3 Managing the Risk of Prescribing Flashcards
(137 cards)
1
Q
What is Diltiazem?
A
Calcium channel blocker
2
Q
Which calcium channel blocker interacts with simvastatin?
A
Diltiazem
3
Q
How would you manage rhabdomyolysis in statin
A
- Stop statin
- Renal failure - dialysis
- IV fluids - prevent renal failure
- Sodium bicarbonate - alkalinize urine
- Monitr serum potassium
4
Q
What is the definition of an adverse drug reaction?
A
Use of a medicial product within the term of the marketing authorisation as well as from use outside the terms of the marketing authorisation, including overdose, miuse, abuse and medication errors, and suspected adverse reactions associated with occupational exposure
5
Q
What is an adverse event and adverse drug reaction?
A
Event - any harmful or unpleasant event that hte patient experiences while using a drug, whether or not it is related to the drug
Reaction - adverse event where it is suspected to be caused by the drug
6
Q
What is a type A drug reaction?
What are some examples?
A
Type A (augmented) reactions are ones that are generally:
- Dose-related
- Common, predictable
- Related to the pharmacology
- Unlikely to be fatal
Digoxin toxicity or constipation with opioid analgesics
7
Q
What is a type B drug reaction?
What are some examples?
A
Type B (bizarre) reactions are generally:
- Not dose-related (within the therapeutic dose range)
- Uncommon, unpredictable
- Not related to the pharmacology
- Often fatal
Penicillin hypersensitivity, and malignant hyperthermia and hepatitis caused by anaesthetic agents
8
Q
What is type C drug reaction?
What are some examples?
A
Type C - Chronic
- Uncommon
- Related to cumulative dose
- Time-related
Suppression to the hypothalamic pituitary adrenal axis with long-term cotricosteroids
9
Q
What is a type D drug reaction?
What are some examples?
A
Type D - Delayed
- Uncommon
- Usually dose-related
- Occurs or becomes apparent some time after use of the drug
Carcinogenesis
10
Q
What is a type E drug reaction?
What is an example of this?
A
Type E - End of treatment
- Uncommon
- Occurs son after withdrawal of the drug
Opiate withdrawal syndrome
11
Q
What is type F drug reaction?
What are some examples?
A
Type F - Failure
- Common
- Dose-related
- Often caused by drug interactions
Failure of the oral contraceptive in the presence of an enzyme inducer
Failure of therapeutic effect in patients taking anticoagulants leading to stroke
12
Q
What does DoTS stand for?
What can ARDS be divided into due to DoTS?
A
- Dose
- Timing
- Susceptability
- Hypersusceptability reactions
- Collateral effects
- Toxic effects
13
Q
What can ARDS be seperated into?
A
- Time dependent
- Time independent
14
Q
What factors make you susceptable to an ADR?
A
- Immunological reactions
- Genetics
- Age
- Sex
- Physiology
- Exogenous
- Disease states affecting the patient
15
Q
What diseases increase the risk of ADRs?
A
- Congestive cardiac failure
- Diabetes mellitus
- Chronic pulmonary disease
- Rheumatological and malignant disease
16
Q
What coniditons happen more in females?
A
- Psychiatric adverse effects with the anti-malarial mefloquine
- Drug-induced torsade de pointes, linked to ventricular fibrillation and death. Women have an intrinsically longer QT interval than men
- Hyponatraemia with diuretics
17
Q
What ethnic factors influence ADRs?
A
- Europeans metabolise warfarin differently
- Afro-carribeans have an increased risk of angioedema with the use of ACE inhibitors
- Chinese and Japanese origin are less likely to suffer psychiatric adverse effects from mefloquine
- Rosuvastatin altered in patinets of Asian origin, which may increase their risk of myopathy
18
Q
What drugs increase the risk and severity of haemolysis with G6PD?
A
- Anti-malarials (primaquine)
- Nitrofurantoin
- Quinolone antimicrobials (ciprofloxacin)
- Rasburicase
- Sulphonamides (co-trimoxazole)
19
Q
What is a main side effect of Clozapine?
