Module 1 Allison Flashcards
(378 cards)
1
Q
Benefits of IP
A
- timely access
- speedier more accessible
- Easier than Dr because more available, more time, more approachable
2
Q
When was it recommended nurses prescribe?
A
1986
3
Q
When did NPF come in?
A
1998
4
Q
When did supplementary prescribing for nurses and pharmacists begin?
A
2003
5
Q
When did allied health professionals start supplementary prescribing?
A
2005
6
Q
In 2006 what happened for prescribers?
A
- Prescribing powers extended for nurses, midwives and pharmacists
- Independent prescribing
- but Independent prescribing for physiotherapist and podiatrists not until 2013.
7
Q
What is Non Medical Prescribing?
A
Prescribing of medicines, dressingsand appliances by health professionals who are not doctors.
8
Q
What are 3 models of Non Medical Prescribing
A
Supplementary Prescribing
Independent Prescribing
Nurse Prescribers Formulary for Community Practitioners
9
Q
What are the NHS 2000 recommended Clinical Tasks
A
- order diagnostic investigations (pathology tests and X-rays)
- make and receive referrals direct (to a therapist or a pain consultant)
- admit and discharge patients for specified conditions and within agreed protocols
- manage patient caseloads (diabetes or rheumatology)
- run clinics (ophthalmology or dermatology)
- prescribe medicines and treatments
- carry out a wide range of resuscitation procedures including defibrillation
- perform minor surgery and outpatient procedures
to triage patients using the latest IT to the most appropriate health professional - take a lead in the way local health services are organised and in the way that they are run.
10
Q
Who are IP’s
A
Nurses, podiatrists/chiropodists, physiotherapists and pharmacists
11
Q
What do IPs have to take responsibility for?
A
- for the clinical assessment of the patient, establishing a diagnosis and the clinical management required
- prescribing or not, and the appropriateness of any prescribing
12
Q
Who are IPs registered with?
A
GPhC, NMC, (Nurse and midwifery council), HCPC (Health and care professional council)
13
Q
What is a PGD?
A
A policy written by Doctor, Senior Manager, Pharmacist, and Senior professional from Profession using the PGD.
Authority comes from the organisation – accountability also falls with organisation
It is not prescribing
14
Q
Example of supply of PGD where?
A
Minor Injuries clinic Walk-In Centre Family Planning Clinic Genito-Urinary Clinic Ante-Natal Clinic Diabetic Clinic Paramedics
15
Q
Named Healthcare professional is authorised to do what under PGD?
A
Supply a pre-labelled, fixed quantity medicine or
Administer fixed quantity medicine
16
Q
What are the Standards of proficiency for prescribers?
A
Standards and proficiencies for programmes of preparation
Standard of conduct
Within own level of competency
17
Q
Introduction of NMC Standards of proficiency for nurse and midwife prescribers in what year?
A
2007
18
Q
Change to Legislation enabling nurse prescribers to prescriber licensed drugs when?
A
2009
19
Q
Physiotherapists and Podiatrists get independent prescribing in what year?
A
2012
20
Q
Nurse & pharmacist independent prescribers prescribe schedule 2-5 controlled drugs with exceptions of diamorphine, cocaine & dipipanone for treatment of addictions in what year?
A
2012
21
Q
Podiatrists & Physiotherapists given independent prescribing status when?
A
2013
22
Q
NHS England sets out proposals for more efficient and responsive access to medicines for patients NHS England is consulting on these proposals, which cover: Independent prescribing by radiographers, Independent prescribing by paramedics, Supplementary prescribing by dietitians . Use of exemptions within the Human Medicines Regulations (2012) by orthoptists.
A
2015
23
Q
Therapeutic radiographers get independent prescribing, dieticians & diagnostic radiographers get Supplementary Prescribing in what year?
A
2016
24
Q
A Competency Framework for all Prescribers is published in what year?
A
2016
25
What is ethics according to Nuttal 1993
judging what we do and the consequences of what we do and considering the justifications that might be given for our moral position
26
What is ethics according to Jones 2008?
The application of the processes and theories of moral philosophy to a real situation
..It is concerned with the basic principles and concepts that guide human beings in thought and action.
..It underlines their values as individuals within a society
27
According to Purtilo, 1993, what is meta-ethics
Determines what is meant by good, bad or happiness and how we know that one decision is better than another
Allows us to discover reasons for moral judgements
28
What is professional ethics?
Term used for moral responsibilities and actions in professional settings
The codes of practice and conduct = ethical framework to which we work in practice.
29
Name some ethical theories
- Deontology: Duty based care, All “duties” equal
- Utilitarianism
- Greatest good for greatest number
- Ends justify means
30
Ethical principles based on?
Autonomy
Beneficence
Non-maleficence
Justice
Sanctity of Life
31
What is the opposite of competence?
Negligence (different from making mistakes)
32
legally you are not guilty of negligence if
if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art
33
The duty of care comes from
Neighbour principle
| Donoghue v Stevenson (1932)
34
Breach of duty comes from
Standard of care
| Bolam v Friern Hosp. Management Committee (1957)
35
Damage or injury & Assessment of damages comes from
Damage would not have happened but for a particular fault, then the fault is the cause of the damage
Hoston v East Berkshire AHA (1987)
36
What is Vicarious liability?
where someone is held responsible for the actions or omissions of another person. In a workplace context, an employer can be liable for the acts or omissions of its employees, provided it can be shown that they took place in the course of their employment.
37
What is professional accountability
to be answerable to oneself and others for one’s own actions
38
How to Maintain duty of care to patients
```
Observe UK law
Operate within limits of professional competence
Maintain prof. Knowledge and competence
Ensure patient consent for treatment
Hold professional indemnity insurance
```
39
What is the distinction between an act or an omission to act?
Not acceptable to actively kill but may be permissible to let someone die
40
What is autonomy?
self rule. freedom from controlling influences. supporting a persons right to accept/refuse treatment and care
41
What is truth telling
to not lie, confuse, deceive or withhold
42
What must you consider when deciding if you are accountable?
```
Do you have:
Sufficient knowledge base
Appropriate skills
Professional attitude
Degree of autonomy
```
43
What protects you when things go wrong?
```
Vicarious libality
Employee
Acting in course of employment
Using due care and skill
Acting within role & policies
Obeying employer
```
44
What are the four key areas to ensure that you exercise a duty of care regarding prescribing
1. Prescribing (info from pt, write clear, pad secure)
2. Product liability (ensure monitoring and prescription use appropriate)
3. Consent
4. Communication (Responsible for giving sufficient information, Respect for autonomy)
45
What are the two branches of law and what do they deal with?
Civil (Disputes between individuals eg Negligence, Assault)
| Criminal (Offences against the state so Crown brings action against the defendant)
46
What are the sources of law?
