide, indapamide, amiloride, spironolactone). ♦ *Diabetic treatment* - change to IV insulin with sliding scale - do NOT stop any basal long acting insulin e.g. glargine or detemir. ♦ *Aspirin, clopidogrel, dipyridamole, warfarin, heparin*. - you must be familiar with the individual requirements of your surgical team. - do NOT stop in patients who have a coronary stent without prior discussion with an anaesthetist or cardiologist. ♦ *Drugs which are not essential in the short term*. eg. vitamins, iron, laxatives, osteoporosis treatment, liquid antacid medicines (eg gaviscon), HRT, anti- histamines, herbal remedies or homeopathic medicines. ♦ *Lithium* should be omitted. ♦ *NSAIDs* (eg. diclofenac, indomethacin, ibuprofen), unless prescribed by an anaesthetist as a pre-med.

St John's wort

a herbal antidepressant its interactions with other drugs are important to note (although rare)

potassium sparing diuretics toxicities and contraindications

aldosterone antagonists e.g. spironolactone, amiloride. Useful for those suffering from hyp*O*kalaemia when using loop or thiazides. toxicities: - hyperkalaemia - metabolic acidosis - AKI - kidney stones contraindicated with: - ACE-i: because of hyperkalaemia risk - CKD: because of hyperkalaemia risk - liver disease - pregnancy: as with all diuretics

drugs to to avoid and drugs considered acceptable in pregnancy?

avoid *- generally*: alcohol, warfarin *- painkillers*: NSAIDs, opioids *- ACE inhibitors and all diuretics* *- certain antiepileptics*: avoid valproic acid, phenytoin, and phenobarbital and carbamazepine (the last of these can cause haemorrhagic disease). If you require an antiepileptic during pregnancy, use lamotrigine. *- certain antibiotics*: tetracyclines, aminoglycosides (streptomycin, gentamycin), fluoroquinolones, trimethoprim (it is a folate antagonist) especially in combination with methotrexate, nitrofurantoin (cannot be used only through the last few weeks of pregnancy) *- folate antagonists* e.g. trimethoprim (unless used with a folate supplements) and methotrexate: but just don't use both these drugs together! *- oral contraceptives*: they're just not required *- anti-depressants*: all of them except maybe TCAs *- retinoids* e.g. isotretinoin *- lithium*: a drug used for bipolar disease ------------------------------------------------------------------------- considered acceptable: paracetamol, codeine, penicillins, cephalosporins, heparin, ranitidine Note: many drugs can cross the placenta. - first trimester (week 1-12): congenital malformations - second trimester (week 13-26) and third trimester (27-42) may result in growth retardation

alendronic acid

bisphosphonate *indications*: - treatment of postmenopausal osteoporosis *alendronic acid 10 mg daily PO, alternatively 70 mg once weekly.* - treatment of osteoporosis in men 10 mg daily. *contraindicated*: - any form of GI bleeding or dyspepsia: most of its side effects are GI related. - abnormalities of the oesophagus for any form of bowel obstruction - hypocalcaemia: this must be corrected before starting biphosphonates *directions of use* - tablets should be swallowed whole and the oral solution should be swallowed as a single 100 mL dose. - doses should be taken with plenty of water on *an empty stomach at least 30 minutes before breakfast and before taking any other oral medication*. Its a drug that loves to be alone! - patient should stand or sit upright for at least 30 minutes after administration. The upright posture limits the risk of the tablet remaining in the oesophagus and promoting oesophageal ulceration. *monitoring* - monitor serum-calcium concentration during treatment.

sulphonamides (antibiotics) adverse effects, warnings and contraindications?

