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PSA 1 Flashcards

Pregnancy, Steroids, CYP450, Anticoagulation, Antiemetics (108 cards)

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1
Q

3 types of fluid prescription reason

A

Resuscitation

Replacement and redistribution

Maintenance

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2
Q

Describe how to prescribe maintenance fluids for children.

A

100ml/kg/day for first 10kg.

50ml/kg/day for next 10kg.

20ml/kg/day for anything over 20kg.

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3
Q

Common teratogenic medications (7)

A

warfarin

roaccutane

ACEi / ARB

topiramate

sodium valproate

methotrexate (M+F must stop 6 months prior to conception)

lithium

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4
Q

Give 7 drugs that are P450 substrates i.e. are metabolised by CYP450 and are therefore affected by coprescription of inducers or inhibitors.

A

Substrates Will Panic As Simultaneous CYP Triggers
Warfarin
SSRIs
Phenytoin (also an inducer?)
Statins
Theophylline
Amitriptyline
Codeine

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5
Q

Give drugs that are CYP450 inducers and therefore decrease the amount of active substrate drug.

A

Carbamazepine
Phenytoin
St John’s Wort
Steroids
Rifampicin & griseofulvin
Nicotine
Chronic alcohol intake

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6
Q

Give drugs that are CYP450 inhibitors and therefore increase amount of active substrate drug.

A

Acute alcohol intake
Sodium Valproate
Amiodarone
SSRIs
Isoniazid
Antibiotics including cipro and erythromycin
Cimetidine and omeprazole
Allopurinol
Ketoconazole

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7
Q

Which CYP450 enzyme inducer should not be coprescribed with oral contraceptive pills?

A

St John’s Wort

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8
Q

Which types of antibiotics should be avoided in pregnancy?

A

Tetracyclines e.g. doxycycline

Fluoroquinolones e.g. ciprofloxacin, levofloxacin

Trimethoprim; teratogenic in first trimester as folate antagonist. Avoidance in pregnancy generally advised.

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9
Q

Endogenous steroids have glucocorticoid and mineralocorticoid activity. Exogenous corticosteroids have varying activity of these. Given 4 commonly prescribed steroids and describe their gluco/mineralocorticoid activity.

A

Fludrocortisone: M very high, minimal G

Hydrocortisone: M high, some G

Prednisolone: Mainly G, little M

Dexamethasone; very high G, minimal M.

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10
Q

Difference between glucocorticoid and mineralocorticoid activity of endogenous steroids.

A

Glucocorticoids usually regulate immune response and metabolism.

Mineralocorticoids regulate electrolyte and fluid balance and blood pressure regulation.

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11
Q

Why should you not withdraw long term steroids abruptly?

A

Long term corticosteroids can suppress the natural production of endogenous steroids and abrupt withdrawal may precipitate an Addisonian crisis.

Gradual withdrawal is warranted if:
>3 weeks
Recently received repetitive courses
>40mg prednisolone daily for >1 week

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12
Q

Most side effects of steroids are due to their glucocorticoid activity. These can be split into endocrine, MSK, psychiatric, GI, opthalmic. State some side effects for each of these systems.

A

MSK; AVN, proximal myopathy, osteoporosis

GI; peptic ulcer disease, acute pancreatitis

Psych; mania, depression, psychosis, insomnia

Imm; increase susceptibility to severe infection, reactivation of TB

Endo; Cushing syndrome, impaired glucose regulation, increased appetite, weight gain, hirsutism, hyperlipidaemia

Opth; cataracts, glaucoma

+ neutrophilia, ICH, suppression of growth in children

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13
Q

What are the sick day rules for patients on long term steroids?

A

Dose doubled during intercurrent illness

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14
Q

Enoxaparin and dalteparin are examples of …

A

LMWH

Prophylactic use for most inpatients include 40mg OD

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15
Q

When to reduce the dose of prophylactic LMWH?

A

<50kg

eGFR <40

(UFH can be used as an alternative to LMWH in patients with chronic kidney disease)

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16
Q

Fondaparinux is mentioned in ACS guidelines; when should it be used?

A

Patients who are NOT at high risk of bleeding and who are NOT having angiography immediately

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17
Q

Contraindications for DOACs?

A

Pregnancy

Antiphospholipid syndrome

Severe renal impairment

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18
Q

State 4 DOACs, their MOA and reversal agents if applicable.