Statute – law enacted by parliament
| Common – evolving as new cases arise (Judge-made law)
47
Name some principles as described by Beauchamp and Childress
Respect for autonomy (following the patient’s wishes)
Beneficence and non-maleficence (the antibiotics are unlikely to be beneficial and over prescribing could do harm by reducing their effectiveness in the future)
48
What are internal prescribing influences
Personal ethics
Knowledge and experience
Fear / loyalty
Convenience / effort
49
What are External prescribing influences
```
MHRA
Patient choice
CPD
ABPI (industry)
DTC (advertising)
Professional code of practice
```
50
What is law according to oxford dictionary
A body of rules enacted or customary in a community and recognised as enjoying or prohibiting certain actions and enforced by the imposition of penalties
51
Consider what with consent and compacity
```
Valid consent
Emergency situations
Patients who are mentally ill
Patients with learning disabilities
Children <16yrs
Young people >16yrs
Patients < 18yrs refusal of treatment
Patient capacity to consent
A patient’s best interest
What is meant by Fraser Competence? (childrens rights and wishes)
```
52
Statutory duty to disclose when
```
Road Traffic Act (1998)
Prevention of Terrorism (2015)
Public Health
Misuse of drugs
Data protection Act
Human Rights Act
```
53
Who can gain access to health record?
```
Road Traffic Act (1998)
Prevention of Terrorism (2015)
Public Health
Misuse of drugs
Data protection Act
Human Rights Act
```
54
Electronic record governed by?
Data protection act
55
Which manual records can be accessed
those made after 1991
56
What did the Caldicott report (1997) find
weaknesses in security and confidentiality of patient records
Recommended Caldicott Guardians and protocols
57
Data protection act March 2000 deals with
handling / storage of confidential personal data.
58
Whistle blowing came under
Public interest disclosure act
59
Single competency Framework for all prescribers 2014, includes
```
Consultation
1. Knowledge
2. Options
3. Shared decision making
Prescribing effectively
4. Safe
5. Professional
6. Always improving
Prescribing in context
7. The healthcare system
8. Information
9. Self and others
```
60
What are the Seven Principles of Safe Prescribing
1. Consider the pt
2. Which strategy (established diagnosis, differential diagnosis, refer, Rx needed, expectation)
3. Consider choice of product (Effective, Appropriate, Safe, cost Effective)
4. negotiate a contract w pt
5. review (is med safe, effective, acceptable)
6. record keeping (local and body guidelines)
7. reflect (peer learning, cpd, aware access points)
UPSIDE DOWN PYRAMID
61
What are the principles of prescribing?
Only Patients they have assessed
Only using their own pad
Only 6 repeats, or reviewed within the last 6 month
62
Ten Principles of Good Prescribing
Clear reasons for prescribing
Establish patient’s medication history before prescribing
Ascertain factors that may alter benefits/risks of treatment
Identify patient’s ideas, concerns, and expectations
Individual, effective, safe, and cost-effective medicines
National guidelines and local formularies
Clear unambiguous legal prescriptions
Monitor adverse & Therapeutic effects of medicines
Communicate and document prescribing decisions
Prescribe within the limitations of your knowledge, skills and experience
63
FP10P is
lilac
64
FP10SS is
green, designed for use with prescriber’s computer system
65
FP10 is
green
66
FP10MDA-SS is
(blue) – used for prescribing controlled drugs (mainly methadone) to addicts. Twice the size of standard FP10 space for pharmacist to record instalment
67
Prescription requirements are
Completed in black ink or computer generated
Clearly indicate the date, the name of the prescriber with professional registration number and contact details (phone number)
Name, address with postcode, age and DOB of patient. It is a legal requirement to state age if prescribing for a child under 12 years
Weight if applicable
68
Prescriptions should be written including
```
Name of medicines should be clearly written
Dosage schedule
Route of administration
Amount prescribed
State duration of course if applicable
Prescribe generically where possible, with no abbreviations (except approved ones in back of BNF)
line under each item
Z at end
```
69
Topical Rx should must include
the quantity to be applied and the frequency of application must be included.
70
Dressings and appliances Rx should include
details of how to be applied and how frequently changed are useful
71
Rules for safety Rx
Avoid unnecessary decimal points e.g. 3.0mg
Do not use abbreviations of units e.g. mcg
When decimals are unavoidable place a zero e.g. 0.5ml rather than .5ml
Less than 1g – use milligrams
Units for insulin not “U”
Write names and preparations clearly and not abbreviated e.g. DF118
Write directions in English without abbreviations
Unused space in the prescription area should be blocked with a diagonal line to prevent fraudulent use
72
When to not use generic name
Modified release preparations
Compound preparations
Same drugs but used at different doses for different indications
Same drug is formulated to give a different potency
Narrow therapeutic index
73
What does the Responsible Officer for prescription pads do
Only authorised personnel are able to issue and record prescription pads
Responsible for keeping records of the prescriptions
Pad destruction when leaving trust
74
Loss or suspected theft of prescriptions
During Office Hours - Report to the Line Manager, the Police, Non-Medical Prescribing Lead, the Local Counter Fraud Specialist and Chief Pharmacist.
Out of office Hours - Report directly to the local police station and the Manager On-Call. Local Counter Fraud Services arranges for all pharmacists to be notified of any lost or missing prescription pads
A new pad is provided by the Trust where procedures are in place for security and stock control
Following the theft or loss of the prescription pad, the Non-Medical prescriber is required to write ALL PRESCRIPTIONS IN RED INK FOR TWO MONTHS
Complete Incident Form.
Local Counter Fraud Services arranges for all pharmacists to be notified of any lost or missing prescription pads
A new pad is provided by the Trust where procedures are in place for security and stock control
Following the theft or loss of the prescription pad, the Non-Medical prescriber is required to write ALL PRESCRIPTIONS IN RED INK FOR TWO MONTHS
Complete Incident Form.
75
What type of errors are there in Rx writing
Transcription prescribing errors
Confusion between dosage forms
Duration of medication
76
What are good sources of information?
```
BNF/ NPF
NICE
Local Prescribing advisors or Pharmacist
MHRA
National and local guidelines and policies
Drug Tariff
```
77
Name some bad sources of info?
MIMS
GP
Pharmaceutical Industry
78
Anti-psychotics were first developed as?
Anaesthetics. Then found to relax patients
79
Name first generation Antipsychotics
Haloperidol, Chlorpromazine, Flupentixol
80
Name second generation Antipsychotics
Clozapine
Risperidone, Olanzapine, Quetiapine
Aripiprazole
81
Which are typical and which atypical out of first and second generation anti-psychotics?
First Typical
| Second Atypical
82
How do antipsychotics work
dopamine blockade
83
What effect will Dopamine blockade have on Mesolimbic pathway
↑ dopamine – psychosis
84
What effect will Dopamine blockade have on Mesocortical pathway
↓ dopamine – negative symptoms
85
What effect will Dopamine blockade have on Nigrostriatal pathway
↓ dopamine in Parkinson’s
86
What effect will Dopamine blockade have on Tuberoinfundibular pathway
Dopamine inhibits Prolactin release
87
Dopamine related Side effects of Antipsychotics
Can worsen negative symptoms
Extra pyramidal side effects (EPSE)
Hyperprolactinaemia
88
What are EPSE
```
(extrapyridal side effects)
Dystonias
Parkinsonism
Akathisia
TD
```
89
Other side effects of antipsychotics
```
Dizziness
Low blood pressure
Dry mouth
Constipation
Weight gain
Sedation
Salivation
```
90
Indication for antipsychotics
```
Schizophrenia
Bipolar disorder
Psychosis in other conditions
Dementia
(Risperidone – Persistent aggression Caution!!!!!!)
