BPS Mocks Flashcards

Question

Who is Sacubitril/Valsartan indicated for?

Answer 1

NICE recommend sacubitril/valsartan as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people with NYHA class II to IV symptoms and with a left ventricular ejection fraction of 35% or less and who are already taking a stable dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). This patient is taking 10 mg daily of ramipril which is the maximum licensed dose for symptomatic heart failure.

Answer 2

an ACE inhibitor or an ARB. ## Footnote Due to the potential risk of angioedema when used concomitantly with an ACE inhibitor, sacubitril/valsartan must not be started until at least 36 hours after discontinuing ACE inhibitor therapy. As this patient is currently prescribed ramipril, sacubitril/valsartan should not be started until 36 hours after discontinuing ramipril.

Answer 3

carvedilol, eplerenone and empagliflozin

Answer 4

Haloperidol (through side effect of rhabdomyolysis) ## Footnote Although: NMS is most likely to cause raised CK

Answer 5

any anti-dopaminergic medicine, such as antipsychotics or metoclopramide ## Footnote Neuroleptic malignant syndrome (NMS) is a rare, but life-threatening complication of treatment with any anti-dopaminergic medicine, such as antipsychotics or metoclopramide. NMS can also be caused by abrupt withdrawal of anti-Parkinsonian medication. First generation antipsychotics such as haloperidol carry the greatest risk. Features include muscle rigidity, hyperthermia, and autonomic instability, with a raised serum creatine kinase, and often delirium. Management is typically supportive, with treatment of the rhabdomyolysis, acute kidney injury, and hyperkalaemia. Aggressive correction of hyperthermia in intensive care is sometimes necessary, as well as management of agitation with benzodiazepines. Dantrolene and bromocriptine are occasionally used in the management of NMS. Stopping the causative agent is critical. Mortality can be as high as 10-20%, although this is reduced by early recognition and treatment. This is a potential cause of this patient's symptoms, including the raised creatine kinase.

Answer 6

muscle rigidity, hyperthermia, and autonomic instability, with a raised serum creatine kinase, and often delirium.

Answer 7

fibrates, or niacin (vitamin B3) ## Footnote Management of statin-induced rhabdomyolysis involves suppo njury and hyperkalaemia, and stopping the causative agent.

Answer 8

In the BNF for Children, the expected body weight for children of different ages is found under 'About BNFc'; 'Approximate Conversions and Units'; 'Prescribing for children: weight, height, gender'.

Answer 9

IDEAL body weight for their height (to avoid overdosing them)

Answer 10

**Ibuprofen** is not an appropriate choice of treatment in view of the patient's history of asthma and presentation with chicken pox. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may induce bronchospasm causing worsening of asthma, either acutely or through gradual worsening of symptoms when used for longer periods.

Answer 11

**Metoclopramide hydrochloride** Under 'Important safety information', the BNF for Children warns that metoclopramide is associated with an increased risk of neurological adverse effects in children and young adults, including extra-pyramidal reactions and tardive dyskinesia. ## Footnote As a result metoclopramde is only licensed for use in children aged 1-18 years for the prevention of delayed chemotherapy induced nausea and vomiting or as second-line treatment of post-operative nausea and vomiting.

Answer 12

Omeprazole is predicted to reduce the efficacy of clopidogrel.

Answer 13

Cause HYPOnatraemia ## Footnote Hyperkalaemia is the most common electrolyte disturbnce

Answer 14

Dual anti-platelet therapy (DAT) is initiated in patients with acute coronary syndrome (ACS) and is usually for up to 12 months in patients who have had a myocardial infarction with percutaneous coronary intervention, unless it is contra-indicated. In patients weighing <60 kg or aged ≥75 years, the treatment of choice is aspirin 75 mg PO daily with prasugrel 60 mg PO as a single dose then 5 mg PO daily. In patients aged 18-74 weighing ≥60 kg the dose of prasugrel is 60 mg PO as a single dose then 10 mg PO daily.

Answer 15

Change to a different drug

Answer 16

anti-Xa concentrations approximately 7 days after starting (to monitor for drug accumulation) ## Footnote Also monitor for: morbidly obese or very thin, pregnant patients or those at increased risk of bleeding or rethrombosis.

