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RESCUE PACK for COPD –> less lung damage, faster recovery, less admissions.
ANTIBIOTIC (non-macrolide if on prophylactic azithromycin)
- Amoxicillin 500mg three times daily for 5 days
- Doxycycline (Pen all) 200mg first day then 100mg daily total 5 days course
- Clarithromycin 500mg twice daily for 5 days
STEROID
- prednisolone 30mg (COPD) - 40mg (asthma)
PPI
Prophylactic antibiotics in COPD ?
Azithromycin
MOA: kills bacteria and reduce inflammation ()
Dose: 250mg THREE time a WEEK
Counsel: Prophylaxis to reduce chest infections and chest symptoms. Avoid indigestion/PPI within 2h
Interactions: theophylline, warfarin, digoxin, statins
doesn’t sig affect CYP450 like other macrocodes
Caution: severe hepatic/renal, QT interval
Criteria: pulmonary rehabilitation completed, 2+ exacerbation in 12m, non-smoker (won’t work if current smoker),
Medication that can affect QT interval
Quinolone, macrolide, azole antifungal or co-trimoxazole
Switching anti epileptic
Category 1: stay on same brand (CP3)
- Carbamazepine, Phenobarbital, Phenytoin, Primidone
Category 2: depends
Clobazam, Clonazepam, Eslicarbazepine, Lamotrigine, Oxcarbazepine, Perampanel, Retigabine, Rufinamide, Topiramate, Valproate, Zonisamide
Category 3: NO evidence to remain on same brand
Brivaracetam, Ethosuximide, Gabapentin, Lacosamide, Levetiracetam, Pregabalin, Tiagabine, Vigabatrin
Refeeding
= Severe electrolyte and fluid shift by rapid reintro (oral enteral or parental) [electrolytes move from extra to intracellular compartment] after little nutritional intake for 5+ days.
Muscarinic agents
SAMA = Ipratropium bromide (atrovent) (3-6 hours)
LAMA = Aclidinium (eklira) (12 hours),
Tiotropium (respimat, Braltus), Glycopyrronium (breezhaler), Umeclidinium (ellipta) – (24 hours)
SE: Dry mouth, headache, urinary retention, constipation
Caution: narrow angle glaucoma, GI motility disorder, BHP
Consider CV SE for px that can be affect by anticholinergic action (recent MI, arrhythmia or HF)
Interaction: beta2 agonist and xanthine (additive bronchodilatory)
Renal: (tiotropium caution eGFR <50mL/min [Tio] increases with decreased renal function); glycopyrronium caution eGFR<30mL/min).
- LAMAs are only licensed for COPD, with the exception of Spiriva Respimat® (tiotropium)
- SAMAs should be discontinued when long-acting antimuscarinic agents (LAMAs) are initiated.
Severity of Liver cirrhosis
Child-Pugh score assess severity of liver cirrhosis
considering (higher score if …): total bilrubin (high), serum albumin (low), INR (high), ascites, hepatic encephalopathy
Spontaneous bacterial peritonitis
= infection of ascites. WCC/Neutrophil in ascitic fluids.
Tx: Tazocin IV 4.5g tds (if severe) 5-7 days or Co-trimoxazole PO 960mg BD 5-7d
Prophylaxis: Co-trimoxazole PO 960mg OD
Ascites
Tx: spironolactone, furosemide
Discontinue all diuretics if there is severe hyponatremia, progressive renal failure, worsening hepatic encephalopathy or incapacitating muscle cramps
Rifaximin prevent episodes of Hepatic Encephalopathy (tx: lactulose).
Prokinetics Antiemetics
Prokinetics (metoclopramide and domperidone) should not be given concurrently with drugs with antimuscarinic activity (for example cyclizine, hyoscine) because antimuscarinic drugs competitively block the action of prokinetics.
Clozapine
Indication = Tx-resistant schizo, psychosis for parkinsons
Dose:
If >48hr, retitrate as tolerance to common SE
SE: Constipation, drowsiness, hypertension, increase in saliva production (tx 2 pillow, hyoscine) and weight gain.
WARNING SIGN: neutropenia (monitor FBC), agranulocytosis, intestinal obstruction
Interactions:
Potential to cause agranulocytosis: carbamazepine, co-trimoxazole, trimethoprim, chloramphenicol
Myelosuppressive drugs: carbamazepine
Risk of NMS: lithium
Causes constipation: anticholinergics, opioids
Reduce [Clozapine]: smoking
Increase [Clozapine]: liver enzyme inhibitors. esp CYP1A2 enzyme. SSRI (inhibit CYP2D6)
Insulin aspart (novorapid, Fiasp (with nicotinamide )
Indication: fast onest of action (when tight control required, if pt has rapid post meal BG increase)
T1 usual dose: 0.4 to 1 unit/kg/day with approximately 50% provided as prandial insulin (mealtime or bolus)
With Multiple daily injection – match prandial insulin dose to carb intake, pre-meal BG and anticipated activity
T2 usual dose (based on metabolic needs, blood glucose monitoring results, and glycemic goal)
Prandial Insulin: Initial dose: 4 units (or 10% of basal dose) subcutaneously with largest meal of the day. Titrate with additional injections of prandial insulin (i.e., 2, then 3) with meals.