```
91
Antipsychotics can not be used to treat which of the following:
```
To treat anxiety
In Huntington’s Disease
To treat heart arrythmias
To treat hiccups
To treat nausea
In Tourette’s syndrome
```
Arrythmias
92
How long does it take anti-psychotics to kick in
1-2 weeks
93
Why is there non compliance with Antipsychotics
poor insight, side effects, poor communication
| therefore Depot can be useful
94
What if no response to antipsychotics?
```
Check compliance
Review diagnosis
?Increase dose
?Augment medication
Change medication
Other types of treatment
```
95
How long to continue Antipsychotics?
1-2 years after response
96
How to stop antipsychotics
Gradual withdrawal
(60-70% relapse in a year, 85% in 2 years
10-30% relapse if on active medication)
97
What is Clozapine used for
Treatment resistant Schizophrenia
Psychosis in Parkinson’s
98
Main side effects of Clozapine
```
Many side effects
Weight gain ++
Hypersalivation
Fits
Myocarditis
Neutropaenia and agranulocytosis (Regular blood monitoring)
```
99
How does Aripriprazole work?
Partial agonist D2 receptor
Works as antagonist in mesolimbic system
(positive symptoms of Schizophrenia)
Works as agonist in prefrontal cortex
(negative symptoms of Schizophrenia)
100
Neuroleptic Malignant Syndrome symptoms
Hyperthermia, autonomic instability
Fluctuating consciousness
Mutism
Severe EPSE / Rigidity
101
What to do if Neuroleptic Malignant Syndrome
Stop antipsychotic
Medical emergency!!!!
only 0.5%, Mortality up to 20%
102
Antidepressants were first developed to treat what
TB
103
How does imipramine act
mental and motor slowing
| ?effect on reuptake of serotonin and noradrenaline
104
Name some Monoamine transmitter
Serotonin
Noradrenaline
Dopamine
105
Name some Selective Serotonin Reuptake Inhibitors (SSRIs)
```
Fluoxetine
Paroxetine
Citalopram
Escitalporam
Sertraline
```
106
SSRI side effects
```
Nausea, GI symptoms
Insomnia, Agitation
Sexual dysfunction
??Suicidal behaviour
Low sodium (in older people)
```
107
Overdose in SSRIs
not so bad
108
Name some Serotonin & Noradrenaline Reuptake Inhibitors (SNRIs)
Venlafaxine
| Duloxetine
109
Name a Noradrenaline Reuptake Inhibitors (NARI’s)
Reboxetine
110
Name some Tricyclic Antidepressants (TCAs)
Imipramine
Clomipramine
Amitriptyline
Dosulepin
111
Side effeccts of TCAs
```
Dry mouth, Constipation, Drowsiness
↑ Heart rate, ↓ Blood pressure
ECG changes
Tremor, headache
Sexual dysfunction
```
112
Over dose with TCAs
bad. Heart defects, convulsions and death
113
Name some Monoamine oxidase inhibitors
Phenelzine
Isocarboxazid
Tranylcypromine
Moclobemide (reversible)
114
Side effects of MAOI
- Tyramine foods (Mature cheese, pickled herring, Bovril, Marmite, “Off” foods, Alcoholic drinks etc)
Cause hypertensive crisis
Throbbing headache
Subarachnoid haemorrhage
115
What is Mirtazapine
1. Noradrenergic and specific serotonergic antidepressants (NaSSA)
2. Inhibit NA a2-auto and heteroreceptors
3. Prevent negative feedback on 5-HT and NA
4. Block 5-HT2 and 5-HT3 enhances 5-HT1
116
Name some other Antidepressants out the main groups
Trazodone
Agomelatine
Bupropion
117
What are the indications for Antidepressants
```
Depression
Anxiety Disorders
Obsessive Compulsive Disorder
Neurological pain
Insomnia
```
118
Prescribe in moderate/severe depression:
SSRIs first line medication
| Don’t forget psychological treatments
119
How long do antidepressants take to work
Up to 6 weeks
| But…Plasma levels steady within 5-7 days
120
What is the minimum continuation period for antidepressants
6-9 months
121
How long withdrawal with Antidepressants
Gradual withdrawal – at least 4 weeks
122
Can you give antidepressants as prophylaxis
Yes, same dose as acute treatment
123
Name some mood stabilisers
Lithium
Sodium Valproate
Carbamazepine
Lamotrigine
124
Indications for mood stabilisers
- Bipolar disorder
Mania
Depression
Prophylaxis
- Augmentation therapy in depression
Lithium
125
Lithium was first used to treat what
Gout
126
How does Lithium work
1. Stabilises glutamate?
2. Increases serotonin release?
3. Deactivates the GSK3β enzyme?
- Restores normal brain cycle?
4. Interacts with nitric oxide?
127
What is the therapeutic window
Between 0.6 and 1.0mmol/l
128
Side effects of lithium
```
Thirst, polyuria
Tremor
Diabetes insipidus
Arrythmias
Weight gain
Thyroid problems
Ebstein’s anomaly in foetus
```
129
What are symptoms of Lithium toxicity
```
GI upset
Muscle weakness
Drowsiness
Ataxia
Tremor
Seizures
Coma / Death
```
130
Lithium interacts with
Diuretics (increase Li concentrations)
ACE inhibitors (increase Li concentrations)
NSAID’s (increase Li concentrations)
((excreted by kidneys))
131
What do we Monitor with Lithium
```
Baseline U&E’s, TSH and ECG
Blood levels - aim for 0.6-1.0mmol/l
Levels every 5-7 days until stable
Then levels every 3-6 months
TFT’s, U&E’s 6 monthly
```
132
How to take lithium
Constantly. intermittent use is bad
133
How long to stay on lithium
min 2-3 years
134
How long does withdrawal take with Lithium
3-6 months. can precipitate relapse
135
Name another mood stabiliser
Anticonvulsants:
```
Sodium Valproate (Semi-sodium Valproate, Valproic acid)
Carbamazepine
```
136
How do anticonvulsants work as mood stabilisers?
Stabilise sodium channels?? - Cells less excitable
| Potentiates GABA receptors?? - Inhibitory neurotransmitter
137
Side effects of Sodium Valproate
Hepatic impairment
| Foetal abnormalities
138
What monitoring with sodium valporate?
Check LFT’s at baseline and 6 monthly
139
Carbamazepine side effects
Agranulocytosis
Rashes
Foetal abnormalities
140
Monitoring with Carbamazepine
FBC closely for 1-2 months
| Then 3-6 monthly
141
There are three general types of side effect. They are
```
Effect more than desired Therapeutic effect (eg antihypertensive hypotension)
Wrong target (on ion channels, carrier proteins, enzymes and receptors like: adrenergic, cholinergic, dopaminergic, opioid and histamine)
Hazardous like chemotherapy or DNA related. These cause things like dry mouth, hair loss, gastro intestinal disturbances and neutropaenia
```
142
Name the five classes of ADR
```
Type A – Augmented reaction
Type B – Bizarre
Type C – Chronic
Type D - Delayed
Type E – End of Dose
```
143
What is augmented reaction ADR
Extended effects of drug therefore responds to dose reduction
More likely in young, old and renal and liver impairment
144
Give examples of augmented reaction ADR
Low blood pressure with antihypertensive
Low blood sugar with insulin
Dry mouth that is associated with tricyclic antidepressants
145
What to do with an augmented reaction ADR
Stopping the drug altogether
Reducing the dose of the drug
Switching to an alternative drug
Record ADR in notes
146
What are the types of Bizarre ADRs
Type I – Anaphylaxis e.g penicillins
Type II- cytotoxic/blood dyscrasias e.g.carbimazole
Type III- immune complex medicated (serum sickess) e.g. thiazides
Type IV- T-cell medicated (rashes) e.g. penicillins
147
What is a bizarre ADR
reactions are novel responses that are not expected from the known pharmacological actions of the drug.
