Effect of a P450 inducer?
Increase metabolism of P450, therefore drug exerts less of an effect
Effect of a P450 inhibitor?
Reduced metabolism of P450, therefore drug exerts more of an effect.
Examples of P450 Inducers ?
Increased enzyme activity, decreased drug concentration
- PC BRAS
- Alcohol (chronic excess)
Examples of P450 inhibitors?
- Ethanol (acute intoxication)
Drugs to stop before surgery - COCP?
4 weeks before surgery
Drugs to stop before surgery
Drugs to stop before surgery
- Potassium sparing diuretics and ACEi?
Day of surgery
Drugs to stop before surgery
Generally Warfarin is stopped and bridged with LMWH.
Drugs to stop before surgery -
Oral hypoglycaemic drugs and insulin?
Patient is NBM before surgery.
Metformin should be stopped because it will cause lactic acidosis.
In all cases - a sliding scale should be started instead - hourly blood glucose monitoring and adjust hourly dose.
Mnemonic for drugs to stop before surgery?
I LACK OP
- K-sparing diuretics
- Oral hydoglycaemics
Management of long-term corticosteroids (pred) before surgery?
Increase steroid requirement
At IOA, patient should be given IV steroids.
Drugs to stop for a patient with haemoptysis?
Drugs to stop patient is hyperkalaemic?
IV fluid with K should be stopped.
Also patient is receiving 6g of paracetamol so should be stopped.
Common pitfalls for prescribing?
Ensuring we have correct patient’s prescription/drug chart
Noticing and recording allergies
SIgning the front of the chart.
Considering contraindications for each drug we prescribe.
Consider the route for each drug we prescribe
Consider the need for IV fluids.
Consider need for thromboprophylaxis
Consider need for antiemetics
Consider need for pain relief.
What is the PReSCRIBER mnemonic?
Patient Details Reaction Sign the front of the chart check for Contraindications to each drug Prescribe Intravenous fluids if needed Prescribe Blood clot prophylaxis if needed Prescribe antiEmetic if needed Prescribe pain Relief if needed.
When working on a new chart what must you write?
3 piece of patient identifying information on the front
- Patient Name
- Hospital Number
Reactions for drug charts?
Check allergy box to include any drug reaction
Don’t forget that co-amoxiclav and Tazocin both contain penicillin.
Contraindications in drug charts? - Bleeding
Consider whether it is contraindicated.
Drugs that increase bleeding (aspirin, heparin and warfarin). Should not be given to those risk of bleeding (liver disease).
Prophylactic heparin is contraindicated in acute stroke - risk of bleeding.
Be wary that enzyme inhibitors AODEVICES can increase PT and INR.
Contraindications for drug chart - Steroids?
Side effects -
- Stomach ulcers
- thin skin
- Right + left heart failure
- Cushing’s syndrome
Contraindications for rugs - NSAIDS?
- No urine (renal failure_
- Systolic dysfunction (heart failure)
- Dyscrasia (clotting abnormality)
Aspirin, whilst not technically an NSAID. It is not contraindicated in renal or heart failure.
Antihypertensives - SE?
Hypotension that may result from all groups of antihypertensives.
Bradycardia = beta blockers + CCBs .
Electrolyte disturbances with ACE and diuretics.
Individual drug classes have specific side effects
- ACEi = Dry cough
- Beta-blockers = wheeze in asthmatics
- CCB = Peripheral oedema and flushing
- Diuretics = renal failure. Loop diuretics can also cause gout.
Route for patients?
if vomiting = antiemetics should be given by non-oral routes = IV/IM/SC
E.g Cycline 50mg 8hrly IV or PO
Metoclopramide 10mg 8 hrly.
If a patient is nil by mouth should still receive oral medication.
When are IV fluids prescribed?
As replacement for dehydrated/acutely unwell patient
As maintenance in patient who is nil by mouth.
Which fluid to prescribe?
- 9% saline UNLESS:
- Patient is hypernatraemic or hypoglycaemic: then give 5% dextrose instead.
- Has ascites: give human-albumin solution instead.
- Shocked with systolic BP <90: give gelofusine instead as it has high osmotic content so stays IV, thus stays intravascularly, maintaining BP for longer.
- Is shocked from bleeding: give blood transfusion, but a colloid first if no blood available.
How much fluid and how fast? - tachycardic or hypotensive
If tachycardic or hypotensive give 500ml Immediately in 10 mins
250ml if heart failure.
Then reassess patient, especially HR BP and urine output to assess response + speed of next bag.
How much fluid and how fast - oliguric (not due to obstruction)?
IL over 2-4hrs.
Then reassess HR, BP and urine output.
How volume depleted is a patient with reduced urine output (<30ml/h)
500ml of fluid depletion
How volume depleted is a patient with reduced urine output (<30ml/h) plus tachycardia?
1L of fluid depletion
How volume depleted is a patient with reduced urine output (<30ml/h), tachycardic plus is shocked?
Indicated >2L of fluid depletion.
Maintenance fluids requirements over 1 day?
Adults = 3 IV fluid per 24hrs Elderly = 2L per 24hrs
Adequate electrolytes are provided by 1L of 0.9% saline and 2L of 5% dextrose.
1 salty and 2 sweet.
K+ = Bags of 5% dextrose or 0.9 saline containing KCL can be used. Patients require roughly 40mmol KCL per day = 20mmol KCL in 2 bags.
Never give IV potassium at more than 10mmol/hour.
How fast to give maintenance fluids?
If 3 L = 8hrly bags
If 2 L = 12hrs bags.
In real life - check patients’ U+E, confirm what to give.
Check patient is not fluid overloaded (increased JVP, peripheral and pulmonary oedema.
Ensure patient’s bladder is not palpable.
Blood clot prophylaxis?
Prophylactic LMWH - dalteparin 5000 units daily s/c.
Compression stocking to prevent VTE.
If a patient is bleeding or at risk of bleeding (recent CVA) - they should not be prescribed warfarin or heparin.
Patients with PAD should not be prescribed compression stockings.
Antiemetics for patients that are nauseated?
- Cyclizine 50mg 8hrly IM/IV/ oral. Most cause fluid retention.
- Metoclopramide 10mg 8hrly IM/IV.
Antiemetics for non-nauseated patients?
- cyclizine 50mg IV/IM/oral.
- Metoclopramide 10mg up to 8hr IM/IV.
Cyclizine (anti-histamine) for most patients except cardiac cases when its safer to give metoclopramide.
When to avoid metoclopramide?
Crosses the BBB
Patients with Parkinson’s diseases due to risk of exacerbating symptoms
young women due to risk of dyskinesia - unwanted movement especially acute dystonia.
Pain relief for patients?
No pain = PRN paracetamol 1g 6hrly.
Mild pain = Paracetamol 1g 6 hourly oral regularly. Codeine 30mg up to 6hourly oral.
Severe pain = Co-codamol 30.500, 2 tablets 6-hourly oral.
Morphine sulphate: 10mg up to 6 hourly oral.
Morphine in order of effectiveness
- Morphine sulphate (oramorph)
Ensure only 4g of paracetamol is being prescribed.
Management of neuropathic pain?
Nerve damage usually shooting, stabbing or burning.
First line = Amitriptyline (10mg oral nightly) or pregabalin (75mg oral 12-hourly).
Duloxetine (60mg oral daily) indicated in painful diabetic neuropathy.
Bendroflumethiazide and potassium?
Leads to hypokalaemia by increasing potassium excretion.
Remember that ACEi can lead to increased Potassium.
Lisinopril and potassium?
Causes kyperkalaemia through reduced aldosterone production and thus reduced potassium excretion in the kidneys.
Loop and thiazide = hypokalaemia.
Aldosterone antagonist and ACEi cause hyperkalaemia.
NSAIDS and indigestion?
Inhibits prostaglandin synthesis therefore risk of influencing inflammation and ulceration.
Oral steroids inhibit epithelial renewal thus predispose to ulceration.
NSAIDS and renal failure?
NSAIDS reduce renal artery diameter and thereby reduce kidney perfusion and function.
ACEi - reduce ACEi and stop aldosterone.
Ibuprofen and asthma?
Must stop as contraindicated!
Trimethoprim and methotrexate?
Avoid as risk for bone marrow toxicity. Therefore stop the trimethoprim.
Methotrexate and sepsis?
Must exclude neutropenic sepsis.
Furosemide and sodium?
Hyponatraemia and Hypokalaemia.
Amlodipine side effect?
incorrectly treated with furosemide therefore stop amlodipine.
When patient has a high INR what should you stop?
Both warfarin and heparin.
Verapamil and beta blockers?
Risk of bradycardia and hypotension.
Make sense to stop the verapamil causing the peripheral oedema.
Beta blockers and asthmatics?
Contraindicated due to bronchospasm.
NSAIDS used with caution.
Normal cardioprotective and treatment dose of aspirin?
75 mg daily
Stroke dose = 300mg daily.
CI in patients with migraine.
Increases risk of stroke too.
Prophylactic heparin in stroke?
CI following stroke.
Novomix is given incorrectly
Never given IV
All insulin is given IV except for sliding scales.
Clozapine worrying side effect?
Antipsychotic. - Agranulocytosis resulting in neutropenia.
Causes of a microcytic anaemia?
Causes of normocytic anaemia ?
Anaemia of Chronic Disease
Acute blood loss
Renal failure (chronic)
Macrocytic anaemia cause?
- B12/folate deficiency
- Excess alcohol
- Liver disease (non-alcohol)
- Haematological disease beginning with M: myeloproliferative, myelodysplasia, multiple myeloma.
