Patient Consultation Flashcards
Gabapentin -Key points
Used to treat Epilepsy and nerve pain caused by other conditions like Diabetes and shingles
In epilepsy it works by reducing electrical activity in the brain and down the spinal chord
Usually taken 3 times a day, with or without food
Most people have no side effects, some may feel sleepy, tired and dizzy
Common side effects are mild and usually go away by themselves
Don’t have to stay on the same brand as there is little differences between preparations
Some people can become addicted after taking them for a long period of time, when stopping Gabapentin it must therefore be done gradually to avoid withdrawal symptoms
Gabapentin - Dosing
- Each Capsule of Gabapentin contains 100mg,300mg,400mg,600mg and 800mg
- If you’re taking it as a liquid 2ml = 100mg of tablet or capsule
- The usual dose for adults and older children over 12, 900mg -3600 divided into 3 doses.
-Younger children aged 6-12 varies with their weight
The dose for never pain: 900-3600 3 times a day also - Changes in doses: to prevent side effects, doctor will start on a lower dose and it is increased gradually over the few days, once they find a suitable dose it will then gradually stay the same
Stopping Gabapentin: Important not to stop taking it suddenly even if you start to feel fine - it may cause serious problems.
If you have epilepsy, suddenly stopping Gabapentin will cause seizures not to stop and may lead to severe withdrawal -Feeling anxious, difficulty sleeping, feeling sick, pain and sweats
It is possible to reduce the symptoms by gradually reducing the dose gradually
Gabapentin- How to take it
-Brand name, Neurontin
- Swallow Gabapentin tablet whole with water, with or without food but its best to do the same each time
How to take it: If you have epilepsy its likely that once your condition is under control - you’ll still need to take gabapentin for many years
- if you’re taking it for nerve pain, once your nerve pain has gone, continue taking it for several months or longer to stop it coming back
If you forget to take a dose:
Take it as soon as you remember, If within 2 hrs of next dose, its better to leave it out miss a dose and return to your regular regimen
- Never take 2 doses at the same time, never take an extra dose to make up for missed one
If you have epilepsy make sure that you take this med regular, missing doses will trigger seizures - If you keep missing doses set alarms or ask pharmacist for help
Tinzaparin AND Enoxaparin
used for treatment of deep venous thrombosis - harmful blood clot in the leg could cause pulmonary embolism
Self injection- prep wash hands with soap and water and dry hands well
decide where to inject yourself soma only but not 5cm or 2 inches near belly button
skin may be sore plus chance of bruising - alternate sides of tummy
- sit or lie in suitable position so you can see they kin that you’re injecting
clean area with sterile wipe
Administarting - carefully remove the cap and syringe from plastic container
remove needle guard
ensure needle doesn’t touch anything else - gently squeeze a well defined part of the tummy with thumb and index finger
quickly insert needle straight down and all the way into fatty layer
- give the drug slowly - push the plunger down as far as you can pull needle out slowly - release skin slowly
disposal - DO NOT Replace needle guard after injection , put syringe in plastic container provider - bring it to us for disposal
possible se- anaemia
burning and itching pain and swelling , breathless ness chest or back pain sweating or collapse 111
Salbutamol
If you haven’t used it in a while it may need priming - instructions that came with it will show you how to do that
- take the cap off
look inside the mouthpiece to make sure that there’s nothing inside it
shake the inhaler hard 10 to 15 minutes before each use
breathe out all the way try and push out as much air as you can
okay so , hold the inhaler with the mouthpiece down place your lips around the mouth piece so that you form a tight seal
as you start to slowly breathe in through your mouth, press down on the inhaler one time
keep breathing in slowly as deeply as you can
hold your breath - take the inhaler out of your mouth if you can , hold your breaths you slowly count to 10 . this lets the medicine get deep into your lungs
- pucker your lips and breathe out slowly through your mouth
- wait for a bit and then take your next puff
- put the cap back on the mouth piece and make sure that it is firmly closed
- after using your inhaler - rinse yourmuth with water and gargle and spit - do not swallow the water, this helps reduce the side effects of the drug
remove l mouth piece and rinse with warm water then leave to dry
keep an eye on the counter to see before you run out
room temp and not too cold
Allendronic acid
Alendronic acid is a drug used for the treatment of osteoporosis. It works by slowing down the production of the cells that wear down bone (osteoclasts). This helps to improve bone strength and makes the bone less fragile.
