Flashcards in CLINICAL- MISCELLANEOUS Deck (53):
What is classed as polypharmacy?
4 or more drugs for multiple conditions/ co-morbidities
What's an example of a common drug patients are left on and they don't need to be?
PPIs like Omeprazole: question the need!!
What's the scoring system used in depression?
What medication should we question the need for in patients over 90?
Reduces 10 year risk of CV disease
Are they going to live this long? Is it worth the side effects?
What is a co-morbidity?
Two long term conditions that accompany eachother e.g diabetes and renal failure
As a pose to multi-morbidity: multiple conditions that don't really relate to each other e.g. Diabetes and IBS
What's the problem with clinical trials?
Usually done on people with only one illness (not co morbidities) and very few done on the elderly population
Guidelines: we can use drugs in elderly but with caution as we have to bare in mind they weren't in the trial
What conditions should beta blockers be avoided in?
Diabetes (mask hypos)
Asthma (constrict airways)
What's the problem with aspirin and SSRIS/ TCAs?
AF can be linked to hypo/hyperthyroidism. How?
Amiodarone is an antiarrythmic Agent used in AF.
Amiodarone can cause hypo or hyperthyroidism.
If it causes hypothyroidism: treat with levothyroxine
If it causes hyperthyroidism: stop the amiodarone
If you stop amiodarone: consider doing TFT (thyroid function test) to see if it gets better
AF can also be caused by hyperthyroidism itself
What can smoking be protective against?
But it causes COPD, HTN etc..
What must we consider with rheumatoid arthritis and COPD/ asthma?
They are required to use inhalers: but can they do this with their arthritis??
Why are patients with parkinsons and dementia an issue??
They have conflicting pharmacology. The drugs in dementia can cause parkinsons symptoms and the drugs in parkinsons can worsen dementia
Why could diabetes cause depression? How should we manage these?
Diabetes causes neuropathic pain which can lead to depression
Kill two birds with one stone:
Amitryptyline: Use the depression dose and hope it works for the neuropathic pain too
(But SSRIS preferred in depression citalopram, sertraline so patient could end up on both!)
What's the issue with diabetes, idiopathic thrombocytopenia (increased platelets) and leg ulcers?
Side effect of idiopathic thrombocytopenia treatment is leg ulcers
But it may be deemed to be from diabetes so patient doesn't get taken off the treatment causing it!
What is the deal with ACE inhibitors and renal function? When are they protective? When are they not?
ACEi: dilate the vessel that leaves the kidneys, therefore they reduce pressure in the kidneys. In the long term, in diabetes, this is protective so could be used as the anti hypertensive of choice in diabetics!
But in the short term, if you suddenly reduce the blood pressure in the kidneys with an ACE inhibitor, you can reduce glomerular filtration.
Therefore you shouldn't use ACEi in patients with renal impatient and they will reduce eGFR even further.
If a patient is on an ACEi and their renal function drops by 20% of the original function: stop the ace inhibitor!
This is why we have to monitor renal function in people on ACEi's: make sure we don't get a sudden change in renal function as a result of initiation or dose change.
At what point should we stop an ACE inhibitor in terms of renal function?
If renal function drops by 20% of their original function after initiation or a change in dose of the ace inhibitor.
This is why we monitor renal function with ace inhibitors!!
What's the deal with Metformin in renal disease?
Metformin is contraindicated in renal impairment.
Review need if renal function is less than 45
Do not use if renal function is less than 30
So it IS an option, Metformin is currently being under used, but we need to be careful
What co morbidity do we often see with diabetes?
Sometimes depression due to neuropathic pain
What co morbidity do we often see with Heart Failure?
Also myocardial infarction and AF
A lot of people in the country take antidepressants. They are over prescribed too often. What's the problem here?
Antidepressants offer little benefit for most people with mild to moderate depression
Just another drug people don't necessarily need contributing to Poly-pharmacy.
Non drug therapies such as CBT and mindfulness have more to offer in these patients
What is the risk of TCAs (antidepressants)?
What medications should PPIs such as Omeprazole be prescribed for?
All cause GI bleed risk!!
Especially in combination with each other!!
What medication do we need to watch out for with regards to renal function?
Suphonylureas (used in T2 diabetes as an alternative to Metformin) have a potentially serious drug interaction with warfarin
This can cause changes to the anticoagulant effect and enhanced Hypoglycaemic effects.
We need to closely monitor the Patients INR if we are starting them on a sulphonylurea and they're on warfarin!! Should change the warfarin to a NOAC!!