Hypovolaemic Hyponatraemia causes?
Fluid loss (especially diarrhoea/vomiting)
Euvolaemic hyponatraemia causes?
SIADH = Small cell lung cancer, Infection, Abscess, Drugs (carbamazepine, antipsychotics) and Head injury.
Hypervolaemic hyponatraemia causes?
Heart failure Renal failure Liver failure Nutritional failure Thyroid failure
Causes of hypokalaemia?
- Drugs (loop and thiazide)
- Inadequate intake or intestinal loss
- Renal tubular acidosis
- Endocrine (Cushing’s and Conn’s syndrome) - excess aldosterone
Causes of hyperkalaemia?
Drugs, Spironolactone, ACEi Renal failure Endocrine: Addisons Artefact (due to clotted sample) DKA (insulin to treat DKA potassium drops requiring regularly hourly monitoring.)
Causes of hypernatraemia?
All begin with D
- Drips (IV saline)
- Drugs (effervescent tablet preps or IV prep with a high sodium content).
- Diabetes insipidus (effectively the opposite of SIADH)
Causes of high neutrophils (neutrophilia)
Causes of low neutrophils?
Chemo and radiotherapy
Causes of high lymphocytes (lymphocytosis)?
Chronic Lymphocytic Leukaemia
Causes of low platelets? Thrombocytopenia
- Infection (viral)
- Drugs (penicillamine (rheumatoid)
- Myelodysplasia, myelofibrosis, myeloma.
Causes of high platelets?
- Tissue damage
- INflammation, malignancy
- Myeloproliferative disorder)
Causes of a raised Urea?
Could indicate AKI
Upper GI bleed.
Therefore a patient with a raised urea and normal creatinine who is not dehydrated (look at haemoglobin for a GI bleed).
Causes of an pre-renal AKI?
Prerenal - Urea rise»_space; creatine rise. eg urea 19 and creatinine 110.
Sepsis /Blood loss
Renal artery stenosis
Multiple urea by 10. If it exceeds creatinine then this suggests prerenal aetiology.
Causes of a renal AKI?
Urea rise «_space;creatinine rise, bladder or hydronephrosis not palpable.
Due to ischaemia - due to prerenal AKI, causing acute tubular necrosis)
Nephrotoxic antibiotics - Gentamicin, vancomycin, tetracyclines.
Tablets (ACEi, NSAIDs)
Negatively birefringement crystals (gout)
Causes of a postrenal AKI?
Urea rise «_space;creatinine rise, bladder or hydronephrosis may be palpable depending on level of obstruction.
In lumen: stone or slough papilla.
In wall: Tumour, fibrosis,
External pressure: Benign prostatic hyperplasia, prostate cancer, lymphadenopathy, aneurysm.
Causes of a raised Alk Phos
Any fracture Liver damage K(Cancer) Paget's Pregnancy Hyperparathyroidism Osteomalacia Surgery
Pattern of prehepatic jaundice and cause?
Raised isolated Bilirubin
Cause: Haemolysis, Gilbert’s and Crigler-Najjar Syndrome
Pattern of intrahepatic and cause of jaundice?
Raised AST/ALT and raised bilirubin
Cause: Fatty liver Hepatitis & Cirrhosis (due to 1) alcohol 2) Viruses (Hep A-E, CMV, EBV) 3) drugs (paracetamol, statins, rifampicin)
Metabolic: Wilson’s disease/haemochromatosis
Pattern of post-hepatic jaundice and causes?
In lumen: Stone (gallstone), drugs causing cholestasis (Flucloxacillin, co-amoxiclav, nitrofurantoin, steroids, sulphonylurea)
In wall: tumour (cholangiocarcinoma), PBC, PSC.
Extrinsic pressure: pancreatic or gastric cancer, lymph node.
Might be asked to change levothyroxine dose according to TFTs results for patient with hypothyroidism.
Use TSH as a guide.
Target range ~0.5-5mlU/L.
If TSH range <0.5 - Decrease dose as it is being suppressed.
If TSH 0.5-5 = Nil action - same dose
If >5 = Increased dose.
increased by smallest increment offered.
Interpretation of Chest X-ray?
Rotation - Distance between spinous process and clavicles.
Inspiration - 7th anterior rib transects diaphragm.
- Heart should be less than 50% of width of lungs.
- Look for effusion, pneumonia, oedema.
- Trachea should be central and if not consider collapse (towards) or pneumothorax (away).
Interpretation of arterial blood gases?
Subtract 10 from the FiO2 and if the PaO2 exceeds this calculated number then the patient is not hypoxic.
Presence of respiratory failure
Type 1 (most common) - Low or normal PaCO2 (fast/normal breathing) and can be caused by anything that damages the heart or lungs causing SOB.
Type 2 - Less common - High PaCO2 (slow shallow breathing) - Low oxygen. Blue bloaters of COPD - less commonly neuromuscular failure or restrictive chest wall abnormalities.
How to check ABG?
Look at pH.
Then look at PaCo2 to indicated respiratory cause.
If only HCo2 is abnormal this is a metabolic cause.
If both increased or both decreased this indicates compensation. If pH normal fully compensated. If abnormal partially compensated.
If both PaCO2 and HCO3 are abnormal but in opposite directions then there is coexistent metabolic and respiratory disease.
Divide 300 by number of large squares between each QRS.
Normal 60-100 bpm. <60bpm.
- P waves. Is it in sinus rhythm
Think about first, second or third degree HB.
QRS - complex. Normally <3 small squares.
If >3 then BB is present.
Height for LVH.
- if elevated then: Infarct or pericarditis
- If depressed then ischaemic or digoxin.
- Height :if more than 2.s QRS then Hyperkalaemia likely.
- INversion: normal in aVR and I leads. In other leads suggests old infarction/LVH.
Common drugs that require monitoring?
Digoxin Theophylline Lithium Phenytoin Vancomycin
When adjusting these drugs?
Move up in the smallest possible increment. this is when response is inadequate and low serum drug level.
If adequate response to drug - normal or low serum drug level then no change required.
If adequate response to drug and high serum drug level then decrease the dose.
If there is evidence of toxicity then omit the drug.
(only exception is gentamicin where a high serum level without signs of toxicity) should pre-empt a decrease in frequency by 12hr rather than reducing the dose e.g changing from every 24hrs to every 36hrs.
Signs of digoxin toxicity?
Digoxin = Confusion, nausea, visual halos and arrhythmias
Late: arrhythmias, seizure, coma, renal failure and diabetes insipidus
Gum hypertrophy Ataxia Nystagmus Peripheral neuropathy Teratogenicity
Ototoxicity and nephrotoxicity
Ototoxicity and nephrotoxicity
What to do generally if there is evidence of toxicity?
Stop drug (± find alternative) Supportive measures (IV fluid) Give antidote
Aminoglycoside for severe infections.
Doses calculated according to patients weight and renal function. High dose regimen of 5-7 mg/kg once daily.
Patients with severe rena lfailure or endocarditis receive divided daily dose of 1mg/kg 12hrly (renal failure) or 8hrs in endocarditis.
Important because of gentamicin can cause ototoxicity and nephrotoxicity
Regimen monitoring for gentamicin?
Measure gentamicin levels are particularly times such as 6-14hr after last gentamicin infusion is started.
Use a nomogram.
f the resultant point on the graph falls within the 24 h area (q24h) then continue at the same dose; if it falls above the q24h area then change the dosing interval as follows:
- if point falls in the q36h area change to 36-hourly dosing
- if point falls in the q48h area change to 48-hourly dosing
- if point rests above the q48h area repeat the gentamicin
level and only re-dose when the concentration <1 mg/L.
Management of a paracetamol overdose?
Use the paracetamol nomogram. If the plasma paracetamol level is below the line the patient does not require NAC. If above they do.
Paracetamol relies on glutathione therefore when this is used up, there is accumulation of NAPQI.
Warfarin excess management?
Warfarin inhibits synthesis of Vit K dependent clotting factors (II, VII, IX, X).
Prolongs the prothrombin time from which the INR is derived.
Targets for INR in most patients is 2.5 unless there is recurrent thromboembolism while on warfarin or metal replacement where it becomes 3.5.
if there is a major bleed causing hypotension or bleeding
- Stop warfarin
- Give 5-10mg IV vitamin K
- Give prothrombin complex
If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg.
Omit warfarin for 2 days then reduce dose
If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg.
Omit warfarin and give 1-5mg oral vitamin K.
If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg.
Vitamin K admin complicates the reintroduction of warfarin so only given when there is presence of bleeding or an INR exceeding 8.
When deciding whether to stop ACEi and NSAIDs for high K and renal failure?
Stop both as they both can cause raised K. Can always restart again.
Ibuprofen - decreases renal blood flow by inhibiting prostaglandins that normally dilate blood vessels flowing in the kidney.
Neutropenic sepsis management alongside hyperkalaemia
Give PipTaz, Gentamicin, Paracetamol and Stop lisinopril.
Hyponatraemia and confusion?
Stop patient’s carbamazepine and furosemide, both contributing to the hyponatraemia.
Trimethoprim in pregnancy?
Contraindicated in pregnancy - predisposed to neural tube defects. OCP during pregnancy is contraindicated!
Digoxin and heart rate?
Addison’s that are sick on steroids?
Increase for sick day rules.
Asthma drugs contraindicated?
Withhold salbutamol inhalers when they are giving nebs.
Management of acute heart failure?
Furosemide is the mainstay for acute heart failure and is administered IV.