When and how you take alendronic acid can affect whether it will work or not. It is very important that you follow these instructions exactly when taking your alendronic acid.
Take your alendronic acid tablet once a week (on the same day every week), first thing in the morning on an empty stomach with a large glass of tap water.
* Swallow the tablet whole.
* Never chew, crush or suck the tablet as this can cause side effects such as mouth ulcers and heartburn.
* Stay upright for the next 30 minutes. This is so the tablet stays in your stomach and it also reduces the risk of indigestion.
You could choose an upright activity such as taking a shower (but try not to bend down to pick anything up), or sitting in a chair and reading or watching television.
* Do not eat anything for at least 30 minutes, including taking any other medication. This will stop the treatment working and your bones will not be protected.
Do not take alendronic acid with:
* tea, coffee, juice, squash or even bottled water; it will not be absorbed properly and won’t be effective in protecting your bones.
Lithium
Lithium is a mood stabiliser. It is used to treat a variety of mood disorders including:
Bipolar disorder (both mania and hypo-mania)
Recurrent depressive episodes which have not responded to anti-depressants
Lithium is prescribed in both tablet and liquid form. It is likely you’ll be told the form and dosing regimen the patient has been prescribed in the brief.
Inform the patient to swallow the medication with plenty of water.
Patients are often encouraged to take lithium at night, although this isn’t essential. The patient can choose when to take it, but you must encourage them to take the medication at the same time every day.
Inform the patient that they should not stop taking lithium suddenly or change their dose without speaking to their doctor first.
If a patient misses a dose of lithium, inform them not to take a double dose and instead to take their next dose as normal.3
Mention that patients on lithium will receive a lithium record book.1 They should take this book to all of their appointments to help keep track of their blood test results. Encourage the patient to carry this book with them at all times in case of emergency, particularly if going on holiday.
Lithium may take several weeks or months to begin working. Explain to the patient that it takes several weeks to get the dose of lithium correct. To do this we will need to take a blood sample every week at the beginning of your treatment.
The lithium level must always be measured 12 hours after their previous dose. Once the lithium level is stable the frequency of blood tests will decrease to once a month, and finally once every 3 months.2
In addition, the patient will require six-monthly thyroid function tests, urea and electrolytes and calcium monitoring.2
Lithium can cause a range of side effects that the patient needs to be warned about.
There are several common side effects that are usually mild and self-resolving:2
Increased thirst
Increased volume and frequency of urination
Tiredness
Weight gain
Fine tremor
Inform the patient that if the above side effects don’t improve with time, the patient should book a consultation with their doctor.
It is also important to explain more concerning side effects associated with lithium toxicity which can be life-threatening.
Encourage the patient to seek urgent medical attention if they experience any of the following:
Confusion
Drowsiness
Problems with vision
Loss of appetite
Difficulty speaking
Seizures
Excessive thirst and urination
Explain to the patient that the risk of toxicity is reduced by taking their dose at the same time every day and regularly attending to have their blood tested.
Reassure the patient that lithium has been prescribed for decades and is safe when taken as prescribed with appropriate monitoring in place.
If the patient is a female of childbearing age (commonly used in lithium counselling OSCEs), it is vital to discuss the risk of taking lithium during pregnancy.
Remember to discuss the risks with the patient using language that is easy to understand.
Although the evidence isn’t clear, it is important to inform the patient of the following risks:2,4
Lithium associated birth defects generally occur within the first trimester of pregnancy when the fetal organs are developing
Lithium has been shown to increase the risk of fetal heart defects
Lithium is able to pass into the baby’s circulation through breastmilk and breastfeeding should therefore be avoided
Advise the patient that they should use a reliable method of contraception such as a subdermal implant or intrauterine system (IUS) to prevent accidental pregnancy whilst taking lithium.
