Mistake Log Flashcards
(458 cards)
1
Q
First line for focal seizures
A
Lamotrigine or levetiracetam
2
Q
First line for tonic-clonic seizures
A
Sodium valproate (males and infertile females)
Lamotrigine or levetiracetam (females who can have children)
3
Q
First line for absence seizures
A
Ethosuximide
4
Q
First line for myoclonic seizures
A
Sodium valproate (men and infertile women)
Levetiracetam (women who are able to have children)
5
Q
First line for atonic/tonic seizures
A
Sodium valproate (men and infertile women)
Lamotrigine (women who can have children)
6
Q
Which antiepileptics are brand specific
A
Cp3 = carbamazepine, phenytoin, phenobarbital, primidone
7
Q
Which antiepileptics have the highest teratogenicity
A
Highest risk - sodium valproate
Increased risk - CP3 + Lamotrigine
8
Q
Who should be informed if a person on antiepileptics becomes pregnant?
A
The UK Epilepsy and Pregnancy Register
9
Q
Which antiepileptics are present in high amounts in breastmilk?
A
ZELP - zosinamide, ethosuximide, Lamotrigine and primidone
10
Q
Which antiepileptics inhibit the sucking reflex
A
Phenobarbital and primidone
11
Q
Signs of antiepileptic hypersensitivity syndrome
A
Rash, fever, lymphadenopathy, systemic involvement (liver dysfunction, multi organ failure)
Occurs 1-8 weeks of starting - discontinue immediately
12
Q
Antiepileptics with highest risk of hypersensitivity syndrome
A
CP3 and Lamotrigine
13
Q
Antiepileptics with increased SJS/TEN risk
A
Lamotrigine, carbamazepine, phenytoin
14
Q
Which antiepileptics are associated with blood dyscrasias?
A
C Vet Plz - carbamazepine, valproate, ethosuximide, topiramate, phenytoin, Lamotrigine, zonisamide
15
Q
What eye problem does topiramate cause?
A
Acute myopia with secondary angle-closure glaucoma. Also choroidal effusions and anterior displacement of lens and iris
16
Q
What antiepileptics can exacerbate absence or myoclonic seizures?
A
Carbamazepine, phenytoin, gabapentin, pregabalin
17
Q
What does the acronym SNAtCHeD represent
A
Signs of phenytoin toxicity:
S - slurred speech
N - nystagmus
A - ataxia
C - confusion
H - hyperglycaemia
D - diplopia, blurred vision
18
Q
Conversion between phenytoin sodium and phenytoin base
A
100mg phenytoin sodium = 92mg phenytoin base
19
Q
What changes in appearance can phenytoin cause?
A
Coarsening of facial features, acne, hirsutism, gingival hypertrophy (maintain good oral hygiene)
20
Q
What allele in which patient group predisposes a patient to SJS when taking carbamazepine or phenytoin?
A
HLA-B*1502 in Han Chinese and Thai patients - pre-treatment screening
21
Q
What vitamin does phenytoin and carbamazepine induce metabolism of?
A
Vitamin D - consider vitamin D supplements in immobilised patients, inadequate sun exposure or dietary calcium intake
22
Q
What should you do if hepatotoxicity occurs with phenytoin?
A
Discontinue immediately and do not re-administer
23
Q
What drugs are common CYP450 substrates?
A
W COAST - warfarin, corticosteroids, oral contraceptives, aminophylline/theophylline, statins, tricyclic antidepressants
24
Q
What drugs are enzyme inhibitors?
A
SICKFACES.COM - sodium valproate, isoniazid, cimetidine, ketoconazole, fluconazole, alcohol (binge), chloramphenicol, erythromycin/clarithromycin, sulfonamides, ciprofloxacin, omeprazole, metronidazole
GAVID - grapefruit, amiodarone, verapamil, itraconazole, diltiazem
25
What drugs are enzyme inducers?
BS CRAP GPS - barbiturates, St John’s wort, carbamazepine, rifampicin, alcohol (chronic), phenytoin, griseofulvin, phenobarbital, sulfonylureas
26
What drugs increase chance of blood dyscrasias with phenytoin?
Methotrexate and trimethoprim - additive anti folate effect
27
Signs of carbamazepine toxicity
I HANDBAG - in coordination, hyponatraemia, ataxia, nystagmus, drowsiness, blurred vision, arrhythmias, GI disturbances
28
When should valproate be discontinued?
Abnormally prolonged prothrombin time or symptoms of acute liver tox - liver toxicity potentially fatal
Signs of pancreatitis
29
Which drugs lower the seizure threshold?
Quinolones, mefloquine, SSRIs, antipsychotics, TCA and related antidepressants - careful in epilepsy
30
What can be given to control status epilepticus or febrile convulsions in the community
Buccal midazolam or rectal diazepam - can give another dose if seizure not stopped 5-10 minutes after first dose
Paracetamol can be used in febrile to lower fever causing seizure
31
What paradoxical effect can benzodiazepines cause?
Increase in hostility and aggression. Can also increase anxiety and perceptual disorders
32
How long should benzodiazepines be used for?
2-4 weeks max
33
How long do signs of withdrawal occur with benzodiazepines?
Within 1 day of stopping a short-acting
Within 3 weeks of stopping a long-acting
34
How to manage benzodiazepine withdrawal
Gradually convert to an equivalent dose of diazepam ON (over 1 week)
Reduce diazepam dose by 1-2mg increments every 2-4 weeks (up to 1/10th every 1-2 weeks for high doses)
Reduce diazepam dose further - reduce in smaller steps (500mcg) near end
35
How long of a washout period is needed when switching to another antidepressant from a MAOI?
2 weeks (moclobemode is short acting and doesn’t require a washout period)
36
How long of a washout period is needed when switching to another antidepressant from an SSRI?
1 week (2 weeks for sertraline, 5 weeks for fluoxetine)
37
How long of a washout period is needed when switching to another antidepressant from a TCA?
1-2 weeks (3 weeks if imipramine or clomipramine)
38
How long should antidepressants be withdrawn over?
4 weeks
39
Which is the only antidepressant licensed for children?
Fluoxetine
40
Which TCAs are best for anxious/agitated patients?
Sedating - e.g. amitriptyline, clomipramine, dosulepin, doxepin, trimipramine
Sedating tetracyclics - mianserin, trazodone
41
Which TCAs are best for withdrawn/apathetic patients?
Less sedating - e.g. imipramine, lofepramine, nortriptylline
42
TCAs are more … than SSRIs
Sedating, epileptogenic, cardio toxic (QT, heart block), antimuscarinic
43
Which MAOIs have the highest risk of hepatotoxicity?
Phenelzine and isocarboxazid
44
When should MAOIs be discontinued?
Postural hypotension/hypertensive crisis - discontinue if palpitations or frequent headaches
Most likely with tranylcypromine
45
What foods should be avoided when taking MAOIs?
Foods high in tyramine (mature cheese, wine, meat stock, marmite) + avoid alcohol
46
Group 1 phenothiazines
Most sedative, moderate EPS
Drugs end in ‘promazine’ - chlorpromazine (contact sensitisation), levomepromazine, promazine (OTC sedative)
47
Group 2 phenothiazines
Least EPS
E.g. pericyazine
48
Group 3 phenothiazines
Most EPS
End in ‘phenazine’ or ‘perazine’ - fluphenazine, perphenazine, prochlorperazine, trifluoperazine
49
Butyrophenones
Most EPS
E.g. haloperidol (QT prolong)
50
Thioxanthenes
End in ‘penthixol’
Flupentixol (alerting affect, don’t take in evening)
Zuclopenthixol (depot preparation)
51
Which second generation antipsychotics have the most/least hyperprolactinaemia?
Most - amisulpride, risperidone
No - aripiprazole
52
Which second generation antipsychotics cause hyperglycaemia and sometimes diabetes?
