Doses in anaphylaxis
Adrenaline
Hydrocortisone
Chlorphenamine
<6 months
Adrenaline - 150 mcg
Hydrocortisone - 25 mg
Chlorphenamine - 250 mcg
6months - 6 years
Adrenaline - 150 mcg
Hydrocortisone - 50mg
Chlorphenamine - 2.5 mg
6 - 12 years
Adrenaline - 300mcg
Hydrocortisone - 100mcg
Chlorphenamine - 5mg
>12 years
Adrenaline - 500 mcg (1:1000)
Hydrocortisone - 200mcg
Chlorphenamine - 10mg
Adrenaline
<6 months
6 months - 6 years
6 - 12 years
>12 years
<6 months - 150 mcg (0.15 ml 1:1000)
6 months - 6 years - 150 mcg (0.15 ml 1:1000)
6 - 12 years - 300 mcg (0.3 ml 1:1000)
>12 years - 500 mcg (0.5 ml 1:1000)
Which two common medicines are commonly prescribed weekly
Alendronate
Methotrexate
Which two medications are commonly taken at night?
Amitryptilline
Simvastatin
Ace-i (postural hypotension)
When do you empircally start n-AC in parectomal overdose?
(3)
What is considered overdose?
>8 hours since overdose at presentation = start empirically
>153mg/L dose at any time also warrants empiral treatment
staggered dose (tablets taken over a period > 1 hour ) = start empirically
>10 mg is considered overdose
OR
>200 mg/kg
If above nomogram treatment line at >4 hours treat empircally
Medications to avoid In HF
Verapamil - negatively inotropic
Thiazolidenidiones - Pioglitazone. Fluid retention
NSAIDs - FLuid Retention
?GCs - fluid retention
Fleicanide (And other Class I VW anti-arrhythmics): Negatively inotropic
Enzyme Inducers and Inhibitors
CRAP GPS
VIP C CEO GFF
Inducers - CRAP GPS
Carbamezapine
Rifampicin
Alcohol (Chronic)
Phenytoin
Grieofulvin
Phenobarbitone
Sulphonyulureas
Inhibitors - VIP C CEO GFF
Valproate
Isoniazid
Protease inhibitors
Cimetine
Ciprofloxacin
Erythromycin - macrolides
Omeperazole - PPIs
Grapfruit Juice
Fluoxetine
Flucanazole
Drugs to stop before surgery
COCP and HRT - 4 weeks before surgery (if they want to carry on give POP,
Lithium - Day before
Potassium sparing diuretics/ ACE-i - Day of surgery
Anticoagulants / Antiplatelets - variable (5 days before for warfarin) continue bridging with LMWH if high risk of thrombosis
Oral hypoglycaemics - Variable
Paracetomal prescription frequency?
6 hourly - NOT four hourly
so 4 times a day NOT 6 times a day
Generally = 1g QDS
Drugs to stop in patients that are bleeding
Aspirin / NSAID
Heparin
Warfarin
Enzyme inhibitors (as they will increase warfarin’s infect)
VIP C CEO GFF
Valproate, isoniazid, protease inhibitors, cimetidine, cipro, erythro, omeprazole, grapefruit juice, fluoxetine, flucanazole
Side Effects/ Contrainidcations to
GCs
STEROIDS
S - stomach ulcers
T - thin skin
E - oedema
R - right and left heart failure ( due to fluid retention )
O - osteoporosis
I - infection
D - iabetes (hyperglycaemia)
S - Cushing’s syndrome
Side effects / Contraindications
for
NSAID
N - No urine (RF)/ Hyperkalaemia
S - Systolic disfunction (fluid retention)
A - Asthma (bronchospasm)
I - Indigestion (any cause)
D - Dyscrasia (Clotting abnormality)
Which replacement fluid if:
Hypernatraemic or hypoglycaemic
In ascites
<90 mmHg
Shocked from bleeding
Hypernatraemic or hypoglycaemic - 5% dextrose
In ascites - HAS
<90 mmHg - Colloid
Shocked from bleeding - Blood/colloid
Two salty - one sweet?
General rule for prescribing fluids
2 - NS
1 - Dextrose
+ 20 mmol KCL in 2/3 of the bags ( 40-60 mmol KCL per day)
Max rate for potassium transfusion
<10 mmol/hour
anti emetic prescribing in:
Cardiac patient
non-cardiac patient
Parkinsonism patients
Young women
Cardiac : Metoclopramide 10 mg maximum 8 hourly
non-cardiac: cyclizine 50 mg maximum 8 hourly
Parkinsonism/ young women - not metoclopramide
Cyclizine –> causes fluid retention
Metoclopramide –> worsens parkinson symptoms and causes dyskinesia in young women
Someone on methotrexate with a raised CRP/Possible sepsis?
Stop the methotrexate - might be neutropenic sepsis..