Encourage the patient to speak to their psychiatrist if they begin to consider starting a family so that an appropriate plan can be put in place. This may involve considering alternative treatment options during pregnancy or making an informed decision to continue treatment with an understanding of the associated risks to both mother and baby.4
Methotrexate
Methotrexate is a disease-modifying anti-rheumatic drug (DMARD), i.e. an immune system suppressant, used as a first-line treatment for certain autoimmune conditions including rheumatoid arthritis and psoriatic arthritis.1,2 It can also be used in the treatment of Crohn’s disease and ectopic pregnancies.3,4
Its mode of action is via blocking the action of the enzyme dihydrofolate reductase, thus inhibiting the reduction of dihydrofolate into tetrahydrofolate.4
At higher doses, methotrexate can also be used as an anti-neoplastic agent in certain cancer treatment regimens due to its action on cell division. Common oncological treatment regimens in which it is used include acute lymphoblastic leukaemia, non-Hodgkin’s lymphoma and lung/breast cancers.1,3,4
Methotrexate tablets are prescribed as a once-weekly dose and are taken on the same day each week.2,3
Starting doses may vary for different conditions. For example, the starting dose for rheumatoid arthritis is 7.5mg whereas psoriasis is anywhere between 2.5 mg and 10 mg.3
To avoid errors with methotrexate prescriptions, it is recommended that only one strength of methotrexate tablet (usually 2.5mg) is prescribed and dispensed. It is good practice to decide with the patient which day of the week they will take their dose and write this down in full on the prescription.6
Folic acid should be co-prescribed with methotrexate. It can be taken once weekly on the day after the methotrexate dose, or it can be taken once daily every day except on the day of the methotrexate dose.1,2
Folic acid reduces the side effects of methotrexate. It can decrease mucosal and gastrointestinal side effects and may prevent liver toxicity.6
Folic acid should never be taken on the same day as methotrexate as it can impair the efficacy of the medication.2
Patients and carers should be informed of the potentially fatal risk of overdose if methotrexate is taken more frequently than once a week, and emphasise that it should never be taken daily. If an overdose does occur, immediate medical attention must be sought.6
Patients should swallow the methotrexate tablets whole with a drink of water. The tablets can be taken before or after food.
Advise the patient to wash their hands after touching the tablets.
Advise the patient that if they forget to take a dose, to take it as soon as they remember the next day or the day after. If the dose is more than two days late, they must contact their GP or clinic for advice. Patients should be advised to never take two doses together to make up for a missed dose.1
As with all medications, there are side effects associated with methotrexate use, some more serious than others.
Educating the patient about the signs associated with serious side effects, and the importance of seeking prompt medical attention should these develop, is an important part of methotrexate counselling.
Patients who are prescribed methotrexate will be issued a treatment booklet to take with them to all appointments and an alert card to advise healthcare professionals that they are taking methotrexate.
Common side effects of methotrexate include:1,2,3
Loss of appetite
Nausea
Indigestion
Diarrhoea
Headaches
Tiredness
Hair loss
Rare but serious side effects of methotrexate include:1,2,3
Liver toxicity: jaundice
Pulmonary toxicity: persistent cough, chest pain, dyspnoea
Renal toxicity: peripheral oedema, polyuria
Signs of infection: fever, chills, muscle aches, sore throat
Thrombocytopenia: bleeding gums, haematuria, unexplained bruising
Stevens-Johnson syndrome: severe skin rash or blisters on skin, mouth, eyes or genitals
Some medicines can affect the way methotrexate works, therefore it is important to advise patients to discuss new medications with a healthcare professional.
When NSAIDs (e.g. ibuprofen) are taken with methotrexate there is an increased risk of toxicity.
Trimethoprim or co-trimoxazole (septrin) co-prescribed with methotrexate can be fatal. This is due to an additive effect of inhibiting dihydrofolate reductase, which increases the risk of bone marrow suppression. This can occur even with short courses and low doses, therefore these drugs must never be co-prescribed.
As mentioned above, there is a risk of bone marrow suppression as well as gastrointestinal, liver and pulmonary toxicity when a patient is taking methotrexate, therefore it is important to monitor the patient closely.3
When beginning treatment, full blood count, renal and liver function tests should be carried out every 1-2 weeks until the therapy is stabilised. Thereafter, patients should be monitored every 2-3 months.3
In addition, testing for viral hepatitis and tuberculosis before starting methotrexate may be required. These results are required before commencing further treatment options should methotrexate be ineffective.
In women of childbearing age, pregnancy should be ruled out before commencing methotrexate. In addition, advice on the use of highly effective contraception methods (e.g. long-acting reversible contraceptives) should be given. Methotrexate is contraindicated in pregnancy and breastfeeding due to its risk of teratogenicity. This point should be emphasised to any young, female patients being counselled about methotrexate.3
Apixaban
Indication for treatment doses: Prevention of stroke and systemic embolism in adult patients with non-valvular AF (NVAF*) with additional risk factor(s); treatment of DVT /PE in adults and prevention of recurrent VTE.
