Side Effects and Interactions

Question 1

What are some common side effects of statins (like atorvastatin)?

Answer 1

ARTHRALGIA, MYALGIA, MYOSITIS, nausea and vomiting, flatulence, constipation, GI discomfort

Question 2

What must you check before starting a patient on statins?

Answer 2

Lipid profile, triglyceride concentrations, liver function tests (LFTs), thyroid stimulating hormone (TSH) and renal function

Question 3

What must you check during statin treatment, and how often?

Answer 3

LFTs repeated three monthly and at 12 months. If >3 times the upper limit of normal, stop atorvastatin therapy.

Question 4

What is a concern in a patient taking statins who develops severe unexplained muscle pain (more than normal myalgia)?

Answer 4

Rhabdomyolysis

Question 5

What drug do statins commonly interact withand what effect does this have?

Answer 5

Macrolide antibiotics like clarithromycin - macrolides inhibit CYP450 enzymes in the liver, increasing the exposure to statins. This can trigger rhabdomyolysis.

Question 6

What are some common side effects of levothyroxine if given in excess?

Answer 6

Anxiety, restlessness, flushing, sweating, fine tremors, diarrhoea, nausea and vomiting

Question 7

What monitoring is required for patients taking levothyroxine, and how often?

Answer 7

TFT every 3 months until stable, then once yearly

Question 8

How can you manage the effects of excess levothyroxine?

Answer 8

Can reduce the dose
Can advise patients to take levothyroxine in the morning, 30 minutes before breakfast and drinks containing caffeine (absorption is reduced by food and caffeine)

Question 9

What can levothyroxine interact with?

Answer 9

Antacids, calcium, and iron supplements can affect absorption of levothyroxine

Question 10

What are some common side effects of PPIs like omeprazole?

Answer 10

Nausea & vomiting, stomach pain, constipation and flatulence

Question 11

What are some long term risks of PPIs like omeprazole? (including electrolyte imbalances)

Answer 11

Increased risk of osteoporosis, Clostridium difficile infection, hypomagnesaemia and vitamin B12 deficiency

Question 12

What are some common interactions with PPIs like omeprazole?

Answer 12

SSRIs - increases SSRI exposure as both are metabolised by the same enzyme
Clopidogrel - reduces it’s effectiveness as both are metabolised by the same enzyme (weirdly lansoprazole isn’t??)
Methotrexate - inhibits renal excretion of methotrexate so increases exposure

Question 13

What are some common side effects of calcium channel blockers?

Answer 13

Dizziness, flushing, palpitations, headaches, peripheral oedema (leg swelling)

(You can work it out if you think about what might happen as a result of vasodilation)

Question 14

What monitoring is required when patients take CCBs?

Answer 14

Regular blood pressure checks
It’s important to check that they don’t become too hypotensive if they’re on multiple anti-hypertensives

Question 15

What can amlodipine interact with?

Answer 15

Simvastatin - both inhibit the same enzyme which increases simvastatin levels, and increases risk of rhabdomyolysis

Question 16

What are the common side effects of ACE inhibitors like ramipril? (including electrolyte imbalances)

Answer 16

A dry cough due to bradykinin accumulation (change to ARBs!)
Hyperkalemia due to inhibition of aldosterone synthesis
Hypotension

Question 17

What is a serious side effect of ACE inhibitors like ramipril and how should it be managed?

Answer 17

Angioedema - it can compromise the airway so ACE inhibitors should be stopped immediately

Question 18

What should be monitored in a patient taking ACE inhibitors like ramipril?

Answer 18

Potassium levels

Question 19

Why might ACE inhibitors be useful in people with renal diseases/diabetes?

Answer 19

They are renally protective - they can decrease proteinuria and slow the progression of diabetic nephropathy.

Question 20

What can ACE inhibitors like ramipril interact with and what effect do they have?

Answer 20

NSAIDs - they reduce renal function and can exacerbate hyperkalaemia

Question 21

What are some common side effects of BBs like bisoprolol?

Answer 21

Coldness of the peripheries, headaches, syncope, erectile dysfunction, dizziness and hypotension, NIGHTMARES

Question 22

What condition are beta blockers contraindicated in?