Answer 17

short half-life and reversibility with protamine HOWEVER: LMWH has more predictable pharmacokinetics and a once daily administration regimen.

Answer 18

pramipexole 88 micrograms PO nightly ## Footnote The first-line treatment for patients with moderate to severe RLS is a non-ergot dopamine-receptor agonist, particularly ropinirole, pramipexole or rotigotine. An alpha-2-delta ligand such as pregabalin or gabapentin may also be used, particularly if sleep disturbance is a problem as sedation is a common adverse effect. However, neither drug is licensed for this indication in the UK.

Answer 19

Sulfonylureas such as gliclazide

Answer 20

Heart failure

Answer 21

For patients with HbA1c ≥48 mmol/mol the BNF and NICE guidance both recommend: * a dipeptidy peptidase-4 inhibitor (DPP-4i) (e.g. alogliptin, linagliptin, sitagliptin, saxagliptin, vildagliptin), or * pioglitazone, or * a sulfonylurea (SU) (e.g. glibenclamide, gliclazide, glimepiride, glipizide, tolbutamide) ## Footnote a sodium-glucose co-transporter 2 inhibitor (SGLT-2i) (e.g. dapagliflozin, canagliflozin and empagliflozin) instead of a DPP-4i if an SU or pioglitazone are not appropriate.

Answer 22

Discontinue the subcutaneous (SC) anticoagulant and start edoxaban at the time of the next scheduled SC anticoagulant dose.

Answer 23

Dependence (however may also be an adverse effect of opioids or simply a low baseline BP) ## Footnote Confusion, sweating and bruising are possible signs of intoxication.

Answer 24

should report any hearing loss immediately ## Footnote Gentamicin may cause both nephrotoxicity and ototoxicity. Although nephrotoxicity is a key adverse effect of gentamicin that requires close monitoring, reduced urine output is a very late sign. Any kidney injury should be detected long before this point through regular monitoring of serum gentamicin and creatinine concentrations. Therefore, there is no need to tell the patient to report reduced urine output.

Answer 25

Because any hearing loss could profoundly impact their quality of life

Answer 26

Cetirizine may cause increased sleepiness ## Footnote NOTE: Cetirizine hydrochloride may affect performance of skilled tasks (e.g. cycling or driving) and cause somnolence but it would be inappropriate to discourage a healthy activity altogether. The patient should be warned of the potential for these problems to emerge and report them if they do. However, in the absence of any problematic symptoms she should be encouraged to continue with health promoting sporting activities.

Answer 27

His partner should phone emergency services as soon as signs of overdose are identified before administration of naloxone. ## Footnote The patient's partner must be told to call the emergency service as soon as signs of overdose (being unresponsive are recognised, after shaking the patient and shouting his name. Any delay in receiving expert medical attention increases the risk of death or serious brain damage.

Answer 28

2 doses of naloxone IM injection 400 micrograms/mL as well as instructions for use, a rescue breathing barrier, non-latex gloves, an ampoule snapper and syringes with needles attached. ## Footnote Kits may also be available containing intranasal or sublingual naloxone which may be easier for a lay person to use and have the advantage of avoiding IM injection in a potentially unhygenic pre-hospital environment. The absorption of naloxone from the IM route may also be reduced if the patient is peripherally shut down.

Answer 29

Hold the syringe at a right angle to the skin and insert the full length of the needle

Answer 30

continue the usual bolus insulin doses at meal times and reduce the night time basal insulin dose by 20%

Answer 31

Constipation However, cannot be stopped suddenly due to risk of withdrawal symptoms and loss of control of depression.

Answer 32

8 weeks ## Footnote The majority of acute fissures (present for less than 6 weeks) will heal with GTN treatment. Around 7 in every 10 chronic fissures heal with GTN therapy if used correctly.

Answer 33

Dopamine hydrochloride infusion

Answer 34

Urine discolouration (reddish-brown) ## Footnote Entacapone is a catechol-O-methyltransferase (COMT) inhibitor which prevents the breakdown of levodopa in the peripheral circulation, allowing it to reach the brain. It is used in advanced Parkinson's disease to reduce 'off' time in patients with motor fluctuations and for end of dose 'wearing off'.