*NVAF - considered to be AF in the absence of a mechanical valve replacement or moderate to severe mitral stenosis usually of rheumatic origin; Ref Heidelbuch et al. Eurospace 2015
3. Alternative anticoagulants: eg. warfarin/acenocoumarol,low molecular weight heparin (e.g. dalteparin), other DOACs
4. Advantages (vs. warfarin): fixed dose, INR monitoring not required, more stable anticoagulation control if taken reliably, favourable major bleeding profile overall, lower incidence of intracranial haemorrhage, less drug/diet interactions, easier to manage around surgery/procedures
Disadvantages (vs. warfarin):not appropriate for all pts (e.g extremes of body weight, renal impairment), some monitoring still required (eg renal function) although less frequent compared to INR monitoring,higher incidence of GI side-effects (dabigatran, rivaroxaban), no specific drug antidote (except dabigatran; others under development), limited long-term data
10. Side effects (and what to do if experienced)
Seek medical attention: Bloody /black tarry stools, coughing/vomiting up blood, bloody urine, nose bleeds (lasting
for > 5-10mins or if pt does not usually suffer from nose bleeds), severe or spontaneous bruising, unusual
headaches, excessive vaginal bleeding, cuts that take longer than 5 minutes to stop bleeding, blood shot eye.
Seek immediate medical attention: involved in major trauma, significant blow to the head or are unable to stop
bleeding
GP/anticoagulation clinic: any other side-effects e.g. gastrointestinal (higher risk of GI bleeding with dabigatran
150 mg, rivaroxaban or edoxaban 60 mg vs warfarin)
11. Monitoring: dose will need to be reduced / stopped if renal function deteriorates. Frequency of monitoring usually depends on the level of renal function (but also other parameters); may vary from minimum 3monthly (more frequently if potentially brittle renal function) to 6-12monthly. Also, FBC (when renal function checked) and LFTs (minimum annually).
12. Potential for drug interactions: may be affected by some medicines / herbal preparations (see SPC for relevant DOAC):
Always let doctor/dentist/pharmacist know that s/he is on anticoagulation
Avoid over the counter medications containing aspirin (e.g. cough &cold remedies) and NSAIDs such as ibuprofen,
aspirin, naproxen, diclofenac etc. Paracetamol is preferred. Avoid herbal medications (unknown interactions)
NB: any proposed/concurrent prescription of an antiplatelet MUST be discussed with referrer and haematologist; if aspirin or clopidogrel are unavoidable, consider using DOAC with lowest GI bleeding risk and add PPI cover. Avoid use with prasugrel / ticagrelor.
13. Alcohol: is not expected to affect DOAC levels per se. Excess alcohol consumption and binge drinking not advised, due to risks of alcohol associated acute injuries (e.g. head injuries) and chronic liver disease (which may affect coagulation). Also at higher risk of GI bleeding
14. Contraception, pregnancy, hormone replacement therapy, breastfeeding (if relevant): Women should not become pregnant nor breast feed whilst taking DOAC. Reliable contraception is required. For women with current or PMH VTE, oestrogen containing preparations are generally avoided (progesterone only preparations are preferred). Women taking a DOAC and who may be pregnant, should be switched urgently to low molecular weight heparin and referred for urgent review by a haematology consultant / obstetrician for discussion re potential implications. If planning to become pregnant, then patient should discuss with GP for onward referral to a haematologist to be advised on switch to alternative anticoagulant BEFORE conception.
15. Surgical procedures (including dental treatment) and hospital admission: patient must inform healthcare professional that s/he is taking DOAC especially as:
patient will need management of anticoagulation around procedures and
VTE thromboprophylaxis (e.g. LMWH) is often prescribed on admission to hospital.
18. Obtain further supplies of DOAC from the hospital (or GP once care transferred). Not to run out of supplies, especially when on holiday.
19. Further advice/info from local A/C clinic, GP, Hospital pharmacy medicines info dept or in an emergency, A&E dept
Amiodorone
ndication – it works by controlling the irregular beating of your heart and helps it return to normal.
Dose and frequency – provide information about the loading dose if/as appropriate, explain why we are loading and that on treatment discontinuation amiodarone stays in the body for up to 3 months.
Do not take if allergic to iodine.
Discuss with your pharmacist or doctor if you are intolerant to lactose.
Duration of treatment.
Importance of compliance and what to do if you take more amiodarone than you should or forget to take it – refer to patient information leaflet and report as/if appropriate to GP or out of hour service. Symptoms of amiodarone overdose: dizziness, fainting, feeling tired and confused, slow heartbeat, nausea and vomiting.