Atrial Fibrillation management in patient with asthma and peripheral oedema?
Can’t use Beta-blocker
Can’t use Calcium Channel Blockers due to risk of peripheral oedema. (Amlodipine not really used, but diltiazem is used).
How are as required doses of morphine sulphate (oramorph) calculated?
one sixth of the total daily dose. - 1/6th of 30mg. Given up to every 4-6 hrs.
Management of STEMI?
ABC + O2 (15L) with non-rebreather
Hx/oe/inv. Diagnose STEMI
Morphine 5-10mg IV with metoclopramide 10mg IV
Primary PCI or thrombolysis
B-blocker e.g atenolol 5mg oral (unless asthma/LVF).
Transfer to CCU
Management of NSTEMI?
ABC + O2 (15L) by non-breather mask.
Hx/oe/ diagnose NSTEMI.
Aspirin 300mg oral
Morphine 5-10 mg IV with metoclopramide 10mg IV.
Clopidrogrel 300mg and LWM heparin 1mg/kg bd SC.
Transfer to CCU.
Management of LVF
ABC + O2 (15L) by non-rebreather mask.
Hx/oe/ diagnose NSTEMI.
Aspirin 300mg oral
Morphine 5-10 mg IV with metoclopramide 10mg IV.
Furosemide 40-80mg IV
If inadequate response, isosorbide dinitrate infusion ± CPAP
Management algorithm for adult Tachycardia?
Assess using ABCDE approach
Give oxygen + obtain IV
Monitor ECG, BP, SpO2, record 12-lead ECG.
Identify and treat reversible cause (electrolyte abnormalities).
Adverse features? = Unstable
- Shock, syncope, MI, HF.
If unstable give DC shock up to 3 attempts.
Then Amiodarone 300mg IV over 10-20mins and repeat shock followed by:
Amiodarone 900mg over 24hr.
If there are no adverse features and narrow QRS.
- If the rhythm is irregular it is AF. = B-blocker or diltiazem or consider digoxin or amiodarone.
If there narrow QRS and regular = vagal manoeuvres, adenosine 6mg rapid IV bolus, if unsuccessful give 12mg. If unsuccessful give another 12mg.
Monitor ECG continuously.
If sinus rhythm restored
- re-entry paroxysmal SVT.
- Record 12 lead ECG sinus rhythm
- If recurs give adenosine again and consider choice of anti-arrhythmic prophylaxis.
If Broad QRS with regular rhythm
= VT = Amiodarone 300mg IV over 20-60 mins. Then 900mg over 24hr.
If previously confirmed
- SVT with BBB. Give adenosine as regular complex tachy.
If irregular QRS - Seek expert help.
Management of anaphylaxis?
ABC H/exam Remove the cause ASAP (blood transfusion) Adrenaline 500micrograms 1:1000 IM Chlorphenamine 10mg IV Hydrocortisone 200mg IV Asthma tx if wheeze. Amend drug chart allergies box.
Management of acute exacerbation of asthma
ABC History of asthma 100% O2 by non-rebreather Salbutamol 5mg NEM Hydrocortisone 100mg IV or prednisolone 40-50mg oral (if moderate) Ipratropium micrograms neb) Theophylline (only if life threatening)
Management of pulmonary embolism?
High flow oxygen
If low BP - IV gelofusine –. Noradrenaline –> thrombolysis
Managemet of GI bleed?
ABC History IV Cannulae Catheter (and strict fluid monitoring) Crystalloid Cross-match 6 units of blood Correct clotting abnormalities Camera Stop culprit drugs (NSAIDs, Aspirin, warfarin, heparin).
Metabolic emergencies? - DKA
- Diabetic )- hyperglycaemia - BM often >30mmol/L
- Keto (check urine and blood ketone)
- Acidosis (low pH on ABG).
IV fluid 1L stat then 1L over 1 hr, then 2hrs, then 4 hrs, then 8hrs.
Sliding scale insulin.
hunt for trigger (infection, MI, missed insulin)
Monitor BM, K, pH.
Metabolic HONK coma?
Hyperglycaemia (usually >35 mmol/L)
HO (Hyperosmolar: osmolality over 340mmol/L (2x (Na +K) + urea + glucose)
Manage same as DKA but half the rate of fluids.
BM blood glucose <3mmol/L.
Give them a high-sugar snack.
Otherwise give IV glucose via a cannula 100ml 20% glucose.
If unable to eat and no cannula give IM glucagon 1mg.
Cannula and catheter, strict fluid balance.
Correct electrolyte disturbance
Reduce absorption - gastric lavage, whole bowel irrigation (if lithium or iron) 3) charcoal.
Increase elimination - Generous IV fluid +
- N-acetyl cysteine (if paracetamol level at 4hrs or more is over the line on treatment nomogram).
-Naloxone (if opiates have been taken and there is now slow breathing)
- Flumazenil (if benzodiazepine have been taken).
Treat BP >150/95 or >135/85 if any of the following are also present
- Existing or high risk of vascular disease, stroke, peripheral vascular disease.
- HTN organ damage.
Target blood pressure on treatment
- Patients aged less than 80 yrs aim for <140/85. and <135/85 for ambulatory or home measurements.
If patient is over 80 add 10mmHg to systolic values.
Under 55 = A Over 55 or black = C A + C A + C + D A + C + D + diuretic, alpha blocker or b-blocker.
IN the chronic setting of microalbuminuria due to diabetes what do you monitor and how do you treat it?
ACEi (ironically can worsen AKI but in the chronic setting offers cardiovascular + renal protection.
Measure the albumin-creatinine ratio.
Most commonly used regimen - co-beneldopa or co-careldopa
If question presents a patient with very mild Parkinsons who is particularly concerned about finite period of benefit from levodopa - give a dopamine agonist (ropinirole) or MAOi (rasagiline).
Epilepsy drug side effects
Rash - Rarely Steven Johnson syndrome.
Epilepsy drug side effects? Carbamazapine?
Rash Dysarthria Ataxia Nystagmus Decreased sodium
Epilepsy drug side effect - pheytoin
MIld = Acetylcholinesterase inhibitors.
- Donepezil, rivastigmine, galantamine.
Management of Crohn’s - does the question talk about inducing remission or maintaining remission?
Treat acute flair with prednisolone 30mg daily.
Treat severe flare with hydrocortisone. 100mg 6-hourly IV.
Treat rectal disease with rectal hydrocortisone.
Azathioprine is a pro-drug metabolisted to 6-merceptopurine.
Therefore check TPMT levels before starting either drugs. If too low consider starting methotrexate instead.
Giving hypnotic to patient on ward?
Start with zopiclone 7.5mg orally nightly in adults.
Management for constipation in the ward?
Stool softener - Docusate sodium, arachis oil. Good for faecal impaction.
Bulking agents - Isphagula husk. Faecal impaction, colonic atony. takes days to develop effect. Dont use in faecal impaction.
Stimulant laxative - Senna, Disacodyl - Don’t use in acute abdomen.
Osmotic laxatives - Lactulose, phosphate enema. Don’t use in acute abdomen.
Asthma management - patient has salbutamol tremor and uses his inhaler more than 2x a week.
Should be stepped up to beclamethasone 200micrograms 1 puff 2x a day + counsel about salbutamol overuse.
Shouldnt need to increase dose of salbutamol inhaler.
Patient has skin infection?
Prescribe flucloxacillin 500mg 6 hrly for 7 days.
Management of acute pulmonary oedema?
Furosemide 40mg IV
Which two drugs are known to have antimuscarinic side effects out of
Cyclizine - antihistamine with some known antimuscarinic side effects
Amitriptyline - Tricyclic antidepressant - used at lower doses to treat neuropathic pain with known antimuscarinic side effects.
Side effects of carbimazole?
Drug-induced neutropenia (sore throat, bone marrow suppression)
Carbamazepine can also cause neutropenia.
Patient is ?Alzheimer’s and is taking a drug that in making his symptoms of parkinson’s
Metoclopramide and haloperidol
Both can precipitate Parkinson’s
Does Domperidone cross the BBB?
Patient with STEMI who is allergic to opioids? What painkiller do you give?
GTN Spray 2 puffs sublingual
Treatment of DVT with raised D-dimer - suggestive of PE?
LWM heparin (enoxaparin, tinzaparin or dalteparin) TREATMENT DOSE = 15,000.
Prophylaxis dose = 4,000 units daily.
Pregnant woman asked for advice regarding HTN management ramipril during pregnancy?
She cannot take it during the first trimester. It is advised to convert to labetalol before conception.
Patient with tamoxifen and is being warned of the risks?
Tamoxifen increases risk of VTE, and swollen leg could suggest a deep vein thrombosis which needs urgent medical attention.
Patient on gliclazide
This is a sulphonylurea
High risk of hypoglycaemia.
Patient must not miss meals as this will increase risk of hypoglycaemia.
Should not double up dose next time
Missed meals do not improve blood sugar control.
Taken in the morning - bedtime will increase risk of nocturnal hygoglycaemia.
Methotrexate management for a patient?
Regular monitoring of WBC is required given risk of neutropenia.
Methotrexate should only ever be taken once weekly.
Infection risks are much higher given its effect on WBC
Folate antagonists such as trimethoprim and co-trimoxazole should never been taken with methotrexate as they increase its effect.
Folic acid should be used alongside methotrexate to limit its toxicity to bone marrow.
Advice when using warfarin?
Warfarin carry significant risk of bleeding. Risk is reduced if the INR is regularly monitored.
