Drugs

Question 1

Bisoprolol

Answer 1

Beta blocker, caution in asthmatics, 
step 1 NICE algorithm stable angina
step 4 NICE algorithm HTN K+>4.5
Prognostic benefit in HF
Don't use with verapamil (low CO)
OD treated with glucagon

Question 2

Amlodipine

Answer 2

Dihidropyridine CCB
Step 2 NICE algorithm stable angina (step 1 in prinzmetal angina)
Step 1 NICE algorithm HTN (afro/caribbean or >55)
Interacts with simvastatin (increase levels)

Question 3

Diltiazem

Answer 3

Dihidropyridine CCB
Step 2 NICE algorithm stable angina (step 1 in prinzmetal angina)
Rate control in AF

Question 4

Isosorbide Mononitrate

Answer 4

Vasodilator, give 0800, 1400 to give nitrate free period + avoid tolerance
SE flushing headaches hypotension
Step 3 NICE algorithm stable angina (MR)

Question 5

Ivabradine

Answer 5

Slows HR down, patient must be NSR w resting HR >70
Step 3 NICE algorithm stable angina
Stop after 3 m if not working
Used in HF if LVEF <35% and NSR + HR >75

Question 6

Ranolazine

Answer 6

Step 3 NICE algorithm stable angina
Helps w HR, good if bradycardia
SE: long QT, avoid in cardiac, renal, liver failure

Question 7

Nicorandil

Answer 7

Vasodilator
Step 3 NICE algorithm stable angina
C/I: low BP, LV dysfunction

Question 8

Statins

Answer 8

Give if Qrisk2>10% or lifestyle changes ineffective
Atorvastatin for >85/CKD with no risk stratification
High dose in proven CVD
C/I : pregnancy
Amlodipine interacts w simvastatin

Question 9

Ezetimibe

Answer 9

Monotherapy of primary hypercholesterolaemia if statins C/I

Question 10

Fibrates

Answer 10

Lipid modification in 2 care
Better to reduce triglycerides
Increased risk of gallstones
Combo w statins-> increase risk of rhabdo

Question 11

Aliro/evoloCUmab

Answer 11

specialist drug for primary heterozygous familial hypercholesterolaemia to lower LDL-C

Question 12

Clopidogrel

Answer 12

Antiplatelet 
Omeprazole interacts (reduces effectiveness) use ticagrelor instead (or lansoprazole)

Question 13

Ticagrelor

Answer 13

Antiplatelet, use instead of clopi in DAPT

Question 14

Tirofiban

Answer 14

Used in ACS for high risk patients, causes anaemia and thrombocytopaenia

Question 15

Ramipril

Answer 15

ACE inhibitor
Step 1 `NICE algorithm HTN (<55 or T2DM)
Control BP in systemic sclerosis 
Prognostic benefit in `HF (helps remodel heart by reducing after load) 
SE: hyperkalaemia, dry cough, angioedema

Question 16

Losartan

Answer 16

ARB
Step 1 NICE algorithm HTN (<55/ T2DM)
Use if dry cough not tolerated

Question 17

Indapamide

Answer 17

Thiazide like diuretic
Step 2 or 3 NICE algorithm HTN
S/E: Impotence, hypo N/K hyper Ca, precipitates gout (hyperuricaemia)

Question 18

Spironolactone

Answer 18

Mineralocorticoid antagonist
Step 4 NICE algorithm HTN (K<=4.5)
Treat HTN in Conns syndrome
K sparing
Prognostic benefit in HF
S/E - painful gynaecomastia, impotence, hyperK
Use selective aldosterone receptor antagonist (eplerenone) if SE not tolerated

Question 19

Furosemide

Answer 19

Loop diuretic, offloads fluids
No prognostic benefit in HF
SE: hypoK/Na, exactas hyperglycaemia + gout
0800 1400 (avoid night diuresis)

Question 20

Entresto

Answer 20

To treat HF, indication LVEF <35% 
Combo valsartan (prognostic benefit) and sacubitril

Question 21

Digoxin

Answer 21

Need loading as long half life
Used in CHF as some positive isotropy
Used for AF in sedentary patients, only reduces ventricular rate at rest
OD: N/V/D, blurred vision w xanthopsia/halos + pals/syncope + confusion. Rx = Fab fragment to digoxin (digibind)

Question 22

Amiodarone

Answer 22

Chemical cardio version in AF, preferred for patients with LV failure. V long half life so needs loading.
SE: photosensitivity, slate grey pigmentation. hepatotoxicity, thyroid (hypo/hyper, contains IODine), pulmonary fibrosis
Interactions: warfarin, digoxin
300mg IV (20-60 mins) then 900mg (24 hrs) in unstable tachycardia, regular broad complex tachycardia, pre-excited AF w adverse features)