CiROQ - clozapine, risperidone, olanzapine, quetiapine
53
Major side effects of clozapine
Myocarditis/cardiomyopathy, agranulocytosis, GI obstruction
54
What salt often indicates a depot antipsychotic formulation?
Decanoate
55
Which second generation antipsychotics cause weight gain?
COW - clozapine and olanzapine
56
Which antipsychotics cause the most sexual dysfunction?
Haloperidol and risperidone
57
What drugs can treat neuroleptic malignant syndrome?
Bromocriptine or dantrolene - dopamine receptor agonists
58
How long can neuroleptic malignant syndrome last?
5-7 days after stopping antipsychotic
59
Why should you never stop Parkinson’s meds abruptly?
Risk of acute akinesis and neuroleptic malignant syndrome
60
What antiemetic should not be given in Parkinson’s?
Metoclopramide - use domperidone instead (does not cause EPS)
61
What first line drug treatment should be given if motor symptoms of Parkinson’s decreased quality of life?
Levodopa
62
What first line drug treatment can be given if motor symptoms of Parkinson’s do NOT decrease quality of life?
Levodopa
Non-ergot dopamine agonists
MAO-B inhibitors
63
Which drugs can be added to levodopa as adjuvant therapy to control dyskinesia and motor fluctuations?
Non-ergot dopamine agonists
MAO-B inhibitors
COMT inhibitors
64
When should ergot dopamine agonists be used (e.g. bromocriptine, cabergoline, pergolide)
Not recommended - use if inadequate response to non-ergot
65
What drug can be used if dyskinesia is not managed by modifying Parkinson’s therapy?
Amantadine
66
What drug can be used in advanced Parkinson’s?
Apomorphine
QT prolongation so careful with domperidone
67
Examples of non-ergot dopamine agonists
Pramipexole
Ropinirole
Rotigotine
68
Examples of ergot dopamine agonists
Bromocriptine
Carbergoline
Pergolide
69
Which Parkinson’s meds cause fibrotic reactions?
Ergot dopamine agonists
Pulmonary - dyspnoea, persistent cough
Retroperitoneal - abdominal pain and tenderness
Pericardial - cardiac failure
70
Which Parkinson’s meds can cause a hypotensive reaction in first few days of treatment?
All dopamine agonists (not levodopa)
71
MAO-B inhibitor examples
Rasagiline
Selegiline (metabolised to amfetamine - driving offence)
72
What side effect can MAO-B inhibitors cause?
Hypertensive crises
Be careful with OTC decongestants and drugs that increase BP
73
Use of COMT inhibitors
Adjunct to levodopa in ‘end-of-dose’ motor fluctuations
74
COMT inhibitor examples
Entacapone - colours urine reddish-brown
Tolcapone - report hepatotoxicity
75
What are the 2 promethazine salts and their uses
Promethazine teoclate - vertigo, motion sickness
Promethazine hydrochloride - allergy/itch, sedation
76
What are the 2 hyoscine salts and their uses
Hyoscine hydrobromide - motion sickness
Hyoscine butylbromide - spasm
77
What antiemetic causes acute dystonic reactions
Metoclopramide
More common in young, especially women, and very old
Use procyclidine (anti-Parkinson’s drug) to abort attack
78
Use of betahistine dihydrochloride
Vertigo, tinnitus and hearing loss associated with Ménière’s disease
79
Uncommon strong opioids
Alfentanil - CD2
Remifentanil - CD2
Pethidine - CD2 - used in labour and causes convulsions if accumulates
Dipipanone - CD2
Papaveretum - CD2 - partial agonist precipitates withdrawal
Pentazocine - CD3
Sulfentanil - CD2
Tapentadol - CD2 - less nausea and constipation than other opioids
80
At what ages can codeine be used?
Should not be used under 12 years old due to risk of respiratory side effects
For 12-18, max dose of 240mg, min interval 6 hours, max duration 3 days
81
Contraindications of codeine
Known ultra rapid metabolisers, younger than 18 with tonsil or adenoid removal, breastfeeding mothers, children with compromised breathing
82
By what route should codeine/dihydrocodeine never be given?
Intravenous as can cause severe reaction similar to anaphylaxis
83
What weight is domperidone licensed for?
35kg and above
84
First line for a acute migraine
Monotherapy with aspirin, ibuprofen or 5HT1 agonist (e.g. sumatriptan)
If patient doesn’t respond to monotherapy with different agents, can use sumatriptan and naproxen together
85
Use of Metoclopramide and prochlorperazine in acute migraine
Can be used as a single dose to treat (unlicensed)
Mainly used for nausea and vomiting
86
Drugs that can be used for migraine prophylaxis
First line - propranolol
Other drugs:
Beta blockers (atenolol, metoprolol, timolol)
TCAs
Antiepileptics (topiramate, sodium valproate)
87
When should triptans be discontinued?
Symptoms of heat, heaviness, pressure or tightness
88
Contraindications of triptans
Cardiac disease: ischaemic heart disease, previous stroke/TIA, previous MI, uncontrolled hypertension
89
Can morphine/oxycodone be used in neuropathic pain?
Yes but must be prescribed by a specialist - use tramadol in interim
90
What drugs can be used for trigeminal neuralgia?
Carbamazepine or phenytoin
91
Short acting hypnotics
Examples: Z-drugs (zopiclone, zolpidem), short half life benzodiazepines (temazepam, lorazepam)
Used for sleep-onset insomnia (difficulty starting sleep)
Little hangover effect
92
Long acting hypnotics
Examples: long half life benzodiazepines (diazepam, nitrazepam)
Used for sleep maintenance insomnia (night time waking)
Hangover effect
Diazepam can have anxiolytic effect for daytime anxiety
93
What is melatonin licensed for?
Short term insomnia in over 55 years
Short term jet lag
94
How long can Z-drugs be used for?
Up to 4 weeks (2 weeks if Zaleplon)
95
Which hypnotics should be avoided in the elderly?
Z-drugs and benzodiazepines- ataxia and confusion
96
Can eye drops be used with contact lenses in?
Hard contact lenses - yes
Soft contact lenses - no as drug and preservatives can collect in the lens and irritate
97
Can oily eye drops or ointments be used with contact lenses in?
No, must always be removed as can cause lens deposits
98
What are the 3 main dangers of steroid eye drop use?
‘Red eye’ could be due to HSV, use of steroid can aggravate which leads to corneal ulceration and potential blindness
Steroid glaucoma
Steroid cataracts - with prolonged use
99
Cycloplegics/mydriatics
Dilate pupil by paralysing ciliary muscle
Tropicamide (lasts up to 6 hours)
Cyclopentolate (lasts up to 24 hours)
Atropine (lasts up to 7 days)
Phenylephrine (lasts up to 5-7 hours) - MAOI interaction and risk of hypertensive crises
100
What drug can be given for nephrogenic diabetes insipidus?
Thiazide-like diuretics - paradoxical effect
101
Main treatment for hyponatraemia in SiADH
Fluid restriction
102
If fluid restriction does not correct hyponatraemia in SiADH, what can be used?
Demeclocycline - blocks renal tubular effect of ADH
Tolvaptan - vasopressin antagonist
103
What specific eye problem can corticosteroids cause?
Central serious chorioretinopathy - report visual disturbances and refer
104
Which brand of methylprednisolone should be avoided in cow milk allergy?
Solu-Medrone - can cause serious allergic reactions due to lactose content
105
Drug treatment of Addison’s disease
Hydrocortisone + fludrocortisone
106
Drug treatment for hypopituitarism
Hydrocortisone only - aldosterone regulated by RAAS
107
Cortisol-inhibiting drugs for Cushing’s
Ketoconazole (potent) - watch out for life threatening hepatotoxicity
Metyrapone (competitive) - adrenal insufficiency
108
How do insulin requirements change throughout pregnancy?
Increase from 2nd semester
109
When should folic acid be supplemented alongside pregnancy?