Answer 22

Asthma - they can cause bronchospasm due to interactions with B2 receptors in the airway, leading to bronchoconstriction

Question 23

What should BBs not be prescribed with, and what might the effect be if they are?

Answer 23

Non-dihydropyridine CCBs (verapamil, diltiazem) or amiodarone - might cause complete heart block

Question 24

What are some common side effects of metformin?

Answer 24

Gastrointestinal and taste disturbances (metallic taste) are common when taking metformin. Metformin may cause B12 deficiency.
Weight loss

Question 25

What are some common side effects of ADHD medications (like methyphenidate, dexamfetamine, atomoxetine)?

Answer 25

Small increase in BP, appetite loss (and subsequent weight loss), trouble sleeping, headaches, stomach aches, feelings of aggression or anxiety

Question 26

What are is a serious side effect of atomoxetine for ADHD?

Answer 26

It might cause suicidal thoughts or liver damage

Question 27

What monitoring is required for children on ADHD medications?

Answer 27

Height, weight, heart rate and blood pressure after every dose change, or every 6 months

Question 28

What is a serious side effect of metformin and what are the symptoms?

Answer 28

Lactic acidosis - symptoms include abdominal pain, nausea, vomiting, shortness of breath and muscle cramps

Question 29

What should be monitored before and during metformin treatment? How often?

Answer 29

Renal function - checked before starting then monitored yearly It shouldn't be used if eGFR <30

Question 30

What can have serious interactions with metformin?

Answer 30

Intravenous contrast agents used in radiological investigations - both cause renal impairment and can increase the risk of lactic acidosis | (remember Dr Stan's story in LICP1)

Question 31

What are some common side effects of salbutamol? (including electrolyte imbalances)

Answer 31

Tachycardia, headaches and tremor due to coactivation of B1 receptors in the heart Hypokalemia in high doses ## Footnote Hypokalaemia is why it's used to treat hyperkalaemia

Question 32

What is a common side effect of inhaled corticosteroids for asthma and how can it be prevented?

Answer 32

Oral candidiasis can be prevented by rinsing your mouth out or brushing your teeth after using the inhaler

Question 33

What is a common side effect of GTN spray?

Answer 33

Headaches (very common) Feeling dizzy, weak, tired or sleepy Feeling sick (nausea) Red face (flushing) Just think about what might occur as a result of vasodilation.

Question 34

What are some side effects of bisphosphonates? (including electrolyte imbalances)

Answer 34

Hypocalcaemia, bone/joint pain, diarrhoea, fatigue, nausea and vomiting

Question 35

What are some long term (but rare) effects of bisphosphonates?

Answer 35

Osteonecrosis of the jaw, atypical femoral fractures

Question 36

What is a side effect of amitriptyline?

Answer 36

Feeling drowsy/sleepy is very common. Also: Constipation, dizziness, dry mouth, difficulty urinating, headache

Question 37

What is a side effect of alpha blockers like tamsulosin?

Answer 37

Postural hypotension (so not prescribed in people with low blood pressure) Retrograde ejaculation

Question 38

What are some side effects of chemotherapy?

Answer 38

Alopecia, nausea, vomiting, fatigue, neutropenia, sexual dysfunction, increased infection susceptibility, anemia

Question 39

Why is carbimazole contraindicated in pregnant women?

Answer 39

It's teratogenic

Question 40

What is a common side effect of carbimazole and PTU for hyperthyroidism? What are the symptoms?

Answer 40

Agranulocytosis Manifests as a sore throat, fever, mouth ulcers

Question 41

What are some side effects of systemic steroids?

Answer 41

Peripheral oedema in the legs Hypertension Problems with mood swings, memory, behavior, and other psychological effects, such as confusion or delirium. Stomach disturbances Weight gain in the abdomen, face and back of the neck Proximal myopathy/weakness Osteoporosis

Question 42

What are some side effects of topical steroids?

Answer 42

Thinning of the skin which can make the skin more prone to tearing, bruising, stretch marks or flaring in future. Can also cause telaniectasia

Question 43

What is a common side effect of sulphonylureas like gliclazide?

Answer 43

Hypoglycaemia

Question 44

What is a rare side effect of SGLT2 inhibitors?

Answer 44

Necrotising fasciitis of the genitals (Fournier's gangrene)