A
Agranulocytosis
Monitor white blood cells
20
Q
What does the yellow card shceme collect data on>
A
Both licensed and unlicensed medicines including:
- Prescription medicines
- Vaccines
- Over-the-counter medicines
- Herbal remedies
21
Q
What percentage of the population to VERY COMMON ADRs occur in?
A
10%
22
Q
What percentage of the population to COMMON ADRs occur in?
A
More than 1% but less than 10% of patients
23
Q
What percentage of the population to UNCOMMON ADRs occur in?
A
more than 0.1% but less than 1% of patients
24
Q
What percentage of the population to RARE ADRs occur in?
A
More than 0.01% but less than 0.1% of patients
25
What is the interaction between warfarin and miconazole?
1. Miconazole inhibits a cytochrome P450 enzyme.
2. This enzyme metabolises warfarin.
3. Therefore more warfarin
26
Who elimates drugs more rapidly from their body female or males?
Females
27
What adverse effect are females more at risk of?
Torsades des points and some severe idiosyncratic (no kown cause) drug reactions
28
In which ethnic group is clopidogrel much less likely to be cleared?
Chinese/Japanese/Korean ancestry
29
What drugs can alcohol interact with?
1. Warfarin
2. Metronidazole
30
What syndrome can amfetamines lead to?
Seotonin syndrome
31
What happens in a pharmacodynamic interaction?
Drugs amplify or negate each other's pharmacological effects
32
What are pharmacokinetic interactions?
When one drug, dietary or herbal chemical, impacts on the biotransformation of a drug, or even their distribution within the body
33
What is an example of two drugs that cause a pharmacodynamic interaction?
Sildenafil and glyceryl trinitrate
Severe hypotension or MI
34
What foods interact with Warfarin?
Leafy vegetables containing vitamin K
35
What foods can interact with ACE inhibitors?
If people have swapped their dietary salt for potassium-containing salt may be at risk of hyperkalaemia.
36
What drugs does grapefruit juice interact with?
1. Calcium-channel blockers
2. Statins
3. Immunosuppressants
4. Anti-arrhythmics
37
What kind of reaction is aminoglycoside and loop diuretic?
1. Pharacodynamic interaction
2. Both cause ototoxicity
38
What type of reaction is lithium salts and ramipril?
1. Pharmacokinetic interaction
2. ACE inhibitors reduce the GFR and increase sodium loss, which is linked with their promotion of lithium retention.
39
What is the interaction of rifampicin and the combined oral contraceptive?
1. Pharmacokinetic interaction
2. Rifampicin induces drug metabolising enzymes in the liver, cytochrome P450
3. This reduces the effectiveness of both oestrogens and progestogens.
40
What is the reaction between verapamil and beta-blockers?
1. Pharmacodynamic interaction
2. They both have similar pharmacological effects, additive effects
41
What is the interaction between warfarin and NSAIDs?
1. Pharmacodynamic interaction
2. NSAIDS inhbit COX-1 and therefore production of protective prostaglandins.
3. This increases the risk of bleeding
42
What is the interaction between warfarin and some macrolide antibacterials?
1. Pharmacokinetic interaction
2. Warfarin is metabolised by CYP3A4, so a reduction in CYP3A4 activity can reduce the metabolism of warfarin and therefore increase its concentration
43
When giving emergency contraception i.e levonorgestrel, what dose should be given in a woman taking carbamazepine?
Double the dose as any cytochrome P450 induces reduce the concentration of progestogens.
44
What drugs use organic anion-transporting polypeptides (OATPs) to enter cells?
Atorvastatin and fexofenadine
45
What drugs inhibit OATPs?
How does this effect atorvastatin?
1. Rifampicin
Means atorvastatin does not enter first pass motabolism and increases its concentration
46
Which drugs are CYP inducers?
1. Rifampicin
2. St John's Wort
3. First gen anticonvulsants (phenytoin, carbamazepine and phenobarbital)
4. Smoking
47
Which drugs are CYP inhibitors?
1. Antigungals e.g. fluconazole, voriconazole
2. Erythromycin
3. Grapefruit juice
4. Cranberry juice
48
What does garlic do?