When on antiepileptics
If diabetic
110
How should oral antidiabetics be treated in pregnancy?
Stop all - can continue with metformin
Use isophane insulin - long acting insulin’s from before pregnancy can be continued if glycaemic control is good
111
What should be done to insulin doses in the postnatal period?
Reduce insulin immediately after birth - monitor blood glucose to establish new dose
112
Antidiabetics in breastfeeding?
Avoid all but metformin
113
Differences between treating gestational diabetes with fasting blood glucose above/below 7
Below 7 - dietary and exercise advice - metformin if target not met in 1-2 weeks
Above 7 - insulin +/- metformin
114
What drug is reserved for when oral antidiabetics cannot be taken?
Acarbose
115
Treatment for corticosteroid-induced osteoporosis
Alendronic acid or risedronate sodium are first line and only licensed options
Consider in all patients on doses >7.5mg daily for more than 3 months
116
Indications for strontium ranelate
Severe post menopausal osteoporosis - if bisphosphonates fail
Men at high risk of fracture where other therapies are unsuitable
117
Side effects of strontium ranelate
Cardiovascular - myocardial infarction + VTE
DRESS rash
118
Choice of HRT for vasomotor symptoms e.g. hot flushes, night sweats
With a uterus - oral or transdermal combined preparation - taken either cyclically or continuous
Without a uterus - oral or transdermal oestrogen only - taken continuously
Under 50 - can use HRT or combined contraceptive
119
Choice of HRT for vaginal atrophy
Low dose topical oestrogen - creams/rings
120
When is continuous combined HRT unsuitable?
Peri-menopause or <12 months after last period - irregular bleeding
121
How to deal with HRT alongside surgery
Stop 4-6 weeks before elective surgery - restart once mobile
Non-elective - parenteral anticoagulation
122
Does HRT provide contraception?
No it does not
Use low oestrogen combined contraceptive below 50
Progestogen only are safe alongside cyclical HRT and can be used above 50
123
How long should HRT be taken?
Review after 3 months and then annually
Most women require 2-5 years of treatment
Premature menopause - continue up to average natural menopause (51 years old)
124
Female fertility information
Women under 50 - potentially fertile for 2 years after last period
Women over 50 - potentially fertile for 1 year after last period
All women can stop contraception at the age of 55
125
HRT contraindications/reasons to stop
Signs indicating VTE - unilateral calf swelling, sudden severe chest pain, breathlessness
Signs indicating stroke
Liver dysfunction
Blood pressure - above 160/95
Prolonged vaginal bleeding
Prolonged immobility
126
Where should testosterone not be applied?
Genital área
127
What drugs can be used for supportive care in hyperthyroidism?
Beta blockers
128
What happens if metabolism increases too rapidly due to initial levothyroxine dosing?
Hyperthyroidism symptoms - reduce dose or withhold for 1-2 days and start again at lower dose
129
Examples of mild topical corticosteroids
Hydrocortisone <2.5%
130
Examples of moderate topical corticosteroids
Betamethasone 0.025% (Betnovate-RD)
Clobetasone (Eumovate)
131
Examples of strong topical corticosteroids
Betamethasone 0.1% (Betnovate)
Hydrocortisone butyrate
Mometasone
132
Examples of very strong topical corticosteroids
Clobetasol (Dermovate)
133
How should emollients and topical steroids be given together?
Emollient first and then steroid 20-30 mins later - max absorption
134
How much is in a fingertip unit?
About 500mg and is enough to cover an area twice that of the flat of the hand with fingers together
135
First line treatment for rosacea
Brimonidine for 6-12 week course repeated intermittently
136
MHRA warnings for brimonidine
Risk of systemic cardiovascular effects (bradycardia, hypotension) - avoid application to broken skin
Risk of rosacea exacerbation - start with small amount of gel and increase gradually
137
Treatments for pustules in rosacea
Topical - azelaic acid, ivermectin, metronidazole
Oral - tetracyclines or erythromycin
138
PPP for isotretinoin
Pregnancy tests excluding pregnancy a few days before, every month during and for at least a month after
2 contraceptives for 1 month before, during and 1 month after - progestogen ineffective
139
How long is an isotretinoin prescription valid for and how much can be dispensed?
7 days valid - 30 day supply
140
Isotretinoin side effects that need attention
Risk of pancreatitis if triglycerides above 9 - discontinue in uncontrolled high triglycerides or pancreatitis
Discontinue if severe skin peeling or haemorrhagic diarrhoea
Visual disturbances + psychiatric effects - expert referral
141
MHRA reports for isotretinoin
Risk of sexual side effects such as erectile dysfunction and decreased libido
Under 18 - 2 independent prescribers must agree on therapy - review after 1 month
142
How long can intranasal sympathomimetic decongestants (e.g. xylometazoline) be used for and why?
7 day max as risk of rebound congestion incentivising further decongestant use
143
Age requirements and max duration of use for OTC intranasal steroids (e.g. fluticasone, mometasone)
18 years+
Max duration of 3 months
144
Which triptan is available OTC and what requirements should be met?
Sumatriptan
Must be 18-65 with a clear diagnosis of migraine and not used prophylactically
Other co-morbidities to avoid: cardiovascular conditions, hypertension, epilepsy
145
Why should analgesics not be used regularly in headache/migraine?
Can cause chronic daily headache (medication-overuse headache) - especially with codeine
146
What analgesics should not be used for tension headaches?
Combinations containing opioids due to risk of medication-overuse headache
147
OTC options for cystitis
Potassium citrate or sodium citrate for 2 days
Cranberry juice has no evidence for use - avoid in diabetes
148
When should a woman seeking EHC be referred to rule out pregnancy?
If menstrual periods are delayed by more than 5 days after levonelle, or 7 days after ellaOne
Abnormal bleeding at expected period date
Pregnancy symptoms
149
How long should barrier methods be used after using EHC for unprotected sex?
Until the next menstrual period is confirmed
150
Which brand of tamsulosin is available OTC and how should it be taken?
Flomax Relief
For use in males aged 45-75 for symptoms of BPH
If no improvement in 14 days then refer, if working then needs GP to confirm diagnosis within 6 weeks of starting
151
Who can be sold sildenafil OTC
18+ years old with erectile dysfunction
152
What side effect can sildenafil cause and which drug should be avoided in treating it?
Chest pains - if long lasting then call 999
Do NOT use nitrates alongside sildenafil as can cause severe hypotension
153
Which NSAIDs are contraindicated in MI/CVD?
High dose ibuprofen (2.4g), diclofenac and COXIBs
154
What is the max dose of simvastatin that can be used alongside a fibrate?
10mg daily
155
What is the max dose of simvastatin that can be used alongside amlodipine, amiodarine, or ranolazine?
20mg daily
156
How much more potent is Qvar compared to generic beclometasone?
2x
157
How much more potent is fostair compared to generic beclometasone?
2.5x
158
MHRA warning for hydrochlorothiazide
Increased risk of non-melanoma skin cancer
159
MHRA warning for warfarin
Reports of calciphylaxis (calcium buildup in small blood vessels)
160
MHRA warning for hydroxychloroquine/chloroquine
Increased risk of cardiovascular events (angina + heart failure) when used alongside macrolides + reminder of psychiatric reactions (within first month of treatment)
161
Contraindications for calcium channel blockers
Unstable angina
Heart failure with reduced ejection (not amlodipine)
162
Which OTC cough and cold meds should not be given to children below 6?
Antihistamines - chlorphenamine, diphenhydramine, promethazine
Cough suppressants - dextromethorphan
Expectorants - guaifenesin or ipecacuanha
Decongestants - pseudoephedrine, oxymetazomine, xylometazoline
163
What PPI does clopidogrel interact with and which PPI should be given instead?
Omeprazole decreases clopidogrel efficacy - give lansoprazole
164
Concurrent use of which drugs require digoxin doses to be halved?