so-called 'dirty' drugs. Sulphur is a dirty element A.E: there are many: just think "CRANK HPS" - Ⓒ rystals (renal stones) - Ⓡ ash - Ⓐ naemia: macrocytic!! - Ⓝ ausea - ☢ * Ⓚ*ERNICTERUS (bilirubin-induced brain dysfunction): because it largely binds to albumin thus displacing bilirubin which releases into the blood causing hyperbilirubinaemia - *H*ypersensitivity - ☀ ☀ *PHOTOTOXICITY* ☀ ☀ - ☣ *STEVEN JOHNSON SYNDROME!!* ☣ Warnings - like most antibiotics, these drugs are also *P450 inhibitors*!! be aware of patients taking oral hypoglycaemics or warfarin since their effects will increase! Note: UR NOthin PNEU: they are used for: - UTI - nocardia infections - pneumonia in immunosuppressed patients.

beta blockers A.E and contraindications

contraindications to non-selective beta blockers like propranolol: think ABCDEFG - *A*sthma: (use metoprolol B1 selective instead) - ♡ *B*radycardia - ♡ *C*ardiac: ACUTE heart failure - *D*yspnoea, *D*izziness - *E*motions run low: depression ☹ - *F*atigue, insomnia (rare) - *G*igidy gigidy: sexual dysfunction!!! - *H*yperlipidaemia: ↑VLDL, ↓HDL - *I*nsomnia, nightmares, hallucinations: rarely note: metoprolol and bisoprolol can be used in asthma: it is a beta1 selective antagonist so does not cause bronchoconstriction. It may still have its adverse effects: bradycardia, fatigue and rarely insomnia. ⛔ DO NOT use beta blockers with verapamil or diltiazem as they will further reduce the HR

aminoglycosides A.E and warnings?

e.g. GENTAMYCIN, streptomycin A.E: just another magic *MON*day with them! Useful for: - endocarditis - neutropaenic sepsis (alongside co-amoxiclav) Adverse Effects - *M*uscular paralysis: rarely - ♬ *OTOTOXICTY* ♬ - ☠ *HIGHLY NEPHROTOXIC* ☠ precipitates ATN - do not use streptomycin in pregnancy remember that gentamycin has a very narrow therapeutic index and so its serum levels in the blood must be monitored closely. Use a normogram when re-prescribing!

BDZ: indications and adverse effects?

e.g. clonazepam, lorazepam, diazepam, chlordiazepoxide dosage e.g. with night sedation: use temazepam 10mg or 5mg for the elderly Indications: remember "MASSA" *M*uscular disorders: diazepam for muscle spasms *A*nxiety: most frequently drugs used for this *ϟϟ S*eizures: diazepam/lorazepam IV for grand mal recurrent seizures and emergency situations *S*leep disorders: careful about the nurses on the ward who will most likely annoy you to sedate those elderly patients who can't sleep. Prescribed commonly is temazepam 5mg (elderly) ON *A*mnesia: short acting meds for unpleasant procedures. A/E: most common: - drowsiness/confusion the next day (very common and especially in the elderly) - muscle weakness - amnesia - ataxia - dependence rarely - narrow angle glaucoma Precautions - *withdrawal s/s* with abrupt discontinuation causes s/s of confusion, anxiety, agitation, restlessness, insomnia, tension - avoid in alcohol abuse patients + other CNS depressants will create *HYPNOTIC EFFECT* - beware in *hepatic impairment* - try to avoid in pregnancy - avoid in breastfeeding

macrolides A.E and warnings

e.g. erythromycin, clarithromycin are useful for atypicals e.g. chlamydia, legionnaires, mycoplasma. Also second line for syphilis in case of penicillin allergy. A.E: very few - GI disturbances - thrombophlebitis - ♬ *OTOTOXICTY* ♬ - cholestatic hepatitis (rare) Warnings: - they are *P450 inhibitors* and thus increase the concentration of those of anticoagulants which means higher INR levels (blood is too thin).

