CPT revision Flashcards
1
Q
What is the pathophysiology of rheumatoid arthritis?
A
Hypertrophy of joint synovial to form pannus.
Infiltration of inflammatory cells, release of pro-inflammatory cytokines.
Pannus erodes cartilage and bone
2
Q
What criteria aids RA diagnosis?
A
Morning stiffness > 1 hour > 3 joints affected Hand joints affected Symmetrical Rheumatoid nodules Serum rheumatoid factor
3
Q
What are the side effects of corticosteroids?
A
Hypertension Osteoporosis Weight gain Bruising Hyperglycaemia Infections Skin thinning
4
Q
What is the MOA of corticosteroids?
A
Inhibit T cell activation
Prevent IL-1 and IL-6 synthesis by macrophages.
5
Q
What SE are common to all immunosuppressants?
A
Hepatitis
Infection risk
Malignancy
BM suppression
6
Q
Name 4 highly protein bound drugs.
A
NSAIDS
Methotrexate
Warfarin
Sulphonylureas
7
Q
What tests are necessary to monitor if giving calcinuerin inhibitors?
A
eGFR - renal toxicity
BP - accelerates hypertension
8
Q
What tests must be done before methotrexate treatment?
A
CXR - pnueumonitis
FBC
LFT
9
Q
What are the side effects of methotrexate, how can they be reduced?
A
Mucositis BM suppression Liver cirrhosis, hepatitis Lungs - pneumonitis Teratogenic
Folic acid reduces mucositis + BM suppression.
10
Q
Which DMARD has poor intestinal absorption and can therefore be used to treat IBD?
A
Sulphasalazine
11
Q
What is the MOA of sulphasalazine?
A
Inhibit T cell proliferation and IL-2 synthesis
Decrease neutrophil chemotaxis and degranulation.
12
Q
Which DMARD causes haemorrhagic cystitis, how can this be minimised?
A
Cyclophosphamide - acrolein metabolite is toxic to bladder epithelium.
Mesna and hydration - mesna binds bladder ep and prevents interaction
13
Q
What is the MOA of anti-TNF alpha?
A
Inhibit cytokine cascade and leukocyte recruitment
Decrease angiogenesis
14
Q
Give 4 conditions methotrexate is used to treat.
A
Cancer
RA
Psoriasis
Crohn’s
15
Q
How can oseltamivir resistance arise?
A
Neuroaminidase enzyme mutation
16
Q
Which viral enzyme activates aciclovir?
A
thymidine kinase
17
Q
What is the MOA of nucleoside RT inhibitors and non-nucleoside RT inhibitors?
A
NRTI - analogues of nucleosides, bind and halt reverse transcriptase.
NNRTI - non-competitive inhibition of HIV reverse transcriptase. Bind to allosteric sight and cause conformational change, inhibiting RT.
18
Q
What is the MOA of protease inhibitors?
A
Inhibits protease enzyme responsible for cleavage of the viral polyprotein into a number of essential enzymes and proteins.
19
Q
What is the MOA of integrase inhibitors?
A
Inhibits insertion of viral DNA into host genome
20
Q
What is the advantage of virus resistance testing?
A
Increases outcome
Reduces costs
No ADRs of ineffective therapy
Decreases resistant virus pool
21
Q
How is virus resistance testing done?
A
Phenotypic characterisation
22
Q
What advice should you give to patients when prescribing warfarin?
A
Risk of bruising and bleeding
Teratogenic
Avoid NSAIDs and aspirin - bleeding risk
Food - too many leafy greens reduce effectiveness
23
Q
What should you check before administering heparin?
A
Renal function - renal clearance
24
Q
What are ADRs of heparin?
A
Bleeding
Osteoporosis
Thrombocytopenia
25
What is used to reverse heparin if actively bleeding?
Protamine sulphate - dissociates heparin from antithrombin III. Irreversibly binds.
26
Name 3 anti-platelet drugs and their MOA.
Aspirin - COX - 1 inhibitor, inhibits thromboxane A2 synthesis
Clopidogrel - ADP antagonist
Dipyridamole - phosphodiesterase inhibitor
27
What are the benefits of anti platelet drugs?
