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1st/2nd Line Treatment Flashcards

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1
Q

TTP

A

1st: Plasma Exchange
2nd: Steroids, rituximab
3nd: Splenectomy

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2
Q

Type 2 Diabetes Mellitus

A

1st: Metformin (Biguanide)

2nd: Add one:
- Want to lose weight / Heart disease: Dapagliflozin (SGL2-I)
- Can gain weight: Gliclazide (Sulfanylurea)
- Weight-Neutral: Sitagliptin (DPP4)

3rd line: Add another of the above

4th line: Swap one of the above for another.

5th line: Insulin

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3
Q

Hyperthyroidism

A

1st line: Multiple, depends on the patient.

  • Radioactive Iodine: Don’t use in pregnancy
  • Thyroidectomy + Levothyroxine
  • Carbimazole +- Levothyroxine.
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4
Q

Hypothyroidism

A

1st line: Titrate levothyroxine.

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5
Q

Prolactinoma

A

1st line: Cabergoline (Dopamine agonist).

Gold standard: Transsphenoidal surgery.

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6
Q

Acromegaly

A

Gold standard and 1st line:
Transsphenoidal surgery

2nd line(surgery refused):
SST analogue (Octreotide)

3rd line: Cabergoline/Bromocriptine (Dopamine agonist).

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7
Q

Neurogenic Diabetes Insipidus

A

1st line: Desmopressin + Thiazide.

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8
Q

Renal Colic

A

1st line:
IM Diclofenac
Expectant +-tamsulosin (∂-blocker) considered for stones <5mm

2nd line (Post NC-CTKUB):
-Lithotripsy if the stone is 5-20mm
-Uteroscopy if stones 10-20mm (overlap)
-Percutaneous Lithotomy if stones >20mm.

Pyelonephritis / Hydronephrosis:
-Emergency decompression

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9
Q

Gout

A

Acute 1st line: Colchicine (Anti-inflammatory)

Long-term 1st line: Allopurinol

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10
Q

Rheumatoid arthritis

A

1st: DMARD:
Methotrexate / Leflunomide / Sulfasalazine (pregnant)

(NSAIDs and steroids while initiating MTX “Bridging”).

2nd: TNF-Blockers e.g., Infliximab

Glucocorticoids for flare-ups

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11
Q

ITP

A

No treatment required for children.

1st: glucocorticoids - prednisolone, IV IgG
2nd: Rituximab / High dose dexamethasone

Final resort: Splenectomy

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12
Q

Asthma

A

1st: SABA e.g. Salbutamol
2nd: Weak ICS e.g. Beclamethosone
3rd: LTRA e.g. Montelukast
4th: Stop LTRA and go for LABA e.g. Salmeterol
5th: Strong ICS e.g Beclamethosone

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13
Q

Migraine

A

-Mild-Moderate: Paracetamol and NSAIDs

-With Aura: Sumatriptan (Serotonin Agonist)

-Vomiting: Metoclopramide (Anti-Emetic)

-Prophylaxis:
1st line: Propanolol
(Avoid asthma)

2nd line: Topirimate
(Avoid Preg)

3rd line: Amitryptaline

Failure: 10 sessions of acupuncture.

Menstrual Migraines: Triptan mini-prophylaxis

Other: Riboflavin (vB2) OD

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14
Q

Polycythaemia

A

1st line:
-Aspirin OD
-Regular venesection

Other:
-Allopurinol (Gout prophylaxis)
-Hydroxycarbamide

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15
Q

Hypocalcaemia

A

1st: IV Calcium gluconate 10mL 10% over 10 mins if severe.

2nd: AdCal + Treat underlying.

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16
Q

Addison’s disease

A

1st line: oral glucocorticoids

Adrenal crisis - IV saline and hydrocortisone

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17
Q

Hypoglycaemia

A

1st:
Glucogel 10-20g PO if they have a safe-swallow.