AMINOSALICYLATES

e.g. mesalazine

tetracyclines adverse effects and warnings?

e.g. tetracycline, doxycycline. These drugs are useful for - exotic intracellular infections (e.g. chlamydia, rickettsia and mycoplasma, lyme disease, syphilis - malaria prophylaxis: should be started 1-2 days before entering the endemic area, and continued for 4 weeks after leaving. - acne and rosacea - and because they are bile excreted: they're good for those with renal impairment!! :-) unless they're out of date :-/ A.E - *GI problems*: diarrhoea, n/v, pseudomembranous colitis - *hypersensitivity/allergy* - * ☀ PHOTOTOXICITY ☀*: damage to the skin with exaggerated sunburn: remember that tetracycline is used topically in acne and orally if severe. - *hepatotoxicty*: jaundice - *renal toxicity*: if outdated tetracyclines are used Warnings: ⛔ *contraindicated in children, pregnancy and breast feeding* - *TEETH EFFECT*: children will develop permanent brown teeth. Do not use in children - *P450 inhibitors*: they can increase the effect of anticoagulants: INR will increase, blood will be more thin and risk of bleeding is higher.

nitrofurantoin

indicated for UTI: probably the best drug if a patient has a whole lot of complications for example: - allergy to penicillin (avoid amoxicillin and cephalosporins) - is pregnant: avoid trimethoprim - taking warfarin (avoid ciprofloxacin) - taking methotrexate (in that case avoid trimethoprim) contraindicated in: - severe renal failure with eGFR<45 - last few weeks of pregnancy - acute porphyria

metronidazole

indicated for bacterial infections of the vagina, mouth, stomach (e.g. H.pylori), GI (e.g. C.difficile), skin, joints, and respiratory tract. learn the dose for C.diff since it's not in the BNF: *400 mg ORAL, three times a day (8 hourly) for 10-14 days* do not use when: *- with alcohol!* disulfiram-like reaction with alcohol. It can lead to flushing, nausea and vomiting and headaches. monitoring: clinical and laboratory monitoring advised if treatment exceeds 10 days.

you notice raised bilirubin, AST and ALT on blood tests. Review the drug chart and explain what common drugs can cause this?

intrahepatic failure: mainly due to alcohol, viral or drugs - paracetamol OD >4g/day - statins - rifampicin

fluoroquinolone indications, adverse effects and contraindications?

mainly for UTI and respiratory tract infections but may have other uses depending on generation Indicated for: *1st gen*: nalidixic acid and norfloxacin very good for uncomplicated UTIs *2nd gen:* e.g. ciprofloxacin: uncomplicated (3-day regime) and complicated UTIs 7 days and pyelonephritis (7-10 days), sexually transmitted diseases, prostatitis, skin and soft tissue infections *3rd gen*: e.g. levofloxacin: acute exacerbations of chronic bronchitis, community-acquired pneumonia *4th gen*: provide broad anaerobic coverage so can be used to intra-abdominal infections A/E *- ☠ ☠ TENDONITIS or TENDON RUPTURE ☠ ☠* - GI upset: n/v, diarrhoea: most common - ♒ CNS: headaches, nausea, vomiting, dizziness, confusion, ϟϟ seizures (if given IV) - ♡ CARDIOTOXICITY: ☠ *increased QT interval*: most of the time does not cause any problems otherwise can precipitate to fatal arrhythmias like VF and sudden death. Be wary of drugs such as amiodarone which can interact increasing the risk of this adverse effect occuring. - very rarely: Steven Johnson syndrome Warnings: - because they affect bone growth cells * ⛔ NEVER USE IN PREGNANCY OR IN CHILDREN* ⛔ - ciprofloxacin is a *P450 INHIBITOR* thus increasing the concentrations of other used drugs

