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1
Q

what do enzyme inducers do

A

increase CP450 enzyme activity -> increase drug metabolism -> decrease drug concentration (+ effect)

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2
Q

pneumonic for common examples of enzyme inducers

A

PC BRAS
Phenytoin
Carbamazepine
Barbiturates (-barbital)
Rifampicin
Alcohol (chronic excess)
Sulfonylureas

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3
Q

what do enzyme inhibitors do

A

decrease CP450 enzyme activity → decrease drug metabolism → increased drug concentration → increased drug effect

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4
Q

pneumonic of common enzyme inhibitors

A

AODEVICES
Allopurinol
Omeprazole
Disulfiram
Erythromycin
Valproate
Isoniazid
Ciprofloxacin
Ethanol (acute intoxication)
Sulphonamides

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5
Q

person on long term corticosteroids is set to undergo surgery - how should their medication be managed (+ why)

A

long term corticosteroid use (>4wks of >5mg prednisolone / day or >1wk >40mg prednisolone) causes HPA suppression i.e. tertiary adrenal insufficiency
means they cannot produce sufficient stress response during surgery which can result in adrenal crisis + profound hypotension if corticosteroids are discontinued.

If undergoing surgery, therefore should receive an increased dose of IV hydrocortisone at induction of anaesthesia

(100mg on induction + 200mg/24hr infusion)

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6
Q

drugs to stop prior to surgery (pneumonic) + when to stop

A

I LACK OP
Insulin - variable (day of)
Lithium - day before
Anticoagulants / antiplatelets - variable
COCP / HRT - 4 weeks before
K+ sparing diuretics (spironolactone) - day of
Oral hypoglycaemics - variable (day of)
Perindopril + all ACEis - day of

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7
Q

how to manage pt on insulin insulin for surgery

A

see local guidelines - procedure + dose dependent
in general: stop day of + commence potassium chloride with glucose and sodium chloride infusion (fixed rate appropriate to fluid requirements) + variable rate insulin infusion
monitor blood glucose hourly + alter insulin infusion accordingly

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8
Q

how to manage patient taking lithium undergoing surgery

A

stop day before

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9
Q

how to manage patient taking COCP / HRT undergoing surgery

A

stop 4 weeks before

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10
Q

how to manage patient taking K+ sparing diuretics undergoing surgery

A

stop day of surgery

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11
Q

how to manage patient taking metformin undergoing surgery (+why)

A

variable - depends on surgery length + metformin dose
in general should be stopped to avoid lactic acidosis

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12
Q

how to manage patient taking ACEi undergoing surgery

A

stop day of surgery

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13
Q

4 key contraindications to look for in prescription review

A

antiplatelets / anticoagulants in pt bleeding / suspected / at risk e.g. liver disease, acute ischaemic stroke

steroids have multiple side effects

NSAIDs have multiple considerations

antihypertensives - multiple side effects

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14
Q

steroids side effects (pneumonic)

A

STEROIDS
Stomach ulcers
Think skin (easy bruising)
oEdema
Right and left heart failure
Osteoporosis
Infection (immune suppression) including candidiasis
Diabetes (hyperglycaemia common + can progress)
cushing’s Syndrome

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15
Q

when are NSAIDs contraindicated

A

renal failure
severe heart failure
UGI bleed / UGI side effects being experienced
3rd trimester (28w) of pregnancy (avoid from 20 weeks)
asthma

low dose aspirin for cardioprotection not subject to same caution

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16
Q

side effect of all antihypertensives

A

hypotension - postural hypo = earliest symptom

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17
Q

B blockers and some CCBs can cause..

A

bradycardia

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18
Q

ACEi and diuretics can cause..

A

electrolyte disturbance

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19
Q

ACEi side effects

A

CAPTOPRIL
Cough (dry cough)
Angioneurotic oedema
Proteinuria
Taste disturbance / Teratogenic in 1st trimester
Other (fatigue / headache)
Potassium increased
Renal impairment
Itch
Low BP

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20
Q

B-blocker main cautions (x2)