Alcohol affects metabolism of warfarin and makes monitoring difficult.
Patients that want to drink should do it over a week, least impact on INR.
Warfarin tablets are colour coded. White (0.5mg), brown (1mg), blue (3mg) and pink (5mg).
Initially weekly blood tests needed then performed monthly.
What cautions should patients be told about when going on ACEi?
High risk of hyperkalaemia
Cough is common
If patient is vomiting or diarrhoea - risk of AKI
Both ACEi and diuretics can cause renal failure.
It is important to monitor renal function following initiation of ACEi
Patients on long term steroids?
Increases risk of DM
Increase risk of osteoporosis.
If taken for more than 3 months then give prophylactic treatment.
Small risk of gastric irritation and gastric duodenal ulceration in steroids therapy. H2 antagonists or PPI should be considered.
Never stop steroids abruptly due to risk of addisonian crisis.
Patients on steroids are at risk of HTN so should be monitored regularly.
Patient on citalopram after being diagnosed with depression? What should she know?
Takes 6 weeks before there is any improvement
Citalopram makes you more photosensitive and precaution should be taken in sunlight.
Antidepressants can still be suicidal and should seek help immediately. Furthermore a small proportion of patients will actually feel work immediately after.
Symptoms of serotonin syndrome which is a life threatening complication of SSRIs. Should attend hospital immediately.
SSRIs can cause a dry mouth.
Patient with new T1DM - how should you advise her?
Depends on consciousness hypoglycaemia should be treated with carbs + glucose tablets.
HbA1c gives an average glucose control over 3 months. Diabetic patients should target an HbA1c of 48mmol/mol or less.
When unwell, increased basal dose as required. Failing this will lead to the risk of DKA.
Poor glycaemic controls increase risk of microvascular and macrovascular complications.
Failure to rotate injection sites can lead to lipodystrophy.
Advice when taking bisphosphonates?
Reduce risk of fractures but do not prevent them.
Alendronic acid is once weekly prep.
Calcium salts reduce the absorption of bisphosphonates and should be taken at the same time of day.
Food should be avoided 2 hrs after taking alendronic acid as it reduced absorption.
Needs to be swallowed with a full glass of water and remain upright for 30 mins afterwards.
Calculations for PSA - How many mg are in 1ml of 1% lidocaine?
1% means 1 in 100. 1% means 1g in 100ml.
1g in 100ml in 1ml there is 0.01g or 10mg.
Therefore 2% solution contains 2g in 100ml.
1% means what?
1g in 100ml
4ml of furosemide 50mg in 5ml is given to a patient. WHat dose has been given?
50mg/5ml = 10mg/1ml.
Therefore 4ml x 10mg/ml = 40mg.
Now you want to give the same patient 75mg
This is because 50mg/5ml = 10mg/ml.
75mg x 1 ml / 10 = 7.5ml.
11 yr old girl weighing 30kg requires a 2mg/kg slow IV bolus dose of antibiotics. Ampoule contains 80mg in 2ml. What volume is required?
30 x 2 = 60mg
60mg/80mg = 0.75 = 1.5ml
When should you not give ‘high dose’ regimens of gentamicin?
When patients have a creatinine clearance of <20ml/min.
If patient is hypernatraemic what fluid do you prescribe and how much?
5% Dextrose 1hr.
Treatment prescription for Pulmonary embolism?
Dalteparin 15,000 units S/C OD = treatment dose.
Enoxaparin 120mg or 12,000 units S/C OD.
Tinzaparin 14,000 units S/C
Dose of HF medication ACEi?
Enalapril 2.5mg ON starting dose.
Lisinopril 2.5 ON
Perinodopril erbumine 2.0 mg OD
Ramipril 1.25mg ON
Can cause Postural hypotension therefore given in the evening.
For HTN only give ARBs if ACEi cannot be tolerated.
First line treatment for acute asthma?
Salbutamol nebs 5mg STAT.
Terbutaline nebs 10mg STAT - correct dose for acute asthma.
Ipratropium nebs 250/500micrograms Neb STAT. Cannot be given more than 4-6/day.
First line pain management in stable angina?
GTN spray Glyceryl trinitrate
2 sprays SUBLINGUAL.
Remember Morphine is used for ACS.
Patient with AF first line treatment has asthma.
Diltiazem - Patient has AF. Suggests he needs rate control due to his age.
Give 120mg OD using modified release prep.
Verapamil 40-120mg OD 8hrly.
Digoxin should be used in patient whom beta or CCB is inadequate or contraindicated.
Drug to reduce potassium in hyperkalaemia?
Actrapid with glucose 10 units of NOVORAPID in 100ml of 20% Dextrose over 30 mins IV.
Hyperkalaemia secondary to renal failure. First potassium lowering therapy is insulin and dextrose.
Insulin causes cellular uptake of potassium and then dextrose is given to prevent subsequent hypoglycemia.
Management of focal epilepsy?
Lamotrigine 25mg OD PO.
Lamotrigine or carbamazepine. However this causes SIADH therefore is not appropriate here as sodium would likely drop further which itself may provoke seizures.
Patient with T2DM with high creatinine management?
Gliclazide 40mg OD with first meal.
When selecting first oral hypoglycaemic drug for diabetic patients, generally pick metformin if overweight or a sulphonylurea if normal/underweight. A creatinine of >150 should also preclude using metformin.
Could also use tolbutamide
When prescribing statins what would you check?
CK level baseline should be checked in patients with risk factors for muscular disorders, muscular toxicity, high alcohol intake, renal impairment, hypothyroidism and elderly.
If there are no risk factors then a baseline check of CK is not most suitable, therefore check ALT.
Statins are metabolised in the liver, so hepatic impairment will increase their level and risk of myopathy.
If ALT or AST is raised more than 3 time normal range then statins are contraindicated.
What to check in bloods before a patient is prescribed vancomycin?
Renal - serum creatinine.
Clearance is reduced in patients with renal dysfunction. Must be taken into account when choosing a dosing regimen for vancomycin.
Two classic side effects of vancomycin are nephrotoxicity and ototoxicity.
If pre-dose trough is within normal range? If there are no seizures then yes must be normal and within range.
Monitoring lithium levels?
Sampling time for lithium is 12hr after last dose.
Normal reference range is 0.4-0.8mmol/l and toxic effects manifest over 1.5mmol/L.
FBC are not routine in patient on lithium.
Routine lithium is performed weekly after initiation and after each dose change until concentrations are stable. Then every 3 months.
Sodium depletion is known to increase the risk of lithium toxicity and patients are advised to avoid making changes in their diet that would lead to increased or decreased sodium intake.
Monitoring methotrexate levels
Known to cause fatal blood dyscrasias. Monitor FBC ar regular intervals is imperative, but once therapy has been stabilised, FBC can be monitored every 2-3 months.
According to BNF, CXR is not required, but may be required later on if pulmonary toxicity is suspected.
Due to liver cirrhosis risk, methotrexate should not be started if liver function tests are abnormal.
If sudden drop in WBC or platelets - Methotrexate should be reduced.
Methotrexate is predominately renally excreted and toxicity is more likely in presence of renal dysfunction.
What to monitor on a patient with olanzapine?
Hyperglycaemia and diabetes can occur in patients prescribed antipsychotic drugs, particularly olanzapine. Fasting blood glucose must be tested at baseline and at regular intervals thereafter.
Baseline ECG prior to commencing an antipsychotic drug is only usually indicated in patients with CVS or associated risk factors. §
What to check in a patient being prescribed the OCP?
HTN is known to increase risk of arterial disease associated with contraceptive medication.
When monitoring patients on amiodarone?
T3, T4 and TSH must all be included in a measurement of thyroid function in patients taking amiodarone. T4 may be raised in absence of hyperthyroidism.
Check X-ray owing to risk of pulmonary toxicity with amiodarone.
Monitor Transaminases throughout duration of therapy.
Patients with carbimazole?
If evidence of sore throat check FBC and neutrophil count.
This is due to carbimazole-induced bone marrow suppression and thus agranulocytosis.
Gentamicin regime for multiple daily dose?
1hr peak serum concentration should be 3-5mg/L for the treatment of endocarditis.
Both pre and post dose levels must be checked at regular intervals.
Principally excreted renally. Patients with renal dysfunction are at increased risk of toxicity thus monitoring of renal function is required at regular intervals in patients on gentamicin.
Monitoring of ACEi?
ACEi are known to cause hyperkalemia, hyponatraemia and in some cases AKI. U+E checked at baseline and after every dose.
Monitoring Digoxin levels?
Predominantly renally excreted and patients with renal dysfunction are at increased risk of toxicity.
Plasma digoxin concentration is not measured unless toxicity, non compliance or inadequate effect are suspected.
Sodium valproate monitoring?
Associated with hepatotoxicity and liver function should be measured at baseline as well as regular intervals through therapy.
Monitoring on clozapine?
Owing to risk of neutropenia and potential fatal agranulocytosis, routine monitoring of full blood count is required at regular intervals as dictated by product licence.
Side effects of gentamicin and vancomycin?
Side effects of general antibiotics (mainly cephalosporins and ciprofloxacin)?
Side effects of ACEi?
Side effects of Beta-blockers?
Wheeze in asthmatics
Worsens acute heart failure
Side effects of CCBS?
Side effects of diuretics?
Side effects of heparin?
Haemorrhage, thrombocytopaenia (Heparin induced)
Side effects of warfarin?
Haemorrhage - does take a few days to become an anticoagulant. Therefore prescribe warfarin and continue until INR exceeds 2.
