Top 100 Drugs Flashcards

Question

What is the mechanism of action of Adrenaline (epinephrine)?

Answer 1

Potent agonist of the a1, a2, b1 and b2 adrenoceptors and has a multitude of sympathetic fight of flight affects. a1 - vasoconstriction of vessles subblying skin, mucosa and abdominal viscera b1 - increases heart rate, force of contration and myocardial excitability b2 - vasodilatation of vessels supplying the heart and muscles Allows redistribution of blood flow in favour of the heat. Bronchodilatation and suppressin of inflammatory mediator release from mast cells - b2 for anaphylaxis.

Answer 2

Adrenaline-induced hypertenson Anxiety, tremor, headache, palpitations Angina, myocardial infarction and arrhythmias (esp. with existing heart disease)

Answer 3

None in Cardiac arrest and anaphylaxis Should be used in caution in heart disease As a combination with local anaesthetic should not be used in areas supplied by an end-artery

Answer 4

Beta-blocker, may induce widespread vasoconstriction because a1 mediated vasoconstricting effect is not oppsoed by b2-mediated vasodilatation.

Answer 5

Shockable rhythm: 1mg IV given after 3rd shock, repeated 3-5 minutes thereafter. None shockable (asystole or PEA): 1mg IV as soon as access attained, repeated 3-5 minutes thereafter. Anaphylaxis: 500 micrograms IM, repeated after 5 minutes.

Answer 6

Intensive clinical and haemodynamic monitoring

Answer 7

(One) Spironolactone Epleronone

Answer 8

(Spironolactone, Epleronone) 1. Ascites and oedema due to liver cirrhosis: spironolactone 2. Chronic heart failure: (with a b-blocker and ace-i/arb) 3. Primary hyperaldosteronism, Conn's syndrome: for patients awaiting surgery or not an option.

Answer 9

(Spironolactone, Epleronone) Aldosterone is a mineralocorticoid produced in the adrenal cortex, acts on receptors in the distal tubules of the kidney to increase the activity of luminal epithelia sodium channels (ENaC). This increases the reabsorption of sodium and water (which elevates blood pressure) with the by-product of increased potassium excretion. **Aldosterone antagonists inhibit the effect of aldosteone by competitively binding to the aldosterone receptor.** This increases sodium and water excretion and potassium retention.

Answer 10

Hyperkalemia (increased potassium absorption): Can cause muscle weakness, arrhythmias and cardiac arrest. Gynaecomastia (impact on adherence) Liver impairment, jauncide and a cause of Stevens-Johnson syndrome

Answer 11

Severe renal impairment Hyperkalaemia Addison's disease (who are aldosterone deficient) Warning: pregnant and lactating women

Answer 12

(Spironolactone, Epleronone) Can interact with other potassium-elevating drugs, including ACE inhibitors and ARBs, increasing the risk of hyperkalemia. Should not be combined with potassium supplements.

Answer 13

Spironolactone - all indications Oral, OD (25mg (HF) -100mg (Ascites) depending on indication)

Answer 14

Men: gynaecomastia and impotence. Regular blood tests to check for hyperkalaemia.

Answer 15

Monitoring of symptoms and clinical findings: Reduction in ascites, oedema and or blood pressure. Monitoring of renal function and serum potassium due to risk of renal impairment and hyperkalaemia.

Answer 16

Week diuretic so usually combined with a loop or thiazide diuretic where it counteracts the potassium wasting and potentiates with diuretic effect. E.g. in ascites, Spironolactone and Furosemide are typically used together.

Answer 17

Gaviscon and Peptac

Answer 18

Gastro-oesophageal reflux disease: for symptomatic relief of heartburn Dyspepsia: short-term relief of indigestion

Answer 19

(Gaviscon and Peptac) Combination of alginate and antacid. Work by buffering stomach acids and increasing the viscosity of the stomach contents reducing the reflux of stomach acid into the oesophagus.

Answer 20

Sometimes GI side effects, constipation or diarrhoea.

Answer 21

In infants not with thickened milk Sodium and potassium containing preparations should be used with caution in patients with renal failure.

Answer 22

Can intefere with several other drugs so should be taken at different times where possible.

Answer 23

Instructions on bottle, only proprietary formulas available. Taken following meals, before bedtime and/or when symptoms occur.