Re-assess when the FBC is done
LMWH / heparin thromboprophylaxis post stroke?
Not advised until >2 months after the stroke
Drug causes of asthma exacerbations
NSAIDs (less so with asthma)
Beta Blockers
Adenosine
Changes to thyroxine dosing?
<0.5 - Decrease Dose
0.5-5 - Same Dose
>5 - Increase dose
Always change by the smallest incrament possible
What do with high serum level in the blood of gentamicin?
Decrease frequency (i.e. 36 hourlty dosing rather than 24 hourly dosing)
Usual gentamicin dosing?
Measuring levels?
5-7 mg/kg OD / divided daily dosing 1 mg/kg for IE
Record when Blood sample taken but usually between 6-14 hours from start of infusion
- Use a nomogram :
if concentration is <q24></q24>
<p>if concentration is between q24- q36 then <strong>change to 36 hourly dosing</strong></p>
<p>if concentration is between q36-q48 then <strong>change to 48 hourly dosing</strong></p>
<p>if dose is >q48 then <strong>repeat gentamicin levels and only re-dose when gent concentration is <1mg/L</strong></p>
</q24>
paracetomal toxicity mechanism
Paracetomal is usually metabolised by glutathione
- paracetomal overwhelms these stores and leads to accumulation of toxic NAPQI —> liver damage
NAC- replenishes glutathione stores
Bradycardic + on digoxin?
Stop digoxin
Fast AF - Pharmacological choices
Beta blockers - not if asthmatic or in HF
CCBs - Verapamil/diltiazem —> not if they oedema
Digoxin
Fast AF plus evidence of heart failure (existing)
Amiodarone or Digoxin
CHADS VASC
Congestive heart failure
Hypertension
Age >75 (2 points)
Diabetes
Stroke or TIA (2 points)
Vascular (PAD or IHD)
Age (65-74)
Sex (female)
Why would you start sulfonylurea instead of metformin?
if low/normal weight
creatinine >150 umol/L
AED of choice
Valproate for everything apart from:
Absence - Ethosuximide/ valproate
Foxal - CZP/ LTG
Constipation treatment options
Stool softeners (2)
Bulking agents (1)
Stimulant laxatives (2)
Osmotic laxatives (2)
Stool softeners (2)
Docusate sodium
Arachis Oil
Bulking agents (1)
Ispaghula Husk
Stimulant laxatives (2)
Senna
Bisacodyl
Osmotic laxatives (2)
Lactulose
Phosphate Enema
Tamoxifen SEs (4)
i) Endometrial Ca
ii) Increases efficacy of warfarin
iii) VTE
iv) Hot flushes
Warfarin tablet colour codes
White - 0.5mg
Brown - 1mg
Blue - 3mg
Pink - 5mg
What do you do to the insulin dose in illness
May need higher doses
Tell them to eat regularly as possible
Check their BMs more frequently
Starting calculations for dose/percentation
1% = 1g in 100ml
10mg in 1ml
When should you give ace inhibitors?
Focal Seizures - Which drug
Lamotrigine
Two classic side effects of vancomycin
Common monitoring of vanc
Nephrotoxicity and ototoxicity
Serum creatinine is commonly used to monitor vancomycin/ assess for suitability / dosing
Baseline chest x ray in what drug?
Amiodarone
What to regularly monitor in Digoxin?
Creatinine
What to measure at baseline and regularly with treatment on valproate?
LFTs
What is Warfarin’s MOA?
Vitamin K Reductase inhibitor
Reduces production of - 2, 7 , 9, 10 ,Protein C and Protein S
—>
Pro coagulant in the first few days due to protein C and S depletion
Why should ACEis and NSAIDs not be prescribed concurrently
NSAIDs- Inhibot prostoglandins. Prostoglandins usually dilate afferent renal vessels
- NSAIDs therefore prevent the dilation —> reduced afferent flow to kidney
ACEis - Cause smooth muscle relaxation of efferent arterioles. This then causes them to widen.
Combination of reduced calibre afferent vessels + increased calibre efferent vessels = renal hypoperfusion
Warfarin
Bleeding?