Digoxin antiarrhythmics SE?
Nausea, vomiting, diarrhoea. Blurred vision Confusion Drowsiness Xanthopsia (yellow/visual perception and halo vision).
Digoxin compete with K at the myocyte, limiting Na influx. Since Ca outflow relies on NA influx, Ca accumulates in the cell. This lengthens action potential and slows heart rate. Therefore low K augments digoxin effects.
High levels of K limit effect.
This is because K competes with digoxin at the receptor
SE of amiodarone?
Interstitial lung disease Thyroid disease Hyperthyroidism Structure related to iodine therefore amIODarone. Skin greying COrneal deposit.
Lithium side effects?
Early - tremor
Intermediate - tiredness
Late - arrhythmias, seizures, coma, renal failure, diabetes insipidus.
Antipsychotic side effects?
Haloperidol - Dyskinesias e.g acute dystonic reactions.
Clozapine - Agranulocytosis - requires intensive monitoring of full blood count.
Corticosteroids side effects?
Dexamethasone and prednisolone
- Stomach ulcers
- Thin skin
- Right and left heart failure
- Cushing’s syndrome
- HTN, salt/water retention
- No urine (renal failure)
- Systolic dysfunction ( heart failure)
- Dyscrasia (clotting abnormality)
- Abdo pain
- Increased ALT/AST
Types of drugs that interact?
Drugs with a narrow therapeutic index = warfarin, digoxin, phenytoin. Can lead to toxic or therapeutic levels.
Drugs that require careful titration of dose according to effect - anti-HTN, anti-diabetic.
Iodinated contrast media can cause renal impairment, which increases risk of metformin-induced lactic acidosis or ACEi AKI.
Drugs that affect P450 enzyme.
Drugs with potent interactions with alcohol?
GI bleeding caused by
- NSAIDS (aspirin and ibuprofen)
Lactic acidosis caused by metformin
Increased anticoagulation caused by: warfarin (with acute alcohol due to enzyme inhibition (acute alcohol dues enzyme inhibition). Chronic alcohol caused enzyme induction and thus reduced anticoagulant effect.
HTN crisis: Monoamine oxidase inhibitors and alcohol.
Sweating, flushing, nausea and vomiting: metronidazole and disulfiram with alcohol
Sedation caused by:
barbiturates, opioids and benzodiazepines.
What blood to check when monitoring ACEi?
Should also check serum creatinine.
Potassium more important than sodium as it can cause arrhythmias.
What are the side effects of beta-blockers?
Associated with cold extremities
Likely to cause hypotension
Drugs known to cause peptic ulcers?
What can diclofenac cause?
Do not co-prescribe NSAIDS and ACEi.
Why not prescribe trimethoprim with methotrexate?
Both are folate antagonist.
Lead to additive toxicity in the form of bone marrow suppression, pancytopenia and neutropenic sepsis.
What is amiloride?
It is a potassium sparing diuretic causing hyperkalaemia.
ACEi also cause hyperkalaemia.
Erythromycin and warfarin?
CYP450 inhibitor = longer bleeding.
Cipro and warfarin also interact.
Management of INR 8 with minor bleeding.
Give IV Vit K via a slow injection.
REMEMBER PROTAMINE REVERSES EFFECTS OF HEPARIN.
Patient with anaphylaxis what do you do first?
Secure the airway - patient will not benefit much from a non-patent airway.
Management of drug-induced hypoglycaemia?
A conscious patient should be given 10-20G of glucose by mouth.
Drug-induced hypoglycaemia should be managed in hospitals as the hypoglycaemic effects of these drugs can persist for many hours.
Glucagon is used in the unconscious patient.
Metformin is less likely to cause hypoglycaemia than sulphonylureas.
How does metformin work
- Limiting hepatic gluconeogenesis. Lacrate is usually taken up by this process, without new sugar production in the liver has a build up of lactic acidosis.
Sulphonylureas squeeze insulin out of the pancreas. Therefore these are more dangerous as they act directly on insulin levels.
Drugs to stop before surgery
Stop Aspirin, heparin and contraceptive pill.
Metformin is stopped day before surgery, due to risk of lactic acidosis.
Insulin should be stopped and converted to a sliding scale.
DO NOT STOP BB or CCBs.
What if you see tamoxifen in a man’s drug chart?
Highly likely a mistake.
What is the daily dose of alendronic acid?
What is the prophylactic dose of aspirin?
Treatment is 300mg.
When in renal failure what should be withheld?
Aspirin does NOT cause renal failure so should be continued.
What can bendroflumethiazide cause?
Check UNITS OF STUFF!!!
Check units of enoxaparin against weight
Check paracetamol dose.
What can affect lithium excretion and contribute to toxicity
ACEi - lisinopril
Diuretics - thiazide and bendroflumethiazide
How to adjust levothyroxine if a patient is receiving too much? (Low TSH)
if you have a hypernatraemia what fluids?
Patients that is losing 1L every 4hrs input should be matched.
Maintenance fluid for people and what bags?
1 salty 2 sweet.
Equating to 3L.
Key tip for a abnormal isolated hyperkalaemia?
Interprete in the context of the patient’s condition.
When is metformin contraindicated?
IN patients with an eGFR of <30 and should be used with caution if <45. Risk of lactic acidosis.
What is ondansetron?
5HT3 antagonist treatment of nausea.
Chemically induced nausea including chemotherapy.
When is haloperidol used?
Dopamine antagonist used in palliative care.
Where is metoclopramide used?
It is a prokinetic antiemetic therefore CONTRAINDICATED in bowel obstruction.
Management of COPD?
Give Salbutamol nebs
Ipratropium bromide 500micrograms NEB
Steroids are later as they take time.
Patient has non-responsive hypotension? Which fluid>
Fluid challenge of 500ml gelofusine IV over 30 mins?
IV Steroids - Hydrocortisone and
Fluid resus happens much quicker.
Angioedema in ACEi?
Delayed and over months later.
When are ACEi blood test done?
Renal function and K essential assessment - 1-2 weeks after initiation.
What is the interaction of statins and clarithyromycin?
They increase toxicity and are CTP450 inhibitors. Increase associated side effects.
Statins taken overnight as cholesterol metabolism occurs overnight.
Immediate relief from dyspepsia?
- Magnesium carbonate 10ml oral
- Aluminium hydroxide 1 capsule oral
- Co-magaldrox 10ml
When do you give heparin in the day?
When prescribing antibiotics what must you ensure?
That you have a stop date. PRevents unnecessarily long antibiotic courses.
Painkillers - As required or Regular?
If patient is currently pain free put it into as required.
Codeine is contraindicated in primary headaches as they can actually make them worse.
First line for hospital acquired pneumonia?
Patient wants a laxative as she has not opened her bowels for 4 days. She is now mobilising, but you attribute her constipation to recent immobility. Feels bloated + denies cramps.
Give a stimulant laxative - an appropriate (no colitis or cramps which are the main contraindication) .
Give it at night time.
Typical opioid side effects?
When you are monitoring the effect of aminophylline on an acute asthma station what are you looking at?
When you have a pneumonia, what are looking at to judge an improvement?
Successful treatment of pneumonia will improve gas exchange, hypoxia, therefore the respiratory rate.
If oxygen sats or ABG were options these would be more accurate and specific.
Consolidation in an X-ray will take weeks to resolve.
How to measure the tacrolimus level?
Morning or evening dose.
Aim for a level of 6-12.
Tacrolimus can manifest as tremor.
How to monitor if a DKA has resolved?
Glucose normalised rapidly after commencing an insulin sliding scale. But this does not necessarily suggest resolution of DKA.
Normalisation of serum ketones suggest cessation of ketogenesis and therefore accurate reflection of response to treatment.
How best to monitor COPD patients?
- Target of 88-92%.
Pre-dose vancomycin should be 10-15mg/L. The reported level is within this range so it would be appropriate to assume, that no dose change is required.
What drug class causes facial flushing?
CCB - Amlodipine
COPD first line?
Remember patient has inhalers but you MUST switch this to NEBULISERS.
Eg Terbutaline sulphate 2.5mg/ml nebuliser.
Salbutamol 2mg/ml nebuliser liquid.
DVT 1st line treatment of DVT/PE?
LMWH or fondaparinux?
Enoxaparin 1.5mg/kg SC daily.
Contraindicated with patients with heparin-induced thrombocytopenia, or acute haemorrhage.
LMWH generally preferred over unfractionated heparin in treatment of DVT and PE except in case of significant renal impairment where unfractionated heparin may be preferable.
Fluid for a patient with elevated glucose (7.2) with current previous stroke not dehydrated, borderline sodium.
Sodium chloride 0.9%
Patient is unable to hydrate or nourish themselves.
Needs maintenance water, electrolytes and nutrition delivered by IV route.
May be depleted indicated by high sodium and urea although BP and HR do not give immediate cause for concern.
No need for rapid fluid replacement.
Appropriate infusion would be a 500ml over 4- 6hrs or 1l over 8-12hrs.
Statin as a choice for lowering LDL cholesterol?
NICE suggests to offer statins to those with a 10yr risk of CVS disease of 10% or more.
Given once daily at night.
Associated with myaglia (Risk of myopathy, myositis, rhabdomyolysis associated with statin use is rare).
Drugs that can irritate the gastric mucosa?
NSAIDS - ibuprofen and aspirin.
Drugs that can damage the kidney?
NB: Digoxin is largely cleared by kidney and accumulate in renal impairment but is not usually a cause of decreased renal function.
