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Phase 3b > Prescribing and Pharmacology > Flashcards

Prescribing and Pharmacology Flashcards

1
Q

Action of ARBs and ACE-inhibitors

A

ARBs prevent the action of angiotensin II on receptors

ACE-i prevent the conversion of angiotensin I to angiotensin II

Reduce peripheral vascular resistance (afterload)

Especially dilates efferent glomerular arteriole, reducing pressure and slowing progression of CKD

Reduce aldosterone levels which promotes excretion of sodium and water via the kidneys - reduces venous return and therefore preload

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2
Q

Where is angiotensin converting enzyme released from

A

Lungs

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3
Q

Indications for ACE-inhibitors

A
  1. Hypertension: first/second-line treatment, reduces risk of CVD, stroke
  2. Chronic heart failure: first-line for all grades, improves symptoms and prognosis
  3. IHD
  4. Diabetic nephropathy and CKD with proteinuria
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4
Q

Adverse effects of ACE-inhibitors

A

Hypotension (especially after first dose)

Dry cough (due to high levels of bradykinin)

Hyperkalaemia (low aldosterone promotes potassium retention)

Renal failure (causes or worsens)

Angioedema and anaphylactoid reactions

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5
Q

Contraindications o ACE-inhibitors

A

AKI or renal stenosis

pregnancy or breastfeeding

Only in low doses if CKD

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6
Q

ACE-inhibitor interactions

A

Potassium elevating medications/fluids

NSAIDs: higher risk of renal failure

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7
Q

Tonsillitis treatment

A

Phenoxymethylpenicillin 10 days

Clarithromycin if penicillin allergy

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8
Q

What should you assess when completing a medication review?

A

What is the indication for each drug

Drug interactions

Contraindications

Suitability of each drug given current presentation (risks and benefits)

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9
Q

Important amitriptyline side effects

A

Antimuscarinic: dry mouth, constipation, blurred vision

H1 and a1: hypotension and sedation

Cardiac: arrhythmias, prolonged QT/QRS

Neurological: convulsions, hallucinations, mania

Dopamine blocking: breast changes, sexual dysfunction, (rarely extrapyramidal dyskinesia and tremor)

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10
Q

What drug should you not use with tricyclics?

A

Monoamine oxidase inhibitors - both increase serotonin and noradrenaline leading to serotonin syndrome, hyperthermia or hypertension

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11
Q

Beta 2 agonists adverse effects

A

tachycardia, palpitations, anxiety, tremor
Raised glucose
LABA can cause muscle cramps
Caution if has CVD as tachycardia can lead to arrhythmias or angina

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12
Q

What effects does Beta 2 agonists have on electrolytes?

A

Shifts potassium into cells - can treat hyperkalaemia

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13
Q

What must LABAs be used in conjunction with?

A

Inhaled corticosteroids

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14
Q

What drug may reduce effectiveness of Beta 2 agonists

A

Beta blockers

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15
Q

Why should verapamil not be given with a beta blocker? except under specialist supervision?

A

both can cause bradycardia or heart failure

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16
Q

What type of mask should be used in COPD and why?

A

Venturi

Avoids risk of T2RF (loss of hypoxic drive)

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17
Q

ABG criteria for long-term oxygen therapy and when should the criteria be assessed?

A

pO2 <7.3kpa

<8kpa in presence of complications - peripheral oedema, pulmonary hypertension, secondary polycythaemia, nocturnal hypoxaemia

> 8kpa if interstitial lung disease with severe dyspnoea

assess criteria twice, 3 weeks apart (and at least 4 weeks after an exacerbation)

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18
Q

Why is LMWH preferred over UH?

A

Lower risk of heparin-induced thrombocytopaenia (which can lead to clot growth)

No need for monitoring anti-factor Xa (unless high risk of bleeding, renal impairment or extremes of body weight)

Longer action, only needed once daily (twice in children)

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19
Q

Direct thrombin inhibitors

A

Dabigatran

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20
Q

Direct factor Xa inhibitors

A

Rivaroxaban

Apixaban

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21
Q

What type of drug is warfarin, and what are its indications?

A

Vitamin K antagonist

Treatment and prevention of VTE
Heart valve prostheses
AF

22
Q

Target INR on anti-coagulation

A

2.5 (sometimes 3 or 3.5 depending on condition)

23
Q

Warfarin absolute contraindications

A

Oesophageal varcies
Within 72 hours of surgery
Hypersensitivity
Pregnancy (and within 48 hours of delivery)

24
Q

When should you use both warfarin and antiplatelet?

A

Prosthetic valve

25
Q

Warfarin relative contraindications

A 
Thrombocytopaenia 
Coagulation disorder 
GI bleed 
Uncooperative or unreliable patient 
Risk of falls or trauma 
Concomitant drugs that increase GI bleeding risk (antiplatelets, SSRI, NSAIDs, duloxetine, venlafaxine)
Protein C deficiency 
Alcohol or drug abuse 
Renal impairment
26
Q

What must a patient understand before commencing warfarin therapy?