High mortality
148
What to do with Bizarre ADR
Require prompt detection and rapid action
Drug suspected withheld
Medical prescriber informed immediately
Any resuscitation measures undertaken
The drug should be stopped/alternative found
Record in patient notes and easily visible to future prescribers
149
Differences between Type A and B (augmented and bizarre)
Type A
PredictableUsually dose dependentHigh morbidityLow mortalityResponds to dose reduction
Type B
UnpredictableRarely dose dependentLow morbidityHigh mortalityResponds to drug withdrawal
150
What are chronic ADR
long term effects
151
give examples of chronic ADR
Continued exposure – tolerance e.g. Opioids
Cumulative effects – e.g. Methotrexate – liver
Long term effects e.g. osteoporosis & steroids
152
What are long term effects, Type C ADR
Continued exposure – tolerance e.g. Opioids
Cumulative effects – e.g. Methotrexate – liver
Long term effects e.g. osteoporosis & steroids
153
What are delayed Effects Type D ADR
Impaired fertility – e.g. Inadequate sperm counts from prior exposure to cytotoxics e.g. Cyclophosphamide
Impaired fetal development – e.g. Spina bifida in the fetus after maternal exposure to sodium valporate in pregnancy.
154
What are End of Dose Type E ADR
Withdrawal effects after long term treatment
155
High Risk Groups for ADR
```
Some genetic groups
Age – very young and old
Sex – female
End organ failure – liver or renal impairment
Polypharmacy
Multiple Disease states
```
156
What side ADR is associated with NSAIDs
Dyspepsia
157
What side ADR is associated with Laxatives
Diarrhoea
158
What side ADR is associated with Iron Preparations
Nausea and Vomitting
159
What side ADR is associated with Ca Ch Blockers
Oedema
160
What side ADR is associated with Antibiotics
Rash or allergy
161
What side ADR is associated with Opiate Analgesics
Constipation
162
What side ADR is associated with Diuretics
Hypokalemia
163
What side ADR is associated with ACE Inhibitors
Cough
164
Give examples of Absorption Interactions
Antacids forming complexes with them: Gaviscon & cipro
| drugs affect gut transit time, affecting rate of absorption: metoclopramide or opiates
165
How can absorption interactions be dealt with
change admin time
166
What is protein binding interaction
Two drugs compete for the same protein binding
| site and one or both is displaced. Result is increased concentration of free drug Eg phenytoin and warfarin
167
What are metabolic interactions
When P450 enzyme is effected
168
If P450 activity is increased then...
some drugs are metabolised more quickly ↓ bioavailability
169
If P450 is inhibited then...
some drugs are metabolised more slowly ↑ bioavailability
170
What are Enzyme inhibition of cytochrome P450 system
drugs that inhibit P450 reduce metabolism, increased free drug
171
What are Enzyme inducers
drugs that induce P450 increase metabolism, reduce free drug
172
Give examples of drugs that given at same time will interact due to enzyme inhibition
```
Allopurinol
Amiodarone
Cimetidine
Ciprofloxacin
Diltiazem
Erythromycin
Ethanol (acute)
Isoniazid
Ketaconazole
Metronidazole
Omeprazole
Sulphonamides
Oral contraceptives
Valproate
Verapamil
```
173
Give an example of two drugs and what would happen with a renal interaction
Methotrexate and NSAIDs both renally excreted – if they are competing for excretion, then methotrexate may not be eliminated as quickly and may cause toxic effects
174
Give examples of Drugs with narrow therapeutic margin
warfarin,digoxin,antiepileptics, theophylline, cyclosporin
175
which Drugs require careful dosage monitoring
antihypertensives, antidiabetic drugs
176
Give examples of Enzyme inducers
rifampicin,phenytoin, carbamazepine, barbiturates
177
Give examples of Enzyme inhibitors
cimetidine,ketoconazole, ciprofloxacin, erythromycin
178
What sources of info are there for interactions
BNF Appendix 1
Stockley’s Drug Interactions
Summary of Product Characteristics – www.medicines.org.uk
179
Give example of food interaction
grapefruit juice interacts with diltiazem, nifedipine
180
Give some examples of herbal remedies interatcing
Ginseng interacts with warfarin, calcium channel blockers, St Johns Wort interacts with simvastatin, HIV drugs
181
How long does it take enzyme inducers to have an interactive effect
1-3 weeks because they stimulate the production of new metabolising enzymes
182
How long does it take enzyme inhibitors to have an interactive effect
24 hours
183
What is pharmacogenetics
the study of the genetic basis for variation in drug response.
184
Genes for enzymes in drug metabolism include
CYP2D6 and CYP2C9, and thiopurine-S-methyltransferase (TPMT)
185
Suspected ADR should be reported to
The Medicines and Healthcare products Regulatory Agency (MHRA)
186
Why should ADR be reported
To recognise unknown hazards
To take adequate regulatory measures
To ensure safety of use of medicines
187
Which ADR reported via yellow card
Report any serious ADR for all medicines
All Black triangle drugs
All occurring in children
New drugs and closely monitored
188
How can we report ADR
Yellow Card Scheme
Electronic
Prepaid yellow cards
24 hour Freephone service
189
What does ▼ mean
closely monitored by MHRA
190
How can you minimize ADR
Prescribe good indication, esp pregnancy.
Check on all previous medication
Assess previous reactions to medicines
Verify other drug use e.g. OTC/ herbals
Take age into consideration – elderly/ children
Check for renal/hepatic disease
Complete yellow cards
Prescribe in accordance to protocols/guidelines/formularies
Give clear instructions on medication to patient esp elderly
Prescribe drugs that are familiar as side effect profiles are known and black triangle drugs with caution.