Drugs that can contribute to dehydration?
When is Metformin contraindicated in patients?
With significant renal impairment
Which antidiabetic can cause hypoglycaemia?
Thiazolidediones - Pioglitazone
Causes of urinary retention?
Morphine sulphate - common in early postoperative period.
- Anticholingerics (antipsychotics, antidepressants, anticholinergics, detrusor relaxants)
- General anaesthetics
- Alpha-adrenoceptor agonist
Drugs that cause confusion
- Others = anticholingerics, antipsychotics, antidepressants, anticonvulsants, H2 receptor antagonist, digoxin, B-blockers, Corticosteroids, NSAIDs.
Management of a patient with longstanding alcohol abuse?
IV Vit B - risk of Wernicke’s encephalopathy. Even if he’s on the tablets doesn’t mean there is any guarantee that he will be taking them.
Fluids - NaCl 0.9% IV infusion over 1hr.
Then insulin 50 units in NaCl normally in 0.1 units/kg/h.
Patient under 55 with HTN and presence of LVH?
ACEi as justified treatment of his BP.
Management for prevention of neural tube defects?
Folic acid 5mg PO daily.
High risk of conceiving a child with neural tube defects.
Those at low risk should take folic acid at a lower dose of 400 micrograms
Alendronic acid advice?
Has been shown to reduce fractures, widely prescribed prophylaxis in patients with osteoporosis
What should patients be warned about when taking Gliclazide?
Take precautions for hypoglycaemia = take a source of sugar with them.
HRT management in patients?
For women with an intact uterus, oestogren is a combined with a progesterone which reduced risk of endometrial carcinoma with unopposed oestrogen.
An 85-year-old man on the coronary care unit is being treated for angina.
He requires treatment with isosorbide dinitrate 0.1% solution by IV infusion via an infusion pump at a rate of 2.5 mg/h.
At what rate of delivery (mL/h) should the infusion pump be set?
Concentration of solution is 0.1%
Therefore 0.1g per 100ml.
Common side effect of methotrexate?
Leucopenia - therefore requires monitoring with regular FBCs.
Management of anaphylaxis?
NSAIDS are most frequent in causing hypersensitivity reactions
Give IM 0.5ml of a 1 in 1000 solution
Other that can cause it are
- B-lactam antibiotics, aspirin, NSAIDs, chemo, vaccines
How to monitor allopurinol’s therapeutic effect?
Aims to reduce serum urate.
Inhibits activity of enzyme xanthine oxidase.
Assessment of a hydrated patient’s rehydration?
Measure with Low BP
What can lithium affect in bloods?
Renal function - monitor with renal function tests.
Can also cause nephrotic syndrome and nephrogenic DI.
Measuring adverse affect of HRT?
BP - Can cause sodium and fluid retention - leading to a rise in BP.
Stop HRT if the bp rises above Systolic 160mmHg and diastolic 95.
Simvastatin with a raised ALT (double)
The ALT is slightly raised but is not an indication to reduce or stop therapy, even if it is related to simvastatin. Current guidance suggests that liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment, (unless indicated at other times by signs or symptoms). Patients with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, should not be routinely excluded from statin therapy. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy.
The dose is the major determinant of the peak concentration post-dose and needs to be reduced in view of the high peak concentration. It is also appropriate to extend the dose interval to allow more time for the gentamicin to be cleared and achieve a lower trough. The trough concentration indicates the concentration to which potential targets of toxicity (e.g. ear and kidney) are constantly exposed.
Patient with SOB and oedema 1 week. IHD, T2DM, CKD, ulcers, gout. Biphasic isophane insulin. 16units bisoprolol fumarate 2.5 PO daily. Alfacalcidol 500 micrograms, allopurinol 100mg PO daily, clopidogrel, enalapril, isosorbide mononitrate, nicorandil 12 hrly.
On exam - Temp 37.1, regular BP 160/92, JVP raised, RR 22, 94% O2, bilateral pitting leg oedema.
Best drug to alleviate breathlessness?
Patient has pulmonary oedema - required immediate treatment.
Loop diuretics and first line and furosemide is optimal choice as it can be given IV.
Correct dose is 20-50mg IV as a once only dose. Doses below 20 score zero. Doses above 50mg up to 100mg would be effective but unnecessarily high.
Furosemide 10mg/ml injection. Pulmonary oedema which requires immediate treatment.
Total hip replacement 12 hrs ago. One drug that is most appropriate for VTE prophylaxis?
LMWH for 10 days followed by aspirin for further 28 days.
LMWH for 20 days combined with Anti TEDs.
Try enoxaparin sodium 100mg/ml injection.
74 yr old being treated on medical ward for AKI. Hypoglycaemic?
One IV Fluid that is most appropriate to treat his current condition .
20% glucose solution.
Over 10-20 mins or less. Need to deliver this urgently
14 yr old boy visits his GP. Concerns about acne. Clinda topical, previously benzoyl peroxide. Erythromycin for throat infection causes nausea.
Need to offer oral antibiotics.
This can be tetracycline, oxytetracycline, doxycycline or lymecycline.
Drugs contributing to hyperkalaemia?
Heparins - Contribute to hyperkalaemia because of inhibition of aldosterone synthesis.
One drug to stop 1 week prior to surgery?
Antiplatelet agents usually stopped 7 days before surgery.
Drugs to withhold until renal function recovers?
Allopurinol - can accumulate in renal dysfunction - BNF advises max daily dose 100 mg until renal function improves.
Drugs contributing to confusion?
Drugs contributing to hyperglycaemia?
Prednisolone - stress response to hyperglycaemia.
Drugs contributing to hyponatraemia?
Patient has mets in breast, depression + osteoporosis. Currently on fentanyl 50 micrograms transdermal patch one patch applied 72hr daily + gabapentin. Wants more pain killers?
Give fentanyl 50 micrograms/actuation nasal spray to one nostril repeated once after 10 mins as required.
Patients receiving at least 25 micrograms of transfermal fentayl per hour can use nasal fentanyl for breakthrough pain.
Max dose is 50 micrograms into one nostril. repeat once if necessary after 10 mins with max of two
When to avoid prescribing nitrofurantoin?
If eGFR is less than 45 ml. May be used with caution if eGFR 30-44 as a short course.
Treat uncomplicated LUTI.
Try trimethoprim as an alternative. 7 day courses in males!
Alcohol withdrawal medications?
If INR is >1.5 before surgery what medicine should be given?
Phytomenadione/ Vitamin K.
Warfarin should be stopped 5 days.
Patient about to start SSRI what should he be warned about the MOST?
Suicidal ideation may worsen in first 4 weeks.
Most important info for patient on rivaroxaban?
Should be taken with food.
Patient has migraines, advised to take topiramate, to control symptoms. She is also taking desogetrel? Most important information option to provide her regarding her contraception?
She should change to an alternative method of contraception until 4 weeks after she has ceased topiramate.
Efficacy of oral progesterone-only prep is reduced by enzyme inducing drugs like topiramate.
An alternative method of contraception should be used.
What are the most likely side effects of beta blockers?
Sexual dysfunction (erectile dysfunction)
Due to co-amoxiclav.
More common in men over 65.
Which drug is most likely to interact with dabigatran etexilate to cause GI bleed?
Patient is given furosemide for flash pulmonary oedema? how do you monitor beneficial effects after 2 days?
Weight is the best.
What to look at when monitoring side effects for carbimazole?
FBC - due to neutropenia.
Patient on ACEi - what is the most appropriate to monitor beneficial effects of it?
Exercise tolerance - indicates that the treatment is working.
Patient has lupus - most appropriate option to monitor adverse effects of ciclosporin after 2 weeks?
Ciclosporin is nephrotoxic and HTN are thought to be mediated by this .
Patient with acute neck spasm and painful eyes? Best management to treat his eye and neck spasm?
Antimuscarinic drugs are first line to treating acute dystonic reactions.
Procyclidine hydrochloride 5mg/ml. Give parenterally as PO may have an unsafe swallow.
Woman with COPD - worsening breathlessness and non-productive cough. Temp 37, HR 90, BP 148, RR 18, O2 88%.
Already been given Ipratropium bromide/salbutamol 2.5.
What additional drug do you need to give?
Prednisolone 5mg tablet equating to 30mg PO daily.
Patient already prescribed 2L of NaCL 0.9% in the last 24hrs. What fluid to prescribe now?
80 kg man.
He needs 80mmol of Na and 80 mmol of.
Do not give another sodium bag.
Give 5% glucose (as glucose is in normal range).
Approprioate infusion rate is 2000-2400ml day (80-100ml/h).
He needs 80 mmol K+ per day so 40 mmol/L KCL in the next bag.
Fluid requirements daily?
1mmol of K, Na, Ch
50-100g/day of glucose.
How much does a bag of NaCL contain?
Sodium = 150 Chloride = 150
Must have glucose in the day!
55 yr old woman presents to her GP for a review of her current HRT. Wants an alternative preparation that will not give her monthly withdrawal bleeds. Wants a transdermal preparation.
Search for continuous patches
A product containing both oestrogen and progestogen is required. The oestrogen will control the hormonal symptoms and the progestogen is required as she has a uterus, to proect against the risk of endometrial cancer, from unopposed oestrogen.
A product that releases the same dose continuously, rather than a sequential product, will avoid withdrawal bleeding.
The patient’s preference is for a transdermal patch, rather than a tablet formulation.
levonorgestrel 7 micrograms/estradiol 50 micrograms/24 hours transdermal weekly patch
estradiol 50 micrograms/norethisterone acetate 170 micrograms/24 hours transdermal twice weekly patch
What drug to avoid in peripheral vascular disease?