2nd:
-IV Glucose 20% (If you have access)

3rd:
IM Glucagon if no IV access (LESS EFFECTIVE IF ON SULFANYLUREA)

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18
Q

Heart Failure (Reduced EF)

A

1st: ACE-I and Beta-Blocker (No mortality benefit in PRESERVED-EF)

2nd/Preserved EF: Spironolactone +-SGLT2-Inhibitors

3rd: Possibly Ivabradine (If HR >75 and LVEF < 35%) / Digoxin

Always add some furosemide if symptoms; no good for mortality.

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19
Q

Heart Failure (Preserved EF)

A

1st: SGLT-Inhibitor; Dapagliflozin

(ACE-Is and Beta-Blockers have no mortality benefit)

Always add furosemide for symptoms; no mortality benefit.

May deteriorate to reduced EF; Go to that treatment then.

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20
Q

Paget’s disease

A

1st: Analgesia & bisphosphonates
2nd: Surgery to correct bone deformities

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21
Q

Osteoporosis

A

1st line: AdCal-D3 & bisphosphonates

2nd line: Denosumab – monoclonal antibody to RANK ligand

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22
Q

Supraventricular tachycardia

A

Acute:

  • Valsalval maneuver
  • Adenosine (or Verapamil in asthmatic pt)

Long term: ß-blockers, Ca-blockers, Amiodarone (K+ blocker)

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23
Q

Tension pneumothorax

A

1st: Needle decompression - 2nd intercostal space, midclavicular
2nd: Chest drain

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24
Q

Simple Pneumothorax

A

1st:
-No Symptoms: even if large: Observe +-O2 over 4-6 hours and discharge.

-Symptoms AND >2cm (or safe to intervene):
Assess high-risk characteristics:
Smoke and >50, Hypoxia / Haemodynamic Instab, Bilateral, or SECONDARY, or FAILED NEEDLE.

Present = CHEST DRAIN
Not Present = NEEDLE

-Success when <2cm afterwards.
-EVERY secondary patient will get admitted for monitoring.
-All patients followed-up in 2-4 weeks.