Decreased risk of intracranial haemorrhage
| No monitoring
28
What are the disadvantages of anti-platelet drugs?
Increased risk GI bleed
| May not have reversal agent
29
Which study designs are best for establishing a temporal sequence?
RCT
Prospective cohort
Poor -case-control, cross-sectional
30
What is a side effect of H2 antagonists in males?
Gynaecomastia
31
What are side effects of proton pump inhibitors?
Diarrhoea
Infection risk
C.difficile risk
Osteoporosis - increase pH, decrease Ca absorption
32
What are some causes of GORD?
Obesity - raised intrabdo pressure
LOS weakness
Delayed gastric emptying
Hiatus hernia
33
What is the treatment for peptic ulcer?
Stop NSAIDs if can
H2RA or PPI for 6 weeks
H-pylori eradication if relevant
34
What are SE of B2 agonists?
Tremor
| Tachycardia, palpitations
35
What is the MOA of montelukast?
Leukotriene receptor antagonist
| Mast cells release leukotriene - mucus secretion, mucosal oedema, bronchoconstiction
36
SE of LTRA?
Fever
Angioedema, Arthralgia, Anaphylaxis
Dry mouth
37
What is the MOA of methylxanthines?
Inhibit phosphodiesterase, increase cAMP
| Inhibit adenosine receptors
38
What are the characteristics of methylxanthines?
Narrow therapeutic window - monitoring required
Poor efficacy
CYP450 metabolism - interactions
39
What are the SE of aminophylline?
Seizures, convulsions
| Arrhythmia
40
Name 2 long acting anticholinergics?
Tiotropium bromide
| Ipratropium bromide
41
What is the MOA of voltage gated Na blockers when treating epilepsy?
Bind to depolarised Na channels and prolong inactivation state to inhibit spread of hyperactivity.
Detach once membrane potential normal again = use dependent.
42
Name 4 VGSC blockers for epilepsy?
Carbamezepine
Phenytoin
Lamotrigine
Valproate
43
Which anti-epileptic drug half life reduces with repeated doses.
Carbamezepine - induces CYP450 enzymes which metabolise it.
44
Which AEDs are highly protein bound?
Carbamezepine
Phenytoin
Valproate
BZDs
45
What is a rare but serious ADR of carbamazepine?
Bone marrow suppression - neutropenia
46
What ADRs are associated with AEDS?
CNS - dizziness, drowsiness, ataxia
Rashes
Nausea and vomiting
47
Outline the pharmacokinetics of phenytoin, what is the significance of this?
Non-linear at therapeutic conc - t/12 unpredictable, monitoring required.
Highly protein bound
CYP450 - enzyme inducing - COCP, warfarin (not itself)
48
How are phenytoin and valproate levels monitored?
Salivary levels - indication of free plasma level
49
What is the MOA of lamotrigine?
Na channel blocker
| Ca channel blocker
50
What are the advantages of lamotrigine?
Fewer CNS SE
No CYP induction - fewer DDI
Safest in pregnancy
51
What is the interaction between the OCP and lamotrigine?
OCP reduces plasma levels of lamotrigine - dose adjustment needed.
52
What are the risks of AEDs during pregnancy?
Neural tube defects - valproate in particular
| Learning difficulties
53
What dietary supplements should be taken if to reduce risk of AEDs during pregnancy?
Folic acid - neural tube
| Vit K in T3
54
What is the MOA of valproate?
Weak stimulation of GABA synthesis
Weak inhibition of GABA inactivating enzymes
VGSC blocker and weak CCB
55
Which AED is associated with hepatotoxicity and raised transaminase levels?
Valproate
56
What DDIs are associated with valproate?
Anti-depressants inhibit valproate action.
Anti-psychotics antagonist valproate - lower seizure threshold.
Aspirin increases plasma conc by competitive binding.
57
Which AEDs are indicated for absence seizures?
Lamotrigine
| Valproate
58
Which AED is first line for generalised seizures?
Valproate
59
What is the protocol used in emergency seizure management or status epilepticus?
Benzodiazepines
2nd dose if continuing after 5 mins
Phenytoin IV
60
Name 2 BZDs used to treat epilepsy and their route of administration.