Inhibits platelet aggregation
Caution with anticoagulants
49
What does Ginseng cause?
1. Hypoglycaemic activity
50
What does Glucosamine interact with?
Warfarin
Increase INR
51
What does St John's Wort interact with?
1. Antidepressants - increase
2. Warfarin - reduction in INR
3. Oestrogen and progestogen - reduces contraceptive cover
52
What can liquorice cause?
1. Hyperkalaemia - increase risk of digoxin toxicity
53
What does the concurrent use of methotrexate and folic acid do?
Reduce the adverse effects of therapy
54
What does oral iron do to the absorption of ciproflixacin?
1. Redcues their absorption (all oral quinolone antibacterials)
55
WHAT IS ERROR THROUGH LACK OF KNOWLEDGE CALLED?
Mistake
56
What is an error through forgetfullness called?
Lapse or 'fumbles' (slips)
57
Which unit of measurement should always be written out in full?
Units
58
What can medication errors be classed as?
1. Prescribing errors
2. Dispensing errors
3. Preparation errors
4. Administration errors
5. Monitoring errors
59
What are the two types of human error?
1. Mistakes
2. Skill-based errors
60
What is an error of mistake?
Error in planning actions
61
What is an error of skill-based error (slips and lapses)?
Error in executing correctly planned actions
62
What can mistakes be divided into?
Knowledge-based and rule-based
63
What can skill-based error be divided into?
Action-based errors and memory-based errors
64
What are some examples of human error?
65
What is an active failure?
What are some examples?
When we do unsafe acts or omissions that are as a result of error or violations, these are termed active failures.
* Confusing similar sounding drug names (e.g. prescribing clotrimazole instead or co-trimoxazole)
* Intending to prescribe a dose of 100mg but writing 200mg instead
66
What are latent conditions?
Examples?
Provide eroor-producing conditions in which unsafe acts occure and can create long-lasting holes or weaknesses in the defences.
* Workload
* Staffing levels
* Lack of training or supervision
* Com,munication problems between healthcare dtaff
67
What are the different classes of recalls?
1. Class one - requires immediatr action including out of hours.
2. Class two - requires the recall to be actioned within 48 hours.
3. Class three - requires the recall tobe actioned within five days
4. Class four - requires caution to be exercised when using the medicine.
68
What are some 'high-risk' medications?
1. Adrenaline
2. Amiodarone
3. Antipsychotics
4. Antimicrobials
5. Benzodiazepines
6. Direct oral anticoaudulants
7. Insulins
8. LMWH
9. Methotrexate
10. NSAIDs
11. Opoids
12. Phyenytoin
13. Potassium
14. Warfarin
69
What are the seven deadly sins of prescribing?
1. Not knowing your drug
2. Not knowing your patinet
3. Failing to take an accurate drug history
4. Writing an illegiable prescription
5. Using inappropriate abbreviations, decimals, and leading zeros
6. Failing to calculate and check drug doses accurately
7. Failing to give clear instructions and using inappropriate verbal orders
70
What does erythromycin do to warfarin?
Enhances warfarin's effect
71
How often should ciprofloxacin be prescribed?
Twice a day
72
What does iron do to quinolone antimicrobials?
Reduced absorption
73
What important compound does Tazocin contain?
Penicillin
74
What route is enoxaprin administered?
SC
75
What do you have to take into account when prescribing digoxin?
Renal GFR
76
How often should you check TFTs when chaning levothyroxine?
6-8 weeks
77
How often should patients be monitored on a maintenance dose of levothyroxine?
Annually
78
What monitoring is required on Amiodarone?
1. TFTs before treatment and every 6 months thereafer
2. Amiodarone is associated with hyperthyroidism and hypothyroidism
3. Amiodarone can also cuase pulmonary fibrosis
Chest x-ray should be done prior to starting
79
What monitoring is required on the combined oral contraceptive pill?
1. Blood pressure
2. Every 6 months
80
What monitoring is done with Digoxin?
1. Heart rate
81
What monitoring is done with Gentamicin?
1. Plasma concentration
82
What monitoring is done with Methotrexate?