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25
Oesophageal varices
1st: ABCDE: IV Fluids + Telipressin + Prophylactic Abx +- Blood transufsion 2nd: Urgent Endoscopy: -Band ligation if possible -Sansken-Blakemore Tube/Baloon if bleeding doesn't stop 3rd: TIPS (Transjugular Intrahepatic Portal Shunt) if above fails.
26
Infective Endocarditis
1st: (Before Cultures) Amoxicillin Streptococci: Benzylpenicillin + Gentamicin Staphylococci: Flucloxacillin ----Prosthetic: Add rifampicin + gentamicin
27
Lupus
1st: NSAIDs to control pain 2nd: Hydroxychloroquine / Azothioprine / DMARDs.
28
Testicular Cancer
1st: - Seminoma (ß-HCG[+]): Orchidectomy + Chemo - Non-Seminoma (∂FP[+]): Chemotherapy 2nd: - Seminoma: Radiotherapy. - Non-Seminoma: Surgery may be needed. 3rd: - Both, in the presence of metastasis: Lots of chemo.
29
Erectile Dysfunction
1st: PDE4-Inhibitors e.g. Viagra (Vasodilation) + Educate about lifestyle changes. 2nd: Prostaglandin Intracavernous injections OR Vacuum pump.
30
Neisserial Infection
In hospital / Meningitis: Cefotaxime Primary Care / Community: Benzylpenicillin Prophylaxis (To close-contacts): Ciprofloxacin/ Rifampcin
31
Minimal Change Disease
1st: Prednisolone 2nd: (If Steroid-resistant) Rituximab / Tacrolimus
32
Trigeminal Neuralgia
1st: Anticonvulsants e.g. carbamazepine, gabapentin, lamotrigine. 2nd line: microvascular decompression/ablative. surgery
33
Polymyalgia Rheumatica
1st: Prednisolone (Reduce dose over time and watch bones)
34
Testicular torsion
1st: Urgent surgical exploration BILATERAL orchidoplexy
35
Malaria
Uncomplicated: Artemisinin --- or --- Quinine and Doxycycline Complicated / Severe: 24h Artensuate then the above treatment.
36
Ulcerative Colitis
Induce Remission: 1st: Rectal Sulfasalazine (Aminosalicylates) 2nd: 4w failure: Oral Sulfasalazine 3nd: Oral Pred Severe: IV Steroid. Maintain Remission: 1st: Sulfasalazine (PO or topical or both) 2nd: (2+ relapses per year): Azathioprine / Mercaptopurine (Thiopurines) Last resort: Full colotomy.
37
Crohn's
Induce Remission: 1st: Prednisolone 2nd: Infliximab (or other anti-TNF antibodies) Maintain Remission: 1st: Mercaptopurine then Azathioprine (Thiopurines) 2nd: Methotrexate
38
Mallory-Weiss Tear
1st: ABCDE + Telipressin 2nd: Urgent Endoscopy + Banding + Adrenaline
39
Barret's Oesophagus
1st: LOTS of lifestyle advice + GORD control + Endoscopic surveillance. 2nd: Resection of dysplastic lesions.
40
Carcinoid syndrome
1st: Surgical resection Octreotide (Somatostatin analogue) Metastases: Additional radiofrequency ablation
41
COPD
1st: QUIT SMOKING (+Vaccines) 2nd: Either SABA or SAMA 3nd: Stop SAMA and add LAMA and LABA 4th: Add ICS 5th: Consider Oxygen
42
Hepatic Encephalopathy
1st Lactulose (Non-Absorbable Sugar) 2nd: Non-absorbable antibiotics (e.g Rifaxamin) The aim is to kill or reduce gut-produced ammonia,
43
Legionella
1st: Clarithromycin / Erythromycin (Macrolides) 2nd: Ciprofloxacin (Quinilones) DO NOT USE B-LACTAMS
44
Giant-Cell Arteritis
1st: IV Methylprednisolone then switch to PO. 2nd: 75mg daily aspirin 3rd: Toxcilzumab (IL-6 Antagonist) for remission.
45
Meningitis
1st/Empirical: -Benzylpenicillin (in the community). -Cefotaxime (In hospital) -Additionally Amoxicillin if Listeria suspected (Patient under 3 months, or over 50 years). 2nd: Sensitivity Antibiotics Close-contact Prophylaxis: Ciprofloxacin or Rifampcin.
46
Autoimmune hepatitis
1st and GOLD: corticosteroids e.g. prednisolone
47
CML with Philadelphia Chromosome | ALL with Philadelphia Chromosome
1st and GOLD: Imatinib (Tyrosine Kinase Inhibitor)
48
Diabetic ketoacidosis
