Monitoring and advice part 2

Question 1

Simvastatin

Answer 1

1. Lipids (before starting)
2. CK
3. LFTs (3 months and 12 months)
4. hBa1c

Avoid with clopidogrel
Manage hypothyroidism before starting a statin.
Avoid in active liver disease.
If LFTs like ALT are raised over 3 times considering lowering dose. Not the same as raised CK. More than 3 times discontinue statin therapy.
If CK raised more than 5 times the limit, then recheck after 7 days and if still high discontinue

Question 2

Atorvastatin

Answer 2

1. Lipids (before starting)
2. CK
3. LFTs (3 months and 12 months)
4. hBa1c

Can exacerbate myasthenia gravis.
Manage hypothyroidism before starting.
Avoid atorvastatin in particular in haemorrhagic stroke.

Question 3

Beta blockers i.e. atenolol

Answer 3

1. Monitor lung function in patients with obstructive lung disease

Question 4

Digoxin

Answer 4

Measure plasma digoxin 6 hours after a dose.

Question 5

Amiodarone

Answer 5

Liver function tests before and every 6 months.
TFTs and then 6 months.
Serum potassium should be measured before treatment
Chest X ray before treatment.
IV use means ECG monitoring and resuscitation facilities

Shield skin due to phototoxicity.
Avoid concurrent use with fososbuvir.
Alert card should be provided.

Question 6

Dalteparin

Answer 6

Measure potassium if therapy will continue beyond 7 days

Question 7

IV GTN

Answer 7

Monitoring BP and HR with IV infusion.

Question 8

Dexamethasone

Answer 8

Monitor BP, weight, BMI, height, hba1c, triglycerides, potassium, eyes etc.

Question 9

Methotrexate

Answer 9

Have a blood count AND LFTs every 1-2 weeks, then every 2-3 months. Folinic acid if toxic levels.

Question 10

Azathioprine

Answer 10

TMPT testing required

Monitor full blood count weekly (more frequently with higher doses or if severe renal impairment) for first 4 weeks (manufacturer advises weekly monitoring for 8 weeks but evidence of practical value unsatisfactory), thereafter reduce frequency of monitoring to at least every 3 months.

Blood tests and monitoring for signs of myelosuppression are essential in long-term treatment.

Question 11

Ciclosporin

Answer 11

Dermatological and physical examination, including blood pressure and renal function measurements required at least twice before starting treatment for psoriasis or atopic dermatitis.

Monitor liver function.

Monitor serum potassium, especially in renal dysfunction (risk of hyperkalaemia).

Monitor serum magnesium.

Measure blood lipids before treatment and after the first month of treatment.

In psoriasis and atopic dermatitis monitor serum creatinine every 2 weeks for first 3 months then every month.

Investigate lymphadenopathy that persists despite improvement in atopic dermatitis.

Monitor kidney function—dose dependent increase in serum creatinine and urea during first few weeks may necessitate dose reduction in transplant patients (exclude rejection if kidney transplant) or discontinuation in non-transplant patients.

Monitor blood pressure—discontinue if hypertension develops that cannot be controlled by antihypertensives.

In long-term management of nephrotic syndrome, perform renal biopsies at yearly intervals.

In rheumatoid arthritis measure serum creatinine at least twice before treatment. During treatment, monitor serum creatinine every 2 weeks for first 3 months, then every month for a further 3 months, then every 4–8 weeks depending on the stability of the disease, concomitant medication, and concomitant diseases (or more frequently if dose increased or concomitant NSAIDs introduced or increased).

Monitor hepatic function if concomitant NSAIDs given.

Question 12

Metformin

Answer 12

Must monitor renal function before treatment and once a year.

Question 13

Levothyroxine

Answer 13

Monitor TSH every 3 months
Only measure T4 if symptoms persist for hypothyroidism

Question 14

Carbimazole

Answer 14

No routine monitoring

Question 15

Olanzapine

Answer 15

Monitor prolactin concentration at the start, 6 months and then yearly.
Physical health monitoring required.
Observe patient for 3 hours after injection.
Blood lipids and weight measured at baseline, at 3 months and then yearly.
Fasting glucose at 4-6 months

Change dose in renal impairment
A high risk of relapse if medication is stopped after 1-2 years.
Drowsiness with driving.

Question 16

Clozapine

Answer 16

Monitor prolactin concentration at the start, 6 months and then yearly.
Physical health monitoring required.
Weekly white blood cell monitoring for 18 weeks weekly and then fortnightly for a year.
Blood lipids at 3 months and then Fasting blood glucose at 4-6 months

Fatal risk of intestinal obstruction, faecal impaction and paralytic ileus.
Monitor blood concentration for toxicity
A high risk of relapse if medication is stopped after 1-2 years.
Drowsiness with driving.

Question 17

Lithium

Answer 17

Samples should be taken 12 hours after the dose to achieve a serum-lithium concentration of 0.4–1 mmol/litre (lower end of the range for maintenance therapy and elderly patients).
Routine serum-lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable, then every 3 months for the first year, and every 6 months thereafter

Question 18

Valproate

Answer 18

Use if lithium not effective
Monitor liver function before therapy and during first 6 months especially in patients most at risk.
Measure full blood count and ensure no undue potential for bleeding before starting and before surgery.