A

cause wheeze in asthmatics
worsen acute heart failure

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21
Q

2x specific side effects CCBs

A

peripheral oedema
flushing

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22
Q

diuretics main side effect

A

renal failure

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23
Q

thiazide diuretic side effect

A

gout

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24
Q

K+ sparing diuretic side effect

A

gynaecomastia

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25
fluid used for replacement + when is this not used (x3)
0.9% saline hypernatraemic or hypoglycaemic → 5% dextrose ascites → human-albumin solution (albumin maintains oncotic pressure - 0.9% saline will worsen ascites due to sodium content) shocked from bleeding → blood transfusion (give saline until available)
26
replacement fluid regimen if tachy / hypotensive
500ml bolus 0.9% saline immediately (<15mins) 250ml in heart failure
27
replacement regimen if reduced urine output only
1L 0.9% saline over 2-4h then reassess
28
maintenance fluid requirements
- 25-30 ml/kg/day water - 1mmol/kg/day of K, Na and Cl - 50-100 g/day glucose - consider less (20-25 ml/kg/day) for: - old / frail - renal impairment / cardiac failure - malnourished + at risk of refeeding syndrome
29
1st line antiemetic + when should an alternative be used
cyclizine 50mg 8 hourly IM/IV/oral in heart failure: metoclopramide 10mg 8 hourly IM/IV - cyclizine can worsen fluid retention
30
classical picture antimuscarinic toxicity + example of antimuscarinic drug + consideration in elderly
- confusion - pupillary dilation + loss of accommodation - dry mouth - tachycardia (after transient brady) e.g. oxybutinin BNF recommends lower dose in elderly
31
methotrexate contraindications
NSAIDs contraindicated in pt on methotrexate - increase risk of nephrotoxicity trimethoprim = direct contraindication - risk of bone marrow toxicity -> pancytopenia, neutropenic sepsis - DO NOT USE IN PT ON METHOTREXATE methotrexate should be withheld in active infection
32
If have peripheral oedema but no HF.... (+ normal ejection fraction)
normal LVEF - 50-80% suspect that a drug e.g. CCB is causing oedema i.e. stop furosemide & stop drug causing oedema
33
what classes of blood pressure medications shouldnt be prescribed together + why
calcium channel blockers and beta blockers due to the risk of bradycardia (or at worst asystole) and hypotension (unless under expert supervision)
34
main caution for clozapine
risk of AGRANULOCYTOSIS + NEUTROPENIA if neutrophil count low STOP drug immediately + refer to haematology requires monthly blood tests to monitor
35
what drug can cause increased neutrophils
steroids
36
3x drugs that can cause decreased neutrophils
clozapine chemotherapy (neutropenic sepsis) / radiotherapy carbimazole
37
what drug class can cause hypovolaemic hyponatraemia
diuretics
38
what 2 drugs can cause euvolaemic hypornatraemia
carbamazepine (anti-epileptic) antipsychotics (both cause SIADH which -> hyponatraemia)
39
3 things that can cause hypernatraemia (drug-related)
too much IV saline effervescent tablets (with high Na content) IV preparations with high saline content
40
2x types of drugs that can cause hypokalaemia
loop diuretics (furosemide) thiazide diuretics
41
2x types of drugs that can cause hyperkalaemia
potassium-sparing diuretics (spironolactone) ACEi
42
3 drug classes that cause AKI + type of AKI caused
ACEi NSAIDs (ACEi + NSAIDs normally cause renal AKI i.e. creatinine rise >> urea rise, but can trigger pre-renal AKI i.e. urea rise >> creatinine rise in renal artery stenosis) nephrotoxic antibiotics - renal AKI
43
name 2 nephrotoxic antibiotics
gentamicin tetracyclines vancomycin
44
3x drugs that cause intrahepatic damage + LFT results
LFT - raised bili + raised AST/ALT paracetamol OD statins rifampicin
45
5 drugs that cause cholestasis + LFT picture
LFT - raised bili + raised ALP co-amoxiclav flucloxacillin nitrofurantoin steroids sulfonylureas - gliclazide, glibenclamide, glimepiride, glipizide, tolbutamide
46
2 drugs that affect thyroid - what do they cause + TFT picture
LITHIUM and AMIODARONE can cause both: PRIMARY HYPOTHYROIDISM (low T4, high TSH) PRIMARY HYPERTHYROIDISM (high T4, low TSH)
47
how to interpret TFTs in levothyroxine dose monitoring
assess TSH levels change dose by the smallest increment offered LOW TSH -> DECREASE DOSE (low TSH suggests that T4 is high & thus negative feedback is high, so dose needs to be reduced) HIGH TSH -> INCREASE DOSE (high TSH suggests that T4 is low & thus negative feedback is increased, so dose needs to be increased)