1. Full Blood Counts
2. Every two weeks for two months, monthly for four months and then three monthly thereafter
83
What are the adult at risk gorups for vitamin D deficiency?
1. Aged 65 and older
2. Little or no exposure to sunlight e.g. care home resident, wear clothes that cover most of skin
3. Those of African, AFrican-Carribean and south Asian origin
84
What compound is best measured for vitamin D status?
plasma 25-hydroxyvitamin D
85
Below what number is a deficiency in vitamin D?
1. \<25 nmol/litre
2. 25-50 nmol/litre is deficient for some of the population
3. \>50 nmol/litre is sufficient for most of the population
86
What are thr signs of vitmain D toxicity?
1. Hypercalcaemia
2. Confusion
3. Deshydration
4. Muscle weakness
5. Vomiting
6. Loss of appetite
87
What should be checked before comencing therapy with adalimumab?
Evaluated for both active and inactive TB infection
88
Who is more susceptable from lupus-like syndrome in methyldopa?
Females
89
Who are more at risk of hyponatraemia from fluoxetine?
Older adults
90
What are examples of drugs that change electrolyte concentrations?
91
What substance is normally monitored for patients at risk of bleeding?
Anti-factor Xa
92
What antibitoic required therapeutic drug monitoring?
1. IV vancomycin 1g twice a day
2. Oral is not significantly absorbed
93
What drugs cause Steven-Johnson syndrome?
1. Penicillin
2. Sulphonamides
3. Lamotrigine, carbamazepine, phenytoin
4. Allopurinol
5. NSAIDs
6. Oral contraceptive pill
94
What long term problems arise from Trimethoprim?
1. Fever
2. Sore throat
3. Rash
4. Mouth ulcers
5. Purpura
6. Bruising or bleeding
95
What monitoring is needed after administering iron dextran?
1. Monitored for adverse effects for at least 30 minutes following each iron dextran infusion
96
WHAT DRUGS CAUSE HYPOKALAEMIA?
1. Excessive use of laxatives
2. Glucocorticoid therapy
3. Insulin
4. Loop diuretics (e.g. furosemide)
5. Salbutamol
6. Antibacterials (e.g. gentamicin, amphotericin)
7. Thiazide diuretics (e.g. bendroflumethiazide)
8. Theophylline
97
What is the maximum concentration of potassium chloride given via the peripheral route?
40 mmol/litre
98
At what rate should potassium be given?
What is the exception to this rule?
10 mmol/hour
20 mmol/hour in emergency situations
99
What are some common drugs that cause hyperkalaemia?
1. ACE inhibitors
2. Acute digoxin overdose
3. Angiotension-II receptor blocker
4. Herpain and LMWH
5. NSAIDs
6. Penicillins
7. Potassium sparing diuretics
8. Trimethorpim
100
What do you give to manage hyperkalaemia?
1. **Protect the heart**
10 ml of calcium gluconate 10% solution, by slow IV injection over 3-5 minutes
2. **Reduce serum-potassium concentration**
IV injection of 5-10 units soluble insulin with 50 ml glucose 50% given over 5-15 minutes
Salbutamol inhaler
3. **Rid of the body excess potassium**
Oral calcium resonium
101
What is an example of a short-acting insulin?
1. Actrapid
102
What are examples of intermediate-acting insulin?
1. Isophane insulin
2. Insulatard
103
What are some examples of long-acting insulin?
1. Insulin glargine
2. Lantus
104
What concentration can you get insulin formulations?
1. 100 units/ml
2. 200 units/ml
3. 300 units/ml
4. 500 units/ml
105
What targets should you expect before and after meals for blood glucose?
1. **Before meals**
Between 4 and 7 mmol/litre
2. **After meals**
Less than 9 mmol/litre
106
What are examples of aminoglycoside antibacterials?
1. Amikacin
2. Gentamicin
3. Neomycin
4. Streptomycin
5. Tobramycin
107
How are aminoglycosides administred?
1. Normally parenterally
2. IV or sometimes IM
108
When should gentamicin levels be checked?