Inform the patient of possible side effects to help identify ADRs
191
What are the characteristics of a bacteria cell
Pilus, capsule, flagellum, cell wall
| and ribosomes, nucleoid (DNA), plasma membrane, cytoplasm
192
What are the two types of bacteria
Gram positive and Gram negative
193
Give an example of G +ve bacteria
Staphylococcus, enterococcus, streptoccous
194
Give an example of G -ve bacteria
E coli, salmonella, psuedomonas, haemophilus
195
What are the characteristics of G-ve bacteria
lipopolysaccharides, Porin,
| and Protein, Cell wall all around
196
What are the characteristics of G+ve bacteria
peptidoglycans surround, cell wall, protein not all way round
197
Bacteria are characterised by shape give examples
cocci, bacilli, budding/appendaged, etc
198
Where most likely to find G +ve bacteria infections
skin/wound, line related, gangerous wound, abdo
| treat with vancomycin, teicoplanin, gentamicin
(resistant to cephlasporin, metronidazole)
199
Where most likely to find G -ve bacteria infections
Gut, UTI, sepsis, pneumonia (cephlasporin, gentamicin, cipro, tazocin, imiprem, trimethoprim)
(Resistant to amox)
leg ulcers, CF, catheters, sepsis (aminoglycosides, cipro, tazocin, imiprem) resistant to everything else
Abdo (metronidazole, co-amoxiclav, clindamycin, tazocin, imiprem) resistant to benzylpenicilin, amox, cefruoxime, gentamicin, macrolides, quinolones
200
What is the difference between Aerobic and Anaerobic bacteria
Aerobic get energy from food and oxygen
201
What is bacteriacidal and bacteriostatic
Bacteriacidal kill bacteria - cell wall (faster)
| Bacteriostatic stunt its growth helping immune sytem - RNA synthesis, no growth/reproduction
202
Antimicrobial agents can inhibit which target zones
Cell wall synthesis, protein synthesis, nucleic acid synthesis, other metabolic processes (eg folic acid pathway)
203
Which antibiotics target cell wall
penicillin, cephlasporin
204
Which antibiotics target protein synthesis
aminoglycosides, chloramphenicol, macrolides, tetracyclines
205
Which antibiotics target nucleic acid synthesis
quinolones, metronidazole, rifampicin
206
Which antibiotics target other metabolic processes
sulphonamides, trimethoprim
207
Difference between broad and narrow spectrum Antibiotics
Broad target G+ve and G-ve
| Narrow primarily against a specific species anaerobic microorganism
208
How do bacteria become resistant
1. recognise and create enzymes to destroy the AB
2. close contact of sick patients and extensive use of antimicrobials
3. incorrect use of AB/wrong diagnosis
4. gene mutation
5. gene transfer
6. use of broad spectrum not specific
209
How do bacteria withstand AB
1. change the target
| 2. stop from reaching target at high conc
210
what are the three mechanisms of AB resistance
1. change permiability
2. enzymatic degradation - B lactamase
3. alter targets
4. efflux
211
What is the role of Clavulanic acid?
B lactamase inhibitor (same structure so sacrifices itself)
212
Extended Spectrum B Lactamase are resistant to
penicillin, cephlasporin,
213
Which bacteria produce ESBL?
E coli, Klebsiella
214
How do bacteria pass on resistance
Conjugation (2 fuse), transduction (virus infects bacteria and leaves DNA which is resistant), transformation (pick up from environment)
215
What is Antibiotic stewardship
resistance growing, v little new AB, therefore public health initiative to encourage responsible prescribing and preserve what we have
216
Start smar initiative says
No AB without clinical evidence, stick to local guidelines, document indication/review date/dosage/route, cultures if poss
217
After 48 hours of AB what are options
1. stop
2. switch route
3. continue
4. switch AB
5. outpatient parenteral AB
218
DOH says what about AB prescribing
right drug, right dose, right time, right duration, for every pt
219
Switch to oral IV why?
IV infections, no IV discomfort, faster admin, faster discharge, cost saving on drug and time.
220
What is the prophylaxis policy with AB
reduces surgical site infections, IV AB 60 min before procedure, significant blood loss then longer treatment
221
How do you prescribe gentamicin
1. weight
2. work out for obese or ideal
3. calculate dose
4. calculate creatinine clearance
5. check dosing interval based on clearance
222
What do chief cells secrete?
pepsinogen (protein to peptides) and gastric lipase (triglycerides to fatty acids/monoglycerides)
223
What do parietal cells secrete?
HCL (pepsinogen to pepsin) and intrinsic factor (for B12 of RBC)
224
What do surface mucous cells and mucous neck cells do?
secrete mucous and absorb
225
What do G cells secrete?
gastrin (stimulate chief and parietal cells. contract oesophogeal sphincter, increase motility, relax pyloric sphincter
226
What do Parietal cells contain receptors for?
acetylcholine, gastrin and histamine, all of which stimulate gastric acid production
227
Acetylcholine is released by
vagus nerve endings in response to stimuli, such as thinking about food
228
Gastrin is a hormone released by
the stomach and duodenum in response to food ingestion - Affects parietal cells which in turn causes gastric acid to be released in stomach.
229
Histamine is released from
cells in the gastric mucosa and diffuses into nearby parietal cells
230
Pepsin is a what enzyme
a proteolytic enzyme that helps digest protein foods and also can digest the stomach wall
231
What is H-pylori
a gram negative bacterium found in the gastric mucosa of most clients with chronic gastritis
232
Who usually has H-pylori
gastric and duodenal ulcers
233
How does H-pylori spread
oral-fecal or iatrogenic
234
The stomach secretes
mucous and bicarbonate
235
Why does acid not harm stomach
diluted by food and secretions. HCL cant be reabsorbed. pancreatic juices and bile alkali the acids.
prostaglandin E
236
What kind of drugs affect the GI system
```
Laxatives
Antidiarrheal
Antiemetic's
Drugs used for acid peptide disorders
Cholinergics
Anticholinergics
```
237
Name an associated disorder with the oral cavity
stomatitis
238
Name an associated disorder with the oesphogus
GORD
239
Name an associated disorder with the stomach
peptic ulcers, gastritis
240
Name an associated disorder with the small intestine
malabsorption, inflammatory bowel
241
Name an associated disorder with the large intestine
diarrhoea, constipation
242
Name an associated disorder with the pancreas
pancreatitis, diabetes
243
Name an associated disorder with the gall bladder
cholecystitis
244
Name an associated disorder with the liver
hepatitis, cirrhosis
245
Underlying Causes of GI Disorders
```
Dietary excess
Stress
Hiatus hernia
Oesophageal reflux
Adverse drug effects
Peptic ulcer disease
```
246
Name some symptoms of digestive disorders
```
Diarrhoea
Constipation
Bleeding from the digestive tract (Gastrointestinal bleeding)
Regurgitation
Difficulty swallowing
```
247
Name some symptoms of digestive disorders which could be something else
```
Abdominal pain (Acute or Chronic or Recurring)
Passing of gas (flatulence)
Loss of appetite
Hiccups
Nausea
```
248
What is GORD
Gastro-oesophageal Reflux. Caused by stomach acid splashing up into the oesophagus. Can be confused with heart problem
249
How to treat GORD
Antacids – usually contain aluminium or magnesium compounds. increase the pH of chime making it less acid
Alginates – form a raft that floats on top of the stomach contents. reduces reflux and protects the oesophageal mucosa
250
Give examples of H₂ Receptor antagonists
cimetidine, famotidine, ranitidine
251
How do H2 receptor antagonists work
Histamine, Gastrin, acetylcholine release HCL and pepsin. H2 receptor antagonists block stimulatory effects of histamine therefore reducing gastric secretions
252
How do PPI work
H in HCL punped into lumen by protein pumps(in parietal cells of mucosa) PPI block the pump irreversibly.
253
Indications for H2 Antagonists
- Short-term treatment of active duodenal ulcer or benign gastric ulcer
- Treatment of pathological hypersecretory conditions such as Zollinger–Ellison syndrome (a condition characterised by severe peptic ulceration, gastric hypersecretion, elevated serum gastrin, and gastrinoma (a tumour) of the pancreas or duodeum)
- Prophylaxis of stress-induced ulcers and acute upper GI bleeding in critical patients
- Treatment of erosive gastroesophageal reflux
- Relief of symptoms of heartburn, acid indigestion, and sour stomach (OTC preparations)
254
Types of Antacids
```
Sodium bicarbonate (Bell/Ans)
Calcium carbonate (Calciday-667, Tums, and others)
Magnesium salts (Milk of Magnesia and others)
Aluminum salts (Amphojel and others)
Magaldrate (Lowsium, Riopan)
```
255
"indigestion" could mean
dyspepsia, regurgitation, and the sensation of having a lump in the throat (globus sensation).