IV lorazepam
| Rectal diazepam
61
What are the side effects of L-dopa?
Nausea
Hypotension (dopamine vasodilator!!)
Tachycardia
Psychosis - hallucinations
62
Name 2 DDI of L-dopa.
Vit B6 increases peripheral breakdown of L-dopa
| Combined with MAOIs - risk of hypertensive crisis.
63
Describe the pharmacokinetics of L-dopa.
Short half life
| Competes with AA for gut absorption - decreased after protein meal.
64
Name a non-ergot derived dopamine agonist.
Ropinirole
65
What are the disadvantages of dopamine agonists to treat Parkinson's?
- Less efficacious than L-dopa
- Psychotic SE are dose limiting
- Impulse control disorders
66
What must you ask about before prescribing a dopamine agonist?
Impulse control disorders:
- pathological gambling
- hyper sexuality
- compulsive shopping
- punding
67
What are the SE of dopamine agonists?
Nausea
Hypotension - dopamine vasodilates!!
CNS - sedation, confusion, hallucinations
68
Name two MAOI's.
Rasagiline, Selegiline
69
What is the MOA of COMT inhibitors?
Inhibits peripheral breakdown of L-dopa to 3-methyldopa which competitively inhibits L-dopa active transport into CNS.
70
What are anticholinergics used to treat in Parkinsons?
Tremor only - ACh may antagonise dopamine
71
Deep brain stimulation of what structure can be used to treat PD.
Subthalamic nucleus.
72
What are the clinical features of Parkinsons plus syndromes?
```
Early onset dementia
Early onset postural instability
Early onset hallucinations or psychosis
Early onset postural hypotension + incontinence
Ocular signs
Symmetrical
```
73
What is the commonest presentation of myasthenia graves?
Diplopia, ptosis
74
When might you prescribe MAOIs?
Either with L-dopa to reduce wearing off effects
| Alone to treat PD
75
What are the 3 theories of depression?
Monoamine hypothesis
Neurotransmitter receptor theory
Monoamine hypothesis of gene expression
76
What are common and rare SE of SSRIs?
Common - anorexia, nausea, diarrhoea
Rare - mania precipitation, suicidal ideation, tremor
Citalopram - prolongs QT
77
Give one advantage of prescribing SSRs rather than TCAs.
Relatively safe in OD.
| TCAs - dangerous in OD due to cardiac effects
78
Name 2 TCAs.
Amitryptylline, imipramine
79
What is the MAO of TCAs?
Non-specific inhibitor of monoamine uptake - NA and 5-HT.
80
What receptors do TCAs have affinity for, what SE do these cause?
alpha 1 adrenoceptors - postural hypotension
Muscarinic receptors - dry mouth, blurred vision, constipation
Histamine receptors
81
What other SE do TCAs cause?
CNS - sedation, lower seizure threshold
CVS - tachycardia, impaired contractility
ANS - decrease gland secretions
82
Give an example of an SNRI.
Venlafaxine.
83
Explain the dose-dependent effects of SNRIs.
Low dose - serotonin action = anti-depressant
| High dose - NA action = anxiolytic
84
Inhibition of which dopamine pathway leads to sexual dysfunction and infertility?
Tuberoinfundibular
85
Name 2 typical antipsychotics.
Haloperidol
| Chlorpomazine
86
Name 2 atypical antipsychotics.
Olanzapine, clozapine.
87
What are 3 features of all antipsychotics?
Sedation
Delayed onset - days to weeks
Extrapyramidal SE
88
Compare and contrast the SE of typical and atypical antipsychotics.
Typical - more extrapyramidal SE - parkinsonism
| Atypical - more metabolic SE - weight gain, hyperprolactinaemia
89
Which atypical antipsychotic is associated with weight gain?
Olanzapine
90
Which atypical antipsychotic is associated with sexual dysfunction and hyperprolactinaemia?
Risperidone
91
Why is clozapine only 3rd line therapy despite being most effective antipsychotic?
Side effects - require weekly FBC
Neutropenia, agranulocytosis
Constipation, weight gain, hypersalivation.
92
What are the side effects of benzodiazepines?
Tolerance
Dependence
Drowsiness, dizziness, ataxia
93
What antidote is used for a benzodiazepine OD?