Answer 24

Advice that symptomatic relief and only temporary measure. Discuss lifestyle measures: smaller meals, avoiding trigger food and drink, stop smoking, raise head of bed. Leave a gap of at least 2 hours between these and other medicines. Red flags: bleeding, vomiting, dysphagia, weight loss.

Answer 25

To prevent acute attacks of gout (not given during attack) To prevent uric acid and calcium oxylate renal stones To prevent hyperuricaemia and tumour lysis syndrome associated with chemotherapy

Answer 26

Xanthine oxidase inhibitor Lowers plasma uric acid concentration and reduces precipitation of uric acid in the joints or kidneys.

Answer 27

Skin rash - may be milf or sign of SJ syndrome or toxic epidermal necrolysis. Drug hypersensitivity syndrome Starting allopurinol can trigger or worsen an acute gout attack.

Answer 28

Sould not be started during an acute attack (can be continued if on already) Recurrent skin rash or severe hyposensitivity Warnings: severe renal and hepatic impairment.

Answer 29

Mercaptopurine and Azathioprine (increased risk of toxicity) Others increase the risk of rash.

Answer 30

PO, 100-600 mg daily in 1-2 divided doses. Titrate to serum uric acid concentration. For gout: co-prescribe with NSAID or colchicine. Take with meals and good fluid intake.

Answer 31

Purpose is to reduce attacks of gout or formation of kidney stones Seek medical advice if there is the formation of a rash. Do not stop if they get an acute attack.

Answer 32

Serum uric acid concentrations should be checked 4 weeks after starting or after a change in dose, aim to achieve levels of \<300 micromol/L. Stop-and-restart if there is the formation of a mild rash.

Answer 33

Thiazide or loop diuretics Aspirin

Answer 34

(Sin) Doxazosin Tamsulosin Alfuzosin

Answer 35

First-line medical symptomatic improvement in Benign Prostatic Hyperplasia. (After lifestyle changes) (+ 5a-reductase inhibitors in some cases) Add on in resistent hypertension (After CCB, ACE-i/ARB, thiazide diuretics)

Answer 36

Highly selective for a1-adrenoceptor Found mainly in smooth muscle, including blood vessels and urinary tract (bladder neck and prostate) Blockade induced relaxation of this smooth muscle Cause vasodilatation and reduce resistance to bladder outflow.

Answer 37

Postural hypotension Dizziness Syncope

Answer 38

Should not be used in patients with pre-existing postural hypotension.

Answer 39

May combine to cause intense postural hypotension when first started, it may be wise to miss dose of beta-blocker on day of starting.

Answer 40

PO, Doxazosin (both) Tamsulosin (BPH only) Doxazosin: 1mg daily, increased at 1-2 weeks intervals according to response. Tamsulosin: 400 micrograms PO, daily. Take at bedtime to reduce effect of postural hypotension.

Answer 41

Postural hypotension, take at bedtime

Answer 42

Symptom control or blood pressure Adverse effect of PH can be measured in lying and standing blood pressure

Answer 43

Gentamycin, amikacin.

Answer 44

Severe, gram-negative aerobe infections (including pseudomonas aeruginosa) Not effective against anaerobes.

Answer 45

(Gentamycin, Amikacin) Severe infections, caused by gram-negative aerobes: Severe sepsis (inc. unidentified source) Pyelonephritis and complicated UTIs Biliary and intra-abdominal Sepsis Endocarditis

Answer 46

(Gentamycin, amikacin) Lack activity against streptococci and anaerobes, so should be combined with **penecillin and/or metronidazole** when the organism is unknown.

Answer 47

Bind irreversibly to bacterial ribosomes and inhibit protein synthesis. Efffect gram-negative aerobic bacteria, staphylococci and mycobacteria (TB). Enter cells via oxygen-dependent transport systems so only aerobes.

Answer 48

(Gentamycin, amikacin) Nephrotoxicity and Ototoxicty Present as reduced urine output and rising serum creatinine and urea. Or, hearing loss, tinnitus and/or vertigo.

Answer 49

(Gentamycin, amikacin) Renally excreted and can cause nephrotixicity More likely in neonates, the elderly and those with renal impairment. Avoid in myasthenia gravis.

Answer 50

(Gentamycin, Amikacin) Adverse effects more likely with: loop-diuretics, vancomycin, ciclospirin, cephaosporins.