A

Dabigatran; direct thrombin inhibitor. Reversal = idracizumab

Rivaroxaban, apixaban and edoxaban; direct factor Xa inhibitor. Reversal = andexanet alfa (for R and A).

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19
Q

Indications for DOACs:

A

Stroke prophylaxis in
AF.

Treatment of DVT and PE.

Prophylaxis of DVT post hip and knee replacement.

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20
Q

Which score is used to determine whether someone with AF should be anticoagulated due to stroke risk, and what factors does it include?

A

CHA2DS2-VASc score

Congestive heart failure
Hypertension
Age >75 scores 2
Diabetes
Stroke or TIA previously
Vascular diseas
Age 65-74
Sex Female

0 = no anticoagulation
1 = consider anticoagulatoin
2 = offer anticoagulation usually in form of DOAC.

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21
Q

What score is used to assess risk of major bleeding in patients with AF taking anticoagulation?

A

ORBIT

Older age >75
Renal impairment <60
Bleeding prev e.g. GI/ IC bleeding hx
Iron low Hb or haematocrit
Taking antiplatelets

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22
Q

Warfarin is a vitamin K antagonist that requires INR monitoring. What happens when INR is too high in cases of a) major bleeding b) minor bleeding and c) no bleeding

A

TREATMENT SUMMARY –> ORAL ANTICOAGULANTS

ALL scenarios require stopping warfarin apart from no bleeding when INR is between 5.0 and 8.0.

Major bleeding: IV vitamin K 5mg + PCC (or FFP if not available)

Minor bleeding: give 1-3mg IV vitamin K, and restart warfarin when INR <5.0. If originally >8.0, can repeat vitamin K dose 24 hours later.

No bleeding, >8.0: give 1-5mg vitamin K PO, can repeat after 24 hours, restart warfarin when INR <5.0.

No bleeding, INR 5-8; withold 1-2 doses, reduce subsequent maintenance dose

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23
Q

Warfarin targets in AF and mechanical valves:

A

INR 2-3 in AF.

INR 2.5-3.5 in mechanical heart valve roughly, mitral valves require a higher INR than aortic valves

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24
Q

Why is heparin administered concurrently when initiating warfarin?

A

When warfarin is first started biosynthesis of protein C is reduced, resulting in a procoagulant state.