Flumazenil
94
Outline the pharmacokinetics of Lithium to treat bipolar disorder.
Narrow therapeutic window + long half life - monitoring essential.
Renal excretion
95
What tests must be done before starting lithium treatment and every 6 months?
Renal function - renal toxicity
| Thyroid function - hypothyroidism
96
What are SE of lithium?
```
Memory problems
Thirst + polyuria (ADH antagonist)
Tremor
Drowsiness
Weight gain
Renal toxicity
Hypothyroidism
```
97
Other than lithium, name 3 drugs which can act as mood stabilisers.
Carbamezepine
Sodium valproate
Lamotrigine
98
Which two drug classes can be used to treat dementia?
Mild-moderate: ACh esterase inhibitors - galantine
| Mod -severe: NMDA antagonist - Memantine
99
Name 3 endogenous opioids?
Enkaphalins
Dynorphin
Endorphins
100
What effect do opioids have on pre-synaptic receptors?
Inhibit adenyl cyclase, less cAMP.
Less Ca influx.
Decreased NT release.
101
What effect do opioids have on post-synaptic receptors?
Increased K+ efflux, decreased excitability.
102
What ADRs are associated with opioids?
```
Nausea + vomiting
Constipation
Confusion
Drowsiness, decreased consciousness
Respiratory depression
Constricted pupils
Dependence + tolerance.
```
103
Why must steroid therapy never suddenly be stopped?
Exogenous steroids mimicking cortisol negatively inhibit the hypothalamus and reduce endogenous cortisol release.
If suddenly stopped, low cortisol levels cause hypo-adrenal crisis.
104
Does prednisolone have more or less mineralocorticoid activity than cortisol?
Less - more glucocorticoid selective
105
What effect do corticosteroids have on bone?
Inhibit osteoblast formation
Increase osteoclast proliferation
Decrease calcium absorption in gut
106
When are cortisol levels the highest?
Morning
107
What are the symptoms of addison's disease?
```
Hypoglycaemia
Hypotension
Weight loss
Nausea
Hyponatraemia
Hyerkalaemia
```
108
What are the symptoms of Cushing's disease?
Same as corticosteroid SE:
- hyperglycaemia
- weight gain
- hypertension
109
What is Cushing's disease?
Excess ACTH resulting from a pituitary adenoma.
110
What drug class is tolbutamide?
Sulphonylurea
111
What 4 pieces of lifestyle advice might you give someone before prescribing oral hypoglycaemic agents?
Diet - low calorie, low sugar
Exercise
Low alcohol
Stop smoking
112
What are the 3 main consequences of inhibiting ACE?
1. Reduced vasoconstriction
2. Reduced sympathetic activity
2. Reduced aldosterone leads to reduced salt and water retention.
113
What advice would you give a patient taking SSRIs?
- Can take 2-6 weeks to be effective
| - Continue taking for at least 1 year even if feeling better to reduce risk of relapse
114
What is the risk of giving NSAIDs + SSRIs together?
GI bleeding + ulcer formation
| - Platelets need 5-HT to clot
115
How would you determine a patients fluid status?
Skin turgor
HR, BP
Mucous membranes
Urine output + colour
116
How is a viral load used clinically?
- Effectiveness of treatment - dose adjustment
- Transmissibility
- When 'cured' - undetectable Hep C viral load
117
What is a 'low genetic barrier to resistance'?
Only 1-2 mutations needed before resistance is likely to develop - more likely
118
What is an 'unfit' virus?
a virus that has mutated to the point where it can no longer replication quickly/at all.
119
What is Zollinger Ellison Syndrome, how does it manifest clinically?
Gastrinoma - G cell cancer
| Gastrin -secreting tumor - recurrent peptic ulcers.
120
Thiazides + carbamezepine result in what?
Hyponatraemia
121
Steroids + thiazide/loop result in what?
Hypokalaemia
122
What does a high blood gas partition mean in terms of solubility and potency?
High blood gas partition = more soluble = more potent
123
How does oil gas partition effect onset and offset?
```
High = slower onset as lipid partitioning
Low = faster onset
```
124
How does pKa of a local anaesthetic alter onset?
Low pKa = faster onset
