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Prescribing Flashcards

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1
Q

Drugs to stop before surgery

A

I LACK OP

Insulin
Lithium
Anticoagulants
COCP/HRT
K-sparing diuretics
Oral hypoglycaemics
Perindopril and other ACE-inhibitors

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2
Q

I LACK OP

A

Insulin
Lithium - Day before
Anticoagulants
COCP/HRT - 4 weeks before
K-sparing diuretics - Day of
Oral hypoglycaemics
Perindopril and other ACE-inhibitors - Day of

Drugs to stop before surgery

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3
Q

Surgery for patients on long term corticosteroids

A

Commonly have adrenal atrophy so unable to mount an adequate physiological response to surgery => profound hypotension if steroids discontinued

Should be given IV steroids at induction of anaesthesia

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4
Q

What does an enzyme inducer do?

A

Increases P450 enzyme activity, hastening metabolism of other drugs and reducing their effect => patient requires more of some other drugs in the presence of an enzyme inducer

Increased enzyme activity => decreased drug concentration

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5
Q

What does an enzyme inhibitor do?

A

Decreases P450 enzyme activity, increasing the levels of other drugs, requiring reduced dosage

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6
Q

Cytochrome P450 enzyme system

A

Metabolises most drugs to inactive metabolites in the liver, preventing them from exerting infinite effects.

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7
Q

Enzyme inducers (decreased drug level)

A

Decreased drug concentration

PC BRAS

Phenytoin
Carbamazepine
Barbiturates
Rifampicin
Alcohol (chronic excess)
Sulphonylureas

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8
Q

Enzyme inhibitors

A

Increase drug concentration

AODEVICES

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

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9
Q

What should be stopped with any bleeding?

A

Antiplatelets/anticoagulants

eg Enoxaparin, aspirin, dalteparin

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10
Q

When should you be cautious with warfarin?

A

With an enzyme inhibitor- can greatly increase INR

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11
Q

Steroid side effects

A

STEROIDS

Stomach ulcers
Thin skin
oEdema
Right and left heart failure
Osteoporosis
Infection
Diabetes (commonly causes hyperglycaemia, uncommonly progresses to diabetes)
cushing’s Syndrome

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12
Q

Safety considerations for NSAIDs

A

NSAID

No urine
Systolic dysfunction (ie HF)
Asthma
Indigestion
Dyscrasia (clotting abnormality)

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13
Q

Antihypertensive side effects

A

Hypotension

Bradycardia with beta blockers and some CCBs
Electrolyte disturbance with ACEi and diuretics

ACEi - dry cough
Beta blockers => wheeze in asthmatics, worsen acute HF but can help chronic
CCBs => peripheral oedema and flushing
Diuretics => renal failure, thiazide diuretics can cause gout, K sparing can cause gynaecomastia

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14
Q

Vomiting patient

A

GIVE MEDICINE NON ORAL ROUTE

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15
Q

Replacement fluid: which fluid for standard patient?

A

0.9 % saline

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16
Q

Replacement fluid: when not to give 0.9 % saline?

A

Hypernatraemia or hypoglycaemia => 5 % dextrose instead

Has ascites => give human albumin solution (HAS) instead

Shocked from bleeding => give blood transfusion but crystalloid first if blood not available

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17
Q

Replacement fluid: how fast if tachycardic or hypotensive?

A

500 ml bonus immediately (250 ml in Hx of HF)

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18
Q

Replacement fluid: how fast if only oliguric (not due to obstruction)?

A

1 L over 2-4 hours then reassess

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19
Q

Max infusion rate of IV potassium?

A

10 mmol/hour

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20
Q

Maintenance fluids: how much for adults/elderly in 24 hours?

A

Adults - 3 L

Elderly - 2 L

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21
Q

Maintenance fluid: which fluid should be prescribed?

A

1 L of 0.9 % saline, 2 L of 5 % dextrose

Add KCl guided by U&Es
For normal potassium level, approx 40 mmol required each day - 20 mmol in each bag

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22
Q

Maintenance fluids: how fast to give each bag?

A

If giving 3 L per day = 8 hourly bags

If giving 2 L per day = 12 hourly bags

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23
Q

When not to prescribe anticoagulants

When not to prescribe compression stockings

A

RISK OF BLEEDING

Recent ischaemic stroke

PERIPHERAL ARTERIAL DISEASE - may cause acute limb ischaemia

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24
Q

When to avoid metoclopramide?