256
Diarrhoea is when
either an increase in fluid secretion into the gut or a reduction in fluid absorption from the gut – or an increase in motility
257
Acute Dairrhoea can be due to
food poisoning
gastroenteritis (infection)
Anxiety
drugs
258
Chronic diarrhoea can be due to
```
Chronic diarrhoea –causes include:
Irritable bowel syndrome
Inflammation of the bowel – e.g. ulcerative colitis
Chronic bowel infections
Hormonal changes
Food intolerance
```
259
How does Kaolin Morphine work
Reduce gut motility e.g. opiates
| Absorb excess fluid e.g. kaolin
260
What is an ulcer
Erosions in the lining of the stomach and adjacent areas of the GI tract
261
What are the symptoms of an ulcer
Gnawing, burning pain, often occurring after meals
262
What can be the cause of an ulcer
Helicobacter pylori
263
What do you treat an ulcer with
Histamine-2 (H2) antagonists
Antacids
Proton pump inhibitors
Antipeptic agents (coat injured area of stomach preventing further damage)
Prostaglandins (Inhibit the secretion of gastrin and increase the secretion of the mucous lining of the stomach, providing a buffer)
264
What happens when vomitting
Abdominal muscles contract- increasing abdominal pressure, cardiac sphincter and oesophagus relax and gastric contents are ejected
265
What can stimulate the vomiting centre
- Physical stimuli from the gut (mechanical or chemical)
- Chemical stimuli (blood) -> CTZ
- Motion stimuli (vestibular apparatus)
- Higher centres (cerebral cortex)
266
Give examples of Antiemetic drugs
Histamine H₁ antagonists
Dopamine D₂ receptor agonists
Serotonin 5HT₃ receptor antagonists
267
Give an example of Histamine H₁ antagonists
meclizine, cyclizine, promethazine and muscarinic antagonists such as hyoscine
268
When are Histamine H₁ antagonists effective
motion sickness and vomiting caused by irritants in the stomach – but have little effect against substances that act directly on the CTZ
269
Give an example of Dopamine D₂ receptor agonists
metoclopramide and domperidone
270
When are Dopamine D₂ receptor agonists effective
act on the CTZ. Both also increase gut motility. Antipsychotics also act on CTZ as D₂ agonists and can be used for acute chemotherapy induced emesis
271
Give an example of Serotonin 5HT₃ receptor antagonists
Ondansetron
272
When are Serotonin 5HT₃ receptor antagonists effective
act on CTZ and are particularly effective for vomiting caused by radiation therapy or cytotoxic drugs
273
What happens to GI when you grow old
- Constipation, diverticulitis and gastritis more common
- can be side effect of drugs
- Stomach lining capacity to protect decreases. esp aspirin/NSAID
- lactase levels decrease (more intolerance)
- more bacteria (pain, bloating and weight loss) and affect absorption of folic acid, iron, calcium
274
normal number of bowel movements ranges
2 or 3 a week to as many as 2 or 3 a day
275
What in the stool may indicate a disorder.
Changes in the frequency, consistency, or volume of bowel movements or the presence of blood, mucus, pus, or excess fatty material (oil or grease)
276
How would you treat constipation
lifestyle
then bulk-forming laxative (adequate fluid intake is important)
then osmotic laxative if stool hard
or stimulant laxative if soft but difficult to pass
stop treatment once soft and easy to pass
277
Which drugs cause constipation
Aluminium antacids
Antimuscarinics (e.g. procyclidine, oxybutynin)
Antidepressants (most commonly tricyclic antidepressants, but others may cause constipation in some individuals)
Antiepileptics (e.g. carbamazepine, gabapentin, oxcarbazepine, pregabalin, phenytoin) Sedating antihistamines
Antipsychotics
Antispasmodics (e.g. dicycloverine, hyoscine)
Calcium supplements
Diuretics
Iron supplements
Opioids
Verapamil
278
What are rome criteria for constipation
1/4 time Straining
1/4 time Lumpy and or hard poo
1/4 time sense of incomplete evacuation
2 or less bowel movements/week
279
For constipation what do we monitor
```
Frequency
Amount
Effort
Consistency
Emptying
Shape
(FAECES)
```
280
Warning signs
Bleeding, palpable mass RHS abdo/pelvis, persistent unexplained change, narrowing stool, FH colon cancer/IBS. unresponsive to treatment, unexplained weight loss, iron deficiency anaemia, fever, or nocturnal symptoms
281
Co-danthramer is used for what and what to watch out for
terminally ill patients. It may colour the urine red and can cause a characteristic red rash over the buttocks and perineum. The risk is increased if the patient is incontinent of urine or faeces.
282
What to avoid in terminal cancer constipation
bulk forming laxatives, such as Fybogel because not suitable for patients with a poor fluid intake, or when opioids have reduced bowel motility.
283
ADR of bulk forming laxatives
```
Flatulence
Sensation of abdominal fullness
Intestinal obstruction
Faecal impaction
Oesophageal obstruction
Severe diarrhoea
```
284
Example of bulk forming laxative
Fybogel®, Celvevac® Normacol®, Regulan.
| acts in 24-36 hours
285
Example of stimulant laxative
Senna, Bisacodyl, co-danthramer, co-danthrasate, dioctyl, docusol
8-12 hours
286
ADR with stimulant laxative
```
Weakness
Nausea
Abdominal cramp
Mild inflammation of the rectum and anus
Urine discolouration (especially senna)
```
287
Give example of Hyperosmolar Laxatives
Lactulose, glycerin
| Saline compounds - magnesium salts, polyethylene glycol (PEG) and electrolytes
288
How does lactulose work
Act by drawing fluid from the body into the bowel by osmosis
Enters the GI tract orally and is minimally absorbed
The drug is distributed only in the intestine – metabolised by bacteria in the colon and excreted in the faeces
289
How do PEG- non-absorbable solution work
as an osmotic – but does not alter electrolyte balance draw water into the intestine fluid accumulation distends the bowel and promotes peristalsis
290
How do stimulant laxatives work
Stimulate an increase in colonic motility (peristalsis) and mucus secretion
Irritate intestinal mucosa or stimulate the nerve endings of the intestinal smooth muscle
291
How do bulk forming laxatives work
Act like dietary fibre increasing water content and faecal mass – increase stool weight and frequency
292
ADR lactulose
Abdo distension
| Nausea and vomittin
293
ADR Saline compounds
Dehydration
Hypernatraemia
Hypocalcaemia
Cardiac arrythmias
294
ADR PEG/Macrogol
Nausea
Abdominal fullness
Explosive diarrhoea
295
Centrally opioids antagonise which receptors
µ (mu), δ (delta), К (Kappa) and ORL-1 (opioid receptor-like 1).
296
Opioid Induced Constipation is caused by which receptors
mu-opioid receptor agonists binding to mu-receptors in the myenteric and submucosal plexus tissues within the GI tract, this leads to inhibition of the propulsive activity of the intestine and slower gut transit time.
and centrally acting opioids may reduce intestinal peristalsis
297
What is Prucalopride
A selective, high affinity 5-HT₄ receptor agonist, which stimulates colonic mass movement
should only be prescribed by clinicians with experience of treating chronic idiopathic constipation and review of the patient’s previous laxative treatments.