Question 23

Flecanide

Answer 23

paroxysmal AF chemical cardioversion - “pill in pocket”

Cant use in patients with structural heart conditions

Question 24

Atropine

Answer 24

500mcg for profound bradycardia, repeat up to 3mg max if risk of asystole

Question 25

Adenosine

Answer 25

6/12/12 mg IV boluses for regular narrow complex tachycardia after vagal manouvres

Question 26

Salbutamol

Answer 26

``` SABA, works acutely S/E tachycardia, tremor/anxiety, cramps, paradoxical bronchospasm Increases lactate (false +ve on blood test), hypokalaemia, hyperglycaemia. ```

Question 27

Salmeterol

Answer 27

``` LABA, DELAYED onset, reduces nocturnal sx S/E tachycardia, tremor/anxiety, cramps, paradoxical bronchospasm Increases lactate (false +ve on blood test), hypokalaemia, hyperglycaemia. ```

Question 28

Steroids (asthma)

Answer 28

Can be inhaled (ICS) or oral/IV (acute 5-7 days, chronic if still uncontrolled by ICS Aim for lowest dose Need bone + GI protection, may cause thrush (rinse mouth after inhaled) Long term use can cause adrenal suppression -> steroid card High acute dose can cause psychosis May cause reactive leukocytosis but pt still "immunosuppressed"

Question 29

Montelukast

Answer 29

Leukotriene receptor antagonist Additive effect w ICS S/E abdo pain, thirst, headache V rare association with drug induced Churg-Strauss syndrome -> eosinophilia, vasculitic rash, pulmonary renal syndrome

Question 30

Theophylline

Answer 30

Aminophylline. Give note to prevent morning dipping. Not used in GP because variable metabolism in liver (smokers/liver/heart failure), affected by inducers, narrow therapeutic index Toxicity - Nausea, tachycardia, seizures, hypokalaemia, hyperglycaemia

Question 31

Sodium Cromoglicate

Answer 31

INH mast cell stabilisers | Good for mild and exercise induced asthma esp kids

Question 32

Omalizumab

Answer 32

Anti-IgE May used in persistent ALLERGIC asthma in SECONDARY care

Question 33

Mepolizumab

Answer 33

Anti-IL5 May used in REFRACTORY EOSINOPHILIC asthma in SECONDARY CARE

Question 34

Ipratropium Bromide

Answer 34

SAMA, used in asthma exac Common S/E - dry mouth (anti M) Less common S/E - Nausea/headache RARE S/E - constipation, tachycardia, retention, confusion, blurred vision as dilated pupils, angle closure glaucoma, hypersensitivity CAUTION -> BPH and glaucoma prone patients

Question 35

Tiotropium

Answer 35

LAMA, used in COPD Common S/E - dry mouth (anti M) Less common S/E - Nausea/headache RARE S/E - constipation, tachycardia, retention, confusion, blurred vision as dilated pupils, angle closure glaucoma, hypersensitivity CAUTION -> BPH and glaucoma prone patients

Question 36

Metformin

Answer 36

Insulin sensitisation (needs residual islet cells to work) No hypos, stop weight gain Improve HbA1c 1-2% S/E - GI upset (can try MR) - lactic acidosis (stopped 2-3 days pre op or pre contrast, dehydration is risk factor) -> stopped if eGFR <30 or Cr >150

Question 37

Gliclazide

Answer 37

KATP channel inhibitor => increase insulin secretion Improve HbA1c 1-2% Causes weight gain, hypos 2nd line for T2DM Rarer S/E: hepatic cholestasis, blood dycrasias, skin allergic rxn Omit morning of surgery

Question 38

Gliptins

Answer 38

DPP-4 inhibitor (increase GLP-1 endogenously)=> insulin secretion Slight HbA1c reduction (<1%) Weight neutral No hypo risk on its own Good 2nd line if eGFR >50 S/E - headaches, N+V, HF, pancreatitis/pancreatic cancer risk, infection risk, arthralgia

Question 39

Glitazones

Answer 39

PPAR-gamma activator => insulin secretion + increase sensitivity Slight HbA1c improvement (<1.5%) Weight gain Use if insulin RESISTANT, better lipid profile and MI risk reduction, also used if NAFLD S/E - fluid retention (so HF =CI), hepatoxicity, osteoporosis, bladder Ca, Need LFTs every 2mon for a yr Monitor + stop in 3-6 mon if not working

Question 40

Gliflozins

Answer 40

Selective SGLT2 inhibitor = blocks glucose reabsorption by kidney => excess glycosuria so only effective if eGFR >60 Reduced mort in pt with cardiovascular disease/HF Weight LOSS S/E - NORMOGLYCAEMIC DKA, UTIs, thrush diuresis, hyperkalaemia