Answer 51

No oral form, OD IV infusion. Calculated on weight (or ideal weight for height if obese) and renal function. Somewhere between 3-5 mg/kg typically. Time between doses is determined with drug level monitoring, usually 24hr but may be more with renal impairment. Usually 7 days or less to reduce risk of toxicity. Diluted and infused slowly to redue ototoxicity.

Answer 52

(Gentamycin, Amikacin) To treat infection Report any change in hearing or dizziness. Blood tests required as dosing depends on plasma concentrations. IV so requires inpatient stay.

Answer 53

(Gentamycin, Amikacin) For efficacy - symptoms and signs e.g. pyrexia and blood inflammatory markers e.g. c-reactive protein Renal function before and during Plasma drug concentration to assess when next dose is required (\<1 mg/mL) if too high withold for longer.

Answer 54

(Salazine) Mesalazine Sulfasalazine

Answer 55

(Mesalazine, Sulfasalazine) Mesalazine: 1st line in mild-to-moderate Ulcerative Colitis Sulfasalazine: Rheumatoid arthritis as a DMARD combination therapy.

Answer 56

(Mesalazine, Sulfasalazine) Release 5-aminosalicyclic acid which is thought to have anti-inflammatory and immunosuppresive effects.

Answer 57

(Mesalazine, Sulfasalazine) GI side effects, headache Rare: Leucopenia, thrombocytopenia Renal impairment Oligospermia Hypersensitivity reaction

Answer 58

(Mesalazine, Sulfasalazine) Salicylates like aspirin Should be avoided in aspirin hypersensivity

Answer 59

PPIs and Lactulose

Answer 60

(Mesalazine, Sulfasalazine) Mesalasine: Enema. suppository or oral. Taken for 4-6 weeks to induce remission. Sulfasalazine: Specialist

Answer 61

(Mesalazine, Sulfasalazine) Make sure understand and happy with rectal administration if this route. Report any bleeding, bruising of infective symptoms as could be a sign of leucopena or throbocytopenia.

Answer 62

Symptoms in UC RA symptoms plus the c-reactive protein concentraton Real function should be checked and FBC + liver function tests.

Answer 63

Management for a wide range of tachycardias including AF, atrial flutter, SVT, VT and refractory ventricular fibrilation (VF). Used only when other theraputic options (drugs or electrical cardioversion) are ineffective or inappropriate. In cardiac arrest after 3rd shock in VF or pulseless VT.

Answer 64

Myocardial cells: blockade of sodium, calcium and potassium channels, and antagonism of a and b adrenergic receptors. Reduce spontaneous depolarisation, slow conduction velocity, increase resistance to depolarisation. Reduced the ventricular rate in AF and atrial flutter. Increases chance of conversion to sinus rhythm in SVT.

Answer 65

Hypotension during IV infusion (less than Adenosine) Chronic use: pneumonitis, bradycardia, AV block, hepatitis, skin photosensitivity and grey discolouration, thyroid abnormalities. May take months to completely eliminate.

Answer 66

Avoided in patients with severe hypotension, heart block and active thyroid disease. (High risk drug)

Answer 67

Many drugs, very interactive. Increases plasma concentrations of digoxin, diltiazem and verapamil. May increase the risk of bradycardia, AV block and heart failure.

Answer 68

Requires senior involvement. Unless: Cardiac arrest when given for VF or pulseless VT immediately after 3rd shock in ALS algorhythm. 300mg IV with flush, peripheral line. For repeated or continuous infusion should be given via central line.

Answer 69

Treatment to correct their fast or irregular heart rhythm. Number of important and potentially serious side effects and being used as condition is serious and no other treatments are suitable. Report signs of breathlessness, cough, jaundice, restlessness, weight loss, tiredness or weight gain. Don't drink grapefruit juice and be careful with sun exposure

Answer 70

Efficacy: Heart rate and rhythm Safety: IV infusion accompanied by continious cardiac monitoring Long-term: Renal, liver and thyroid profiles and chest-x ray Liver and thyroid profiles repeated 6 monthly.