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25
Which drugs should you stop in an AKI?
Stop the DAAAMN drugs: Diuretics Aminoglycosides e.g. gentamicin ACEi ARB Metformin (can cause lactic acidosis) NSAIDs
26
How long before surgery should you stop the COCP and HRT?
4 weeks
27
When should you stop lithium prior to surgery?
1 day before
28
Which 2 commonly prescribed drugs for diabetes and hypertension respectively should you stop on the day of surgery?
Metformin Ramipril
29
A patient on prednisolone is going for surgery. What should change with their corticosteroid prescription?
Double the dose of prednisolone but give it as hydrocortisone instead.
30
Give 3 classes of drug that contribute to peptic ulcer risk.
NSAIDs Steroids Anticoagulants / antiplatelets
31
Amlodipine can cause what side effect?
Peripheral oedema i.e. ankle swelling
32
A patient is found to have hyperkalaemia - give 2 types of drugs that could have caused this and explain how.
ACEi/ARBs; inhibition of the RAAS pathway Spironolactone; potassium sparing diuretic
33
What drug can cause blue discolouration to vision?
Sildafenil
34
Atorvastatin interacts with erythromycin (an aminoglycoside); what does this interaction run the risk of?
Rhabdomyolysis
35
Why must methotrexate and trimethoprim not be used in conjunction with one another?
They are both folate antagonists
36
Which other antibiotic class has a degree of cross reactivity if a patient has a penicillin allergy?
Cephalosporins Cross reactivity reduces as generation increases e.g. 10% cross reactivity with cephalexin, 2-3% with cephotaxime. Avoid if any history of immediate hypersensitivity
37
Which drug classes should be avoided in asthmatics and why?
Beta blockers and NSAIDs can both precipitate exacerbations.
38
Which medication class commonly prescribed for pain relief / anti-inflammatory properties can increase the risk of lithium toxicity?
NSAIDs
39
A man has been started on metformin but is experiencing a common side effect. What is the likely side effect he is experiencing and what can be done to combat this?
Diarrhoea is a very common side effect of metformin. Switch to MR metformin to see if this can reduce the unwanted side effect. If this is not successful then other medications can potentially be tried.
40
A patient is prescribed a drug to treat her hyperthyroidism. She is not pregnant or planning on becoming pregnant. What drug is this likely to be, and what is the most important safety netting that should be given alongside this prescription?
Carbimazole. Blocks thyroid peroxidase from coupling and iodinating tyrosine residues on thyroglobulin, reduces thyroid hormone production. Agranulocytosis (bone marrow suppression). If any signs of infection / especially sore throat MUST seek medical attention. It is usually given in high doses for 6 weeks until the patient becomes euthyroid and then reduced.
41
Describe common side effects of the tuberculosis medication regimen.
Rifampicin; hepatitis, orange secretions Isoniazid; peripheral neuropathy (prevent by co-prescribing pyridoxine vitB6) Pyrazinamide; hyperuricaemia causing gout, arthralgia, myalgia, hepatitis Ethambutol; retinopathy / optic neuritis
42
Absorption of ferrous fumarate is improved if taken with ...
Vitamin C / orange juice
43
A patient is started on alendronate for osteoporosis. What advice should be given regarding taking of the medication?
Take in morning on an empty stomach, 30 mins before food or any other medication. Stay upright for 30 minutes afterwards, to reduce risk of oesophagitis.
44
Which antidiabetic medications are considered safe in pregnancy?
Metformin Insulin Other oral hypoglycaemics are not considered safe in pregnancy.
45
If co-prescribed with SSRIs which two classes of drugs can increase the risk of serotonin syndrome?
Triptans MAOIs
46
Some drugs need plasma concentration monitoring. Give 3 reasons why a drug may require this.
1. Not feasible to measure the clinical endpoint. 2. Clinical effects are predictable in relation to plasma concentration. 3. Low therapeutic index / small target conc range.
47
Give 5 drugs that require plasma concentration monitoring.
Lithium Gentamicin Vancomycin Digoxin Phenytoin
48
Give 3 common side effects of NSAIDs.
Gastrotoxicity Renal impairment Hypertension
49
Give 4 common side effects of opioids.
Confusion Constipation Drowsiness Urinary retention
50
Give 3 common side effects of loop diuretics e.g. furosemide.
Dehydration Renal impairment Hypokalaemia
51
Samples for lithium and digoxin plasma concentration monitoring should be taken how long after dose is given?
6 hours.
52