298
What is Lubiprostone
A bicyclic fatty acid derived from prostaglandin E1 that acts by specifically activating CIC-2 cholride channels on the apical aspect of gastrointestinal epithelial cells, producing a chloride-rich fluid secretion.
Chloride channels are key regulators in the intestinal tract, which transport chloride ions into the lumen with sodium and fluids passively following, thus increasing intestinal fluid secretion
These secretions soften the stool, Increase motility and promote bowel movements.
299
Naloxone is a
centrally and peripherally acting opioid antagonist
inhibits the stimulation of µ-opioid receptors within the GI tract
high first pass metabolism
Crosses BBB therefore opioid withdrawal and loss of analgesic effect
Naloxegol doesnt cross BBB because pegylated
300
Methylynaltrexone bromide is a
peripheral selective antagonist of the mu receptor. Indicated for opioid induced constipation in terminally ill patients.
301
What is pharmacokinetics
the way body affects the drug:
Absorption •Distribution •Metabolism •Excretion
302
What is pharmacodynamics
effects of drug on body
303
Give examples of enteral routes
oral and rectal
304
Give examples of parenteral routes
IV, IM, SC, Intra-arterial, Intrathecal, Intra-peritoneal
305
Give examples of percutaenous routes
ingalation, sublingual, topical, transdermal, intranasal
306
Give examples of Absorption-Related Food/Drug Interactions
Grapefruit juice increases absorption of antihistamines, codeine, tranquilizers, cardiovascular & antiretroviral drugs
•Vegetables or vitamins with iron can decrease absorption of erythromycin
•Dairy foods or other calcium rich items decrease absorption of tetracycline
307
degree of drug distribution depends on:
Properties of the drug (physical & chemical)
| • Drugs ability to penetrate cell membranes
308
Which factors determine how much of the drug reaches its target
* Plasma protein binding
* Blood flow
* Blood brain barrier
309
What are Plasma protein binding
Manufactured in the liver.
They contribute to osmotic pressure, help to control water balance and are involved in the transport of substances in blood including drugs
310
How are drugs transported in the bloodstream
albumin transports Free (unbound) drug and Partially reversibly bound. Protein bound not available to exert effect.
Only "free" drug may: • Diffuse through capillary walls • Produce a therapeutic effect • Be metabolised • Be excreted
(Concentration of unbound drug determines the drug concentration and therefore efficacy of the drug )
311
What is the effect of protein binding on drug action?
* Changes in the concentration of plasma proteins will influence the effect of a highly bound drug
* low plasma protein level may occur in old age or malnutrition
* Reduced doses in both hepatic and renal failure
312
What gets into the BBB
lipid soluble and small
E.g. Second generation antihistamines (loratadine), achieve far lower brain concentrations cf some of the first generation antihistamine (diphenhydramine), and thus are classified as non-sedating
313
What is metabolism
enzymatic conversion of one chemical compound into another. Most drug metabolism occurs in the liver, although some processes occur in the gut wall, lungs and blood plasma.
Metabolic processes will convert the drug into a more water-soluble compound. This is an essential before the drug can be excreted in the body fluids such as urine or bile.
314
What is phase 1 metabolism
involve reduction or hydrolysis of the drug, but the most common biochemical process that occurs is oxidation (
315
How is a drug oxidised
Oxidation is catalysed by cytochrome P450 enzymes and results in the loss of electrons from the drug (electrons are negatively charged subatomic particles).
316
What is Phase 2 metabolism
conjugation - attachment of an ionised group (metabolite more water soluble) to the drug. These groups include glutathione, methyl or acetyl groups. These metabolic processes usually occur in the hepatocyte cytoplasm.
This facilitates excretion as well as decreasing pharmacological activity
317
Cytochrome P450 enzymes are essential for the production of
cholesterol, steroids, prostacyclins, and thromboxane A2
318
How does cytochrome p450 effect drug metabolism
It can be inhibited or induced by drugs, resulting in clinically significant drug-drug interactions that can cause unanticipated adverse reactions or therapeutic failures
319
What is the relation of cytochrime p450 and adverse drug reactions and interactions
knowing which drugs are metabolised by cP450 and which are most inhibiting/inducing helps reduce ADR and interactions
320
What is an inducing agent
with another medication, the dosage of the other medication may need to be adjusted since the rate of metabolism is increased and the effect of the medication reduced
321
What is an inhibiting agent
If a medication is taken with an agent that inhibits its metabolism, then the drug level can rise and possibly result in a harmful or adverse effect
322
Name some cytochrome p450 inducers
Carbamazapine, Rifampacin, Barbiturates, Phenytoin, St Johns Wort
323
Name some cytochrome p450 inhibitors
Sod Valporate, cipro, sulphonamide, cimitidine, omeprazole, antifungals, amiodarone, isoniazid, erthythromycin, clarithromycin, grapefruit juice
324
Where does elimination mainly occur
Kidneys, Liver, Faeces
325
How does the liver affect elimination
makes into more soluble for kidneys to excrete.
| excreted into bile and therefore faeces
326
Who has altered physiology
Pregnancy • Old Age • Children
327
How is absorption affected in pregnancy
gastric emptying and SI motility reduced (progesterone) this increase Tmax, reduce Cmax
gastric pH increase, mucous production increase
N&V
328
How is distribution affected in pregnancy
plasma volume & extravascular water content expansion. total body water increase by 8L (hydrophilic drugs can distribute)
plasma albumin conc falls so binding falls (more free drug)
placental hormones and steroids displace drugs from binding site
329
How is metabolism affected in pregnancy
- some drugs induced by oestrogen/progesterone. Therefore higher metabolism, inc excretion
- some isoenzymes competitively inhibited by progesterone/estridiol imparing elimination eg theophylline
330
How is elimination affected in pregnancy
renal elimination increased by 60-80%. GFR up by 50%. so more elimination of drugs. eg penicillin, digoxin
331
How is absorption affected in elderly
Decrease absorption because:
decrease cardiac output, blood flow, drug abs.
reduced gastric PH. loss of intestinal surface
332
How is distribution affected in elderly
Increase toxicity, drug effect
| decreased albumin production, in blood, and how much binds to drug.
333
How is metabolism affected in elderly
increased duration and affect of drug
| reduced hepatic enzyme activity, hepatic blood flow, metaboloisation
334
How is excretion affected in elderly
lowered renal function
335
Other names for liver disease
```
Alpha 1 antitrypsin
Alagille syndrome
PFIC
Hepatitis B,C
Autoimmune hepatitis
Primary sclerosing cholangitis
Budd chiari syndrome
Veno-occlusive disease
Fatty Liver Disease
Primary biliary cirrhosis
Hemochromatosis
CF Liver disease
Alcoholic steatohepatisis
```
336
Name some functions of the liver
Production of bile
Synthetic function - plasma protein - clotting factor
Metabolism - fat - carbohydrate - protein
Storage - vitamins - glycogen
Detoxification (metabolites of drugs sometimes harmful like para)
337
How is aspirin metabolised
Phase one - salicylic acid
Phase two - joins glucoronic acid or glycine
metabolite excreted kidneys
338
Paracetamol metabolised with
glutathione
339
prodrugs are
metabolised into active drug
340
Symptoms of choleostasis
```
Jaundice
Pale Stools
Coloured Urine (yellow-brown dependant on age)
Steatorrhoea
Pruritis
Fat soluble Vitamin deficiencies
```
341
Symptoms of Cirrhosis
```
Portal hypertension
Haematemesis
Malaena
Coagulopathy
Ascites
Encephalopathy
Hepatopulmonary syndrome
Failure to thrive
Malaise
Lethergy
Jaundice (late change)
```
342
Symptoms of Acute Liver Failure
```
Jaundice
Hypoglycaemia
Coagulopathy
Encephalopathy
Hepatorenal Syndrome
Electrolyte and acid base disturbance
Cerebral oedema
```
343
Changes in drug distribution in liver disease
Hypoalbuminaemia- resulting in high fraction of free drug
| Blood bypassing the liver – portosystemic shunting
344
Changes in excretion in liver disease
Compounds excreted in bile via the enterohepatic circulation may reach high concentrations resulting in hepatoxicity e.g phenytoin and some antibiotics.