Answer 71

(Pril) Ramipril Lisinopril Perindopril

Answer 72

1. Hypertension - 1st or 2nd line treatment to reduce the risk of stroke, MI and death from CVD 2. Chronic heart failure - 1st line treatment of all grades of heart failure 3. Ischaemic heart disease - to reduce the risk of subsequent cardiovascular events such as MI and stroke 4. Diabetic nephropathy and CKD with proteinuria: to reduce proteinuria and progression of nephropathy.

Answer 73

ACE inhibitors block the action of ACE, to prevent the coversion of angiotensin I to angiotensin II. Aniotensin II is a vasoconstrictor and stimulates aldosterone secretion. Blocking its action preduced peripheral vascular resistance (afterload), which lowers blood pressure. Also dilates the efferent glomerular arteriole which reduces intraglomerular pressure and slows progression of CKD. Reducing aldosterone level promotes sodium and water excretion (and causes K+ retention) which can help reduce venous return (preload), having a beneficial affect in heart failure.

Answer 74

Hypotension (esp. after 1st dose) Persistent dry cough Hyperkalaemia (lowered aldosterone) Can cause or worsen renal failure and CI in renal artery stenosis. Rare: angioedema and anaphylactoid reactions

Answer 75

Should be avoided in patients with renal artery stenosis or acute kidney indury (can be used in chronic) Avoid in pregnancy and breastfeeding Lower doses in chronic kidney disease Avoid with potassium elevated drugs and potassium sparing diurets.

Answer 76

Avoid with potassiuum elevating drugs and potassium-sparing diuretics due to the risk of hyperkalarmia. Avoid with NSAIDs as increases the risk of renal failure.

Answer 77

PO 1.25-2.5mg depending on indication Titrated up to 10mg daily over a period of weeks based on response, side-effects and renal function Take before bed, PO, OD to reduce symptomatic hypotension.

Answer 78

Efficacy: breathlessness, blood pressure Safety: electrolytes and renal function, repeat 1-2 weeks into treatment and after increasing the dose. (creatine concentration and eGFR).

Answer 79

Taking diuretics such as look diuretics and those with limited salt and water intake. Start at low dose, at bedtime and increase gradually.

Answer 80

(Sartan) Losartan Candesartan Irbesartan

Answer 81

Used when ACE inhibitors are not tolerated due to cough, the indications are the same. 1. Hypertension - 1st or 2nd line treatment to reduce the risk of stroke, MI and death from CVD 2. Chronic heart failure - 1st line treatment of all grades of heart failure 3. Ischaemic heart disease - to reduce the risk of subsequent cardiovascular events such as MI and stroke 4. Diabetic nephropathy and CKD with proteinuria: to reduce proteinuria and progression of nephropathy.

Answer 82

ARBs block the action of angiotensin II on the AT1 receptor. Aniotensin II is a vasoconstrictor and stimulates aldosterone secretion. Blocking its action preduced peripheral vascular resistance (afterload), which lowers blood pressure. Also dilates the efferent glomerular arteriole which reduces intraglomerular pressure and slows progression of CKD. Reducing aldosterone level promotes sodium and water excretion (and causes K+ retention) which can help reduce venous return (preload), having a beneficial affect in heart failure.

Answer 83

Can cause hypotension (esp. 1st dose) Hyperkalaemia (due to less aldosterone) Renal failure (No dry cough or angioedema like ACEi s)

Answer 84

Avoided in patients with renal artery stenosis and AKI (can cause or make worse) Unsuitable in pregnancy and breasfeeding May be used as part of treatment of CKD but in reduced doses with careful monitoring.

Answer 85

Avoid with potassium-elevating drugs, including potassium supplements and potassium sparing diuretics. (Hyperkalaemia) Avoid with NSAIDs as increases risk of AKI.

Answer 86

PO 12.5 - 50 mg depending on indcation Titrated up to the maxiumum dose over a number of weeks accordings to response, side effects and renal function. Take before bed to help avoid hypotension.

Answer 87

Improve BP and reduce strain on heart Risk of dizziness/hypotension - take at night Need for blood test monitoring as can affect kidneys Don't take OTC NSAIDs to reduce the risk of kidney damage

Answer 88

Effiicacy: reduction of breathlessness in HF and improved BP in HTN. Safely: Electrolytes and renal fucntion before starting treatment, check 1-2 weeks into treatment and after increasing the dose. (eGFR and creatinine concetration)

Answer 89

In black people of African or Caribbean origin there is a reduced risk of angioedema as compared to ACEi (though CCB is still 1st line).