B-blockers can cause peripheral vasoconstriction and worsen ischaemia.
Drugs likely to contribute to exacerbation of biventricular failure
ACEi Aldosterone inhibitor (Spiro)
Drugs contributing to vaginal candida?
Clarithromycin 250mg oral
Prednisolone 10mg oral
Antibiotics are more likely to contribute to thrust.
Which drug is important not to abruptly stop?
Prednisolone due to chronic adrenal suppression.
Which drug most likely to cause a cough?
If you want to improve a patient’s morning dose of insulin?
Increase Novomix dose - breakfast biphasic insulin dose to 48.
Patient has +ve nitrate, leucocyte and blood in urine. UTI treatment?
Give nitrofurantoin - avoid trimethoprim.
Scarlet fever? - Macular red rash, strawberry tongue, red throat, fever >38.3).
Needs antibiotic treatment.
Patient has clarithromycin and warfarin INR is 3.3?
Leave dose as it is as clarithromycin will likely increase it.
This is correct. Her INR is in range for the indication. For a mechanical heart valve target INR is 3.5 (range 3–4). Whilst she is currently in therapeutic range, she still requires close monitoring because of the interacting clarithromycin, which can prolong the effects of warfarin leading to a rise in INR. It is sufficient to recheck INR in 48 hours.
How should eplerenone be monitored?
K-sparing diuretic and therefore hyperkalaemia.
Serum potassium should be monitored during initiation, especially in at-risk groups. (Elderly, CKD, DM).
Warn a man starting methotrexate
Effective contraception should be used whilst he is taking methotrexate and for at least 3 months after stopping treatment.
Side-effects of mirtazapine
Causes abnormal dreams very commonly.
Thiazide-like diuretic causing hypokalaemia.
Interaction of simvastatin and gemfibrozil?
Gemfibrozil is known to interact with simvastatin and increases the risk of simvastatin-associated severe myopathy and rhabdomyolysis. Therefore, concomitant use should be avoided.
Gemfibrozil significantly increases simvastatin acid plasma concentrations, probably because of inhibition of simvastatin acid uptake by the hepatic sinusoidal xenobiotic uptake transporter OATP1B1. Gemfibrozil is also a potent mechanism-based inhibitor of CYP2C8.
Unconscious patient that is hypoglycaemic?
Give Glucose 20% 75 ml.
Admin of 15g of glucose using a 20% solution is correct treatment of hypoglycaemia.
Beta blocker therapy in AF - response to treatment?
Amiodarone monitoring option
Hypokalaemia is a caution for amiodarone.
Any regular monitoring for sertraline?
May cause hyponatraemia.
No routine blood monitoring
Patient with catheter associated urinary sepsis - best way to monitor benefical effects?
Resolution of acute symptoms over next 72 hrs.
Statin suspected of causing myopathy and CK is raised (more than 5x)
If symptoms resolve - creatinine kinase levels return to normal - statin should be reintroduced at a lower dose.
Patient is taking 180mg of morphine PO daily. What is this equivalent to?
Patient undergoes elective cholecystectomy. On return she feels nauseated and vomited twice. Most appropriate medication to alleviate nausea?
From choice of droperidol, dexamethasone, prochlorperazine all cause QT prolongation therefore need to use cyclizine.
Administer 25-50mg via parenteral route (IM, IV, S/C). Woman has a cannula therefore IV is preferable.
Patient has painful rash on right side of face. Has breast cancer. Demarcated vesicular rash in the mandibular region of right side of her face.
Case of shingles, don’t need it to be IV therefore PO.
Patient presents with 3 day history of vomiting and gastritis. HR 115, BP 100/50/ JVP not raised RR 21.
This patient is dehydrated and shocked. A fluid bolus of 500ml crystalloid over 15 mins is recommended.
E.g NaCl 500ml in 15 mins.
Can consider hartman’s/PLasma-lyte.
Patient with Type 2 Diabetes what is first line treatment?
Start low to minimise effects.
What drugs can cause hyperkalaemia?
Ciclosporin and eplerenone.
Drugs contributing to dyspepsia?
Drugs causing loose stools?
Lansoprazole (All PPI)
Drugs that cause ankle swelling?
NSAIDs - Naproxen
Drugs that cause bradycardia?
Pregnancy woman with vulvovaginal candidiasis?
Clotrimazole pessary - systemic therapy is not recommended during pregnancy.
Management of C.difficile?
First episode = mild or moderate = oral metro for 10-14 days.
Second episode or for severe infection or not responding to metronidazole. = Vancomycin.
Long-acting insulin therapy/
Management of DKA with current insulin (both long and short-term).
Restore SBP if below 90 with 500ml NaCl over 10-15 mins.
When over 90 give NaCl 0.9 maintenance. Include KCl.
Then start IV soluble insulin infusion 0.1 units/kg/hr fixed rate.
Established subcut therapy with long-acting insulin analogues.
Patient has post-herpetic neuralgia what is first line?
Paracetamol (in an elderly person who may be vulnerable to adverse effects).
Amitriptyline is useful for second line or unresponsive to simpler measures.
Most important information for loperamide hydrochloride?
Take after each loose stool.
Patient must realise that the medicine must be taken regularly but that it make take several weeks before any positive benefit is likely to be seen.
Advice for patient taking ciclosporin?
Regular monitoring of kidney function is required.
Nephrotoxicity is a well-known adverse effect of ciclosporin therapy. Renal function measurements are required before starting ciclosporin.
What are the adverse effects of GLP 1 analogues?
Which drug when taken with citalopram has the increased risk of causing serotonin syndrome?
Drug that interacts with Microgynon to reduce effect of contraceptive effect?
Best way to monitor adverse effect of COCP?
COCP can increased BP
What to monitor with azathioprine before treatment?
Measure thiopurine methytransferase.
Patient started on furosemide? Best way to assess beneficial effects of this treatment?
Patients with apixaban - best way to monitor adverse effects?
Patients should be informed when starting that they should report any bruising or other signs immediately.
Patient develops signs of opioid toxicity on morphine?
- oxycodone is metabolised by the liver to inactive metabolites. Therefore it is good in the context of those with renal impairment.
Switch to oxycodone.
Patient on warfarin is shocked with an INR of 10?
Dried prothrombin complex.
Patient with a very high T4 on amiodarone?
TFTs suggest development of thyrotoxicosis - therefore amiodarone should be withdrawn to achieve control.
Patient needs fluids. Is currently hypokalaemic and therefore needs replacement of potassium as well. If she has had losses then give 4-6 litres. Need to give more.
Give NaCl 0.9% 1L in 4-6hr but also replace K+ with KCL 40mmol 0.3%.
If hypokalaemia likely to need max 40mmol in 4hrs.
Need to give propranolol over split doses, not 1 big dose.
therefore 40mg BD.
Medications contraindicated with Parkinson’s Disease?
Haloperiodol and antipsychotics
Others that increase risk of acute dystonic reactions
- Antipsychotic drugs
Drugs that require specific timings?
Drugs depending on night time?
Less crucially statins
Drugs relating to other medications/stomach
Relating to mealtimes
Relating to days of the weeks?
Opiates needs to be used with caution in patients with hepatic cirrhosis?
Drowsiness = Morphine
Bleeding = Naproxen
Patient needs increasing of dose for heart failure?
Drugs that are nephrotoxins?
Diuretics ACEi/ARBS NSAIDS Aspirin Statins and fibrates Anti-infectives (aminoglycosides, vancomycin, penicillins, intravenous anti-fungals) Radiocontrast Lithium in overdose
Fluid for resuscitations?
Need for hypotension
Reduced capillary refill
Other evidence of hypovolaemia
Use crystalloids that contain sodium in the range 130-154 - 0.9% NaCl.
Bolus of 500ml over less than 15 mins
Which fluid for regular maintenance?
1L of NaCl 0.9% over 8hr/12hrs alongside KCl 0.15/0.3%.
Patient has already had a bag of sodium. Therefore they have had 154 mmol of NaCl, what is the next prescription
Given them 154 mmol of Na and Cl.
This man needs glucose therefore 5% glucose. He has had some potassium (40mol) therefore needs some more.
Therefore 5% glucose with 0.15% potassium chloride over 12hrs.
Patient has been vomiting and diarrhoea for the past 2 days. Currently hypokalaemic but not tachy or hypo.
Has ongoing losses that need to be replaced.
Therefore will require around 4-6 L over first day. Therefore 1L over 4-6 hrs.
Will need sodium/Chloride and potassium.
Has not has any potassium but has lost 140 mmol.
Will need to replace glucose as some point too.
Give potassium at the fastest rate you can (10mmol an hour).
Patient has only had 1 bag of 5% glucose. Therefore he has had no sodium, chloride or glucose?
Therefore give NaCl 0.9% 1L over 12 hr + 0.3% KCl.
Paediatric fluid prescription for resus?
20ml/kg over less 15 mins.
Hypercalcaemia fluid requirements
NaCl 0.9% over 4hr.
Hypoglycaemia management fluid?
50ml 20% glucose in 5 mins. STAT! It’s 20% therefore 10g given as 50ml.
IV furosemide for acute heart failure
Remember IV 40mg or more
Palliative care prescribing?
Oral medications can be satisfactory unless there is severe nausea and vomiting, dysphagia, weakness, or coma.
Dosing of chlordiazepoxide?
Calculated based on level of alcohol dependence.
Advice with chlordiazepoxide?