A 
Indication 
How long it will continue 
Potential hazards and benefits 
Need for regular monitoring 
Effect of concomitant drugs and illnesses 
Long-term and short-term management 
Potential requirement to vary dose
27
Q

What leads to a hypercoaguable state in the early stages of warfarin therapy, and what is used to manage that?

A

Initial depletion of protein C (natural anti-coagulant)

Fast acting LMWH can be given

28
Q

How to reverse effects of warfarin?

A

Small dose of Vitamin K - phytomenadione (IV or IM)

Large doses can induce warfarin resistance for up to a week

29
Q

How is rapid loading of warfarin given?

A

Treatment takes 5-10 days to reach maximum effect, and is preceded by hypercoaguable state

Fast-acting LMWH given at the start until two consecutive days of target INR reached (around 4-5 days after starting)

30
Q

How long does slow loading of warfarin take to reach maximum effect?

A

3-4 weeks

31
Q

What should be monitored with patients on LMWH?

A

After 5 days, platelet count and potassium should be monitored (risk of HIT and hyperkalaemia)

32
Q

Who are most at risk of hyperkalaemia when starting on LMWH?

A

Diabetics, CKD, potassium-sparing diuretics, acidosis

33
Q

What baseline tests should be done before starting on LMWH?

A

INR, APTT, platelets LFTs

Coagulation disorder screening if INR>1.4 before therapy

34
Q

How is LMWH dose calculated?

A

According to weight and clinical scenario (may change if obese or renal impairment)

35
Q

Who should unfractionated heparin be used in?

A

Pregnancy or renal impairment (more easily reversible)

DVT or PE if LMWH has less evidence - UH is faster acting

36
Q

What is the initial bolus for UH?

A

5000 units IV (or 75 units/kg)

Followed by 18 units/kg/hour

37
Q

Slow loading starting dose for warfarin?

A

1 to 3mg

38
Q

What factors should be considered before starting a patient on warfarin?

A 
Drug history 
Allergies 
Liver function 
Renal function 
Thyroid function
39
Q

How long should you be on warfarin for following PE or DVT?

A

At least 3 months

40
Q

When should INR be checked following a warfarin dosage change?

A

2 days later

41
Q

Management of major bleeding in a patient on warfarin?

When should you restart warfarin?

A

Stop warfarin

Give slow IV 5mg phytomenadione (can take over 6 hours for full reversal of warfarin): 1-3mg if minor bleed

Dried prothrombin complex - II, VII, XI, X (or fresh frozen plasma)

Restart warfarin when INR <5

42
Q

In what patients should you give oral menadiol sodium instead of phytomenadione?

What dose tablets do they come in?

A

Patients with malabsorption syndromes (it is water soluble and so better absorbed)

10mg (can be halved)

Can take over 24 hours to reverse warfarin

43
Q

What dosage tablets are usually used for warfarin?

A

1mg and 3mg (5mg can be used but uncommonly)

44
Q

What drugs enhance the anti-coagulant effect of warfarin (those requiring a reduced dose)?

A 
Amiodarone
Macrolides, metronidazole, quinolones 
SSRIs, venlafaxine, mirtazapine 
Antifungals
PPIs 
Statins 
Levothyroxine
45
Q

What key points should be covered when counselling a patient about to start on warfarin?

A 
Indication 
How long for 
Medications (colours and strengths)
Dosage (loading and maintenance)
Monitoring (INR and why it is important)
Adherence (what to do if missed a dose)
Drug interactions (alcohol under 2 units a day, avoid cranberry juice and eat consistent vitamin K foods) 
Side effects (signs of bleeding, when to seek medical attention)
Obtaining medications 
Alerting other HCPs
46
Q

Fast-acting insulins, and when to take them?

A 
Insulin aspart (Novorapid)
Insulin lispro (Humalog)

Taken just before eating

47
Q

Short-acting insulins, and when to take them?

A

Porcine neutral
Actrapid
Humulin S
Insuman rapid

15-30 mins before meal

48
Q

Long-acting insulin example

A 
Insulin detemir (Levemir)
Insulin glargine
49
Q

Post-prandial blood glucose targets for T1 and T2 diabetes

A

T1: 5-9mmol/l
T2: <8.5 mmol/l

50
Q

Intermediate acting insulin example?

A

Isophane (NPH) insulin

51
Q

What is a twice-daily insulin regimen?

A

Biphasic isophane mixed insulins taken before breakfast and dinner

Require snacks between meals to counteract overlapping of the two and avoid hypoglycaemia

Phase 3b (18 decks)

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