Answer 35

circumoral numbness/tingling Also: tongue paraesthesia, and dizziness.

Answer 36

Most drugs cause non-neurogenic postural hypotension, with appropriate tachycardic response to standing; however some can exacerbate postural hypotension caused by dysfunction of the autonomic nervous system. An increase in heart rate of <20/min is associated with orthostatic hypotension caused by reduced neurogenic autonomic response.

Answer 37

flucloxacillin 1 g PO 6-hrly ## Footnote This is under 'important safety information' on the BNF monograph Cholestatic jaundice and hepatitis are very rare adverse effects of flucloxacillin. However, they can occur up to 2 months following treatment and are more common in people who have received treatment with flucloxacillin for more than 2 weeks.

Answer 38

Increased risk of developing benign intracranial hypertension

Answer 39

Ondansetron

Answer 40

Initial infusion over 1 hour Second infusion over 4 hours Third infusion over 16 hours

Answer 41

**Glucose monohydrate 40% gel two tubes buccally** The blood glucose should be rechecked after 10-15 minutes to ensure it is >4 mmol/L. ## Footnote Very unpalatable - should be squeezed between the inner cheek and gum rather than being applied directly in the middle of the mouth or tongue. Alternatives include 200 mL of pure fruit juice, 60 mL of Lift® (GlucoJuice®) containing 15 g of fast-acting carbohydrate, glucose tablets or 3-4 teaspoonfuls of sugar dissolved in water.

Answer 42

Tthe treatment can be repeated up to a maximum of three treatments. ## Footnote After 15 minutes, if blood glucose is >4 mmol/L, the patient can then be given a snack providing a long-acting carbohydrate to eat to prevent blood sugar falling again. This could be a slice of bread, 2 digestive biscuits or 200-300 mL of milk. Chocolates and biscuits should be avoided if possible as initial treatment because they have a low sugar content and a high fat content that may delay stomach emptying. Insulin should not be omitted if due, but the dose regimen will require review.

Answer 43

Full blood count - due to risk of myelosuppression.

Answer 44

If the patient has ongoing symptoms on treatment. The aim of treatment is to resolve signs and symptoms of hypothyroidism and maintain TSH and free T4 levels close to or within the normal range. Symptoms may lag behind treatment changes for several weeks or months.

Answer 45

peak anti-Xa concentration

Answer 46

The remainder of the pregnancy and at least 6 weeks postnatally AND until at least 3 months of treatmetn has been given in total. ## Footnote Peak anti-Xa activity need not be checked routinely except in women at the extremes of body weight (<50 or >90kg), renal impairment or recurrent venous thromboembolism. This is based on PRE-PREGNANCY WEIGHT.

Answer 47

nausea, diarrhoea, vomiting, or negative behavioural disturbances ## Footnote Therapy with donepezil should be stopped after 3 months unless there has been improvement in cognitive function, as measured by a formal cognitive assessment such as a Montreal Cognitive Assessment (MoCA) test or Mini-mental State Examination (MMSE), behaviour, or functional status, as assessed by a thorough collateral history from the family. Where there is improvement in the above domains, therapy may continue as it is likely to be beneficial for the patient.

Answer 48

Normally: dopamine exerts negative feedback on the release of prolactin. antipsychotic drugs are dopamine antagonists

Answer 49

For olanzapine the BNF suggests that prolactin, serum lipids, fasting blood glucose, and weight are measured at initiation of treatment. Fasting glucose should be repeated after 1 month then every 4-6 months. Weight should be measured at frequent intervals during the first 3 months of treatment then every 3 months for the first year, then yearly. Prolactin should be measured at 6 months and then yearly. Blood lipids should be measured every 3 months for the first year and then yearly. This is the most appropriate monitoring option after 3 months of treatment.

Answer 50

Liver function tests ## Footnote ECG abnormalities (including QTc interval prolongation) are a known adverse effect of sublingual buprenorphine. However, regular ECGs are NOT recommended.