1. 6-14 hours after the first infusion
109
What affects the toxicity of gentamicin?
Renal dysfunction
110
In what conditions is a multiple daily dosing considered for IV gentamicin?
1. Ascites
2. Children
3. Cysticd fibrosis
4. Endocarditis
5. Extensive burns
6. Pregnancy
111
1. What is the dose for gentamicin?
2. How fast should it be administred?
1. 5-7 mg/kg/day
2. Over 60 minutes
112
What are the two types of monitoring for gentamicin?
What dose is each for?
What is the way to monitor single dose gentamicin levels and what level should you aim for?
1. The Hartford Nomogram - 7 mg/kg/day
2. Urban and Craig Nomogram - 5 mg/kg/day
3. Measure trough pre-dose, before the second infusion (document the time)
Aim for less than 1 mg/litre
113
What do you need to monitor on a gentamicin multiple daily dose regimen?
1. Peak and trough concentrations
2. Peak - one hour post dose
3. Trough - measure pre-dose
114
What are the symptoms of gentamicin toxicity?
1. Tinnitus
2. Nausea and vomiting
3. Renal dysfunction
4. Colitis
5. Stomatitis
6. Blood dyscrasias
115
What is bacteria does Vancomycin target?
Gram positive cocci
116
What is Vancomycin prescribed for?
When might it be given orally?
1. Septicaemia
2. Febrile neutropenia
3. Prophylaxid/treatment of endocarditis
1. C. difficle infection
117
What is dose adjustment dependent on in Vancomycin dosing?
Creatinine clearance
118
What is the usual dosing of Vancomycin?
How long is it administered over?
1. 1g every 12 hours
2. 60 minutes
119
What are the side effects of Vancomycin?
1. Cardiac arrest
2. Cardiogenic shock
3. **Skin disorders** (including Toxic Epidermal Necrolysis and Stevens-Johnson syndrome)
4. **Red man syndrome**
managed by disconinuing infusion and administering antihistamines
120
When do you measure the Vancomycin levels?
1. 36-72 hours (3-6 doses)
2. Trough - pre dose level
3. Concenteation - 10-15 mg/litre
121
WHAT CAN ERYTHROMYCIN DO TO THE ANTICOAGULANT EFFECT OF WARFARIN?
1. Increase the anticoagulant effect
122
What are the different colours of warfarin and what strength are they?
1. 500 micrograms = white
2. 1 mg = brown
3. 3 mg = blue
4. 5 mg = pink
123
What dose of warfarin is required for patients with hyperthyroidism?
1. LOWER doses
124
What substances decrease the effect of warfarin?
What does everything else do?
1. St John's Wort
2. Alcohol Dependance
3. Foods rich in vitamin K (e.g. Leafy greens)
125
How often should you check INR?
1. Every two weeks when changing regieme
2. Then every 12 weeks when stable
126
What does digoxin do?
1. It increases the force of contractility
2. Recues conductivity in the atrioventricular node
127
When is digoxin indicated?
1. Heart failure
2. Supraventricular tachycardia
128
What needs to be monitored when on digoxin?
1. Renal function
2. Electrolytes
129
What is the antidote to digoxin toxicity?
Digibind
130
When should Digoxin blood levels be checked after administration of the last dose?
When is the full effect felt?
1. At least 6 hours (8-12 hours)
2. 8-10 days
131
When do you need to check Digoxin levels for toxicity?
1. Only when toxicity is suspected
132
What is the theraputic range of Lithium?
0.4 - 1 mmol/litre
133
How often should Lithium be checked after administration?
1. Weekly after dose change
2. Then 3 montly when stable
134
What isa the starting dose of methotrexate?
7.5-15 mg weekly
135
What needs to be monitored on methotrexate?
1. FBC - weekly then 3 months
2. LFTs - weekly then 3 months
3. Renal function - weekly then 3 months
4. Chest X-ray - before starting
136
What are the signs and symptoms of methotrexate toxicity?
1. Lymphopenia
2. Thrombocytopenia
3. Pallor
4. Nausea
5. Vomiting
6. GI Bleeding
7. Dysuria/Anuria
137