Do not stop taking amiodarone until your doctor tells you to do so.
Do not drive if you experience any blurred vision after taking amiodarone.
Possible interactions with other medications including herbal remedies – advise patient to discuss with pharmacist or GP before taking any OTC remedies.
Food interactions – do NOT drink grapefruit juice (increases the chances of getting side effects), and limit the amount of alcohol (increases the chances of liver problems).
Monitoring required before and while on amiodarone:
Yearly eye test
Regular blood tests including liver function
Regular thyroid tests
ECG
Chest X-rays
If you develop a new or progressive cough you should see the GP to rule out pneumonitis.
Possible side effects:
Eyes – blurred or colourless vision, loss of eyesight, painful, sore and tender eyes; corneal micro- deposits which can lead to being dazzled by bright headlights if driving at night (these are reversible on withdrawal).
Thyroid – sign of hyperthyroidism (increased sweating, restless, weight loss) or hypothyroidism (run-down, tiredness, weight gain).
Heart – palpitations (report to 999).
Lungs – chest tightness, difficulty of breathing, fever, flu like symptoms, persistent cough.
GI – change in taste, feel tired of sick, yellowing of the skin or eyes, stomach pain and discomfort.
Skin – blister or peeling of the skin around the eyes, lips, mouth, nose and genitals.
Advise to seek urgent medical attention if feeling numb or weak, tingling or burning feelings in any part of your body.
Advise patient to seek medical advice if planning to become pregnant or breastfeed.
Additional information:
Keep out of direct sunlight while taking this medicine and for a few months after you have finished taking it. This is because the skin will become much more sensitive to the sun and may burn, tingle or severely blister. Advise to always use high factor sunscreen and wear a hat and clothes that cover head, arms and legs.
Inform other healthcare professionals where necessary that you are on amiodarone or have recently stopped it.
Provide patient with patient information leaflet
Warfarin
Using patient-friendly language, explain how warfarin works.
“Warfarin is a type of medicine known as an anticoagulant. It helps to thin the blood, making it less likely that a dangerous blood clot could form.”
“Warfarin can be used to treat people who have a previous blood clot in the leg or lungs. It can also be used to prevent future blood clots in people who are at high risk of having them in the future, such as people with an irregular heartbeat or an artificial heart valve.”
“The action of warfarin can be rapidly reversed with an antidote in situations where we need to reduce the risk of bleeding.”
Explain the role of INR in monitoring the effect of warfarin.
“The INR is a measure of how long it takes blood to clot. In healthy people an INR of 1 is normal. Since you are at a higher risk for blood clots we want your blood to be thinner than normal and therefore take longer to clot. As a result, the target range for your INR would be between 2-3, meaning it takes two to three times as long for your blood to clot compared to someone not taking warfarin.”
“In order to ensure that we keep your blood within the necessary range we will need to monitor your INR level every so often; this is done through a blood test. The blood tests will initially be frequent (every 3-4 days until two consecutive readings are within range), and then after this, you will be tested twice weekly for 1-2 weeks (again until two consecutive readings within range). Thereafter, testing can increase to longer periods (e.g. every 12 weeks). Your dose of warfarin will be adjusted based on the INR results with the aim of keeping it within the target range.”
Key points to communicate when discussing warfarin use:
“Warfarin should be taken at the same time each day to keep the levels of warfarin steady.”
“Tablets have different colours depending on their strength (e.g. 0.5mg white; 1mg brown; 3mg blue; 5mg pink).”
“If you forget to take a dose you should take it as soon as you remember, but if you don’t remember till the following day you should skip the missed dose. You should never take two doses together to make up for a missed dose and you should inform your doctor or warfarin clinic about any missed doses at your next appointment.”
“Whenever you are going to purchase or be prescribed a new medication you should let the doctor or pharmacist know that you take warfarin so they can avoid prescribing medications which alter your warfarin level.”
“When you start taking a new medication you should let your doctor or anticoagulant clinic know so that they can consider if your warfarin levels need monitoring more frequently.”
“You should continue to take your warfarin tablets regularly until you have been told to stop.”
“Warfarin is not safe to be used during pregnancy and therefore you should have an effective contraceptive method in place before you start taking warfarin.”
Bleeding whilst on warfarin
The main side effect of warfarin involves bleeding more easily than normal (e.g. epistaxis, bleeding gums, heavier periods, bruising). These side effects most commonly occur in the first few weeks of treatment or when the patient is unwell. It is important to discuss the different types of bleeding the patient may experience and inform them what to do in these situations.