Amiodarone, dronedarone, and quinine
165
Which analgesics should be avoided alongside DOACs?
NSAIDs
166
How long should contraception be continued after stopping leflunomide?
2 years after for women, 3 months after for men
To accelerate elimination, colestyramine can be used at dose of 8g TDS for 11 days
167
How long should contraception be continued after stopping methotrexate?
6 months after for both men and women
168
What drugs should be paused in acute illness as per sick day rules?
SADMAN - SGLT2, ACEi, Diuretics, Metformin, ARBs, NSAIDs
169
Which beta blocker should not be used in AF?
Sotalol
170
What drugs can be used for pharmacological cardioversion?
Flecainide or amiodarone
171
Which cardioversion is preferred >48 hours after AF onset?
Electrical
172
How long should anticoagulation occur for alongside cardioversion?
3 weeks before to allow for full anticoagulation and then at least 4 weeks after
173
What should be done before electric rapid electric cardioversion where anticoagulation can’t be established prior?
Rule out left atrial thrombus and parenteral anticoagulation (heparin) commenced immediately before cardioversion
174
What approach can be used to control AF episodes in paroxysmal AF?
Pill-in-the-pocket approach - use of flecainide or propafenone PRN when episode occurs
175
How should you manage risk of clotting while waiting for confirmation of AF?
Use parenteral anticoagulation (heparin) until assessment is made and appropriate anticoagulation is started/not indicated
176
How to treat pulseless ventricular tachycardia or ventricular fibrillation
Immediate defibrillation and CPR - IV amiodarone given refractory to defibrillation
177
How to treat unstable sustained ventricular tachycardia
Direct current cardioversion. If fails, give IV amiodarone and repeat direct current
178
How to treat stable sustained ventricular tachycardia
IV anti arrhythmic - amiodarone preferred
179
How to treat non-sustained ventricular tachycardia
Beta blocker
180
Long term treatment after ventricular fibrillation
Implantable cardioverter defibrillator - most patients
Beta blocker, sotalol, or amiodarone and beta blocker - some patients
181
Torsade de pointes treatment
Usually self-limiting
If not controlled/severe - magnesium sulfate infusion
182
First line for treating paroxysmal SVT
Tends to terminate spontaneously or can use reflex vagal nerve stimulation e.g. valsalva manoeuvre, immersing face in ice cold water
Direct current cardioversion if haemodynamically unstable
183
How to treat paroxysmal SVT if vagal nerve stimulation ineffective
IV adenosine (don’t use in COPD/asthma)
IV verapamil in asthma/COPD or ineffective adenosine
184
Treatment for recurrent paroxysmal SVT
Catheter ablation or drugs like diltiazem, verapamil, sotalol etc
185
In which patients should flecainide/propafenone not be used?
Asthma/severe COPD
Structural/ischaemic heart disease
186
Risks and discontinuation criteria for dronedarone
Hepatotoxicity - stop if 2 consecutive ALT concs exceed 3x upper limit
Heart failure - stop if develops
Pulmonary toxicity - discontinue in dyspnoea or dry cough
187
How can amiodarone be used alongside electrical cardioversion?
Start 4 weeks before and continue up to 12 months after to increase success
188
How to manage concomitant thyroid dysfunction with amiodarone
Hyperthyroidism - withdraw amiodarone and use carbimazole of necessary
Hypothyroidism - can continue alongside levothyroxine if essential
189
Digoxin dose ranges based on indication
Heart failure - 62.5-125mcg OD
Atrial flutter and non-paroxysmal AF in sedentary - 125-250mcg OD
190
Acronym for digoxin interactions
CRASED - CCBs (verapamil), rifampicin, amiodarone, St John’s wort, erythromycin, diuretics
191
How long should VTE prophylaxis continue after general surgery?
At least 7 days
192
How long should VTE prophylaxis continue after major cancer surgery?
28 days
193
Thromboprophylaxis options in elective hip replacement
LMWH for 10 days, followed by low dose aspirin for 28 days
OR
LMWH for 28 days + AES/rivaroxaban until discharge
194
Thromboprophylaxis options in elective knee replacement
Low dose aspirin for 14 days
OR
LMWH for 14 days + AES/rivaroxaban until discharge
195
First line treatment for confirmed DVT/PE
Apixaban or rivaroxaban
Stop after 3 months in provoked (if provoking factor gone), 6 months if unprovoked
Continue longer in cancer
196
LMWH options for DVT/PE if first line treatment unsuitable
LMWH for at least 5 days followed by dabigatran or edoxaban
OR
LMWH given alongside warfarin for at least 5 days or until INR >2 for 2 consecutive readings - followed by warfarin alone
197
Anticoagulation considerations for DVT/PE in renal impairment
Apixaban, rivaroxaban, and edoxaban can’t be given below CrCl 15
Dabigatran can’t be given below CrCl 30
Unfractionated heparin preferred to LMWH in renal impairment
198
VTE treatment in pregnancy
LMWH used as maintenance
Lower risk of osteoporosis and HIT
Stop at labour onset
199
Anticoagulant reversal agents
Heparins - protamine if rapid reversal required (partial effect on LMWH)
Apixaban and rivaroxaban - andexanet alfa
Dabigatran - idarucizumab
Warfarin - phtomenadione
Edoxaban - no reversal agent
200
Electrolyte imbalance caused by heparins and monitoring for it
Hyperkalaemia - heparins inhibit aldosterone secretion
Higher risk of diabetes and CKD
Monitor before treatment and if >7 day use
201
INR monitoring frequency with warfarin
Every 1-2 days initially, once stable reduced to 3 monthly
202
Warfarin INR ranges
2.5 +- 0.5 - AF, DVT, MI, biprosthetic heart valves in mitral position
3.5 +- 0.5 - recurrent DVT/PE, mechanical heart valves
203
OTC interaction with warfarin
Miconazole gel contraindicated alongside warfarin
204
Peri-operative warfarin for elective surgery
Stop 5 days before
If INR >1.5 day before before surgery, give oral phytomenadione
Restart warfarin at previous maintenance in evening or next day
205
Peri-operative warfarin for elective surgery in those at high VTE risk (VTE within last 3 months, AF with previous stroke)
Treatment dose LMWH bridging - stop 24 hours before surgery
If high risk of bleed - start LMWH 48 hours after surgery
206
Peri-operative warfarin for emergency surgery
If surgery can be delayed by 6-12 hours - give IV phytomenadione
If not, give IV phytomenadione and dried prothrombin complex
207
Which patients have 130/80 BP target for hypertension?
Atherosclerotic CVD
Diabetes with target organ damage - eye, kidney, cerebro vascular disease
CKD
ACR of 70 or more
208
First line for pre-eclampsia, gestation or chronic hypertension
Labetalol - be careful of hepatotoxicity
209
Other treatment options for gestational hypertension if labetolol unsuitable
Nifedipine MR (unlicensed)
Methyldopa (unlicensed) - stop 2 days after birth and switch treatment
210
Which drugs can be given at low dose for renal protection in CKD?
ACE inhibitors
211
Indication for hydralazine
Resistant hypertension in adjunct with other antihypertensives
When used alone - tachycardia and fluid retention
212
Side effects of minoxidil and how to fix
Increased cardiac output, tachycardia, fluid retention - beta blockers and furosemide required
Hypertrichosis - unsuitable for females
213
Acronym for beta blockers with intrinsic sympathomimetic activity
ice PACO - pindolol, acebutolol, celiprolol, oxprenolol
Less bradycardia, less coldness of extremities
214
Acronym for water soluble beta blockers
water CANS - celiprolol, atenolol, nadolol, sotalol
Less BBB crossing - less nightmares and sleep disturbances
215
Acronym for cardioselective beta blockers
Be A MAN - bisoprolol, atenolol, metoprolol, acebutol, nebivolol
Less bronchospasm - can be used in asthma under specialist
216
Acronym for long acting beta blockers
BACoN - bisoprolol, atenolol, celiprolol, nadolol
Once daily dosing
217
What diuretics should be avoided with beta blockers in diabetes/high diabetes risk?