48
common signs of digoxin toxicity
confusion, nausea, visual halo, arrhythmia
49
signs of lithium toxicity: early intermediate late
early - tremor intermediate - tiredness late - seizures, coma, renal failure, arrhythmia, diabetes insipidus
50
signs of phenytoin toxicity
gum hypertrophy ataxia nystagmus peripheral neuropathy teratogenicity
51
signs of gentamicin + vancomycin (aminoglycoside) toxicity
ototoxicity nephrotoxicity
52
how is a normogram used in paracetamol toxicity
plot plasma paracetamol conc against time if above treatment line, give NAC
53
where to find warfarin over-anticoagulation rules in BNF
oral anticoagulants (haemorrhage section)
54
3 steps if pt on warfarin has major bleed
1. stop warfarin 2. give 5-10mg IV vitamin K 3. give prothrombin complex e.g. beriplex
55
dry mouth, tachycardia, neuro disturbance - what drug class may cause these side effects + 2 common examples
examples of antimuscarinic (anticholinergic) side effects CYCLIZINE and AMITRIPTYLINE are both known to have antimuscarinic side effects
56
what to do if taking anticholinergics at high doses + signs of toxicity (what are the signs)
anticholinergic syndrome (dry mouth, flushed skin tachycardia) anticholinergic delirium (confusion, hallucination, psychomotor symptoms) low doses -> STOP anticholinergic drugs + should resolve high doses -> ACETYLCHOLINESTERASE INHIBITORS as antidote - DONEPEZIL + RIVASTIGMINE
57
2 drugs that can cause neutropenia
carbimazole carbamazepine
58
2 drugs (+ class) that can precipitate parkinsonian symptoms
metoclopramide haloperidol
59
1st line hypertension in pregnancy
labetalol
60
what common drug can cause lactic acidosis
METFORMIN can accumulate in renal failure - review dose stop if undergoing general anaesthesia / MI or sepsis
61
how often should methotrexate be taken, what should be taken alongside it, and what is absolutely contraindicated
ONCE WEEKLY folic acid - to limit bone marrow toxicity trimethoprim + co-trimoxazole (folate antagonists)
62
describe 4 stages of warfarin monitoring
INR MONITORED: 1. daily until within target therapeutic range 2. twice weekly for at least 2 weeks 3. weekly, until at least 2 measurements are within therapeutic range 4. once stable, monthly-12 weekly (depending on stability)
63
when is more frequent warfarin monitoring indicated
starting an enzyme inducer / inhibitor risk of overcoagulation: severe HTN, liver disease, renal failure high target INR (risk of bleeding) over 65 (inc risk of bleeding) poor control
64
what should be co-prescribed with long term steroid + why
bone protection e.g. BISPHOSPHONATE (alendronic acid) inc risk of osteoporosis, especially in elderly
65
how should SSRIs be reviewed + duration of treatment
review 1 week after starting + every 1-2 weeks depending on response continue for >6 weeks before changing continue for >6 months after remision (12 mo in generalised anxiety disorder + the elderly)
66
main caution with citalopram/escitalopram + how prevented
QT PROLONGATION + torsades de pointes contraindicated in: those with known QT prolongation congenital long QT concurrently taking another drug that can prolong QT
67
drugs that can cause QT prolongation
(citalopram, escitalopram) lithium antiarrhythmics e.g. amiodarone antipsychotics e.g. haloperidol TCAs venlafaxine
68
main caution with all SSRIs + symptoms
SEROTONIN SYNDROME - agitation, confusion, temp changes, delirium / hallucinations, change in BP, myoclonus
69
drug class contraindicated with SSRIs + why + examples
monoamine oxidase inhibitors e.g. tranylcypromine, phenelzine, isocarboxazid HIGH RISK SEROTONIN SYNDROME
70
what drugs increase risk of serotonin syndrome
(when used together) SSRIs SNRIs e.g. venlafaxine lithium opioids triptans
71
other cautions/interactions of SSRIs (x4)
can affect diabetic control - monitor blood glucose when start / stop increase risk of bleeding if also taking NSAID, aspirin, anticoagulant, antiplatelet increase risk of hyponatraemia if taken with other drugs that can cause hyponatraemia (e.g. diuretics)
72
SSRI contraindications
manic phase bipolar poorly controlled epilepsy - can reduce seizure threshold / interact with antiepileptic drugs escitalopram / citalopram - congenital long QT / known prolonged QT / taking drugs known to prolong QT sertraline - severe hepatic impairment
73
insulin sick day rules
DO NOT STOP INSULIN!!! mositor glucose / ketones regularly (2hrly) + increase fast-acting insulin if glucose / ketones high
74
2 T2DM drugs that should be stopped when unwell
metformin SGLT2 inhibitors (flozins)
75

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