Less serious bleeding
“It is normal to bleed more easily when taking warfarin as the medication works by thinning the blood. Common types of bleeding include:
periods that are heavier and last longer than normal
bleeding for a little longer than usual if you cut yourself
occasional nosebleeds (that last for less than 10 minutes)
bleeding from your gums when you brush your teeth
bruises that come up more easily and take longer to fade than usual
This type of bleeding is not dangerous and should stop by itself. If it happens, keep taking the warfarin, but tell your doctor if the bleeding bothers you or does not stop.”
Serious bleeding
“Occasionally, you can have serious bleeding from taking warfarin. This can be dangerous and needs urgent medical attention.”
“Stop taking warfarin and call your doctor or anticoagulant clinic, or go to A&E if you experience:
red pee or black poo
large bruises or bruises that happen for no reason
nosebleeds that last longer than 10 minutes
blood in your vomit or you’re coughing up blood
severe headaches, fits (seizures), changes to your eyesight, numbness or tingling in your arms or legs, or feel very tired, weak or sick – these can be signs of bleeding in your brain
any bleeding from a cut or injury that will not stop or slow down”
Other side effects of warfarin
Common side effects
Common side effects (other than bleeding) of warfarin include:
a mild rash
hair loss
These side effects are typically mild and the patient should be advised to contact their doctor or pharmacist if they become bothersome.
Serious side effects
Serious side effects of warfarin can include:
jaundice
skin necrosis
As a result, patients should be advised to seek urgent medical review if they develop:
yellowing of the skin
painful swollen areas of skin
Lifestyle advice
Diet
Drastic changes in diet, especially an increase in consumption of foods high in vitamin K (such as broccoli, kale, or spinach) can potentially affect control of anticoagulation. If the patient ever wishes to significantly change their diet, they should inform the anticoagulant clinic so necessary dose adjustments and monitoring requirements can be fulfilled. Cranberry juice is also known to interact with warfarin and enhance its anticoagulant effect and therefore it should be avoided.
Alcohol
Patients should limit their alcohol intake to a maximum of one or two drinks a day and never binge drink. If there are major changes in alcohol consumption (e.g. the patient stops drinking, or starts drinking more) the INR can be affected.
Other
Patients should be advised to take extra care when carrying out routine tasks such as brushing teeth or shaving; a soft toothbrush or an electric razor can help. Patients should also be advised to inform their dentist that they take warfarin when booking an appointment as this may have implications for dental procedures.
Yellow booklets and alert card
At the start of treatment, all patients should be provided with two yellow anticoagulant booklets, an INR monitoring booklet and a patient information booklet. Patients should also be provided with an anticoagulant alert card.
Patients should be advised to always carry the anticoagulant alert card with them in case of an emergency and always take the yellow INR monitoring book with them to each appointment at the anticoagulant clinic and if possible to other appointments (e.g. GP, pharmacy reviews, dental appointments etc).
The patient information book is a useful resource since it provides the patient with a point of reference and reinforces what has been covered in this guide.
Digoxin
USE: heart failure (with atrial fibrillation)
This medicine is called a cardiac glycoside which is indicated for heart failure, especially in patients with atrial fibrillation (heart ‘flutter’). Digoxin has complex activity, where it increases the contraction force of the heart but also slows the rate at which the heart pumps (useful in fibrillation).
It also has a very low therapeutic index, because there is a narrow difference between optimal therapeutic dose and toxicity so special care is taken by your doctor when prescribing digoxin.
Caution:
Previous digoxin (digitallis) toxicity
Elderly (special care with kidney impairment)
Hypokalaemia (low potassium levels causes toxicity)
Recent MI (heart attack)
Hypothyroidism
Pregnancy and breast-feeding (discuss with doctor)
Side effects:
Usually dose-related: anorexia (loss of appetite), abdominal pain, stomach upset (nausea, diarrhoea), headache, fatigue, drowsiness, mind disturbances (confusion, delirium, hallucinations).
Overdose: heart block and arrhythmias (disturbances in the rhythm of the heart).
Interactions:
Increased toxicity with quinine, calcium-channel blockers, anti-arrthymias and possibly ACE-Inhibitors. Hypokalemia (low potassium levels) associated with diuretics, lithium and corticosteroids give rise to increased toxicity. Antacids and anion-exchange resins impair absorption of digoxin.