Question 41

Exenatide Liraglutide

Answer 41

Glucagon-like peptide mimetic => augment insulin release and slow gastric emptying. S/c 5 mins pre meal No hypos when used alone Weight LOSS HbA1c improved <1.5%, doesn't improve CV outcomes. Indications: BMI >35 + problem ass w obesity, BMI <35, insulin poses occupational implications or weight loss may benefit obesity comorbidities S/E TDS inj, GI inc pancreatitis/panceatic Ca risk, worsens gastroparesis (CI). CI if eGRF<30

Question 42

Repaglinide Nateglinide

Answer 42

Secretogogues = sulphonylurea receptor binders => increase insulin release HbA1c <1.5% reduction Rapid onset/short duration, give 30 min pre meal S/E - rash, N+V, GI upset, hypos, hepatotoxic disfavoured

Question 43

Acarbose

Answer 43

Instestinal alpha-glucosidase inhibitor = less starch breakdown = less absorption v small HbA1c benefit Weight neutral. Rarely used in Type 1s to reduce post prandial hyperglycaemia and in DUMPING SYNDROME post fundoplication S/E flatulence, abdo discomfort, diarrhoea

Question 44

Orlistat

Answer 44

Inhibit pancreatic and gastric lipase => less fatty acids => steatorrhea and weight loss NICE guidelines BMI>28 + RF or BMI >30 Only continue >3 months if >5% weight loss

Question 45

Cyclizine

Answer 45

H1 antagonist anti emetic | emetogenic for GI (PONV) or vestibular causes

Question 46

Metoclopromide

Answer 46

D2 antagonist (also haloperidol, domperidone, prochlorperazine) Emetogenic for GI/Vestibular/Opiates S/E: pro kinetic (NOT USED IN BO) can cause dystonias and oculogyric crises

Question 47

Ondansetron

Answer 47

5-HT3 antagonist antiemetic | Emetogenic for chemo / surgery

Question 48

Methotrexate

Answer 48

``` DMARD Terratogenic Req folate replacement S/E - PNEUMONITIS, GI upset, myelosuppression, hepatotoxicity. Monitor FBC, LFT, CXR, Cr at baseline. ```

Question 49

Sulfasalazine

Answer 49

DMARD Similar to aspirin so don't use if aspirin allergy S/E - Myelosupression (FBC monitoring, Hepatotoxic (LFTs), rash, oligospermia/male infertility), Heinz body anaemia

Question 50

Hydroxychloroquine

Answer 50

DMARD BULLSEYE maculopathy /retinopathy/corneal deposits Yearly screen if >40 or prev ocular problem

Question 51

Azathioprine

Answer 51

DMARD S/E Fever, bruising, hepatotoxicity, myelosupression Check LFTs, FBC at baseline Check thiopurine methyltransferase before starting

Question 52

Penicillamine

Answer 52

DMARD Can give drug induced SLE S/E rash, ulcers, taste loss, proteinuria (check protein:Cr ratio), Myelosupression, check FBC, exacerbation of myasthenia graves

Question 53

Cyclophosphamide

Answer 53

DMARD | S/E - skin pigmentation, male infertility, HAEMORRHAGIC CYSTITIS

Question 54

Ciclosporin

Answer 54

DMARD | S/E myelosupression, renal failure (hyperK+, Cr, HTN, oedema), gingival hyperplasia

Question 55

Anti-TNFa

Answer 55

Mabs DMARDs Screen for TB first (cause disseminated TB from reactivation Other S/E: CHF, sepsis, demyelination

Question 56

Unfractionated Heparin

Answer 56

Inhibits Xa, IXa, XIa, XIIa Continuous IV a infusion Needs monitoring of APTT (1.5-2.5) tricky FULL reversal w protamine sulphate S/E long term osteoporosis, pain on inj site, hyperkalaemia (inhibits aldosterone secretion)

Question 57

Fondaparinux

Answer 57

Binds ATIII Xa - lower HIT rate NO reversal with protamine sulphate S/E long term osteoporosis, pain on inj site, hyperkalaemia (inhibits aldosterone secretion)

Question 58

LMWH

Answer 58

Binds ATIII Xa Sub cut, renal excretion, easy dosing, half life 10h (long) no monitoring S/E long term osteoporosis, pain on inj site, hyperkalaemia (inhibits aldosterone secretion)

Question 59

Dabigatran

Answer 59

``` DOAC, vs THROMBIN, for non valve AF, VTE Not for metal valves, arterial clot, pregnant or breast feeding Interactions - AED, ART, anti fungal, rifampicin Coag test = thrombin time RENAL elimination Needs 5d heparin (like Edox) Can cause GI bleeds Antidote = Idarucizumab ```