What is the T2 diabetic drug PIOGLITAZONE contraindicated in?
There is a potentially serious interaction between Amlodipine and Simvastatin. What does this increase the risk of?
What can CCBs like Amlodipine cause?
Oedema!! Particularly ankle swelling.
Change patient to a thiazide-like diuretic to control the blood pressure instead.
SSRI combined with tramadol. What's there a risk of the patient developing?
What could cause shortness of breath?
TCAs or SSRIs: which are first line in patients with suicidality?
TCAs are cautioned in suicide. SSRIS less toxic in overdose
Which is more Risky after 6 months, a STEMI or NSTEMI?
As all STEMIs get PCI now so less likely to clot and cause Myocardial infarction again
Does warfarin cause falls?
What do bisphosphonates do in osteoporosis?
Decrease the 10 year risk of a patient having a fracture
An example bisphosphonate is alendronic acid
What do we generally aim for a patients Total Cholesterol level to be under?
Post CV event/ stroke: generally aim for it to be a 20% reduction (but this isn't classed as a level- remember for MCQ!)
(LDL level under 2 mmol/L)
What are the common side effects of beta blockers?
BP falling too low: postural hypotension
What is a common side effect of Alendronate (alendronic acid) we must look out for?
What should we monitor with statins?
Signs of myopathy
What's the target Heart rate range in AF?
Should we take Rivaroxiban with food?
Yes! 100% bioavailability with food, 66% without food- massive difference!!
What can Bendroflumethiazide cause which can be a problem in elderly?
Can cause confusion and falls
What can ACEinhibitors combined with NSAIDS increase the risk of?
What can Ace inhibitors in combination with potassium sparing diuretics cause increased risk of?
Examples of potassium sparing diuretics: spironolactone, amiloride
Potassium sparing diuretics should be discontinued before starting an ACEi, apart from low dose Spironolactone may be beneficial in severe heart failure with an ACEi but potassium levels need to be very closely monitored!!
What do we monitor with ace inhibitors?
Renal Function and electrolytes, and K+ before starting ACE inhibitors and every time the dose is increased, and also monitored during treatment.
How would we tell Helena how to start e.g. Ramipril?
Start on 1.25mg OD then increase by 1.25mg at intervals of 2-4 weeks to a max of 10mg if tolerated. Stop titrating dose at a level that appears to maintain adequate blood pressure control (below 140/90 or appropriate target). Monitor renal function, U& Es and K+ level at initiation and every time there is a dose change, as there is potential for ace inhibitors to cause renal damage.
Also Monitor for signs of intolerance such as dry cough, if this happens switch to an ARB.
Also tell her: if an ACE inhibitor doesn't control BP, add in a CCB
Why can't we just suddenly stop a beta blocker?
Due to risk of rebound tachycardia
We need to slowly reduce the dose / ween patients off them
What risk assessment test do we use when deciding whether to start a Statin or not in a patient if their cholesterol level is slightly high?
Review 10 year risk and helps us to decide whether to treat or not
If a question asks you to dose using iDeal body weight (IBW) how do we work this out?
Males IBW: 50kg + 2.3kg for each inch over 5 feet
Females IBW: 45.5kg + 2.3kg for each inch over 5 feet
With heparins, if the patients platelets are LOW, what should we not give?
Don't give LMWH or UFH
If a patient comes in with stroke symptoms and they're taking aspirin or clopidogrel (or both) already what should we do?
Stop these immediately in case the stroke is heamorrhagic (as these increase bleeding)!!!
Then follow normal flow chart: CT scan to rule out heamorrhage, alteplase, re-scan to check for bleeds, after 24 hours give aspirin 300mg for 14 days then clopidogrel forever
Check if they still need both Antiplatelets: e.g. If it was for post STEMI has it been 12 months?
With stroke patients, we don't want to meddle with their medication in the acute phase so we wait 48 hours to do things like increasing antihypertensive doses, diabetic medicine doses etc. What about if we want to introduce an antihypertensive for a person not previously on one?
We need to wait 2 weeks post stroke and then follow the hypertension guidelines
Remember to wait 2 weeks!!
What's the preferred Statin to use following a stroke?
Start at 20mg and titrate them up to 80mg
Swap people on simvastatin to Atorvastatin
With beta blockers, what may the patient experience when they first start? What monitoring is required with beta blockers?
Patients may initially feel worse when first starting- tell the patient this
Monitor for cold extremities, blood pressure and heart rate