Patient information:
Follow the instructions carefully on the label of this medicine
Do not stop taking this medicine unless directed by your doctor
Food: take with food if this medicine upsets your stomach or as directed
Antacids: take 6 hours apart to prevent impaired absorption
Missed dose: take the next dose as soon as you remember (don’t double dose)
Avoid taking other medicines unless directed by your doctor/pharmacist
Regular monitoring of plasma-digoxin levels maybe needed if you are on diuretic therapy (discuss with doctor)
Contact your doctor or seek urgent medical help if side effects occur or overdose is suspected
Risedronate sodium
Risedronate is a drug used for the treatment of osteoporosis. It works by slowing down the production of the cells that wear down bone (osteoclasts). This helps to improve bone strength and makes the bone less fragile.
When and how you take risedronate can affect whether it will work or not. It is very important that you follow these instructions exactly when taking your risedronate.
Take your risedronate tablet once a week (on the same day every week), first thing in the morning on an empty stomach with a large glass of tap water.
* Swallow the tablet whole.
* Never chew, crush or suck the tablet as this can cause side effects such as mouth ulcers and heartburn.
* Stay upright for the next 30 minutes. This is so the tablet stays in your stomach and it also reduces the risk of indigestion.
You could choose an upright activity such as taking a shower (but try not to bend down to pick anything up), or sitting in a chair and reading or watching television.
* Do not eat anything for at least 30 minutes, including taking any other medication. This will stop the treatment working and your bones will not be protected.
Do not take risedronate with:
* tea, coffee, juice, squash or even bottled water; it will not be absorbed properly and won’t be effective in protecting your bones.
Tiotropium -Sirvia and Bradtus
What is the most important information I should know about tiotropium inhalation?
A tiotropium capsule is for use only in the HandiHaler device. Do not take the capsule by mouth. Use only one capsule at a time.
What is tiotropium inhalation?
Tiotropium inhalation is a bronchodilator that is used to prevent bronchospasm (narrowing of the airways in the lungs) in adults with COPD (chronic obstructive pulmonary disease), including bronchitis and emphysema.
Tiotropium inhalation is also used to prevent asthma attacks in adults and children who are at least 6 years old.
Tiotropium inhalation may also be used for purposes not listed in this medication guide.
What should I discuss with my healthcare provider before using tiotropium inhalation?
You should not use this medicine if you are allergic to tiotropium or ipratropium (Atrovent, Combivent, DuoNeb).
Tell your doctor if you have ever had:
narrow-angle glaucoma;
kidney disease;
a milk allergy; or
an enlarged prostate or urination problems.
Tell your doctor if you are pregnant. It is not known whether tiotropium will harm an unborn baby. However, having uncontrolled asthma during pregnancy may cause premature birth, a low birth weight baby, or complications such as eclampsia (dangerously high blood pressure that can lead to medical problems in both mother and baby). The benefit of treating asthma may outweigh any risks to the baby.
It may not be safe to breast-feed while using this medicine. Ask your doctor about any risk.
Tiotropium inhalation is not approved for use by anyone younger than 6 years old.
How should I use tiotropium inhalation?
Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed.
Tiotropium inhalation is not a rescue medicine for bronchospasm attacks. Use only fast-acting inhalation medicine for an attack. Seek medical attention if your breathing problems get worse quickly, or if you think your medications are not working as well.
Read and carefully follow any Instructions for Use provided with your medicine. Ask your doctor or pharmacist if you do not understand these instructions.
Tiotropium inhalation powder is packaged in capsules that are for use only with a special inhaler device (Spiriva HandiHaler). Do not take the capsule by mouth.
Tiotropium inhalation aerosol is a cartridge that is inserted into a special inhaler device (Spiriva Respimat). Turning the base of the Respimat device until it clicks will release the medicine into the inhaler chamber.
Any child using tiotropium inhalation should be supervised by an adult while using this medicine.
You may need frequent lung function tests.
Store this medicine at room temperature away from moisture and heat. Do not freeze.
Do not remove a tiotropium capsule from its blister pack until you are ready to place the capsule into the HandiHaler and use the device.
What happens if I miss a dose?
Use the medicine as soon as you can, but skip the missed dose if it is almost time for your next dose. Do not use two doses at one time.
Do not use more than two times in a 24-hour period.
Get your prescription refilled before you run out of medicine completely.
What happens if I overdose?
Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.
Overdose symptoms may include dry mouth, eye redness, constipation, stomach pain, and confusion or drowsiness.