Thiazide-like diuretics - hyperglycaemia
218
Nifedipine MR prescribing practices
Prescribe by brand name as different MR forms have different clinical effect
219
Diltiazem MR prescribing practices
Prescribe by brand name if more than 60mg as different MR forms have different clinical effect
220
What juice should be avoided alongside CCBs?
Grapefruit
221
At what eGFR do thiazide-like diuretics become ineffective?
<30 except for metolazone - use in severe renal failure
222
High intensity statin doses
Atorvastatin 20-80mg
Rosuvastatin 10-40mg
Simvastatin 80mg
223
Statin and systemic fusidic acid interaction
Risk of rhabdomyolysis
Stop statin and restart 7 days after last fusidic acid dose
224
Important statin side effects
Muscle effects - creatinine kinase, stop if 5x upper limit
Diabetes - statins can increase blood sugars but benefits outweigh risks
Interstitial lung disease - dyspnoea, cough, weight loss
225
Max dose of atorvastatin with ciclosporin
10mg
226
Max dose of rosuvastatin with clopidogrel
20mg
227
Statins and pregnancy
Teratogenic - contraception needed during and for 1 month after stopping
Attempts to conceive should be done 3 months after stopping
228
What lipid parameter do fibrates primarily work on?
Triglycerides
229
When can fibrates be used?
Under specialist advice
If statin/ezetimibe inappropriate or as addition to statins if triglycerides are high despite LDL-cholesterol being controlled (fenofibrate) - try ezetimibe first as not specialist
230
Which fibrate should statins never be used with?
Gemfibrozil - considerable rhabdo risk
231
Bile acid sequestrant examples
Colesevelam, colestipol, colestyramine
Specialist use
232
Main side effect of bile acid sequestrants and how to deal with it
Impairs absorption of fat soluble vitamins (ADEK) and other drugs
Take other drugs 1 hour before (4 hours for coleveselam) or 4 hours after
233
Special storage requirements for GTN sublingual
Foil-lined container with no cotton wadding
8 week expiry after opening
234
How many PRN GTN doses until long term treatments are considered
2 times a week
235
After how many GTN doses should 999 be called if chest pain still present?
3 doses + 5 minute wait periods for each dose
236
Options for angina prophylaxis if beta blockers and CCBs fail
Long acting nitrates
Ivabradine - only in sinus rhythm
Ranolazine
Nicorandil - second line as risk of ulcer + adult only
237
How to avoid tolerance with long acting nitrate patches
Leave patches off for 8-12 hours - overnight
238
How to avoid tolerance with long acting nitrate BD formulations (MR dinitrate/IR mononitrate)
Take second daily dose after 8 hours rather than 12
239
How to avoid tolerance with long acting nitrate OD formulations (MR mononitrate)
Does not produce tolerance - no adjustment
240
Electrolyte disturbances of loop diuretics
Hypo - potassium, sodium, chloride, magnesium (exacerbated in alcoholic cirrhosis), calcium
Hyper - glucose (caution in diabetes but less than thiazides), uric acid (caution in gout, furosemide most likely)
241
Electrolyte disturbances of thiazide-like diuretics
Hypo - potassium, sodium, chloride, magnesium (exacerbated in alcoholic cirrhosis)
Hyper - calcium, glucose (caution in diabetes), uric acid (caution in gout)
242
Side effects of loop diuretics
Ototoxicity
Acute urinary retention - too rapid diuresis (caution in BPH)
243
Side effects of thiazide-like diuretics
GI disturbances, impotence, high LDL/triglycerides
244
Non-aldosterone potassium sparing diuretic examples and indications
Triamterene
Amiloride
Oedema monotherapy
Potassium conservation alongside loop or thiazide-like diuretics
245
Unusual side effects of spironolactone
Gynaecomastia, benign breast tumours, menstrual disturbances, hypertrichosis, change in libido
246
The 2 types of peripheral vascular disease and example
Occlusive (intermittent claudication in peripheral artery disease)
Vasospastic (Raynaud’s)
247
Treatment of peripheral artery disease
Supervised exercise plan + lifestyle modification
Aspirin/clopidogrel 75mg + secondary prevention statin
248
Treatment of intermittent claudication not improved by exercise program
Naftidrofuryl oxalate - review after 3-6 months
Cilostazol and pentoxifylline are licensed but not as effective
249
Treatment of Raynauds
Lifestyle modification - smoking cessation, avoid cold
If not enough - nifedipine as prophylaxis
250
Which CDs require safe custody?
CD 1, 2 and 3 - except phenobarbital, midazolam, tramadol, pregabalin, gabapentin
251
What sleep related side effect does donepezil cause?
Insomnia
252
What side effect is shared by all AChEi but not memantine
Bradycardia - can switch to memantine if issue
253
What are the biochemical findings that indicate rhabdomyolysis?
Very high CK + AKI
254
How does the PPP for sodium valproate differ to other PPP drugs?
Negative pregnancy test not required before each prescription
255
What is first line for chronic primary pain?
Antidepressants (off label)- mainly SSRIs as lower risks
Other options have no evidence
256
What serum lithium range target is used for patients newly initiating lithium?
0.6-0.8mmol/L
257
What is the only antimalarial preparation that can be bought OTC?
Maloff Protect (atorvaquone/proguanil)
Packs of 24 and 36
258
Age requirement for Maloff Protect?
18+
259
How many travellers can Maloff Protect be bought for?
4 travellers
260
What is the maximum amount of time Maloff Protect can be sold for OTC?
12 weeks
261
How should Maloff Protect be taken?
With food or milky drinks to improve absorption
262
What insect repellent should be used to protect from Malaria and what is its age requirement?
DEET 50% - can be applied to skin and reapply frequently
2 months+
263
After EHC, how long are barrier methods needed alongside a COC compared to Qlaira?
7 days - COC
9 days - Qlaira
264
Should COC be continued alongside levonogestrel?
Yes continue
265
Should COC be continued alongside ulipristal?
No, restart 5 days after EHC
Use extra protection until next period confirmed
266
Which HRT treatment can be sold OTC?
Gina vaginal tablets
267
What is the first line treatment for pain in pregnancy?
Non-pharmacological methods e.g. hot water bottles, physiotherapy, light exercise, yoga
268
What is the first line and second line pharmacological treatments for pain in pregnancy
First line - paracetamol
Second line - refer to GP
269
What analgesics should be avoided in pregnancy?
Ibuprofen - from 20 weeks
Contraindicated from 28 weeks due to risk of premature closure of ductus arteriosus and maternal bleeding
Opioids - respiratory depression around delivery + withdrawal
270
Can antispasmodics be bought over the counter for IBS?
Yes - can purchase hyoscine butylbromide, mebeverine, alverine and peppermint oil
Need IBS diagnosis for all but peppermint oil
271
Should 300mg aspirin be chewed for treatment of stroke in the community?
No - there is a risk of stroke being haemorrhagic
Can use for MI
272
What foods should be avoided alongside fexofenadine?
Apple juice + orange juice
273
Requirements for amorolfine 5% nail lacquer OTC
18 years+
Max of 2 nails affected
Infection in upper half or sides of nail
No broken nails
274
Which drugs interact with cigarette smoke?
Aminophylline/theophylline - dose adjust
Clozapine - dose adjust
Watch out for tox with:
Chlorpromazine
Flecainide
Methadone
Olanzapine
Warfarin
275
What monitoring can be done to check compliance to NRT treatment?
Carbon monoxide monitoring after 4 weeks - should aim for less than 10ppm
276
Can NRT be used in pregnancy?
Yes but try to manage with short acting to reduce foetal nicotine exposure
277
What factors can increase risk of otitis externa?