Answer 51

The effectiveness of treatment in Addison's disease is usually assessed by monitoring for resolution of symptoms e.g. malaise, salt cravings, hypotension, anorexia, electrolyte disturbances. This includes measurements such as blood pressure, electrolytes and **WEIGHT**.

Answer 52

Liver function tests ## Footnote Fluconazole is an antifungal medication of the azole class, which works by interrupting synthesis of ergosterol and thus disrupting fungal membranes. Fluconazole is known to cause derangement of liver enzymes, and may result in hepatic toxicity and fulminant hepatic failure, especially if high doses or prolonged courses are used. The typical treatment course of fluconazole in cryptococcal meningitis is 8 weeks. Other rare, but serious adverse effects of fluconazole include agranulocytosis, QTc prolongation, and seizures.

Answer 53

APTT Ratio of current vs baseline is used to decide on dose changes.

Answer 54

MICROGRAMS

Answer 55

glucose-free crystalloids that contain sodium in the range 131-154 mmol/L bolus of 10 mL/kg over less than 10 minutes,

Answer 56

TIA Peptic ulcer

Answer 57

Weak opioids ## Footnote The inital step of the World Health Organization (WHO) pain ladder recommends simple analgesia such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID). NICE NG 59 'Low back pain and sciatica in over 16s: assessment and management' guidance does not recommend the use of paracetamol alone for the management of low back pain. NSAIDs are the recommended first-line treatment for low back pain. However, as this patient has a history of transient ischaemic attack NSAIDs are not appropriate. NICE recommends that opioids should not be offered for the treatment of chronic back pain but weak opioids (with or without paracetamol) should be considered for managing acute low back pain only if an NSAID is contraindicated, not tolerated or has been ineffective. The next step in the WHO ladder recommends the use of mild opioids such as codeine phosphate with paracetamol and therefore this is an appropriate choice for this patient.

Answer 58

co-dydramol dihydrocodeine tartrate co-codamol (codeine phosphate/paracetamol) codeine phosphate

Answer 59

Prazosin Selegiline hydrochloride ## Footnote Other drugs that can cause nasal congestion include phosphodiesterase type 5 (PDE5) inhibitors (e.g. sildenafil, tadalafil, vardenafil), amiloride, methyldopa, selexipag, travaprost, raltegravir, mepolizumab, hydralazine hydrochloride, ivacaftor, antipsychotic drugs (e.g. haloperidol, amisulpiride, olanzapine, quetiapine), promazine hydrochloride, bromocriptine, and ribavirin.

Answer 60

Ciclosporin Nifedipine (and other CCBs) Phenytoin MMF

Answer 61

topiramate, orlistat, ethosuximide, trastuzumab emtansine, ribavirin, anagrelide and varenicline

Answer 62

Increase risk of bleeding

Answer 63

Strong to moderate CVP2C19 inhibitors should be discouraged. Examples of medicinal products that are strong or moderate CYP2C19 inhibitors include: omeprazole and esomeprazole, fluvoxamine, fluoxetine, moclobemide, voriconazole, fluconazole, ticlopidine, carbamazepine, and efavirenz. ## Footnote results in reduced concentrations of the active metabolite of clopidogrel.

Answer 64

Erectile dysfunction can be an adverse effect of drugs such as antidepressants (e.g. citalopram, clomipramine hydrochloride, duloxetine), antihypertensives (e.g. thiazide diuretics, Badrenoceptor blockers (except nebivolol), clonidine), antipsychotics (e.g. amisulpride, olanzapine), cytotoxic drugs (e.g. ponatinib) and recreational drugs (including alcohol).

Answer 65

The manufacturers of glyceryl trinitrate and nicorandil contraindicate use with phosphodiesterase type 5 (PDE) inhibitors (e.g. avanafil, sildenafil, tadalafil, vardenafil), since this can lead to a serious drop in blood pressure (symptomatic hypotension). In addition, the co-administration of PDE5 inhibitors with guanylate cyclase stimulators, such as riociguat, with nitrates or nitric oxide donors (such as amyl nitrite) in any form is contraindicated as it may potentially lead to symptomatic hypotension.