insulin

note: all insulin is given s/c except for sliding scales which uses regular *SHORT ACTING INSULIN*. So if a drug chart shows medium or long acting insulin as IV... then it's wrong! Long acting insulin is of course maintained during VR sliding scale. *Rapid Acting* - huma*LOG* (lispro), novo*RAPID* (aspart), actrapid - just think of a 'log' rolling down the hill with rapid acceleration - start 15mins, peak 1 hour, lasts 3-4 hours *Short Acting* - regular insulin: insulin names will end in 'R' e.g. humul*IN R* - starts 30mins, peaks 3-5 hours, lasts 6-10 hours - these type of insulins are the only ones that can be given IV during VR sliding scale. *Intermediate Acting* - humulin e.g. NPH, lente, insulatard (isophane insulin comes in preloaded pens) - start 1 hour, peaks 6-12 hours, lasts 20-24 hours *Long Acting* - e.g. ultralente, glargine (lantus), detemir - starts 2-8 hours, peaks 12 hours, lasts 18-24 hours. - if a patient is taking this ON and has been switched to VR insulin, then they are to remain on their s/c dose of long acting drug. *Premixed insulin* - 70/30: NPH/regular - 50/50: NPH/regular - 75/25: NPH/humalog

combined oral contraceptives: why are they used? what do they? contraindications?

oral contraceptives suppress ovulation (egg release). ツ it offers protection against pregnancy ツ reduces the onset of painful periods (dysmenorrhoea). ツ produces regular and shorter periods (and frequently a decrease in menstrual cramps). ツ protect against ovarian and endometrial cancer however they are associated with a small risk of breast and cervical cancer :-( ツ protect against ectopic pregnancies and infections of the fallopian tubes. A/E: - nausea, breast tenderness, mild headaches, weight gain or loss. - very rarely, it can lead to thrombotic disease (e.g. blood clots, MI, and stroke) but risks are higher for women over 35 years who smoke. CONTRAINDICATIONS - personal history of venous or arterial thrombosis - severe or multiple risk factors for arterial disease - heart disease associated with pulmonary hypertension or risk of embolus - sclerosing treatment for varicose veins - migraine with aura - TIA without headaches - chorea - SLE - acute porphyria - gestational pemphigoid - gallstones - history of haemolytic uraemic syndrome - history during pregnancy of pruritus - cholestatic jaundice - personal or family history of breast cancer or surgery for breast cancer: but can be used after 5 years if no evidence of disease and non-hormonal methods unacceptable. Otherwise, recommend a copper intra-uterine device instead. - undiagnosed vaginal bleeding - avoid in pregnancy: there's no need for them since oestrogen and progesterone levels will already be high --> so get rid of them

what is the normal dose of levothyroxine prescribed?

over 18 years, - initially *25-100 MICROGRAMS OD*, preferably taken at least 30 minutes before breakfast, caffeine-containing liquids (e.g. coffee, tea), or other medication. Initial dose *25mcg* if there are cardiovascular risk factors - adjusted in steps of 25-50 micrograms every 3-4 weeks according to response (*usual maintenance dose 100-200 micrograms OD*) - in cardiac disease, severe hypothyroidism, and patients >50 years, *initially HALF THE DOSE @ 25 micrograms OD*, adjusted in steps of 25 micrograms every 4 weeks according to response (usual maintenance dose 50-200 micrograms once daily)

68 year old woman is admitted with worsening breathlessness and leg swelling involving both legs. PMH: diabetes type II (takes insulin), rheumatoid arthritis (treated with methotrexate) and migraine headaches in which she takes naproxen. O/e: raised JVP and has SaO2 of 85% (with air). RR 30/min, HR 91bpm, BP 150/70 mmHg. Bloods are normal. Propose the most likely diagnosis and treatment for this condition