Swimming
Eczema
Using hearing aids
278
What non antibiotic treatment can be used OTC for otitis externa and its requirements
Acetic acid 2% (earcalm)
Must be 12+ and no perforation in eardrum
279
How long should earcalm treatment be continued for?
2 days after symptoms have disappeared
However no longer than 7 days
280
What’s the latest a loop diuretic can be used in the day?
4pm
281
What is the first line resource for researching international drugs or drugs by street name?
Martindale’s
282
What surgery related contraindication does Metoclopramide have?
Contraindicated 3-4 days after GI surgery
283
What steroid is in otomize ear spray?
Dexamethasone
284
What can clioquinol ear drops be used for and special patient information
Eczematous inflammation in otitis externa and mild bacterial or fungal otitis externa
Can stain skin and clothing
285
GLP-1 analogue targets for continued used in diabetes
At 6 month review:
Reduction in HbA1c of at least 1%
Weight loss of at least 3%
286
GLP-1 analogue targets for continued used in weight loss
At least 5% weight loss in 3-6 months
287
What potency is aclometasone diproprionate 0.05% (Modrasone)
Moderate - similar to eumovate and betamethasone 0.025%
288
Age requirement for OTC Anusol Plus HC
18+
289
What is the difference between Dioralyte and Dioralyte Relief
Dioralyte Relief contains rice starch - little evidence to show better effect
290
What GI symptom would you not expect in IBS and therefore warrant referral?
Vomiting
291
At what age is naproxen licensed OTC?
15-50 for dysmenorrhea
292
Should beta blockers be used in pregnancy?
Should avoid - can cause intrauterine growth restriction, neonatal hypoglycaemia and bradycardia
Can use labetolol - for hypertension in pregnancy
293
Which PPIs are available GSL?
Esomeprazole 20mg (Nexium Control)
Omeprazole 20mg (Pyrocalm Control)
294
Age and supply requirement for OTC PPIs
18+
No more than 14 days treatment
295
Age restrictions for Regaine - minoxidil 5%
18-65
18-49 for men scalp foam
296
When should you get a yellow fever vaccine before travelling to a high risk country?
At least 10 days before to allow vaccine to work
297
Can you give MMR vaccines and yellow fever vaccines together?
No, should ideally leave a 4 week gap to allow proper antibody formation to both infections
298
What clinical sign can be seen on removal of scales in plaque psoriasis
Auspitz sign - pinpoint bleeding (red dots) from dilated capillaries
299
What drinks should be avoided during shigella infection? (Traveller’s diarrhoea)
Highly osmotic solutions of glucose like soda - may draw water into GI and exacerbate diarrhoea
300
How quickly does bisacodyl provide a laxative effect?
Oral - 10-12 hours
Rectal - 20-60 mins
301
How quickly does docusate provide a laxative effect?
Oral - 24-48 hours
Rectal - 20 mins
302
How quickly does lactulose provide a laxative effect?
Up to 48 hours
303
How quickly does senna provide a laxative effect?
8-12 hours
304
What products can be used for earwax removal?
Olive/almond oil drops
Sodium bicarbonate 5% ear drops
Sodium chloride 0.9% nasal drops (off-label)
Do not use in perforation
305
What are the advanced services in the community pharmacy framework?
Pharmacy first
Flu vaccination
Contraception
Hypertension case finding
Smoking cessation
Stoma appliance customisation
Appliance use review
Lateral flow device services
306
Vulvovaginal sores occur in what infection?
Genital herpes - not normally seen in chlamydia
307
Age requirement for crotamiton cream
3 years+
308
Criteria required for tranexamic supply OTC
For heavy menstrual bleeding
Regular 21-35 day cycle
Cycle variability of no more than 3 days
18+ years old
309
Dosage for OTC tranexamic acid
2 x 500mg tablets TDS for max of 4 days
310
What contact lens solution can be used with lens still on the eye?
Rewetting solution
311
What type of UV radiation causes photosensitivity reactions when taking photosensitising drugs
UVA radiation - recommend sun cream with broad cover (not just UVB)
312
Sunscreen agents that protect against UVA
Avobenazone
Ecamsule
313
Sunscreen agents that protect against UVB
PABA
Padimate O
Octinoxate (octyl methoxycinnamate)
Homosalate
Octisalate
Ensulizole
314
Sunscreen agents that protect against UVA + UVB
Zinc oxide
Titanium dioxide
Tinosorb S and M
315
Carbamazepine has cross sensitivity with what drug class?
TCAs as structurally similar - should avoid if patient hypersensitive to TCAs
316
What effect can benzoyl peroxide have on hair and clothes
Bleaching effect
317
Does sunlight minimise acne lesions?
Little evidence - most acne meds photosensitise skin so avoid direct sunlight
318
After which event is enoxaparin contraindicated?
Acute stroke (cerebral haemorrhage) - usually for about 2 months but depends on local guidance
319
What symptoms would require a patient to stop taking alendronic acid?
Dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain
Can be a sign of severe oesophageal reactions
320
Can atovaquone/proguanil be used in pregnancy?
Should be avoided - can be considered in second and third trimester if nothing else suitable
Take folic acid alongside
321
Can chloroquine be used in pregnancy?
Can be given - effectiveness has declined so can’t confirm protection
322
Can mefloquine be used in pregnancy?
May be considered in second or third trimester
Caution in first - risk vs benefit
323
Can doxycycline be used in pregnancy?
Contraindicated
Can be used unlicensed for malaria prophylaxis if completed before 15 weeks gestation
324
How does prednisolone affect potassium levels
Increased potassium loss - hypokalaemia
325
Which antibiotic can interact with spironolactone to cause hyperkalaemia?
Trimethoprim - co-trimoxazole by extension
326
Which antidepressants have the highest chance of withdrawal symptoms?
Short-acting SSRIs and SNRIs - paroxetine, venlafaxine
327
Which cuisine contains foods that may interact with MAOIs?
Traditional Japanese diets
328
What is the brand name of the nasal flu vaccine and is it live or dead?
Fluenz Tetra - live nasal vaccine
Don’t use in immunocompromised or those in close contact with them
329
What type of immunoglobulins should be considered after a physical injury such as knife wound
Tetanus immunoglobulin if not sure if vaccine history
330
How should lansoprazole be taken?
30-60 minutes before food
331
How should flucloxacillin be taken?
On an empty stomach
332
Which glaucoma medication can cause eyelashes to become darker, thicker and longer?
Latanoprost
333
MHRA warning with latanoprost
pH change of formulation (Xalatan) to be more acidic has increased incidence of eye irritation - report if experiencing eye irritation severe enough to make them want to stop
334
Which glaucoma medication can cause blurred vision and affect driving
Pilocarpine
335
LABAs and LAMAs in Breezhaler inhalers
LABA - indacaterol
LAMA - glycopyrronium
336
LABAs and LAMAs in Respimat inhalers
LABA - olodaterol
LAMA - tiotropium
337
LABAs and LAMAs in Genuair inhalers
LABA - formoterol
LAMA - aclidinium
338
LABAs and LAMAs in Ellipta inhalers
LABA - vilanterol
LAMA - umeclidinium
339
Which progestogen contraceptive has a longer cover before missing a dose
Cerazette (desogestrel) - 12 hours
Other progestogens - 3 hours
340
Which combined phasic contraception can be given continuously?
Qlaira
341
What is a phasic contraceptive?
Release of hormone is different throughout the month - helps to reduce side effects
342
What is Depo-provera and how often should it be given
Depot injection contraceptive - redo every 12 weeks
343
Linaclotide indication
Moderate to severe IBS with constipation
Review treatment after 4 weeks
344
Which laxative can be useful in the treatment of hepatic encephalopathy?
Lactulose
345
What strength pens do insulin detemir come in?
100 units/ml
346
What strength pens do insulin glargine come in?