1st: IV fluids. (Especially if SBP <90mmHg) 2nd: Fixed-Rate 0.1U/kg/h Insulin 3rd: Glucose IV when <14mmol/L 4th: Careful Potassium Replacement
49
Cluster headache
1st line (acute): 100% O2 for 15 mins SC triptans Prophylaxis: Verapamil
50
Rhabdomyolysis
1st: IV Fluid No great 2nd line- Difficult to manage
51
SEPSIS (6)
GIve 3: 1: Fluids IV 2: Administer Oxygen 3: Empiric Antibiotics IV Take 3: 1: Take blood cultures 2: Check lactate 3: Check urine output
52
Antiphospholipid Syndrome
Before any events occur: 75mg Aspirin OD After an event, lifelong: Warfarin (INR 2-3) or LMWH if pregnant. After recurrent events: Warfarin with INR 3-4 +- Aspirin.
53
Essential Tremor
1st: Do nothing 2nd: Problematic? Propanolol.
54
Hodgkin's Lymphoma | Non-Hodkin's Lymphoma
Hodgkin's: ABVD Non-Hodgkin's: RCHOP +Radiotherapy in both
55
Lead poisoning
1st line: remove the exposure 2nd line: chelating agent - calcium disodium edetate Depends on severity.
56
Beta thalassaemia
1st line: regular blood transfusions + iron chelating agent (deferipone) to prevent iron overload 2nd line: bone marrow transplant
57
Sickle cell anaemia
Vaso-occlusive crisis: IV fluids & analgesia Prophylaxis: Hydroxyurea/hydroxycarbamide + folic acid supplementation OR regular blood transfusion Bone marrow transplant in severe disease
58
Peripheral vascular disease
1st line: Risk factor modification 2nd line: Revascularisation 3rd line: Amputation (when there is foot pain at rest) AVOID beta blockers
59
Second degree heart block
Mobitz I -No treatment required ;) Mobitz II -Pacemaker
60
Third degree heart block
1st line: IV atropine GOLD: Permanent pacemaker insertion
61
Irritable bowel syndrome
1st line: Dietary modification to avoid triggers 2nd line: Antispasmodics 3rd line: Antimotility agents - loperamide 4th line: TCA or SSRI (if TCA ineffective) Other: CBT, hypnotherapy etc
62
Pheochromocytoma
1st line and gold: Phenoxybenzamine (∂-Blocker) + Surgical resection
63
Duchenne muscular dystrophy
Multiple supportive therapies: - Wheelchair for mobility - Orthopaedic care - orthotics/surgery for contractures/scolisos - Cardiac and resp surveillance Medication: 1st line and gold: corticosteroids
64
Disseminated Intravascular Coagulation (DIC)
When SLOWLY EVOLVING and NON-BLEEDING -Consider Heparin (to prevent platelet loss) When BLEEDING: - Specifically low fibrinogen: - -----Cryoprecipitate (Replace Fibrinogen) - Specifically low clotting factors: - -----FFP - Specifically low platelets: - -----Platelets
65
Osteoarthritis
1st line: topical NSAIDs + paracetamol 2nd line: oral NSAIDs + PPI 3rd line: Paracetemol / Weak opioids [ONLY if all other treatments have failed and the course will be short]. 4th line: intra-articular steroid injections if all else fails Final resort: complete joint replacement
66
Urinary incontinence
1st: Bladder training 2nd: Oxybutinin (muscarinic antagonist)
67
Ankylosing Spondylitis
1st: Ibuprofen for pain 2nd: Infliximab for disease modifying Other: Steroid injection for acute flare up
68
Septic Arthritis
2 weeks IV antibiotics 2-4 weeks oral Abx
69
Sarcoidosis
Oral prednisolone if: 1- Hilar Infiltrates AND symptoms 2- Any pulmonary infiltrates 3- Hypercalcaemia 4- Eye/Neuro/Heart involvement. Otherwise: Supportive management, should remit.
70
Type 1 Diabetes
1: Insulin (Basal bolus regime, then adding meal-time regimes) -4 daily glucose measurements. If BMI >25 consider adding Metformin.
71
Myocardial Infarction
1. Aspirin + either -Ticegrelor if all is normal OR -Prasugrel to PCI OR -Clopi to Cloti (High Bleed RIsk) 2. Isosorbide Mononitrate / GTN 3. Acutely; Morphine / Oxygen IF required. 4. STEMI: -PCI + Heparin/LMWH if available within 2h (OR AFTER 12h) -Thrombolysis - Tinectaplase/Alteplase within 12h NSTEMI: GRACE: >3% = PCI : <3% = Dual AP. 6. After: Secondary Prevention (DABS): -Above dual antiplatelet choice. -Beta-blocker + ACE-Inhibitor. -Statin.