A

Dopamine antagonist

Parkinson’s patients - may exacerbate symptoms

Young women due to risk of dyskinesia

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25
Antiemetic in nauseated patients
Regular antiemetic Cyclizine 50 mg 8-hourly IM/IV/oral for most cases but causes fluid retention Metoclopramide 10 mg 8-hourly IM/IV if HF Ondansetron 4 mg or 8 mg 8-hourly IV/oral
26
Antiemetic in not nauseated patients
As required antiemetic Cyclizine 50 mg 8-hourly IM/IV/oral for most cases but causes fluid retention Metoclopramide 10 mg up to 8-hourly IM/IV if HF
27
When not to use cyclizine?
Cardiac cases as it can worsen fluid retention
28
Causes of microcytic anaemia
Iron deficiency anaemia Thalassaemia Sideroblastic anaemia
29
Causes of normocytic anaemia (4)
Anaemia of chronic disease Acute blood loss Haemolytic anaemia Chronic renal failure
30
Causes of macrocytic anaemia
B12/folate deficiency (megaloblastic anaemia) Excess alcohol Liver disease (including non alcoholic causes) Hypothyroidism Haematological diseases starting with “M”: myeloproliferative, myelodysplastic, multiple myeloma
31
Causes of high neutrophils
Bacterial infection Tissue damage (inflammation/infarct/malignancy) Steroids
32
Causes of low neutrophils
Viral infection Chemotherapy or radiotherapy Clozapine (antipsychotic) Carbimazole (antithyroid)
33
Causes of high lymphocytes
Viral infection Lymphoma CLL
34
Causes of thrombocytopenia
REDUCED PRODUCTION Infection Drugs (penicillamine) Myelodysplasia, myelofibrosis, myeloma INCREASED DESTRUCTION Heparin Hypersplenism DIC ITP HUS TTP
35
Causes of thrombocytosis
REACTIVE Bleeding Tissue damage (infection/inflammation/malignancy) Postsplenectomy PRIMARY Myeloproliferative disorders
36
Causes of hypovolaemic hyponatraemia
Fluid loss (diarrhoea/vomiting) Addison’s Diuretics (any type)
37
Causes of euvolaemic hyponatraemia
SIADH Psychogenic polydipsia Hypothyroidism
38
Causes of hypervolaemic hyponatraemia
Heart failure Renal failure Liver failure (causing hypoalbuminaemia) Nutritional failure (causing hypoalbuminaemia) Thyroid failure (can also be euvolaemic)
39
Causes of SIADH
SIADH Small cell lung tumours Infection Abscess Drugs (carbemazepine and antipsychotics) Head injury
40
Causes of hypercalcaemia (5)
EXCESSIVE PTH PRODUCTION Primary hyperparathyroidism (adenoma, hyperplasia) Tertiary hyperparathyroidism (long-term stimulation of PTH secretion in renal insufficiency) EXCESSIVE VITAMIN D PRODUCTION Granulomatous diseases (sarcoidosis, TB) Lymphomas Vit D intoxication HYPERCALCAEMIA OF MALIGNANCY Tumour lysis syndrome Bone metastasis PRIMARY INCREASE IN BONE RESORPTION Hyperthyroidism Immobilisation EXCESSIVE CALCIUM INTAKE Milk-alkali syndrome TPN
41
Causes of hypokalaemia (DIRE)
DIRE Drugs (loop and thiazide diuretics) Inadequate intake or Intestinal loss (D&V) Renal tubular acidosis Endocrine (Cushing’s and Conn’s syndromes)
42
Causes of hyperkalaemia (DREAD)
DREAD Drugs (K-sparing diuretics and ACE inhibitors) Renal failure Endocrine (Addison’s) Artefact (very commonly due to clotted sample) DKA
43
What is raised urea indicative of?
Kidney injury or upper GI haemorrhage Raised creatinine for kidney injury, low Hb for GI bleed
44
Types of AKI
Prerenal Intrinsic renal Postrenal
45
Biochemical disturbance of prerenal AKI
Urea rise > creatinine rise
46
Biochemical disturbance of intrinsic renal AKI
Urea rise < creatinine rise Bladder or hydronephrosis not palpable
47
Biochemical disturbance of postrenal AKI