345
After first pass metabolism the clearance of the drug is determined by
Extent of drug binding
Blood flow
Functional hepatocytes
346
Liver Function Tests
```
AST = Aspartate Transaminase 50 iu/l
ALT = Alanine Transminase 40i u/l
```
Enzymes found in hepatocytes (particularly ALT)
Raised level = inflammation/necrosis of liver
ALP, GammaGT, glucose, albumin, prothombin time, partial thromboblastin time, 1NR
347
Two types lipoprotein
High and low density
| high HDL and low LDL good
348
How do statins work
inhibit of enzyme (3-hydroxy-3-methylgulutaryl-Coenzymes A reductase) - HMG CoA reductase
HMG CoA reductase is involved in the production of cholesterol
As a result Hepatocytes import LDL cholesterol from the blood.
Serum cholesterol levels fall
349
```
What are the effects of the following on liver:
PHENYTOIN
WARFARIN
CORTICOSTERIODS
NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
HYPNOTICS/SEDATION
CIMETIDINE
```
PHENYTOIN - Hepatic clearance decreased
WARFARIN - Inhibit clotting factor synthesis
CORTICOSTERIODS/NSAIDs - Leads to excess sodium and water retention/ gastrointestinal bleeding
HYPNOTICS/SEDATION - May precipitate hepatic encephalopathy
CIMETIDINE - Enhanced risk of adverse drug reaction
350
How can you deal with blood poisoning with Urine pH
Altering urine pH increases excretion - alkaline means acid dissolved vice versa
351
What is therapeuric index
The therapeutic index of a drug is the ratio of the dose that produces toxicity to the dose that produces a clinically desired or effective response in a population of individuals.
Therapeutic index= (TD 50)/ED50
Where: TD50 is the dose of drug that causes a toxic response in 50% of the population and ED50 is the dose of drug that is therapeutically effective in 50% of the population.
352
Which drugs have effect on the kidneys
```
many antibiotics,
histamine H2-receptor antagonists,
digoxin,
anticonvulsants
non-steroidal anti-inflammatory drugs (NSAIDs)
Drugs inc potassium potassium supplements and potassium-sparing diuretics
drugs inc sodium eg antacids
vit d because calcium inc
```
353
Name some Drugs that have been reported to cause glomerulonephritis
penicillamine, gold, captopril, phenytoin and some antibiotics, including penicillins, sulphonamides and rifampicin
354
Name some Drugs that may cause interstitial nephritis
penicillins, cephalosporins, sulfonamides, thiazide diuretics, furosemide, NSAIDs and rifampicin
355
Name some drugs that cause direct toxicity to the renal tubules
aminoglycosides, amphotericin and ciclosporin.
356
Name some drugs which causes crystalluria and could therefore cause urinary tract obstruction
High-dose sulfonamides, acetazolamide or methotrexate
357
Name some drugs which cause urinary tract obstruction due to retention of urine in the bladder
Anticholinergics (eg, tricyclic antidepressants), and alcohol
358
What information is needed on a Clinical Management Plan
```
• Pt name
• The illness being treated
• Start and review date
• class of meds/appliances under plan
• Any restrictions or limitations to the strength or dose of any medicine
• warnings/sensitivities
• The arrangements for notification of:-
a) Suspected or known reactions
b) Incidents which might lead to death or serious deterioration
• when SP to refer
```
359
Can a Supplementary prescriber prescribe CDs under the CMP
yes since 2005 nurse and pharmacist and 2006 for physiotherapist, podiatrist, radiographer, and optometrist
360
who can be a Supplementary Prescriber
nurse, midwife, pharmacist, physiotherapist, podiatrist, radiographer, optometrist, chiroprodists, podiastrists, dietican
361
What pharmacokinetic differences are there in kids?
Absorption - gastric pH, intestinal transit
Skin - SA, thickness,
Less muscle
Distribution - more water, less protein binding
362
Give example of rectal route good in kids
diazepam for epileptic seizures or analgesics eg paracetamol, may be given this way if the child is vomiting
363
Give example of drugs requiring high doses in kids
carbamazepine,
phenytoin and
theophylline
364
Child under 16 and can understand can consent to meds under
Gillick competence
365
What does STOPP and START stand for?
STOPP-Screening Tool of Older Persons Prescriptions START -Screening Tool to Alert doctors to Right i.e. appropriate, indicated Treatments
366
How is absorption affected in elderly
less motility, gastric acid, emptying
367
How is distribution affected in elderly
less lean body mass, water in body plasma protein
| more adipose tissue
368
How is metabolism affected in elderly
liver size and mass less and less blood flow to it. therefore less proteins, less CHD transformed, less cholesterold, bile, phsospholipids,
369
How is excretion affected in elderly
renal function less. in size, blood flow, functionality, secretion.
370
What is polypharmacy
the practice of prescribing four or more medications to the same person
371
How does antihistamine work
allergen on mast cell triggering histamine release (by IgE antibodies) - antihistamine blocks other side
372
Name first gen antihistamines
diphenhydramine ( benedryl), chlorphenamine, cyclizine, hydroxyzine, promethazine (phenegran)
373
Name second gen antihistamines
loratidine, cetirizine, desloratidine, acirvastine,
374
Name some drugs used in opiate detox
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Lofexidine is the main drug used - withdrawal
Adjuvent therapies can be added
Buscopan
Loperimide
Zopiclone
Diazipam
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375
How does Naltrexone work
Pt who are drug free and want the safety of not being able to use heroin
Helps people to cope with triggers and high risk situations with the knowledge that heroin use would have no effect
Works by binding tightly to opiate receptors in the brain to block the effects of heroin
376
What drugs used in alcohol withdrawal
Chlordiazepoxide (Librium tablet) - 6-11 days, sedative, anti-anxiety effect
Disulfiram (trade name Antabuse) - producing an acute sensitivity to alcohol
Acamprosate (brand name Campral) - stabilise the chemical balance in the brain that would otherwise be disrupted by alcoholism. works with abstinance and support groups
Naltrexone
377
Give example of drugs for therapeutic monitoring
Gentamycin
Vancomycin
Cyclosporin
Aminophylline
378
How does Nalaxone work
binds to the opioid receptors and blocks them, preventing the body from responding to opiates. Used for respiratory depression/coma caused by opioids therefore reverses. technically anyone can give because emergency.