100 units/ml
300 units/ml
347
What strength pens do insulin degludec come in?
100 units/ml
200 units/ml
348
Which sulfonylurea can be used if a patient is experiencing regular hypos
Use a short-acting sulfonylurea - tolbutamide
349
Mechanism of action of reboxetine
Selective inhibitor of noradrenaline reuptake - use in major depression
350
Maximum daily dose OTC of naproxen?
750 mg - 3 x 250mg
351
Maximum daily dose OTC of ibuprofen?
1200mg - 6 x 200mg or 3 x 400mg
352
Maximum daily dose of pepto-bismol
4200mg - 16 x 262.5mg
353
What eye problem can herpes simplex cause and how to treat
Herpetic keratitis - causes dendritic corneal ulcers
Treat with aciclovir or ganciclovir eye ointments
354
Which antidiabetics cause weight loss?
GLP-1 agonists
SGLT2 - lesser extent
355
Is regular blood glucose monitoring needed for all diabetic patients?
No, only for those at risk of hypo e.g. on hypo meds like insulin or multiple meds together
356
Which SGLT2s are licensed for heart failure and CKD?
Dapagliflozin and empagliflozin
357
How does nitrofurantoin perform its mechanism of action?
Inhibits ribosomal protein synthesis
358
When can a UTI be considered recurrent and may need prophylaxis?
2 or more UTIs in last 6 months
359
Which antibiotics should be avoided alongside dairy, calcium, iron and zinc?
Tetracyclines and quinolones - avoid 2 hours before and after
360
What happens to SGLT2 effectiveness as renal function decreases?
Diabetic effectiveness decreases - action linked to kidney
Becomes more renal protective
361
When can finerenone be used for CKD?
Pt has type 2 diabetes
CKD 3/4 with albuminuria
362
Which SGLT2 can increase muscle effects with atorvastatin?
Empagliflozin - anecdotal interaction
363
At what eGFR should finerenone be stopped?
Consistently below 15 - limited evidence
364
What electrolyte should be monitored with finerenone and how often?
Potassium - causes hyperkalaemia
Monitor at baseline alongside ECG and then at 4 weeks - more frequently if K+ >4.8
Don’t start >5
365
What is the Cockroft-Gault equation for creatinine clearance?
((140-age) x ideal body weight) / (creatinine x 72) plus multiply by 0.85 if female
366
Which patient groups have eGFR that appears higher than it really is?
Low muscle mass
E.g. elderly, cirrhosis, amputee, low protein diet
367
Which patient groups have eGFR that appears lower than it really is?
High muscle mass e.g. bodybuilders
High protein diet
368
What skin symptom is commonly seen in CKD
Pruritis
369
What drugs can be used to treat CKD pruritis
Creams and emollients
Antihistamines
Gabapentin/pregabalin
Difelikefalin - only in hospital and severe
370
What drugs should be used to slow progression of CKD?
Always start ACE inhibitors if diabetic and CKD. Should also always have statin
Can add on SGLT2 later
Finerenone used later on in treatment
371
How to decide between SGLT2 in CKD
Can only start dapagliflozin with ACR >25 as per guidance
Empagliflozin normally more acceptable
372
Indication of argatroban
Anticoagulation in patients with HIT
373
What GI indication does colestyramine have?
Relief of diarrhoea in Crohn’s disease, ileal resection, diabetic vagal neuropathy
374
When should plasma theophylline levels be measured after initiation and after dose changes?
5 days after initiation
3 days after dose change
Sample taken 4-6 hours after MR prep
375
How should digoxin dose be modified when switching from IV to oral?
Dose may need to be increased by 20-33%
376
What electrolyte imbalance is there an increased risk of in alcoholic cirrhosis?
Hypomagnesaemia
377
What electrolyte imbalance is there an increased risk of when taking diuretics in hepatic failure?
Hypokalaemia - precipitating encephalopathy
378
Different types of chlamydia
Chlamydia trachomatis - STI
Chlamydia psittaci - lung disease
379
Chlamydia psittaci symptoms and cause
Commonly seen in bird owners or poultry farmers (parrot fever)
Causes severe pneumonia, splenomegaly, leucopaenia and thrombocytopenia
380
Symptoms of trichomonas vaginalis
Profuse, frothy, greenish-yellow and malodorous discharge
Valvular itching
Dysuria
381
Common cause of legionnaire’s disease
Uncommon severe community-acquired pneumonia
Caught from water droplets - such as from hot tubs, air con systems
382
Which patient groups are exempt from prescription charges?
Individuals under 16
Individuals between 16-18 in full time education
Over 60
Inpatients in hospital
Pregnant women and 12 months after birth
Patients with treatment for cancer or cancer-related side effects
383
What facial symptom can calcium channel blockers cause and how to fix
Facial flushing
Can reduce dose to alleviate
384
What are the symptoms of hypomagnesaemia?
Nystagmus, muscle cramps, fatigue
385
Can sulfonylureas be used in renal impairment?
Yes - principally metabolised by liver so may be preferentially used
386
Indication for diazoxide
Chronic intractable hypoglycaemia
387
Can carbapenems be given if patient has a reaction to beta-lactams?
Yes, as long as the reaction wasn’t anaphylactic or severe
388
When should oral iron be started after parenteral iron and how long should it continue?
Start 5 days after parenteral and then continue for 3 months
389
Age requirement for OTC sodium cromoglycate
6+
390
How often should a spacer be replaced?
Every 6-12 months
391
Three main types of nebulisers
Jet nebs - driven by air or oxygen (caution in hypercapnia)
Ultrasonic nebs
Vibrating mesh nebs
392
Common flow rate of jet nebs
6-8 L/min
393
Use of pentamidine isethionate nebs
Prophylaxis of pneumocystis jirovecii
394
How often should peak flow monitoring be done?
At least twice a day - usually before taking medications
395
Peak flow results and how to interpret
80%+ of personal best + no symptoms - normal
50-80% of personal best - speak to GP or asthma nurse
<50% of personal best - urgent action
396
FeNO level for diagnosis or asthma
>50 ppb in adults
>35 ppb in children 5-16
Not normally raised in COPD
397
Expected spirometry and bronchodilator reversibility results in asthma and COPD
FEV1/FVC ratio - <70% for both
FEV1 - increase in 12% or more and 200ml from pre-bronchodilator OR increase in 10% or more of predicted normal FEV1 with asthma
COPD shows minimal reversibility
398
Expected peak flow variability with asthma and COPD
Measure for 2-4 weeks
Variability is 20% or more - asthma
Minimal variability - COPD
399
Initial treatment of moderate asthma attack in the community
SABA - 2-10 puffs every 10-20 mins via a spacer. If symptoms persist after 15-30 mins, call 999
400
What steroids can be used if oral prednisolone not possible in acute asthma?
IV hydrocortisone or IM methylprednisolone
401
When can magnesium sulphate be used in acute asthma
Single IV dose
With severe acute asthma (PEF <50% best or predicted)
OR
Those who have not had a good response to inhaled bronchodilators (unlicensed)
402
Use of IV aminophylline in acute asthma
Not likely to produce any additional bronchodilation
May provide benefit in life-asthma or near-fatal asthma (PEF <33% best or predicted)
Only use after consultation with senior medical staff
403
When should ipratropium be used in acute asthma
In severe life-threatening asthma (PEF <33% best or predicted) if not responding to SABA therapy alone
404
What non-hormone therapies can be used for vasomotor systems post menopause?
SSRIs (paroxetine and escitalopram)
SNRIs (venlafaxine and desvenlafaxine)
Gabapentin - night sweats
Clonidine
Oxybutynin
405
When should aminophylline levels be measured?
4-6 hours post dose - no 5 day wait as IV
Range is 10-20 mg/L as per theophylline
406
How long and at what dose should prednisone be used in children for asthma attack?
