What is Carbimazole used for?
Report any sore throat, ulcers, fever, malaise, bleeding with Carbimazole
What is the difference between:
Agranulocytosis: WBC's go down; sore throat, fever, malaise all symptoms
Thrombocytopenia: Platelets go down: blood very thin: unexplained bleeding/ bruising. Can be from Heparins
Blood Dyscrasias: Entire blood profile goes down; symptoms of both of the above, this is why we report both sets of symptoms with some drugs
What is the loading dose of Amiodarone?
200mg TDS for 7 days
200mg BD for 7 days
Then 200mg OD from there on (maintenance)
Why load? Long half life (50 days) means it would take ages to reach therapeutic levels. Also means interactions can still occur months after stopping.
Symptoms of Aspirin Overdose (5)
Why is rifampicin considered High Risk do you think?
(Rifampicin is one of the TB drugs)
Many interactions- as it is an enzyme Inducer, it induces ALL of the CYP enzymes: decreases efficacy of COC's
HEPATOTOXIC: Monitor LFTs, counsel on liver toxicity signs, stop if:
Also colours urine/ body fluids/ soft contact lenses red/ orange
What monitoring is needed with Rifampicin?
LFT's before starting- continue to monitor if on prolonged therapy
Renal function before starting
FBC if on prolonged therapy
Which class of antibiotics do we need to use with caution in EPILEPTICS?
These lower seizure threshold!
Particularly if used with theophylline
Why do we need to check albumin levels with warfarin?
Warfarin is highly protein bound to albumin- if this is low there may be issues transporting it round the body
need to monitor both renal and liver function with warfarin
People stable on warfarin- how often is INR checked?
Every 3 months
Unless changes in clinical status occur e.g. diarrhoea and vomitting
What (quite unpleasant) side effects are associated with Amiodarone use, what signs should patients look out for? (7)
Nausea and vomitting and taste disurbance
Thyroid function- Hypo and Hyperthyroidism through action of IODINE in the drug
Phototoxic skin reactions: burning sensation, erythema, slate grey skin discolouration
Pulmonary toxicity- persisitent SOB/ Cough
Tremor- peripheral neuropathy- numbness in hands and feet
Corneal microdepositis in eyes- dazzled by headlights- common SE: this is reversible once drug stopped
Liver toxicity: Jaundice
What 5 things need monitoring at baseline with Amiodarone?
LFT's- Hepatotoxicity a risk
THYROID FUNCTION- hyper/hypothyroidism
Serum Potassium!!!! before starting
Chest X-ray- pulmonary toxicity
ECG with IV use
LFT's and TFT's need monitoring after 6 months too!
What is Amiodarone used for?
Both supraventricular and ventricular Arrhythmias
Ventricular fibrilation, ventricular tachycardia
Usually used when other drugs failed as quite a nasty drug
Rhythm control as part of pharmacological cardioversion in AF
Methotrexate inhibits dihydrofolate reductase and therefore reduces folate in the body. What drug has to be given with methotrexate as supplementation to prevent its nasty side effects, and when?
For prevention of methotrexate induced horrible side effects in Chron's/ RA:
Folic acid 5mg ONCE WEEKLY- dose to be taken on a DIFFERENT DAY to methotrexate
Methotrexate may lead to blood disorders (most significantly neutropenia and increased infection risk) through BONE MARROW SUPPRESSION. Its anti- folate propertied may explain how it suppresses bone marrow...
Bone marrow is where the body creates new cells. Cell division requires folate in order to occur.
Since folate deficiency limits cell division, erythropoiesis, production of red blood cells, WBC, neutrophils etc is suppressed in the bone marrow when methotrexate is taken as it is anti- folate. This is the same story as with Trimethoprim/ Co- trimoxazole and Phenytoin as these are also anti-folate- Avoid use together!
Production of RBC's being hindered also leads to megaloblastic anemia, which is characterized by large immature red blood cells that cannot divide.
What monitoring does Methotrexate require?
FBC (due to blood disorder risk)
These should be 1-2 weekly until dose stabilised then 2-3 monthly thereafter
Exclude pregnancy- pregnancy test before starting?
Avoid in hepatic impairment and reduce dose in renal impairment unless severe- then avoid.
What is Methotrexate used for?
Main use in:
Severe Chron's (Inflammatory Bowel Disease)
It is cytotoxic- stops cell division- part of chemotherapy
What are the Methotrexate warning signs
Blood disorder: Bone marrow suppression- sore throat, ulcers, fever, rash
Liver toxicity- N&V, abdominal pain, dark urine, Jaundice
Gastro-intestinal toxcitiy: stomatitis, GI upset (sore mouth first symptom)
Pulmonary Toxicity- persistent SOB, cough
PREGNANCY & Breastfeeding- its anti-folate so avoid!!- contraception needed during treatment and for 3 months after stopping
WITHDRAW TREATMENT IF ANY OF THESE OCCUR
What OTC med's can increase the risk of Methotrexate toxicity?
NSAIDS/ ASPIRIN !!