Question 60

Apixaban

Answer 60

DOAC, vs Xa, for non valve AF, VTE Not for metal valves, arterial clot, pregnant or breast feeding Interactions - AED, ART, anti fungal, rifampicin 1st line for VTE Faecal elimination Bleeding - no antidote, give PCC, oral charcoal

Question 61

Rivaroxaban

Answer 61

DOAC, vs Xa, for non valve AF, VTE Not for metal valves, arterial clot, pregnant or breast feeding Interactions - AED, ART, anti fungal, rifampicin LIVER excretion Increased menorrhagia Bleeding - no antidote give PCC, oral charcoal (if taken <4 hrs ago)

Question 62

Warfarin

Answer 62

Reduces II, VII, IX & protein C VTE - aim 2.5 if recurrent/PE 3.5, AF - aim 2.5, mech valves 2.5-3.5 in old, 2-3 in new S/e haemorrhage, teratogenic (but can use if breastfeeding) skin necrosis, purple toes. Causes of high INR: diet, liver disease, Omeprazole, Disulfiram, Erythromycin, Valproate, Isoniazid, Cipro/Cimetidine, acute Ethanol, Sulphonamide, Cranberry juice, NSAIDs Avoid foods high in vitamin K (brocoli spinach, kale sprouts) Reverse w VIT K Use if CrCl <30

Question 63

Levodopa

Answer 63

PD, combined with decarboxylase inhibitor (carbidopa) to prevent peripheral metabolism to dopamine Reduced effectiveness with time S/E: dyskinesia, on off effect, dry mouth, anorexia, palps, postural hypotension, psychosis, drowsiness. Don’t use in neuroleptic induced Parkinsonism Don’t acutely stop it! (patches if can’t take orally)

Question 64

Bromocriptine, cabergoline

Answer 64

PD, Ergot derived dopamine agonists Ass with pulmonary, retriperitoneal and cardiac fibrosis. Need echo, ESR, Cr and CXR before Rx and closely monitor Can cause impulse control disorders and daytime somnolence More likely to cause hallucinations in elderly than levodopa S/E nasal congestion, postural hypotension.

Question 65

Ropinirole, Apomorphine

Answer 65

PD: Newer, non ergot derived dopamine agonists Can cause impulse control disorders and daytime somnolence More likely to cause hallucinations in elderly than levodopa S/E nasal congestion, postural hypotension.

Question 66

Selegiline

Answer 66

MAO-B inhibitor, PD | Inhibits breakdown of dopamine secreted by dopaminergic neurons

Question 67

Amantadine

Answer 67

PD, mech not fully understood | S/E: ataxia, slurred speech, confusion, dizziness, livedo reticularis

Question 68

Entacapone, Tolcapone

Answer 68

COMT inhibitor, adjunct to levodopa in patients with established PD

Question 69

Procyclidine, Benzotropine

Answer 69

Antimuscarinics, used more for drug induced Parkinson’s disease, help tremor and rigidity

Question 70

Carbemazepine

Answer 70

Used for partial seizures (1st line), trigeminal neuralgia. P450 enzyme INDUCER S/E dizziness and ataxia, drowsiness, headache, Diplopia, Steven-Johnson syndrome, leucopenia, agranulocytosis, hyponatraemia 2 to SIADH

Question 71

Lamotrigine

Answer 71

Antiepileptic 2nd line for generalised and partial seizures | Adverse effect: Steven Johnson syndrome

Question 72

Phenytoin

Answer 72

Antiepileptic P450 INDUCER Lots of adverse effects. Acute: dizziness, diplopia, nystagmus, slurred speech, ataxia, then confusion, seizures Chronic: gingival hyperplasia, hirsuitism, coarsening of facial features, drowsiness, megaloblastic anaemia, peripheral neuropathy, osteomalacia, lymphadenopathy, dyskinesia Idiosyncratic: fever, rashes, hepatitis, dupuytrens, aplastic anaemia, drug induced lupus. Teratogenic - cleft palates, heart disease

Question 73

Sodium Valproate

Answer 73

1st line generalised seizures P450 enzyme INHIBITOR Adverse effects: Terratogenic (not used in women of childbearing age), nausea, weight gain, alopecia, ataxia, tremor, hepatotoxicity, pancreatitis, thrombocytopenia, hyponatraemia, hyperammonemic encephalopathy

Question 74

Triptans

Answer 74

5-HT1B and 5-HT1D agonists for migraine 1st line combo with NSAID or paracetamol Take asap after onset headache (not aura) Adverse effects: tingling, heat, tightness, heaviness, pressure CONTRAINDICATED in IHD or CVD