Side effects are similar to other benzodiazepines
Pregnancy - risk of neonatal withdrawal symptoms.
breastfeeding - benzos are present in milk to ideally not to breastfeed while prescribed chlrodiazepoxide.
Hepatic impairment - dose reduced
Renal impairment - dose reduced
Skilled tasks - drowsiness may persist the next day and affect performance of skilled tasks.
What to do if warfarin is missed?
Appropriate to take dose later in the day.
- oxycodone is metabolised by the liver to inactive metabolites. Therefore it is good in the context of those with renal impairment.
Discuss bleeding risk, and patient to report any abnormal bleeding, and unusual headaches
Seek urgent medical attention if you’re taking warfarin and you have a fall or accident, experience a significant blow to your head, are unable to stop any bleeding, have signs of bleeding, such as bruising
Skin rashes and hair loss are also common side effects
Missed dose in warfarin?
- If evening doses is missed, take on the same day if remembered before midnight on the same day
- If midnight has passed, leave that dose and take your normal dose the next day at the usual time
Monitoring in Warfarin?
INR determined daily or on alternate days in early days,thenat longer intervals (depending on response),thenup to every 12 weeks.
Change in clinical condition, e.g liver disease, renal disease, intercurrent illness, or drug administration, necessitates more frequent testing
INR only indicates short-term control
Assessing impact of lunchtime dose of insulin?
Pre-evening meal capillary blood glucose would be the most likely time point to detect hypoglycaemia.
Anticoagulation in pregnancy?
LMWH - used because they do not cross the placenta.
Monitor anti-Factor Xa.
Dosed according to renal function.
Other anticoagulants are not recommended/contraindicated in pregnancy (apixaban, dabigatran edoxaban, rivaroxaban).
DMARDs in pregnancy?
Methotrexate Penicillamine Hydroxychloroqune Azathioprine Ciclosporin Leflunomide
Should not dual anticoagulate patients on apixaban!
No to apixaban and enoxaparin.
Management of Addisonian crisis?
Hydrocortisone is initial management. 100-500mg IM or IV.
Pregnancy antibiotics of UTI?
Nitrofurantoin - suitable in first and second trimesters - should be avoided at term.
Penicillin suitable but second line.
Sulphonamides - avoid during pregnancy
Trimethoprim - Avoid in first trimester. Avoid throughout
Treatment of neuropathic pain?
Dizziness and falls?
Increased fracture risk?
Drugs that interact with statin and increase risk of myopathies?
Poorly controlled hypertension?
Naproxen (salt and water retention)
Drugs not advised in pregnancy
- Methotrexate (Most DMARDs) penicillamine, hydroxychloroquine, azathioprine, ciclosporin, leflunomide, monoclonal antibodies.
Which drugs should not be prescribed with apixaban?
Do not dual prescribe antiplatelets.
Nausea and vomiting in pregnancy?
First line is Promethazine
COPD Oxygen level
28% oxygen via Venturi Mask
When converting morphine, add up total of regular and PRN.
Sick day rules for T1DM?
Never omit insulin
Maintain adequate fluid intake
Maintain regular carb intake.
Consider antiemetic if nauseated
Consider oral electrolyte replacement in diarrhoea
If prolonged inability to keep down fluids - likely needs hospital admission
Ketones testing 2-4 hrly.
Patients on oral antidiabetic medication - not including sulphonylureas?
Continue with medication as normal
- Encourage adequate fluid
- Consider providing an oral electrolyte replacement
Patients taking sulphonylureas?
- Minimum of daily self-blood glucose monitoring
- Advice should be provided regarding the increased risk of hypoglycaemia.
- Seek advice if blood glucose persistently elevated (e.g >17)
Patient taking insulin?
Never omit insulin
Emphasis on the importance of regular carb intake
Minimum twice daily self-blood glucose monitoring
Seek advice if blood glucose persistently elevated >17
Diabetic specialist nurse should provide individualised plan
C diff management?
First line - oral metronidazole
Second line - (intolerant to metro or severe/subsequent episodes) = Oral Vancomycin
Missed NOAC dose?
Take missed dose if it is more than 6rh until your next dose. If it is less than 6 hrs, skip the dose.
Missed dose - Take if on same day, do not double up
Seek medical attention if
- Pass melaena, haematemesis, haemoptysis, haematuria, PR bleeding.
- Prolonged >10 mins epistaxis, bleeding gums.
- Unusual headaches.
- Have a fall or an accident.
Rash and hair loss is common
Be wary of drug interaction
Be aware of leafy greens.
Do not binge drink
Increased dose of Sinemet - most likely side effect?
Dyskinesia - together with nausea.
Also falls but less common.
Neuroleptic Malignant Syndrome!
Causes by Antipsychotic drugs.
- Hyperthermia, fluctuating level of consciousness, muscle rigidity, autonomic dysfunction.
Management = Discontinuation of the antipsychotic drug - no proven effective treatment.
- Bromocriptine and dantrolene have been used.
Hyperreflexia - INCREASED REFLEXES
Altered mental state
Sumitriptan likely to interact with Paroxetine to increase risk of serotonin syndrome.
Manage with stopping offending medications, active cooling, possibly cyproheptadine.
Taking long term steroids what do you need?
Patient on digoxin for AF, currently admitted, what is the best way to manage her AF?
Starting a loading dose 250 micrograms IV.
Yellow green visual halos
Initial resp alkalosis, followed by severe metabolic acidosis.
N+V, hypoglycaemia, hyperpyrexia, non-cardio pulmonary oedema.
Use sodium bicarb when overdose level is not meeting criteria for haemodialysis
Monitoring of a pneumonia?
Monitoring of nitrates?
BLood pressure and pulse guide titrating IV GTN minute-to-minute.
Management of Raised ICP?
Intubate - Hyperventilation to decreased PaCO2
Fluid restrict <1.5L a day.
Dexamethasone 8-16/24hr if malignancy
Fluid to maintain BP and cerebral perfusion. Aim for SBP > 160.
Management of acute glaucoma?
Acetazolamide 500mg IV
Exacerbation of asthma?
Salbutamol nebs with O2
Is severe add Ipratropium
Hydrocortisone IV or Prednisolone PO
repeat salbutamol nebs every 15-30mins if PEFR <75%.
If poor response to initial therapy - Consider single dose MgSO4 1.2-2g.
If not improving - then consider ventilatory support - Aminophylline, IV salbutamol.
Exacerbation of COPD?
Ipratropium 0.5 mg/6hr
Hydrocortisone and prednisolone IV
Antibiotics if infection
Physiotherapy for sputum expectoration.
If no response - consider IV aminophylline
if no response - consider NIPPV if RR >30.
Secure airway 100% O2 Adrenaline IM 0.5mg = 0.5ml of 1:1000. Chlorphenamine 10mg IV Hydrocortisone 200mg
Acute pulmonary oedema?
Furosemide 40-80mg IV slowly
GTN spray 2 puff
Consider nitrate infusion if SBP >100.
Pulmonary Embolism management?
If haemodynamically untable consider thrombolysis
Morphine 5-10mg GTN Spray Aspirin 300mg and second antiplatelet (ticagrelol) Beta-blocker Fondaparinux 2.5mg or LMWH IV nitrate.
Broad Complex Tachycardia?
Correct Decreased K
Torsades De pointes?
Narrow Complex Tachy?
Adenosine if vagal manoeuvres unsuccessful.
Acute Upper GI bleed?
Give terlipressin + broad spectrum antibiotics
Management of DVT
- Enoxaparin 1.5mg/kg/24hrs or fondaparinux
- Start Warfarin and continue of 3 months.
Consider Aciclovir 10mg
IV bolus lorazepam
Then secon dose.
Then IV infusion - Phenytoin.
Fluid - 500ml saline bolus if SBP <90
Fluid - DKA = 1L over 1 hr, then 1 L over 2rh, 1L over 4 hrs.
Due to fluid deficit of 7L.
Fixed rate - 50u Actrapid to 50ml 0.9% saline.
Assess need for K replacement.
Conscious = 15-20g quick acting CHO snack.
If conscious and uncooperative –> glucose gel.
If unconscious –> 20-30 glucose IV 200ml-300ml of 20% dextrose.
Give T3 5-20 micrograms IV slowly.
Antithyroid = Carbimazole
Then Lugol’s solution
Hydrocortisone 100mg IV STAT
IV fluid bolus
Alpha blockade - Phentolamine
Then long acting alpha blocker - phenoxybenzamine.
10ml 10% calcium gluconate
10 units actrapid in 50ml 20% glucose.
B blocker overdose?
Atropine up to 3 mg
If major bleed - give prothrombin
Naloxone 0.4-2mg IV
Decreased cognitiion, yellow-green visual halos
Correct hypokalaemia to prevent arrhythmias.
Inactivate digoxin specific antibody fragments - DigiFab
Chlorpomazine - leading to dystonia (torticollis, retrocollis, glossopharyngeal dystonia, opisthotonus)?
Try procyclidine 5-10mg IM or IV
Vomiting, dehydration, hyperventilation.
Give activated charcoal if <1hr
Correct acidosis - alkalinisation of urine sodium bicarb.
Consider dialysis - >700.
> 3.5 and symptomatic
Correct dehydration wit hIV 0.9% saline
Use bisphosphonates to prevent bone resorption.
10ml 10% calcium gluconate IV over 2 mins
10 units Actrapid in 50ml 20% glucose
Salbutamol 10-20mg via nebulisers
Oral K+ Supplements e.g Sando K