Answer 66

Nifedipine is a calcium-channel blocker which is also commonly associated with constipation. Calcium-channel blockers cause relaxation of smooth muscle in the vasculature which helps to lower blood pressure. They also relax smooth muscle in the gastrointestinal tract which may cause constipation.

Answer 67

Based on pre-pregnancy (booking) weight For 50-90kg, this is 5000 units SC daily

Answer 68

Patients at increased risk for the development of hyperkalaemia include those with renal insufficiency, age >70 years, uncontrolled diabetes mellitus, hypoaldosteronism; or those using potassium salts, potassium-retaining diuretics and other plasma potassium-increasing active substances; or those with conditions such as dehydration, acute cardiac decompensation and metabolic acidosis.

Answer 69

The objective in the preoperative patient is to continue to control blood glucose in the day before surgery, and to prevent hypoglycaemia overnight while the patient is fasting. Thus, the patient should continue his rapid-acting insulin aspart (NovoRapid®) with meals as usual the day before surgery, as this will prevent hyperglycaemia. The BNF recommends that on the day before surgery, once daily long-acting insulin analogues should be given at 80% of the usual dose; otherwise the patient's usual insulin should be given as normal. On the day of surgery and throughout the intra-operative period, once daily long-acting insulin analogues should be continued at 80% of the usual dose; all other SC insulin should be stopped until the patient is eating and drinking again after surgery. Therefore, for this patient this morning's dose of long-acting insulin glargine (Lantus®) should be reduced by 20%. This should prevent instances of hypoglycaemia overnight, and allow smooth transition on to the variable-rate IV insulin infusion the following morning. If a patient is on a twice daily regimen of long-acting insulin, the morning dose is typically given as normal, with the evening dose halved.

Answer 70

withdrawal of zopiclone following prolonged use may cause rebound insomnia

Answer 71

For patients treated with rivaroxaban for the prevention of stroke and systemic embolism, manufacturers advise that vitamin K antagonist treatment (such as warfarin) should be stopped and rivaroxaban treatment should be initiated when the INR is ≤3.0. Allowing the INR to return to <1.4 could put the patient at higher risk of stroke or systemic embolism.

Answer 72

In patients with severe renal impairment (creatinine clearance <30 mL/min)

Answer 73

With food Taking it on an empty stomach may reduce efficacy (increase in thromboembolic events)

Answer 74

adrenaline 1 g in 1000 mL = 1000 mg in 1000 mL = 1 mg in 1 mL.

Answer 75

volume (ml) = dose (mg) / concentration (mg/ml) ## Footnote Example: Volume of adrenaline solution = dose ‡ concentration = 3.6 mg / 1 mg/mL = 3.6 mL.

Answer 76

infusion rate (ml/h) = dose (mg/h) / concentration (mg/ml)

Answer 77

hyponatraemia, hypokalaemia, and hypocalcaemia Ranitidine may be considered as an alternative. ## Footnote NOTE: hypoNa via SIADH Water restriction and even sodium supplementation is known to be insufficient to correct PPI-induced hyponatraemia without discontinuation of the offending drug. Indeed, the first stage in assessment of hyponatraemia in any patient should be a thorough review of their drug history, and consideration of stopping or finding alternatives for offending agents. Other drugs known to cause hyponatraemia include diuretics, some antidepressants and some antihypertensive drugs such as angiotensinconverting enzyme (ACE) inhibitors (e.g. ramipril). ACE inhibitors cause electrolyte imbalances and SIADH, and are becoming more commonly recognised as a cause of hyponatraemia.