72
Obesity
1. BMI >40 : Early bariatric surgery BMI >30 OR >28 + Risk Factors: -Orlistat (Pancreatic Lipase Inhibitor) for <1 year. 2. BMI >35 (or 32.5 if high-risk ethnic group, or any BMI with signs of non-diabetic hyperglycaemia): -GLP-Agonist (E.g Semaglutide) for <2 years. 3. BMI >30: Bariatric surgery as third line.
73
Atrial Fibrilation
RATE CONTROL: -48h+ Symptoms RHYTHM CONTROL: -(Under 48h Symptoms OR >3w DOAC OR TO-Echocardiogram of LAA with no thrombus found) -Concurrent Heart Failure -First episode of AF -Reversible Cause Rate: -Bisoprolol / Verapamil / Diltiazem -DOAC (CHADSVaSc) Rhythm: -LMWH + -Flecainide (Don't use if structural heart disease) -Amiodarone (Don't use if hypothyroid) -DC-Cardioversion IF HAEMDYN UNSTABLE. -4 WEEKS DOAC.
74
Ectopic Pregnancy
NON-SURGICAL if ALL THREE: <35mm No or minimal pain hCG <5000 SURGICAL IF ANY: >35mm Ruptured Intolerable Pain Visible Heartbeat hCG >5000 Details: Non-Surgical: -hCG < 1500 and no pain = Expectant -hCG > 1500 = Methotrexate 50mg + Followup (+- second dose MTX) Surgical: -1: Salpingectomy -2: Salpingotomy (If previous removal a tube/ovary)
75
Inguinal Hernia
1. Surgery In all patients (unless not fit for surgery): -Laparoscopic in bilateral -Open mesh surgery in unilateral Strangulated: Immediate surgery
76
Peri-Anal Fistulae
(IE, in Crohn's) 1: Oral Metronidazole (Should close spontaneously if infection subsides) 2. Complex: Surgical closure. Steroids play no role unless there is an actual flare of the disease.
77
Hiatus Hernia
1. Lifestyle advice (Lose weight, quit alcohol/smoking, sit up after meals, don't eat before bed etc). 2. PPI 3. Surgery (Fundoplication): Mostly for symptomatic "Rollling" Hernias where a bit of the stomach recurrs over the gastro-oesophageal junction and above the diaphragm.
78
Ischaemic Stroke / TIA
After confirmed no haemorrhage: 1. Aspirin 300mg 2. (Only for actual strokes) -Alteplase in 4.5 hours if no haemorrhage or bleeding risk WITH thrombectomy within 6 hours. -Thrombectomy alone 6-24 hours. 3. No glucose for 24 hours 4. (Secondary Prevention) -AF: CHADSVaSc/ORBIT then Rivaroxaban if ok. -No AF: ----Switch Aspirin to Clopidogrel ----No clopidogrel? ADD dipyridamol -High-dose statin (80mg OD) 5. Carotid Endarterectomy if >50-70% stenosed.
79
Prostate Cancer
T1/T2 (Both lobes, but within capsule): -Watchful waiting (Mostly in the old) -Radical prostatectomy -Brachytherapy T3/4 (Penetration into areas around prostate): -Radiotherapy -Endocrine therapy (Gozerellin [GNRHAg] + short Cyproterone [Anti-androgen] course) -Radical prostatectomy. Metastatic: -Endocrine therapy (Gozerellin [GNRHAg] + short Cyproterone [Anti-androgen] course).
80
Achalasia
1. Nitrate or CCB before meals to reduce symptoms (Helps sphincter relax) while awaiting definitive management. Definitive: -Tolerate surgery: Pneumatic dilateion or Cardiomyotomy -Not tolerate surgery: Botox injections.
81
ALS / Unconscious Cardiogenic Patient
Strategy: -CPR + Help immediately -Shock (3x if monitored) ASAP and every two mins -Adrenaline (ASAP if PEA/Asystole) every 3 mins + 3rd shock -Amiodarone every 3 shocks. -Oxygen -Reverse causes (e.g PE = Alteplase)
82
Urticaria
1. Non-Sedating Antihistamine (Cetirizine or Loratidine) 2. Sedating antihistamine on top of non-sedating for night-time use 3. Severe/Resistant: 5 day course of oral steroids.

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