Urea rise < creatinine rise bladder or hydronephrosis may be palpable depending on level of obstruction
48
Causes of prerenal AKI
Dehydration of any cause eg sepsis, blood loss Renal artery stenosis (often triggered by drugs, ACEi or NSAIDs, effectively causing hypoperfusion of kidneys)
49
Causes of intrinsic renal AKI
INTRINSIC Ischaemia (due to prerenal AKI causing acute tubular necrosis) Nephrotoxic antibiotics Tablets (ACEi, NSAIDs) Radiological contrast Injury (rhabdomyolysis) Negatively bifringent crystals (gout) Syndromes (glomerulonephrodites) Inflammation (vasculitis) Cholesterol emboli
50
Nephrotoxic antibiotics
Gentamicin Vancomycin Tetracyclines
51
Causes of postrenal AKI
IN LUMEN Stone or sloughed papilla IN WALL Tumour (renal cell, transitional cell) Fibrosis EXTERNAL PRESSURE BPH Prostate cancer Lymphadenopathy Aneurysm
52
Markers of hepatocyte injury or cholestasis
Bilirubin Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) Alkaline phosphatase (ALP)
53
Markers of synthetic liver function
Albumin Vitamin K dependent clotting factors measured via PT/INR
54
Vitamin K dependent clotting factors
II VII IX X
55
Causes of raised alk phos
Any fracture Liver damage (post-hepatic) Cancer Paget’s disease of the bone Pregnancy Hyperparathyroidism Osteomalacia Surgery
56
LFT derangement in prehepatic jaundice
Isolated raised bilirubin
57
LFT derangement in intrahepatic jaundice
Raised bilirubin Raised AST/ALT
58
LFT derangement in posthepatic jaundice
Obstructive jaundice Raised bilirubin Raised ALP
59
Causes of prehepatic jaundice
Haemolysis Gilbert’s and Crigler-Najjar syndromes
60
Causes of intrahepatic jaundice
Fatty liver Hepatitis Cirrhosis Malignancy Metabolic - Wilson’s disease/haemochromatosis Heart failure causing hepatic congestion
61
Causes of posthepatic jaundice
OBSTRUCTIVE IN LUMEN Gallstones Drugs causing cholestasis IN WALL Tumour (cholangiocarcinoma) Primary biliary cirrhosis Sclerosing cholangitis EXTRINSIC PRESSURE Pancreatic or gastric cancer Lymphadenopathy
62
Causes of hepatitis and cirrhosis
Alcohol Viruses (hepatitis A-E, CMV, EBV) Drugs (paracetamol overdose, statins, rifampicin) Autoimmune (primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis)
63
Drugs causing cholestasis
Flucloxacillin Co-amoxiclav Nitrofurantoin Steroids Sulphonylureas
64
TFTs in primary hypothyroidism
Decreased T4 Increased TSH Decreased T4 from thyroid causing compensatory increased TSH Hashimoto’s thyroiditis, drug induced hypothyroidism
65
TFTs in secondary hypothyroidism
Decreased T4 Decreased TSH Decreased TSH causing decreased T4 Pituitary tumour or damage
66
TFTs in primary hyperthyroidism
Increased T4 Decreased TSH Increased T4 causing decreased TSH through negative feedback Grave’s disease, toxic nodular goitre, drug induced hyperthyroidism
67
TFTs in secondary hyperthyroidism
Increased T4 Increased TSH Increased TSH from pituitary causing increased T4 Pituitary tumour
68
Type 1 respiratory failure
Low or normal PaCO2 Fast/normal breathing Caused by anything that damages heart or lungs causing SOB
69
Type 2 respiratory failure
High PaCO2 Slow/shallow breathing COPD, neuromuscular failure or restrictive chest wall abnormalities
70
Respiratory acidosis
Low pH High PaCO2 Normal or raised HCO3 (compensation) COPD, neuromuscular failure or restrictive chest wall abnormalities
71
Respiratory alkalosis
High pH Low PaCO2 Normal or reduced HCO3 (compensation) Rapid breathing from disease or anxiety
72
Metabolic acidosis
Low pH Low HCO3 Normal or reduced PaCO2 (compensation) Lactic acidosis, DKA, renal failure