What should I avoid while using tiotropium inhalation?
Avoid getting the powder from a tiotropium capsule in your eyes. If this does happen, call your doctor.
Avoid driving or hazardous activity until you know how this medicine will affect you. Your reactions could be impaired.
What are the possible side effects of tiotropium inhalation?
Get emergency medical help if you have signs of an allergic reaction: hives, itching; difficult breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have:
wheezing, choking, or other breathing problems after using this medicine;
blurred vision, eye pain or redness, seeing halos around lights;
sores or white patches on your mouth, lips, or tongue;
pain or burning when you urinate; or
little or no urinating.
Common side effects may include:
dry mouth;
blurred vision;
constipation, painful urination;
upset stomach;
chest pain, fast heart rate; or
cold symptoms such as stuffy or runny nose, sinus pain, sore throat.
This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
What other drugs will affect tiotropium inhalation?
Tell your doctor about all your other medicines, especially:
medicine to treat depression, anxiety, mood disorders, or mental illness;
cold or allergy medicine (Benadryl and others);
medicine to treat Parkinson’s disease;
medicine to treat stomach problems, motion sickness, or irritable bowel syndrome;
medicine to treat overactive bladder; or
bronchodilator asthma medication.
This list is not complete. Other drugs may affect tiotropium, including prescription and over-the-counter medicines, vitamins, and herbal products. Not all possible drug interactions are listed here.
Symbicort
Symbicort contains a combination of budesonide and formoterol. Budesonide is a corticosteroid that reduces inflammation in the body. Formoterol is a long-acting bronchodilator that relaxes muscles in the airways to improve breathing.
symptoms of chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.
Turbuhalers can be used by children over 8, and adults.
Shake your inhaler well for 5 seconds.
2. Remove the mouthpiece cover by squeezing gently at both sides, then pulling out, as seen here. Check the mouthpiece for foreign objects.
3. Breathe out fully, then place the mouthpiece into your mouth and close your lips around it. Make sure that the inhaler is upright and that the opening of the mouthpiece is pointing towards the back of your throat. Inhale deeply and slowly while pressing down firmly on the top of the counter on the inhaler.
4. Continue to breathe in and hold your breath for about 10 seconds, or for as long as comfortable. Before you breathe out, release your finger from the top of the counter. Keep the inhaler upright and remove from your mouth.
For your second puff, shake the SYMBICORT inhaler again for 5 seconds and repeat steps 3 and 4.
AFTER USING THE SYMBICORT INHALER
After use, close the mouthpiece cover by pushing until it clicks in place. After you finish taking SYMBICORT (two puffs), rinse your mouth with water. Spit out the water. Do not swallow it.
REMEMBER
Use SYMBICORT twice a day, morning and evening. While taking SYMBICORT, never use another medicine that contains a LABA. SYMBICORT is not, and will not replace, a rescue inhaler for sudden symptoms. Contact your doctor if your asthma does not improve or gets worse. If you have any questions about using your inhaler, contact your health care professional.
I’ve had Symbicort Turbohaler before, so will my new inhaler be different to the one I used before?
No, your Symbicort Turbohaler will be the same as before. But now you will also use your Symbicort Turbohaler when you would have used your reliever (blue) inhaler previously.
What should I do if I forget to take one of my morning or evening doses of Symbicort Turbohaler?
You should take a dose as soon as you remember. However, if it is nearly time for your next dose, skip the missed dose. Do not take a double dose to make up for a forgotten dose. If you have any further questions on the use of this medicine, ask your doctor, nurse or pharmacist.
How can I tell how many inhalations are left in my inhaler?
When there are 20 doses remaining, a red band will appear at the top of the dose counter window, to remind you to request a new Symbicort Turbohaler. When the ‘0’ that appears on the red background reaches the middle of the counter, you must start using your new Symbicort Turbohaler
I am worried about not having my blue reliever inhaler anymore
Some people can find it difficult getting used to a new routine and worry that they will still need their blue reliever inhaler. But, because Symbicort Turbohaler contains a reliever, it will help relieve your symptoms as quickly as your blue reliever would have. This means that you will no longer need a separate blue inhaler to use as
a reliever.
If you are doing exercise and you get asthma symptoms you can use Symbicort Turbohaler. It is important that you discuss with your doctor the use of Symbicort Turbohaler
to prevent asthma symptoms from happening; how often you exercise or how often you are exposed to allergens could impact the treatment that is prescribed to you.
