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pa30327: polypharmacy long answer question > polypharmacy > Flashcards

polypharmacy Flashcards

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1
Q

The 7 steps

A
  1. Aims
  2. Essential?
  3. Unnecessary
  4. Effective?
  5. Safety
  6. Cost effectiveness
  7. Adherence/ patient centredness
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2
Q

Aims

A

What matters to the patient?
Objectives of drug therapy
Managing existing problems
Prevention of future problems

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3
Q

Essential?

A

Discuss with expert before stopping

Discuss with expert before altering

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4
Q

Unnecessary?

A

Expired indication
Valid indication?
Benefit vs risk

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5
Q

Effectiveness?

A

Intensifying existing drug therapy

Specified drug therapy

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6
Q

Safety

A

Cumulative toxicity
Anticholinergic burden
Frail
(Think about detail by therapeutic area)

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7
Q

Cost effectiveness

A

Dispersible
Specials?
Branded
More than 1 strength/ formulation of same drug

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8
Q

Adherence/ patient centredness

A

Cognitive self administration
Technical self admin
Tablet burden

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9
Q

PPIs

A

Clostridium difficile
Osteoporosis
Hypomagnesia
Try not to treat long term, keep at low doses

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10
Q

H2 blockers

A

Anticholinergic ADRs

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11
Q

Laxatives

A

Fluid loss> hypokalemia> constipation

If more than 1 do NOT stop abruptly

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12
Q

Antispasmodics

A

Rarely effective
Rarely indicated long term
Anticholinergic side effects

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13
Q

Anticoagulants

A

Bleeding risk - avoid use with antiplatelets and NSAIDs

Much more effective for stroke prevention in AF than antiplatelets

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14
Q

Antiplatelets

A

Bleeding risk - avoid use with anticoagulants and NSAIDs
Aspirin + clopidogrel only indicated for 12 months after ACS
Conisder PPI if GI risk factors

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15
Q

Diuretics

A

AKI risk

Electrolyte disturbance risk

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16
Q

Spironolactone

A

Hyperkalemia risk

Risk factors: CKD, high dose, co treatment with ACEIs/ ARBs, amiloride, triamteren, potassium supplements

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17
Q

Digoxin

A

Toxicity risk

Risk factors: CKD, high dose, poor adherence, hypokalemia, drug-drug interactions

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18
Q

Peripheral vasodilators

A

Rarely effective

Rarely indicated long term

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19
Q

Quinine

A

Risk of thrombocytopenia, blindness, deafness
Only short term if leg cramps
Review effectiveness regularly

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20
Q

Antianginals

A

Hypotension caution

If mobility has reduced, consider reducing dose

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21
Q

Antiarrhythmics

A

Overdosing risk

Thyroid complication risk

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22
Q

Statins

A

Rhabdomyolysis risk

Consider life expectancy

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23
Q

BP lowering drugs

A

Little evidence supporting tight BP control in older frail group
Individualise targets

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24
Q

Beta blockers

A

Risk of bradycardia (esp in combination with rate limiting CCBs)