Comparators: Apidra® (insulin glulisine) Humalog® (insulin lispro)
NICE: don’t advise routine us of RA insulin analogue after meals in T1DM adults
Which condition do you avoid Calcium channel blocker?
Dihydro (-pine) CI: cardiac outflow obstruction, uncontrolled HF
Rate limiting (diltiazem, verapamil): cardiac outflow obstruction, AF, HF, severe bradycardia, sick sinus syndrome, second- or third-degree AV block (unless pacemaker fitted)
Pt with Heart failure (with reduced EF) –> instead rx amlodipine
CCB caution: Elderly, hepatic impairment (dose adjustment)
CCB with exception of amlodipine, should be avoided in heart failure as they can further depress cardiac function and exacerbate symptoms. As they can also increase mortality after MI in patients with left ventricular dysfunction and pulmonary congestion.
Triple immunosupression
Steroid + biologic + thiopurine/methotrexate e.g CD
ADD co trimoxazole 480mg BD 3 days a week for Pneumocystis jirovecii prophylaxis {monitor renal and FBC}
Avoid live vaccines
Live vaccines
live vaccines = oral polio, yellow fever, BCG (tuberculosis), chickenpox, MMR (measles, mumps and rubella) and shingles.
Amlodipine & Simvastatin interaction
Simvastatin is metabolised by the cytochrome P-450 isoenzyme CYP3A4 and is very sensitive to the effects of CYP3A4 inhibitors.
Amlodipine is a weak inhibitor of CYP3A4.
Concurrent use of amlodipine and simvastatin causes a significant increase in blood levels of simvastatin.
Fluvastatin, pravastatin and rosuvastatin are not metabolised by CYP3A4 to any significant extent and they do not interact with amlodipine.
Medication Alzheimers pt should avoid. Anti——
Anti-cholinergics such as medication for insomnia stomach cramps, incontinence, asthma, motion sickness, and muscle spasms.
Side effects, such as confusion, can be serious for a person with Alzheimer’s
Cinacalcet (calcimimetics? = bone resorption inhibitors)
MOA: reduces parathyroid hormone –> decreases in serum calcium concentrations.
Indication: hyperparathyroidism, hypercalcaemia
CI: hypocalcaemia (caution esp if condition that worsen with hypo e.g. QT, Seizures, impaired cardiac function) –> Monitor [Ca]
Counsel: dizziness, sign of hypocalcaemia (paresthesia, muscle spasms, cramps, tetany, circumoral numbness, seizures.)
status epilepticus
treated if last >5m
Buccal midazolam is recommended by NICE as the first line treatment of prolonged or repeated seizures in the community, rectal diazepam is an alternative.
insulin sick day rules
DO NOT STOP TAKING your insulin (illness increases bodies need for insulin)
- test BG and urine for ketones every 2 hours
- Drink 2.5L per day, eat normally if smaller appetite replace solid with milk, fruit juice
- Avoid XS exercise
How to manage HypoKalaemia (<3.5)
Diet or potassium supplements (SE: N/V -> poor compliance)
(smaller dose if renal imp to reduce risk of hyperK)
IV (if need to treat more rapidly) potassium chloride with sodium chloride (not Glucose as will decrease K [ ] )
K sparing diuretic (amiloride, eplerenone, spironolactone) if kidney functioning normally and if caused by furosemide/ thiazide
Common cause (by inadequate potassium intake, increased potassium excretion, or a shift of potassium from the extracellular to the intracellular space): diuretics, vomiting/diarrhoea, CKD, DKA, insulin overdose, metabolic or respiratory alkalosis, chloroquine, antipsychotic drug (risperidone, quetiapine), amphotericin B, adrenal gland disorder, long term CS
Both extremes are related to risk of cardiac arrythmias
IMPT to compensate for K loss in pt taking antiarrythmic (digoxin), pt with XS loss of K in stool (lax abuse), elderly (low K in diet)
HyperKalaemia management >5.3mmol/L
1.IV Ca chloride/gluconate 10% [protect heart]
- to reduce K
2a. IV soluble insulin 5-10 units (actarapid?) + 50ml 50% glucose over 5-15m
2b. Salbutamol neb/slow IV - sodium bicarbonate [correct acidosis]
if mild-mod with no ECG change can use ion exchange resin to remove XS [K]
Management of Hyponatraemic
Check medication and fluid balance (osmolality)
Common causes: diuretic, ARB, TCA, SSRI, MAO inhibitor, PPI, anticonvulsant, xs water
Tx: Sodium chloride 0.9% infusion or balanced crystalloid solution (Hartmann)
Management of uncontrolled asthma
Signs: In last month: difficulty sleep ~ A(sthma) symptoms; usual A symptoms in daytime; interfered with usual activity?
–> Check diagnosis, inhaler technique, adherence, use of rescue med, lung function, exposure to trigger, SE.
–> think TTT (adherence to Therapy, inhaler Technique, eliminate Trigger), consider stepping up
Aim for lowest ICS dose for maintenance therapy
Move up if 3+ Salbutamol doses / wk
Step up if asthma uncontrolled 4-8 weeks