73
Metabolic alkalosis
High pH High HCO3 Normal or raised PaCO2 (compensation) Vomiting, diuretics, Conn’s syndrome
74
How to manage over anticoagulation with an INR 5-8 and no bleeding?
Omit warfarin for 2 days then reduce dose
75
How to manage over anticoagulation with an INR >8 and no bleeding?
Omit warfarin and give 1-5 mg PO vitamin K
76
How to manage over anticoagulation with an INR 5-8 and minor bleeding?
Omit warfarin and give 1-5 mg IV vitamin K
77
How to manage over anticoagulation with an INR >8 and minor bleeding?
Omit warfarin and give 1-5 mg IV vitamin K
78
How to manage over anticoagulation with major bleeding?
ie causing hypotension or bleeding into confined space (brain/eye) Stop warfarin Give 5-10 mg IV vitamin K Give prothrombin complex
79
Gentamicin and vancomycin ADRs
Nephrotoxicity Ototoxicity
80
ADR of any antibiotic, but mainly broad spectrum
C. diff colitis
81
ADRs of ACE inhibitors
Hypotension Electrolyte abnormalities AKI Dry cough
82
ADRs of beta blockers
Hypotension Bradycardia Wheeze in asthmatics Worsens acute HF Improves chronic HF
83
ADRs of CCBs
Hypotension Bradycardia Peripheral oedema Flushing
84
ADRs of diuretics
Hypotension Electrolyte abnormalities AKI Subclass dependent effects
85
ADRs of heparins
Haemorrhage Heparin-induced thrombocytopenia
86
ADRs of warfarin
Haemorrhage
87
ADRs of aspirin
Haemorrhage Peptic ulcers Gastritis Tinnitus in large doses
88
ADRs of digoxin
Nausea D&V Blurred vision Confusion Drowsiness Xanthopsia
89
Xanthopsia
Disturbed yellow/green visual perception including “halo” vision
90
ADRs of amiodarone
Interstitial lung disease Thyroid disease Skin greying Corneal deposits
91
ADRs of lithium
EARLY Tremor INTERMEDIATE Tiredness LATE Arrhythmias Seizures Coma Renal failure Diabetes insipidus
92
ADRs of antipsychotics haloperidol and clozapine
Dyskinesias Agranulocytosis
93
ADRs of statins
Myalgia Abdominal pain Increased ALT/AST Rhabdomyolysis
94
Drugs with narrow therapeutic index
Warfarin Digoxin Phenytoin Theophylline
95
Drugs requiring careful dosage control
Antihypertensives Antidiabetic drugs
96
GI bleeding caused by
NSAIDs
97
Lactic acidosis caused by
Metformin
98
Hypertensive crisis caused by
MAOIs
99
Sweating, flushing, nausea and vomiting caused by
Metronidazole Disulfiram
100
Sedation caused by
Barbiturates Opioids Benzodiazepines
101
What drugs to avoid in peripheral vascular disease?
Beta blockers ACEi cautioned in severe disease
102
What drug should be continued through intercurrent illness?
Prednisolone (in case of chronic adrenal suppression)
103
How many micrograms fentanyl/hour are equivalent to 60 mg oral morphine per day?
25 micrograms/hour
104
Drugs causing hyperkalaemia
Potassium-sparing diuretics Beta blockers ACEi/ARBs Digoxin at toxic levels Heparin Trimethoprim and co-trimoxazole Ciclosporin Tacrolimus Non-steroidal anti-inflammatory drugs (NSAIDs)
105
Drugs causing hypokalaemia
Laxatives (excessive use) Thiazide and loop diuretics High dose beta 2 agonists Theophylline High dose penicillins Gentamicin Amphotericin Echinocandin antifungals High dose insulin Corticosteroids Cisplatin Sodium bicarbonate Parecoxib
106
Vitamin K BNF
Phytomenadione
107
Drug induced extrapyramidal side effects/Parkinsonism treatment
Procyclidine hydrochloride Not tardive dyskinesia
108
Tardive dyskinesia treatment
Tetrabenazine
109
How many mg of oral morphine/day are equivalent to 25 microgram fentanyl/hour?
60 mg

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