Reduce methotrexate excretion in kidney
As do penicillins!
A patient comes in complaining of mouth sores, they think it may be cold sores. After further questioning you find out they are on Methotrexate. What do you do?
Advise they seek medical attention ASAP
Mouth sores may be a sign of stomatitis (inflammation of mouth) which is the first sign of Gastro-intestinal toxicity associated with Methotrexate!
A patient asks for some Lozenges as they are experiencing a very sore throat. You find out they are on Methotrexate. What do you do?
Seek medical attention ASAP
Sore throat is most common side of blood disorders with Methotrexate
Patients can sometimes overdose on Methotrexate as they get confused that it is Just once weekly dosing. What are the symptoms? what is methotrexate toxicity treated with?
Headache, seizures, coma
Treatment: FOLINIC ACID- rescues normal cells from methotrexate effects
What happens when Baclofen (used for pain of muscle spasms in palliative care/ trauma) is suddenly withdrawn? What if it is given with ACE inhibitors or Beta blockers?
Suddenly withdrawn: hyperactivity, hyperthermia, hallucinations, convulsions
Enhanced Hypotensive effects with ACEi/ Beta blockers
Which NOAC is contra-indicated in patients with a Prosthetic valve?
What needs monitoring with Vancomycin (4)?
Full blood count: can cause both LOW PLATELETS and LOW NEUTROPHILS (Neutropenia)
Renal function- Nephrotoxic- Urinalysis, CrCl used for dosing
Hearing function in the elderly
What needs monitoring with Gentamicin?
NB: differs to vancomycin as do not need to monitor FBC- does not cause neutropenia/ low platelets
Which antihypertensive drugs require the SAME BRAND to be maintained?
Which CCB cannot be used in both Supraventricular and Ventricular arrhythmias?
Used for Supraventricular only
Verapamil NOT to be used in Ventricular Arrhythmias
Ciclosporin (an immunosuppressant drug) has many interactions. This is because it is toxic to many organs, so any drug effecting each of those organs will be contra-indicated with ciclosporin use. What toxicitys can it cause (5)?
Neurotoxicity (CNS- tremor, convulsions, encephalopathy)
Liver toxicity (jaundice, N&V, abdo pain, dark urine)
Blood toxicity/ disorders (fever, sore throat, ulcers, bleeding)
Hypertension- BP needs monitoring regularly
Patient should report any of these signs
What type of vaccines are Ciclosporin and Tacrolimus Contra-indicated with?
Live vaccines can, in some situations, cause severe or fatal infections in immunosuppressed individuals due to extensive replication of the vaccine strain that the immune system cannot fight off.
Same goes with high dose corticosteroids: these can suppress the immune system so avoid live vaccines
What should patients on corticosteroids be told with regards to chickenpox/ measels?
If they have not have these before, avoid any exposure to anyone with these as they can contract very severe forms of these if they do.
Why is an eye exam needed with corticosteroid use?
Risk of eye problems:
Glaucoma- look for intraocular pressure
What drugs can increase the risk of someone developing gout (build up of uric acid)?
Diuretics– clears excess fluid out of body but the remaining fluid is more concentrated; increases the risk of developing the crystals that cause gout
Beta-blockers and ACE inhibitors
low-dose aspirin – used to reduce the risk of blood clots
niacin – used to treat high cholesterol
ciclosporin – used to treat conditions such as psoriasis
What are the symptoms of gout?
What are the dietary risk factors of gout?
Build up of uric acid causing:
sudden attack of severe pain in one or more joints, typically big toe.
joint feeling hot and very tender, swelling in and around the affected joint
Dietary risk factors: high in meat and seafood and high in beverages sweetened with fructose promotes higher levels of uric acid, also alcohol.
Phospohorus can help cure gout: Banana is a rich source of phosphorus.
What is the main symptom of Hypokaleamia?
What drugs can cause hypokaleamia?
(Hyperkaleamia can also cause arrhythmias!)
Thiazide, thiazide-like and Loop diuretics
Atomoxetine (used for ADHD)
Can you inject potassium chloride 20% w/v straight?
No- must be diluted first with sodium chloride 0.9%
Must be given by slow infusion
Monitor ECG- rapid infusion would be toxic to heart and arrhythmias occur
Need to the patient is weeing enough- contraindicated in anuria (absence of urination) as potassium would build up
What could black stools or coffee groung vomit be suggestive of with NSAIDs? What about Iron deficient aneamia?
What are the following indicative of with NSAID therapy?
Unexplained weight loss
nausea or vomiting
burping or acid reflux- recent onset dyspepsia
What could swollen ankles indicated with NSAID therapy?
Which NSAID is now contra-indicated in patients with a cardiac disease history/ risk of CV disease?
The new treatment advice applies to systemic formulations (ie, tablets, capsules, suppositories, and injection available both on prescription and via a pharmacy, P); it does not apply to topical (ie, gel or cream) formulations of diclofenac.
What electrolyte disturbance could NSAIDs effectively cause?