1-2 mg/kg OD for 3 days
Dose as adult for 12+
407
When can magnesium sulfate be nebulised in asthma attack in children over 2?
Unlicensed use alongside each salbutamol and ipratropium neb in first hour
In short duration of severe asthma symptoms presenting with sats <92%
408
What conditions can increase theophylline concentrations in blood?
Heart failure, hepatic impairment and viral infections
409
MHRA warning with magnesium sulfate
Risk of skeletal adverse effects, hypocalcaemia and hypermagnesaemia in neonates following prolonged (5-7 days) or repeated use in pregnancy
410
Diagnostic criteria of moderate asthma attack in adults
Increasing symptoms
PEF >50-75% best or predicted
No features of severe asthma
411
Diagnostic criteria of severe asthma attack in adults
PEF 33-50% best or predicted
RR >25 /min
HR >110 /min
Inability to complete sentences in one breath
412
Diagnostic criteria of life-threatening asthma attack in adults
PEF <33% best or predicted
Oxygen sats <92%
PaO2 <8 kPa
PaCO2 4.6-6 kPa (normal)
Silent chest
Cyanosis
Poor respiratory effort
Arrhythmia
Exhaustion
Altered consciousness
Hypotension
413
When should regular prednisolone be used in asthma
Under specialist only
If unresponsive after therapy with high dose ICS and have tried LABA/LTRA/tiotropium/theophylline
414
Which monoclonal antibodies can be used to reduce use of regular corticosteroids in severe asthma?
Omalizumab
Mepolizumab
Benralizumab
Reslizumab
Dupilumab
All interfere with IL-5 receptor binding - reducing survival of eosinophils and basophils
Dupilumab interferes with IL-4 and IL-13
415
Which drug can be used unlicensed for severe asthma in special cases
Methotrexate
416
First line asthma management for children less than 11
Low dose ICS BD - 8-12 week trial in under 5s
Can consider MART if uncontrolled above 5 years
Refer if not controlled in trial in under 5s
417
When and how should inhaler maintenance be reduced in asthma?
Consider reduction if patient controlled for at least 3 months
Reduce by 25-50% each time
Only stop ICS fully in those on low-dose who are fully symptom free
418
Which medications can be added to asthma therapy if exercise is a problem despite normal control of symptoms?
LTRA
LABA
Sodium cromoglicate
Nedocromil sodium
Theophylline
419
What drug is preferred to control exercise-induced asthma?
SABA immediately before exercise
420
Side effects of SABAs
Muscle cramps, tachycardia, tremors (loss of sensitivity for beta-2 receptor at high doses)
Hyperglycaemia
Hypokalaemia - careful with theophylline, steroids and diuretics
CV effects - QT prolongation, arterial hypoxia
421
MHRA warning with SABAs
Risk of airway obstruction from aspiration of loose objects - check mouthpiece before use
422
What paradoxical effect can inhaled corticosteroids have?
Paradoxical bronchospasm - discontinue or switch therapy
If mild - can use SABA beforehand or switch to DPI
423
Side effects of leukotriene receptor antagonists
Bed wetting in children
GI upset
Churg-Straus syndrome - occurs on withdrawal or reduction of oral steroid. Look out for eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications and peripheral neuropathy
424
Organ effect of zafirlukast
Liver toxicity
425
MHRA alert with leukotriene receptor antagonists
Risk of neuropsychiatric reactions - nightmares, speech impairment, OCD symptoms -> discontinue
426
When can tiotropium be added to asthma therapy?
Patients with severe asthma who have suffered 1+ exacerbations in the last year
427
Why should patients eyes be protected with nebulised ipratropium?
Risk of glaucoma if spayed near eyes
428
How many cartridges can be used in a spiriva respimat until it needs replacing?
6 total
429
Signs of toxicity with theophylline
FAST AND SICK
FAST - tachycardia, arrhythmias, CNS stimulation (restlessness, agitation, dilated pupils), convulsions
SICK - vomiting, haematemesis, GI effects (diarrhoea, GI irritation)
Also hyperglycaemia
430
Differentials between asthma and COPD
Smoker - COPD
Under 35 - asthma
Chronic productive cough - COPD
Breathlessness - persistent in COPD, variable in asthma
Nighttime waking - asthma
Diurnal variation - asthma
431
Which vaccine should be offered to patients with COPD
Pneumococcal
Annual inactivated influenza
432
First line for COPD
SABA or SAMA PRN
433
Second line for COPD
Assess for asthmatic features
If present - LABA + ICS
If not - LABA + LAMA
434
Third line for COPD
Triple therapy - LABA + LAMA + ICS
Only use 3 month trial in COPD with non-asthmatic features with only day-to-day symptoms - revert if no improvement
435
When should nebulisers be used in COPD?
In people with distressing or disabling breathlessness despite maximal inhaler therapy
Those unable to use inhalers due to physical or cognitive impairment
436
What GI problem should carbocisteine and acetylcysteine be avoided in?
Active or history of peptic ulcer - can disrupt gastric mucosa
437
When should mucolytics not be started?
During active exacerbation - no benefit as takes longer to work
438
When can oral theophylline be used in COPD?
If patient has symptoms despite optimal inhaled therapy
If unable to use inhalers due to physical or cognitive impairment
439
Which COPD patients can be considered for prophylactic azithromycin?
Those with 4+ exacerbations requiring steroid therapy and at least 1 exacerbation requiring hospitalisation in last year
440
What baseline investigations should be done before starting azithromycin in COPD?
ECG - rule out QT prolongation
LFTs
Sputum culture
CT - rule out bronchiectasis
441
When can roflumilast be added to COPD therapy?
Pt on triple therapy
If disease is severe - FEV1 <50% predicted
Pt has chronic bronchitis
Pt has had at least 1 exacerbation requiring hospitalisation in last year
Must be started by specialist
442
When should long term oxygen therapy be considered for COPD?
Under specialist
Oxygen sats 92% or less
FEV1 <30% predicted
Cyanosis
Peripheral oedema
443
How long should oxygen be used a day to provide benefit?
15 hours or more
444
Oxygen target if on oxygen for COPD
88-92% (risk of hypercapnic respiratory failure)
Use 24/28% Venturi mask if history of hypercapnic respiratory failure
445
What should all patients on long term oxygen recieve?
Oxygen alert card - patient may be sensitive to too much oxygen
446
What condition does pulmonary hypertension in COPD cause?
Cor pulmonale - right side of heart becomes enlarged and fails due to high BP in lungs
447
Treatment of pulmonary hypertension/cor pulmonale
Optimal COPD therapy
Oedema treated with diuretics
Avoid alpha blockers, ACEi, CCBs and digoxin (unless AF)
448
Treatment of mild croup
Largely self-limiting
Single oral dose of dexamethasone may be useful
449
Treatment of moderate-severe croup
Hospital admission - use single dose of corticosteroids while waiting
If can’t take oral meds - IM dex or budesonide nebs
450
How to treat croup unresponsive to corticosteroids
Nebulised adrenaline solution 1 in 1000
451
Age requirement for OTC chlorphenamine (not cough meds)
1+
452
Age requirement for OTC promethazine
2+
453
Age requirements for OTC cetirizine and loratidine
2+
454
Age requirement for OTC fexofenadine
12+
455
How may allergen immunotherapy be given and for how long?
Sublingual - can be self-administered after initial dose
Subcutaneous - regular injections in healthcare setting
Typically 3 year course
456
Contraindications to allergen immunotherapy
Uncontrolled asthma, significant CVD, use of beta blockers
457
Anaphylactic adrenaline doses for adults and children
12+ - 500mcg
6-12 - 300mcg
6 months - 5 - 150mcg
<6 months - 100-150mcg
458
What is hereditary angioedema and what can be used to treat?
Rare genetic condition characterised by recurrent severe swelling
Lanadelumab - mAb that inhibits plasma kallikrein
Berotralstat - oral kallikrein inhibitor