Answer 78

Postural hypotension Lying and standing BP should be measured after 1 week ## Footnote The prevalence and severity of hypotension are influenced by the rate and magnitude of dose titration. Patients should be monitored for 6 hours after the initial dose of clozapine or during dose retitration following a gap in therapy. Lying and standing BP should be checked before the first dose is given, then hourly for 6 hours on day 1 of (re)treatment. From day 2 onwards, the monitoring frequency can be reduced. For example, on day 2 lying and standing BP should be checked pre-dose, then at 2 h, 4 h and 6 h post-dose. Further monitoring is then required for the following 2-3 weeks. A postural drop >30 mmHg should be discussed with the consultant. The patient should be advised to stand up slowly to avoid associated dizziness. HR and body temperature must be similarly monitored during dosage initiation or retitration. HR >100/min or body temperature >38°C should also be discussed with the consultant. Tachycardia is a very common adverse effect of clozapine. A rise in body temperature is relatively common but may be indicative of infection (linked to leucopenia or neutropenia, especially if accompanied by flu-like symptoms or a sore throat), myocarditis or neuroleptic malignant syndrome (NMS). This patient may be at increased risk of NMS due to sudden withdrawal of clozapine. Isolated cases of myocarditis have been reported, mostly within the first 2 months of treatment, but fatalities have occurred. If fever is reported, FBC should be checked. If the blood result is satisfactory and the temperature is <38.5°C, clozapine can be continued. If the temperature is >38.5°C, clozapine should be withheld until the fever subsides but paracetamol may be administered to treat the fever.

Answer 79

visual field and acuity tests 6-monthly intervals

Answer 80

On the second day of treatment Usually given 12rly, so this is before the THIRD dose ## Footnote NOTE: if renal impairment (CrCl <10) must wait for results of conc before giving next dose

Answer 81

measure BP twice a week in the community until BP is 135/85 mmHg or less ## Footnote Also: check dipstick for proteinuria It is also recommended that LFTs, U&Es and FBC are checked at presentation and then weekly

Answer 82

a loading regimen of 12 mg/kg (or 800 mg) IV 12-hrly for 3-5 doses (days 1-3) is recommended, followed by 12 mg/kg IV daily. ## Footnote teicoplanin trough serum concentrations should be monitored at steady state after completion of the loading dose regimen in order to ensure that a minimum trough serum concentration has been reached.

Answer 83

mL/min/1.73 m2, following the normal dose regimen on days 1-3, the dosage should be further halved to 800 mg IV 48-hrly or 400 mg IV 24-hrly ## Footnote Teicoplanin trough concentrations should be monitored to maintain serum teicoplanin concentrations of >20 mg/L. The BNF advises that serum teicoplanin concentration should be monitored in patients with renal impairment receiving treatment with parenteral (IV) teicoplanin, despite the fact that a relationship between plasma teicoplanin concentration and toxicity has yet to be established. Renal and auditory function should also be monitored throughout treatment with parenteral teicoplanin due to the risk of ototoxicity and nephrotoxicity during prolonged treatment.

Answer 84

patient's usual oral dose should be increased by 25% i.e. carbamazepine 100 mg tablets are considered approximately equivalent in therapeutic effect to carbamazepine 125 mg suppositories.

Answer 85

generally recommended that serum concentrations are checked 1-2 weeks after starting treatment, but only 2-4 days after a dose or formulation change.

Answer 86

'Arrhythmias > Atrial fibrillation'

Answer 87

sodium chloride 0.45%/ glucose 5% / potassium chloride 0.15% solution The usual starting rate of infusion is 83-125 mL/h so a 1000 mL bag will run over 8-12 h. ## Footnote Potassium should be omitted from the IV fluid for patients with a high serum potassium (>5 mmol/L).

Answer 88

cyclophosphamide

Answer 89

The ROUTE of administration Example: vincristine should never be given intrathecally

Answer 90

SGLT-2 inhibitors e.g. dapagliflozin

Answer 91

dapagliflozin metformin hydrochloride sitagliptin

Answer 92

DPP-4 inhibitors have been associated with acute pancreatitis, several cases of which have presented as diabetic ketoacidosis. Sitagliptin is therefore contraindicated in the presence of ketoacidosis.