No Bleeding:
INR>8
INR 6-8
INR <6
Bleeding - IV slow vit K/ FFP/ Prothrombin Complex Conentrate
No Bleeding:
INR>8 - Oral vit k (withold warfarin)
INR 6-8 - omit 1-2 doses
INR <6 - lower dose of warfarin
Dose: Paracetomal
NSAIDs
Co-Codamol
Codeine
Paracetomal : 1g QDS
NSAIDs : 300-400 mg TDS (Ibuprofen)
Co-Codamol : 2 x 30/500 QDS
Codeine : 30 - 60 mg QDS
Dose:
Cyclizine
Metoclopramide
Amoxicillin
Clarithromycin
Lansoparazole
Omeprazole
Cyclizine - 50 mg TDS
Metoclopramide - 10 mg TDS
Amoxicillin - 500 mg TDS
Clarithromycin - 500 mg BD
Lansoparazole - 15-30 mg OD
Omeprazole - 20-40 mg OD
Doses:
Aspirin
Clopidogrel
Simvastatin
Atenolol
Ramipril
Bendroflumethiazide
Frusemide
Amlodipine
Aspirin - 75-300mg OD
Clopidogrel - 75-300 mg OD
Simvastatin- 10-80 mg ON
Atenolol - 25-100 mg oD
Ramipril - 1.25-10mg OD
Bendroflumethiazide - 2.5mg OD
Frusemide - 20-80 mg BD
Amlodipine - 5-10mg OD
Doses :
Levothyroxine
Metformin
Levothyroxine - 25-200mcg OD
Metformin 500 mcg OD- 1g BD
Drugs worsening seizure control
P450 Inducers
Stimulants - alcohol, cocaine amphetamines
Fluroqunilones
Methylxanthines - ophyllines
Bupropion
Methylphenidate
Mefanamic acid
HB1aC Targets in diabetes
<48 mmol/mol TItrate up metformin
-Target for lifestyle / lifestyle + metformin <48 mmol/mol
If Hba1c >53 mmol/mol then add second drug
-Target for any other medicine than metformin <53 mmol/mol
Hba1c shouold be checked every 3-6 months until stable and then six monthly therafter
Enzyme induction etc.
Chronic alcohol intake?
Acute alcohol intake?
Chronic alcohol intake? - Inducer
Acute alcohol intake? - Inhibitor
Aminophylline loading dose
5mg/kg
Slow IV over 20 minutes
Attached to cardiac monitor
Meningitis when penicillins CI?
Chloramphenicol
Indications for high dose statin therapy
Known CVD
Known history of ischaemic CVA
Known PAD
which classification system is used for paracetomal/overdsoe related liver failure.
King’s COllege Hospital
ph >7.3
Prothrombin time> >100s
Creatinine >300umol/l
Encephelopathy - Stage III/IV
Three things to look for when assessing for digoxin toxicity
Digoxin levels
Us and Es
ECG
Drugs improving mortality in HF (4)
Beta blockers (although are contraindicated in acute HF) Ace-i
Aldosterone antagonists
Hydralazine with nitrates
two most common side effects of CCB
Headache
Anke oedema
Conversions:
Codeine/Tramadol to morphine
Morphine to oxycodone
Oral morphine to subcut morphine
Oral morphine to subcut diamorphine
Oral oxycodone to subcut diamorphine
Any oral opioid to its SC form
Oral morphine to transdermal fentanyl
Oral morphint to transdermal buprenorphine
Codeine/Tramadol to morphine - 10:1
Morphine to oxycodone - 1.5:1
Oral morphine to subcut morphine : 2:1
Oral morphine to subcut diamorphine: 3:1
Oral morphine to subcut oxycodone: 1.5:1
Any oral opioid to its SC form : 2:1
Oral morphine to transdermal fentanyl: 100:1 (nb look at the units fentanyl will be in mcg)
Oral morphint to transdermal buprenorphine: 75:1
metronidazole + warfarin?
metronidazole enhances its effect —-> increases INR
indications for the need to taper steroid withdrawal?
Steroid given for more than 3 weeks
>40mg steroid given for >1 week
Repeated recent courses
Drugs to stop when someone has established IHD
NSAIDs
Oestrogens
Varenicline
BP Targets
<80
>80
Clinical/ABPM
< 80
140/90 / 135/85
>80
150/90 / 145/85
Monitroring paramaters:
Statin
LFTs:
Baseline
3 months
12 months
Monitroring paramaters:
ACE-is
U&E
prior to starting
when changing dose
at least annually
Monitroring paramaters:
Amiodarone
TFT, LFT
Prior to treatment - TFT,LFT, U&Es, CXR
Every 6 months - TFT, LFT
Monitroring paramaters:
Methotrexate
FBC, LFT, U&E
Before starting and weekly until stabilised
2-3 monthly when stabilises
Monitroring paramaters:
Azathiaoprine
FBC LFT
Before treatmentm,
Weekly for first 4 weeks
Then 3 monthly
Monitroring paramaters:
Lithium
Lithium level, TFT, U&E
Lithium Level sweekly until stabilised and then 3 monthly
TFT / U&E before starting and then 6 monthly
Monitroring paramaters:
Sodium Valproate
LFT (FBC)
Before starting - LFT/ FBC
LFT periodically within first 6 months
Monitroring paramaters:
Glitazones
LFT
Before starting
and regularly throughout
Gentamicin
If on a >OD routine what do you do if the trough levels are raised?
If the peak level is high?