NSAIDs can damage the kidneys (AKI)
This can in turn lead to HYPERKALEAMIA
A dose increase for an opioid should be no more than __% of the last dose
No more than 50%
Due to risk of overdose
Aside from their use in pain, what else can strong Opioids be used for?
Relief of breathlessness in palliative care
Relief of breathlessness and anxiety in acute pulmonary oedema (alongside oxygen, furosemide, nitrates)- Myocardial infarction
But do not give them in respiratory failure!
Suprising when they can cause respiratory depression! This is because they reduce cardiac work and oxygen demand- hence their use in Myocardial Infarction.
What side effects do opioids have on the skin?
They cause histamine release- this can cause ITCHING and urticaria (hives/ nettle rash), also sweating
Biliary colic is a type of pain related to the gallbladder that occurs when a gallstone obstructs the cystic duct and the gallbladder contracts. Should we use opioids for this pain?
No- opioids can worsen the pain due to sphincter spasm
How is chronic pain usually managed with strong opioids?
Oral route first:
Start with an immediate release solution such as Oramorph
Then once optimal dose found- switch to modified release (MST Continus- administered BD [12 hourly])
For breakthrough pain, immediate release (Oramorph) morphine at a dose of 1/6 the usual.
Why must codeine/ dihydrocodeine never be given via the IV route?
Can cause a severe reaction similar to anaphylaxis (but not allergy based)
Which opioid should be avoided in epileptics?
Tramadol: it lowers the seizure threshold
Avoid with other drugs that lower seizure threshold: SSRI's, TCA's, quinolones, theophylline
What is heaviness in the centre of the chest likely to indicate?
How should oral antiplatelets be administered?
With or just after food (to protect stomach)
Except for Dipyridamole: 30 to 60 mins before food
Why is Tacrolimus such a high risk drug? What can it cause?
Hint: Similar to Ciclosporin. Both toxic to many organs
Neurotoxicity (CNS)- tremor, headache
Eye disorders (ciclosporin not toxic to eyes)
Blood disorders- report fever, sore throat, ulcers etc
Skin disorders- rash
What dietary substances should patients on Tacrolimus / Ciclosporin avoid?
Avoid a diet high in Potassium (as these can BOTH cause Hyperkaleamia)
Avoid grapefruit juice- Increases plasma concentrations of these as its an enzyme inhibitor
What drugs can cause Hyperkaleamia?
Ace inhibitors/ ARBs
Potassium sparing diuretics (spironolactone + eplerenone)
Ciclosporin and Tacrolimus (immunosuppressants)
What do we use to treat hyperkaleamia?
The priority is to stabilise the heart: do not want it to arrest due to fatal cardiac arrhythmias
Then sort out hyperkaleamis:
IV insulin or salbutamol as temporary measures to drive K+ back into cells
If its severe- use Heamodialysis
Why not use diuretics, as these cause hypokaleamia too?- as diuretics will effect fluid balance. do not want to put any more strain on the heart.
What should a patient do if they miss a warfarin dose?
Do not double up!
If later that evening- take dose. If next day- skip dose
Why are beta blockers used with caution in diabetes?
Can mask hypoglyceamia:
beta blockers blunt the of adrenalin: if someone becomes hypoglycemia adrenalin doesnt kick in and they dont get warning symptoms. Sweating is the only symptom that still shows.
Can also prevent adrenalin from stimulating the liver to make glucose, and therefore may make the hypoglycemia more severe
Why are beta blockers cautioned in asthma and COPD?
Risk of bronchospasm
If absolutely need one: choose a cardio selective BB like Bisoprolol
Why do we get a dry cough with Ace inhibitors and not ARB's?
ARB's do not increase bradykinin levels, because they do not inhibit ACE
Why are NSAID's cautioned in asthma, what can they cause?
Bronchospasm- does not happen to every asthmatic.
Which diuretics can exacerbate diabetes?
Thiazides (most likely)
Due to hyperglyceamia side effect!
What do we need to monitor with diurectic use?
Uric acid levels (risk of gout)
Hyperglyceamia- can exacerbate diabetes
Hypotension- BP lowering effects
When do we use simvastatin at a max dose of 10mg?
With fibrate use in combo: massive risk of myopathy
Do not use gemfibrozil at all- risk of Rhabdomylosis too great
Which oral antidiabetic carries the least risk of Hypoglyceamia?
What vitamin deficiency can Metformin cause?
Vitamin B12 (cobalamin)
Symptoms of deficiency:
neuropathy (numbness, pain, or tingling in hands or feet)
extreme tiredness (fatigue)
lack of energy (lethargy)
Ace inhibitors have some protective and some negative effects on the Kidneys. When are they contra- indicated?
Bilateral Renal artery stenosis - they will make it progress into renal failure
Less effect on Unilateral renal artery stenosis
Best to avoid in patients with known or suspected RENOVASCULAR disease
What is the max daily dose of Codeine?
How long must intervals between doses be?
,Max number of days OTC?
6 hour intervals
3 days OTC
What drug causes 'Purple glove syndrome' skin disease in which the extremities become swollen, discoloured and painful
Phenytoin if given IV