When should gentamicin samples be taken for plasma concentration monitoring?
6-14 hours post dose for patients who are having once daily dosing, and then a nomogram is used to determine dose interval.
53
When should a vanc level be taken?
Pre-dosage vancomycin level should be taken after 3-4 doses. Target concentration is 10-15mg/L, but higher if severe infection or less sensitive organism.
54
How is efficacy of digoxin best measured?
Clinically via endpoint e.g. heart rate. Toxicity risk increases at levels >1.5, and is likely at >3.0
55
What is the formula for fluid deficit replacement in a child?
% dehydrated x weight (kg) x 10 This formula gives what should be corrected over 48 HOURS, so must be halved when being added to maintenance fluids.
56
What is the formula for resuscitation fluid in a child?
10ml/kg over <10 minutes NaCl 0.9%
57
What is the formula to estimate a child >1 year of age's weight?
(age + 4) x 2 Under 1 year: 3.5kg at birth 7.5kg at 6 months 10kg at 1 year
58
Name 4 live vaccines.
BCG MMR rotavirus varicella Neonates who have been exposed to biological agents in-utero should have their live vaccines deferred for 6 months.
59
State 4 drug classes that should be avoided in heart failure as they may cause an exacerbation?
Thiazolidinediones - pioglitazone CI due to fluid retention Verapamil - negative inotropic effect NSAIDs & glucocorticoids should be avoided / used with caution as they cause fluid retention BUT low dose aspirin is an exception Class I antiarrhythmics e.g. flecainide, as it has a negative inotropic and proarrhythmic effect.
60
What equation links volume, dose and concentration?
Volume = dose / concentration
61
What is the equation linking rate, dose and time, and when should it be used?
Rate = dose / time Calculating minimum duration of an infusion based on maximal rate
62
What equation exists to calculate rate of an infusion?
Rate = dose-per-time / concentration Where rate = V/T (volume over time)
63
What does 1%, 2% and 10% figures mean when referring to medications?
1% = 1g in 100ml 2% = 2g in 100ml 10% = 10g in 100ml
64
What are daily requirements for water, Na, K, Cl and glucose?
25-30ml/kg/day water 1mmol / kg / day Na, K, Cl 50-100g / day glucose DO NOT replace K faster than 10mmol / hour K replacement needs to be exact, Na less so
65
How many mmol of Na is in 1L of NaCl 0.9% solution?
150mmol
66
How many mmol of K is in 0.3% and 0.15% KCl respectively?
40mmol 20mmol
67
What is first line drug class for T2DM with hypertension regardless of age?
ACEi / ARB
68
Which antidiabetic medication is contraindicated in heart failure?
PIOGLITAZONE (a thiazolidinedione)
69
Which diabetic drug class inhibits renal glucose reabsorption?
SGLT2i
70
Which diabetic drug class has a risk of heart failure and bladder cancer?
Thiazolidinediones e.g. pioglitazone
71
Which diabetic drug class carries a risk of causing pancreatitis?
DPP4i e.g. linagliptin
72
Which diabetic drug classes are known to cause increase in weight?
Sulfonylurea e.g. gliclazide Thiazolidinediones e.g. pioglitazone
73
Describe how you monitor for adequate effect for the following anticoagulants a) LMWH b) UFH c) DOACs d) warfarin
A anti-factor Xa B APTT C monitor clinically D INR
74
State 4 drugs that are commonly prescribed in g .
NAC Paracetamol Lithium Calcium carbonate
75
Give 8 common drugs that are commonly prescribed in MICROgrams.
Levothyroxine Tamsulosin Digoxin Naloxone Fludrocortisone Inhalers GTN spray Ipratropium nebs
76
What time of day should diuretics and steroids be prescribed?
MORNING Diuretics; don't want to be up and down all night Steroids; can affect sleep
77
What time of day should statins be prescribed?
NIGHT
78
Give 2 drugs that should always be given with meals.
INSULIN CREON
79
Give 3 drug classes that can cause oral thrush.
Steroids esp ICS Antibiotics Immunosuppressants
80
Give some medications that commonly cause diarrhoea.
Metformin Colchicine Antibiotics e.g. C.Diff PPIs Antacids containing Mg Laxatives
81
Give some medications that can cause hyperglycaemia.
Steroids Antipsychotics Thiazides Beta Blockers Tacrolimus
82
Give some medications that cause constipation.
Opioids Iron CCBs e.g. amlodipine, verapamil Some diuretics Some Parkinson's meds Anticholinergics
83
Give 3 drug classes that can cause confusion.
Opioids Sedatives Anticholinergics
84
Give some medications that can cause falls.
Benzos Antidepressants esp TCA and SNRI MAOIs Antipsychotics Opiates Most antihypertensives Parkinson's meds e.g. ropinirole, selegiline Drugs that can cause hypoglycaemia?
85
Give 4 drugs classes that can cause hypertension.