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25
ACEIs/ ARBs
Risk of AKI Avoid using with NSAIDs Stop when at risk of dehydration Sick day rule guidance
26
CCBs
Risk of constipation and ankle oedema If rate limiting, risk of bradycardia If dihydropyridines, risk of reflex tachycardia
27
Spironolactone
Risk of hyperkalemia Risk factors: CKD, ACEI/ARB Risk of AKI Do not combine with NSAIDs
28
Theophylline
Risk of toxicity (tachycardia, CNS excitability) Monotherapy in COPD NOT appropriate Avoid combining with macrolides/ quinolones
29
Steroids
Risk of osteoporotic fractures If long term needed, give bone protection Long term oral use rarely indicated Withdraw gradually
30
Antihistamines
Risk of anticholinergic ADRs | Rarely indicated long term
31
Hypnotics and anxiolytics
Risk of falls, fractures, confusion, memory impairment | Risk of dependency
32
Antipsychotics
Risk of stroke and death in elderly patients with dementia Anticholingeric ADR for chlorpromazine Worsening of PD
33
Antidementia drugs
Only continue if functional/ behavioural symptoms improve | Use MMSE
34
TCAs
Confirm need Risk of anticholinergic ADRs Risk of GI bleeding Avoid with MAOI because of risk of serotonin syndrome
35
Metoclopramidde
Only licensed for 5 days unless palliative | Worsening of PD (domperidone more suitabel)
36
Antihistamiens
Anticholiergic ADRs
37
Opioids
``` Risk of constipation Risk of cognitive impairment Risk pf respiratory depression Risk of immunosuppression Risk of sex hormone suppression ```
38
Paracetamol
Risk of overdosing | Dose reduction when low body weight/ renal/ hepatic impairment
39
AEDs
Risk of dizziness, blurred vision, sedation Check renal function Reduced dose in CKD DN4/ LANSS to aid diagnosis
40
Antibiotics
Review long term antibiotics for recurrent UTI
41
Nitrofurantoin
Risk of pulmonary/ renal ADRs | Avoid in renal impairment
42
Antidiabetics
Takes years for the microvascular benefit of tight HbA1c
43
Metformin, sulfonylureas, glitazones
Risk of lactic acidosis Avoid if eGFR, stop with dehydration Risk of hypoglycaemia Avoid in patients with HF
44
Bisphosphonates
Check willingness to take
45
Antimuscarinics e.g oxybutynin
Review continued need/ effectiveness after 3-6 months Risk of anticholinergic ADRs May decrease MMSE score in dementia
46
Supplements
Review need | Monitor weight
47
Potassium
Risk of hyperkalemia | Risk factors: CKD, ACEI/ARBs, spironolactone, amiloride, trimethoprim, triamterene
48
NSAIDs
GI ADRs (consider GI protection with PPI) CV ADRs Renal ADRs
49
Skeletal muscle relaxants
Rarely indicated long term | Anticholinergic ADRs
50
DMARDs
Risk of Mtx overdosing
51
Highest risk falls medication in elderly
``` Antidepressants, esp TCAs e.g amitryptyline Antipsychotics Antimuscarinics Benzodiazepines Hypnotics Dopaminergic drugs in PD ```
52
Moderate falls risk medication in elderly
``` Antiarrhythmics AEDs Opioids Antihistamines Alpha blockers ACEIs/ARBs Diuretics Beta blockers ```
53
Lower falls risk medication in eldelry
CCBs (incidence of dizziness low) Nitrates (sit when taking GTN) Oral antidiabetics: dizziness due to hypoglycaemia usually avoidable AVOID long acting sulfonylureas e.g chlorpropamide
54
People more susceptible to anticholinergic ADRs
Mental illness | Older
55
Anticholinergic effects
``` Mouth dryness Urinary retention Anhidrosis Blurred vision Mydriasis Tachycardia Palpitations Restlessness Fatigue Headache AtAXIA Decreased gut motility Delusions Coma Agitation Delirium ```
56
Antidepressants and anticholinergic burden
TCAS/ SSRIs/ mirtazapine > venlafaxine, trazodone, duloxetine
57
Antipsychotics and anticholinergic burden
Clozapine/ chlorpromazine/ levopromazine/ olanzapine/ quetiapine/ risperidone/ haloperidol > aripiprazole
58
Nausea and vertigo and anticholinergic burden
Prochlorperazine> metoclopramide (PD effects)/ | Domperidone
59
Urinary antispasmodics and anticholinergic burden
Oxybutynin > mirabegron
60
Zolpidem and zopiclone
Sedatives No anticholinergic activity Falls risk
61
Secondary CVD prevention
Aspirin + antiplatelets
62
Abnormal ACR (>3) on 2 consecutive occaisions
Renal damage
63
HbA1c target if managed on metformin and glicazide
53mmol/mol
64
HbA1c target if just on metformin
48mmol/mol
65
Why is the HbA1c target higher on glicazide?
More likely to cause a hypo
66
Empagliflozin
More likely to cause weight loss
67
eGFR cut off for metformin
30
68
Ipratropium
SAMA
69
ICS issues
Weight gain Increased risk of infection Cautioned in COPD
70
Umeclidium
LAMA
71
High blood pressure and COPD
High BP is NOT a symptom of COPD
72
MMRC
Modified medical research questionnaire used to assess the severity of COPD
73
Mucolytics
Evidence poor | Tiring
74
RPS competency framework for rxers(July 2016)
``` Consultation + rxing governance Assess the patient Conisder the options Reach a shared decision Prescribe Provide info Prescribe safely Prescibe professionally Improve prescribing practice Prescribe as part of a team ```
75
Symptoms of hyperkalemia
Tingling and numbness in fingers | Palpitations
76
AEDs with low teratogenic potential
Lamotrigine | Levetiracetam
77
K+ targets ACEI
Less than 5mmol/L
78
When to stop, monitor and refer for ACEIs
If K+ >5mmol/L | If Cr >20% increase or eGFR >15% decrease
79
Creatinine normal levels
45-90 micromol/L
80
eGFR normal level
Greater than 90
81
eGFR normal level
Greater than 90
82
T2DM 1st line for HTN
CCB regardless of age
83
Category A
1 or less non serious exacerbations MMRC 0-1 CAT <10 Bronchodilator only
84
Category B
1 or less non serious exacerbations MMRC of 2 or more CAT 10 or more LAMA/ LABA > LABA + LAMA
85
Category C
``` at least 1 serious exacerbation MMRC 0-1 CAT of 10 or less LAMA LAMA + LABA OR LABA + ICS ```
86
Category D
``` At least 1 serious exacerbation MMRC 2 or more CAT 10 or more LAMA LABA + LAMA LAMA + ICS Consider rofluminast if FEV1 less than 50% prednisolone macrolide IN FORMER SMOKERS ```
87
SOCRATES
``` Site Onset Character Radiation Associations Timing Exacerbating/ relieving factors Severity ```
88
5 underlying principles of ethical decision making
``` Benificence Non malificence Respect for autonomy Justice Respect for patient ```
89
2006 study
50% of ADRs resulting in hospital admission caused by 4 types of drugs: 1. NSAIDs 2. Diuretics 3. Antiplatelets 4. Anticoagulants
90
Falls in older people
4 or more meds
91
NICE screening tools to identify potential medicines related to patient safety issues
Explicit criterion based tools | Implicit judgment based approach
92
Explicit crierion based tools
BEERs criteria | STOPP/START
93
Implicit judgement based apporach
NO TEARS | MAI
94
T2DM patients with severe frailty
Avoid hypoglycaemia Decrease risk of infection Avoid hospital admission Control symptoms
95
Statin monitoring
LFTs and cholesterol
96
Empagliflozin
SGLT2 inhibitor | Causes weight loss
97
Metformin
Doesn't cause hypos when given alone

pa30327: polypharmacy long answer question (1 decks)

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