Trough high = Decrease the frequency
i.e. from TDS —> BD
Peak high = decrease the dose
Croup what is the principle drug?
Oral dex. 0.15 mg/kg
ANtipsychotics monitorin
All at baseline then …
Baseline - ECG
Annually - FBC (clozapine more freuqent), LFT, U&Es, Cardiovascular assessment
3 months and then annually - Lipids, wieght
6 months and then annually - FBG, prolactin
frequently - BP
Why don’t you give aspirin to women post - partum that are breast feeding ?
Risk of reye’s syndrome
TSH level to aim for when treating hypothyroidism?
0.5-2.5
Drugs worsening psoriasis (7)
LAABIAN
Lithium
ACE is
Alcohol
Beta blockers
Infliximab
Anti malarials
NSAIDs
IF someone has been given to sodium consecutive fluid prescriptions … what hsould the next one be?
Glucose ( unless have stroke then think twice )
Factors for developing candidiasis infections?
DM
SGLT 2 Inhibitors
Antibiotics
Steroids
What to do when someone is given a drug that might interact with warfarin?
If in therapeutic range then keep at the same dose and re-check freuqnetly
If not in therapeutic range - act appropriately (if warfarin toxicity then withhold meds/treat /// if warfin underdosing then icnrease meds) and re check the INR
What is the optimal method of correcting hypoglycaemia in hospital inpatietns that are unconscious
Go for IV glucose
IM glucagon is second line and illadvised in people who are anticoagulated
If someone is shocked and you’re giving a fluid bolus. How quickly should it be given and how much should you give
<15 mins
No evidence of heart failure - 500 ml
Evidene of heart failure -250 ml
What insulin do you stop/ continue in DKA?
Stop short acting
Continue long acting
Amioarone induce:
Hypothyroidism
Hyperthyroidism
Hypothyroidism - Don’t stop amiodarone but start thyroxine
Hyperthyroidism - Stop amiodarone
Patient develops renal failure on aspirin what do you do?
Patient is bleeding on aspirin what do you do?
Patient is going for surgery on aspirin what do you do?
Patient develops renal failure on aspirin what do you do?
-Carry on
Patient is bleeding on aspirin what do you do?
- Stop
Patient is going for surgery on aspirin what do you do?
- Stop
First line diabetic med in kidney diseaase?
Sulfonylurea
Initial response to fluid challenge but BP drops again. (not likely to be a haemorrhaging patient)
Likely to be significant ongoing third space losses –think bowel obstruction/ pacnreatitis
Colloid bolus
What to do if a patient develops ACE-i related cough
Trial of ARBs
candesartan
losartan
etc.
Which laxatives to avoid in someone already bloated?
Ispaghula Husk
Lactulose
Tacrolimus level monitoring?
Trough level prior to morning dose
FOr PSA questions:
What suggests response to DKA treatment?
Serum ketones
- This is because serum ketones will resolve more slowly than CBG, which likely responds rapidly to rehydration + insulin
Measuring effect of oxygen therapy?
ABG > O2 sats
(not RR - too non-specific , VBG - better for mreasuring acidosis)
Vanco therapuetic range?
When do you measure
Measured as a trough dose
10 mg - 20 mg
Urticarial drug looking reaction
What do you do ?
Chloremphenamine is best
- Adrenalien is only appropirate if there are clear signs of anaphylaxis - airway compromise, tachycardia, hypovolaemia, wheeze
- Hydrocortisone will take too long to work
Managing drug induced hypoglycaemia?
Always as an inpatient
When to transfuse for anaemia?
Severely symptomatic
HB <7 / <10 in patients with IHD
How long do you treat IDA orally for?
for 3 months after the Hb is in normal range
Why is cardioversion inappropriate if AF has been present >48 hours
Due to the risk of thrombombolism
Appraoch should be - Rate control (BB, CCB, Dig)
Then elective cardioversion –> pre treatment with amiodarone and anticoagulants —-> cardiovert —>post treatment with antiocoagulant
First line for GAD?
Sertralline likely to get you fulll marks?
Why do you monitor serum creatinine when prescribiing digoxin?
Digoxin is predominantly renally Excreted
Assessing for resolution of pneumonia while on the ward
REspiratory rate
CXR - chekced after 6 weeks
Tacrolimus monitoring
Trough level
What to monitor for in SSRIs?
Rash
Mood assessment (suicidal ideation)
Old people on anti-depressants?
The dose is usually a very mild one
If there appears to be a ‘normalish’ looking dose of anti-depressant in an elderly person look it up as it might be a prescribing error
Allopurinal in Renal failure?
Maximum dose 100 mg!
It accumulates in RF
NB on fentanyl patches to morphine conversion
Very confusin – Found the BNF treatment summary is available so look for prescribing in palliative care
Managing transiently poor glycaemic control due to steroids
10% increase in insulin should do the job