pulmonary oedema but obviously a CXR should be taken to confirm and if it is due to CHF or non-heart related causes. treatment for acute HF - supportive therapy: sit patient up and give oxygen 15 litres/min (unless COPD) but not fluids because her BP is ok. If her BP was low, then you should prescribe the lowest dose of IV replacement fluids e.g. 0.9% NaCl 250ml within 15 minutes and continuously monitor his hydration status and U&E. *- IV FUROSEMIDE 40mg bolus* before 20-40mg of maintenance therapy of course with continuous hydration status and U&E monitoring. - if she was taking medications: search for fluid retention ones e.g. NSAIDs, prolonged corticosteroids, insulin, calcium channel blockers, certain antihistamines e.g cyclizine. note: - do not routinely offer opiates to people with acute HF - do not routinely offer nitrates to people with acute HF - beta blockers are contraindicated in acute HF

hypothyroid patient comes in for routine check up of levothyroixine levels. Their TSH levels are below: TSH <0.5 next best step?

reduce dose of levothyroxine If 0.5-5 then no change required if >5: then increase the dose of levothyroxine

phenobarbital: use and side effects

ϟϟ an anticonvulsant: 2nd line therapy (after BDZ) for status epilepticus and long term management for tonic clonic seizures. 3rd line after phenytoin for seizures in the acute setting A/E: - dependence - ⚠ *CNS DEPRESSION* ⚠: respiratory depression --> death - ⚠ *AGRANULOCYTOSIS* - thrombocytopenia - allergic skin reactions - ataxia, nystagmus, behavioural disturbances (irritability), lethargy, depression drowsiness; hallucinations, impaired cognition, impaired memory - hepatitis - hyperactivity particularly in the elderly and in children - hypotension - megaloblastic anaemia (may be treated with folic acid) Cautions: - avoid in the elderly: CNS depression likely - avoid in alcohol abusers: because of CNS depression!! - P450 inducer "PC *B*RAS" - contraindicated in pregnancy - withdrawal s/s: anxiety, insomnia

what to give in patient with n/v?

۞ *CYCLIZINE 50mg PO 8 hourly (TDS)* IM/IV/oral - beware that it can cause fluid retention because it is an antihistamine antiemetic. - it also has antimuscarinic effects: dry mouth, constipation, blurred vision, urinary retention, GI disturbances. ۞ *METOCLOPRAMIDE 10mg PO up to 8 hourly (TDS)* - give IM/IV if HF is present - beware since it is a dopamine antagonist, it can worsen Parkinson's Disease symptoms and those at risk of dyskinesia. others: ۞ *DOMPERIDONE PO 10 mg 6-hourly QDS*). A better alternative for metoclopramide since it doesn't cross the BBB so is safe in Parkinson's but it will still carry a low risk of dystonias and akathisia due to its dopamine antagonism. ۞ *ONDANSETRON: 4 mg, once-only dose* IM, IV usually used for the treatment of postoperative nausea and vomiting - common side effects: constipation, flushing, headache, injection site-reactions - rarely: arrhythmias, bradycardia, chest pain, hiccups, hypotension, movement disorders, seizures

in an acutely unwell/dehydrated patient: approach? and which IV fluids are required?

➀ always assess hydration status: *HR, RR, BP* mainly and later on (for maintenance) you can assess *urine output*. Early National Early Warning Score (NEWS) of >5 may also be used. *REPLACEMENT/RESUSCITATION IV fluids* for volume expansion in cases of hypovolaemia e.g. in haemorrhage, severe diarrhoea/vomiting, burns or sepsis. ➁ insert correct sized IV catheter and then give: ✔ *fluid bolus of 500 ml of a CRYSTALLOID* solution e.g. 0.9% NS or Hartmann's solution *over less than 15 minutes* (✔ *250ml for frail/CHF patients*). Continuously re-assess hydration status and the response to the fluids. remember: insert a urinary catheter and ask nurses to write up input/output chart ➂ If patient still needs fluid resuscitation, give a further fluid bolus of 250-500ml but ⚠️ *NO MORE THAN 2 LITRES IN TOTAL*!! If that is required seek expert help ⚠️ do not give IV 0.9% NaCl if you find out the patient is hypernatremic or hypoglycaemic. Give 5% dextrose solution instead.