NSAIDs Steroids Oral contraceptives Mirabegron
86
Give 3 drug classes that can cause osteoporosis.
Steroids PPIs LHRH agonists e.g. goserelin
87
Give 2 drug classes that can cause high cholesterol.
Steroids Thiazide diuretics
88
Give 4 drug classes / drugs that can commonly cause hypokalaemia.
Loop diuretics e.g. furosemide, bumetanide Thiazides Steroids Salbutamol
89
Give 4 drug classes / drugs that can commonly cause hyperkalaemia, and state some symptoms.
K+ sparing diuretics e.g. spironolactone, eplerenone ACEi e.g. lisinopril ARBs e.g. losartan, candesartan UFH / LMWH Blood transfusion (can also cause hypocalcaemia) Sx include diarrhoea, metabolic acidosis, arrhythmias, muscle weakness, reduced reflexes. Absent p waves, tall peaked T waves, prolonged QRS. , sine wave pattern
90
Give 4 drug classes / drugs that can commonly cause hyponatraemia.
SSRIs e.g. sertraline, citalopram, fluoxetine TCAs e.g. amitriptyline Carbamazepine Opiates PPIs e.g. omeprazole, lansoprazole
91
Give 4 drug classes / drugs that can commonly cause hypernatraemia.
Lithium Demeclocycline
92
Give 3 classes of medications that should be stopped during intercurrent illness.
Metformin SGLT2is Statins
93
Give 3 drug classes that are most likely to worsen heart failure.
NSAIDs CCB Pioglitazone
94
Give 3 drug classes that are most likely to worsen myasthenia gravis.
Antibiotics BB Local anaesthetic Sedating drugs
95
Give 3 drug classes that are most likely to worsen psoriasis.
BB Lithium Chloroquine and hydroxychloroquine (NSAIDs) ACEi ?Some antibiotics
96
Give 3 drug classes that are most likely to worsen Parkinson's.
Haloperidol, olanzapine Metoclopramide Antidepressants
97
Drugs are common causes of AKIs. Give examples of a drug culprit for each of a) pre-renal b) renal and c) post-renal AKI.
Pre-renal: diuretics, ACEi, ARB Renal: IV contrast, penicillins, NSAIDs, trimethoprim, gentamicin Post-renal: oxybutynin, anticholinergics, opiates
98
Give 3 drugs that can cause QT-interval prolongation.
Amitriptyline Sertraline Ondansetron
99
Discuss 4 drug classes to avoid in Parkinson's disease.
Typical antipsychotics are D2 antagonists. Chlorpromazine, Haloperidol Atypical antipsychotics are D2 and 5HT antagonists; less EPSEs than typicals. Clozapine, risperidone, quetiapine, olanzapine Antiemetics e.g. chlorpromazine, metoclopramide, prochlorperazine Antidepressants e.g. phenelzine, tranylcypromine, isocarboxazid, amoxapine
100
What is the max rate for potassium replacement, and what does this look like in real time for a 0.3% and 0.15% bag?
10mmol/h is max rate of replacement generally (can be done faster in ITU/emergency settings with cardiac monitoring) KCl 0.3% contains 40mmol, so minimum 4 hours KCl 0.15% contains 20mmol, so minimum 2 hours
101
What should the fluid prescription in an emergency resuscitation be?
NaCl 0.9% 500ml 10 minutes
102
What should the fluid prescription in an emergency hypoglycaemic episode be?
Glucose 20% 100ml 15 minutes
103
What should the fluid prescription in an emergency hypokalaemia situation be?
NaCl 0.9% / KCl 0.3% 1000ml 4 hours / may be available in 500ml bags
104
What should the fluid prescription in an emergency hypercalcaemia situation be?
NaCl 0.9% 1000ml 4 hours
105
Outline the parameters for maintenance fluids in terms of what is required per 24 hours.
WATER: 25-30ml/kg/24h Na and K: 1mmol/kg/24h Glucose: 50-100g/24h Aim ~1000ml 8-12h
106
Discuss causes of hypo and hypercalcaemia respectively, diagnosis threshold and treatment.
HYPOCALCAEMIA Hypoparathyroidism 1^ and 2^, Vitamin D deficiency, blood transfusion, hypomagnesaemia, steroids. Treatment: Calcium gluconate 10%, 10-20ml over 10 mins. ?Cholecalciferol with CaCO3 but consider cause. HYPERCALCAEMIA Primary and tertiary hyperparathyroidism, cancer, multiple myeloma, sarcoidosis, TB, Paget's, thiazide diuretics. Treatment: 0.9% NaCl, 1000ml over 4 hours
107
Hyperaldosteronism's leading cause is now recognised as bilateral idiopathic adrenal hyperplasia. Give some symptoms of hyperaldosteronism, and the most commonly used drug to treat it.
Hypertension Metabolic alkalosis Hypernatraemia Hypokalaemia (muscle weakness) Spironolactone
108
Discuss the fasting glucose, OGTT and HbA1c criteria for diabetes and prediabetes.
Fasting D: >= 7 PD: 6.1-6.9 OGTT D: >= 11.1 PD: either impaired glucose tolerance 7.8-11, or impaired fasting glucose <7.8 HbA1c D: >= 48 / 6.5% PD: 42-47 (6-6.4%) If symptomatic, test once. If asymptomatic, test twic. HbA1c <48 does NOT exclude diabetes. HbA1c gives 3 month picture, but fructosamine can be used for ~2 week picture.

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