Answer 93

Cardiac disease adult dose for a patient without cardiac disease is stated as 1.6 micrograms/kg daily (i.e. LOWER initial dose) --> 25-50 micrograms PO daily Same is true for age (lower dose if over 65 years old)

Answer 94

combination of an osmotic laxative such as lactulose or macrogol and a stimulant laxative such as senna (which also has faecal softening properties)

Answer 95

sodium chloride 0.9% IV infusion then investigate and manage the cause

Answer 96

should not share his towels, facecloths and bedding ## Footnote should be excluded from school until either lesions are healed/crusted over OR 48 hours after strting antibiotics Options A and E are correct, but are considered less important in this case. Patients should be warned to avoid naked flames as there is a risk of severe burns due to product build-up in fabrics such as clothing and bedding which present a fire hazard. However, as the patient is a young child, it is unlikely that he will be allowed near naked flames, although his mother should be warned of the risk (option A). The BNF lists skin reactions such as erythema and pruritis as uncommon (≥ 1 in 1000 and <1 in 100) adverse effects of topical fusidic acid treatment, so this is a less important information (option E).

Answer 97

drink plenty of water and eat a balanced diet whilst taking lithium carbonate

Answer 98

If they have a history of migraines or other regular headaches ## Footnote NOTE: patients should also be told that if vomiting occurs within 3 HOURS they will need a replacement dose

Answer 99

Drowsiness is a very common adverse effect of amitriptyline hydrochloride. The risk of drowsiness is reduced by titrating slowly to the minimum effective dose, with a lower starting dose in elderly patients. The recommended starting dose is 10-25 mg PO daily in patients over 65 years old.

Answer 100

Ferrous sulfate ## Footnote Ferrous sulfate decreases the absorption of doxycycline, which can lead to reduction in therapeutic effect. Doxycycline should be taken 2-3 hours after ferrous sulfate to avoid problems with absorption. This information is found within the BNF monograph for doxycycline in the section on 'Interactions'.

Answer 101

Dantrolene sodium 140 mg IV once onl ## Footnote Patients with a specific ryanodine receptor mutation are more susceptible to malignant hyperthermia as a result of administration of anaesthetic agents. In this case, both sevoflurane and suxamethonium chloride are possible causes. Dantrolene is a muscle relaxant which reduces intrasarcoplasmic calcium concentrations by inhibiting the ryanodine receptors to impair calcium efflux from the sarcoplasmic reticulum, thus reducing the muscle rigidity associated with malignant hyperthermia. Untreated, malignant hyperthermia carries a mortality of up to 80%. Proper recognition and prompt administration of dantrolene 2-3 mg/kg IV reduces this mortality to approximately 5%.

Answer 102

Full blood count ## Footnote Eosinophilia, **leucopenia** and thrombocytopenia are common adverse effects.

Answer 103

Before treatment is started, then repeated within 3 months and at 12 months of starting treatment.

Answer 104

People should be referred for specialist assessment if there is a lack of response (that is, an increase of less than 2 g/100 mL in the haemoglobin level) after 2-4 weeks. NOTE: this is AFTER checking compliance (often poor due to side effects) ## Footnote If upper and lower GI investigations for IDA are normal and anaemia persists, check for H. pylori + eradicate if present

Answer 105

following high serum concentrations, in the presence of renal impairment, or when other nephrotoxic or interacting medicines are used concurrently.

Answer 106

Tobramycin ## Footnote Higher than average doses are required to treat lung infection in cystic fibrosis patients and a dose of 8-10 mg/kg/day given in three divided doses by IV injection is recommended. The manufacturer recommends monitoring of peak and trough serum concentrations **starting after 2-3 doses** and repeated at intervals of 3-4 days throughout treatment. More frequent monitoring may be required following high serum concentrations, in the presence of renal impairment, or when other nephrotoxic or interacting medicines are used concurrently. Tobramycin can be administered by IV infusion over 30 minutes or as an IV bolus over 3-5 minutes as described above. Peak concentrations should be checked one hour after IV adminstration begins (i.e. 1 hour after IV bolus or 30 minutes after IV infusion is complete). When tobramycin is administered as an IV bolus injection serum concentrations may exceed 12 mg/L for a short time. Therefore, it is important the blood sample to check the peak concentration is taken at the correct time to allow accurate interpretation.

Answer 107

fasting plasma glucose concentration of 5-7 mmol/L on waking and 4-7 mmol/L before meals at other times of day ## Footnote When an oral corticosteroid is taken in the morning it is most likely to cause hyperglycaemia from late morning through to the evening.

BPS Mocks Flashcards

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