Answer 90

(Pram, Ine) Citalopram, Fluoxetine, Sertraline, Escitalopram

Answer 91

1st line treatment for moderate-to-severe depression, mild if psychological treatment fails Panic disorder Obsessive Compulsive Disorder

Answer 92

SSRIs preferentially inhibit neuronal reuptake of serotonin (5-HT) from the synaptic claft, increasing its availability for neurostransmission.

Answer 93

Fewer adverse effects and less dangerous in overdose

Answer 94

GI upset Appetite and weight disturbance (loss or gain) Hypersensitivity reactions Hyponatremia (elderly, confusion and reduced consiousness) Suicidal thoughts/behaviours (particularly young and on starting) Lowering of seizure threshold Prolonging of QT interval can cause arrhythmias Increase risk of bleeding Serotinin syndrome in high doses or overdose (or combined)

Answer 95

Autonomic hyperactivity Altered mental state Neuromuscular excitation

Answer 96

GI Upset Neurological and Influenza-like symptoms Sleep disturbance

Answer 97

Epilepsy (lowers seizure threshold) Peptic ulcer disease Young people - suicidal ideation Hepatic impairment (All cautions)

Answer 98

Monoamine oxidase inhibitors - increase risk of serotonin syndrome Gastroprotection when given with aspirin or NSAIDs Bleeding risk with anticoagulants Should not be given with other drugs prolonguing the QT interval, such as antipsychotics.

Answer 99

PO, OD Started small dose and increased approx. 20-100 mg.

Answer 100

Should improve symptoms over a few weeks, particularly sleep and appetite. Offer psychologicaal therapy in conjunction. Must take for 6 months after depression is gone, then stopped gradually over 4 weeks. Side effects may be unpleasant but it is wide to persist with treatment.

Answer 101

Symptoms should be reviewed 1-2 weeks after starting. If no effect seen by 4 weeks the drug or dose should be changed, otherwise the dose should not be adjusted till 6-8 weeks of therapy.

Answer 102

Amitriptyline Lofepramine

Answer 103

(Amitriptyline, Lofepramine) 2nd line treatment for moderate-to-severe depression where 1st line SSRIs are ineffective Treatment option for neuropathic pain though unlicenced

Answer 104

Inhibit neuronal reuptake of serotonin (5-HT) and noradrenaline from the synaptic cleft, thereby increasing availability for neurotransmission. Also block other receptors causing extensive adverse effect profile (see adverse effects)

Answer 105

Blockade of antimuscarinic receptors: Dry mouth, constipation, urinary retention, blurred vision. Sedation, hypotensin, arrythmias, ECG changes Convulsions, hallucinations, mania Breast changes, sexual dysfunction, extrapyramidal side effects VERY DANGEROUS IN OVERDOSE: Severe hypotension, arrhythmias, convulsions, coma, respiratory failure. Sudden withdrawal can cause GI upset, neurological and influeza-like symptoms and sleep disturbance

Answer 106

Elderly Cardiovascular disease Epilepsy Constipation Prostatic hypertrophy Raised intraocular pressure

Answer 107

Should not be gieevn with Monoamine oxidase inhibitors - hypertension, hyperthermia, serotonin syndrome. Also interact with more other drugs.

Answer 108

Only when SSRIs are ineffective, more dangerous in overdose. Loferamine preferred for depression. Neuropathic pain: Amitriptyline at low dose e.g. 10mg at night instead of around 75 mg for depression. Prescribe in small quantities to reduce the risk of overdose.

Answer 109

Will improve over a few weeks Also offer psychological therapy Should carry on for 6 months after they feel better. Warn them not to stop suddenly as this may cause withdrawal symptoms - reduce slowly over 4 weeks. Side effects may be unpleasant but should be encouraged to persist.

Answer 110

Should be reviewed 1-2 weeks after starting treatment, changed if no effect at 4.

Answer 111

Two main ones Venlafaxine (SNRIs) Mirtazapine (Atypical)

Answer 112

As an option for the treatment of major depression where the 1st line SSRIs are ineffective or not tollerated Generalised anxiety disorder (Venlafaxine)

Answer 113

SNRI and Atypical Both increase the availability of monoamines for neurotransmission, improving mood and physical symptoms in moderate-to-severe depression.

Answer 114

GI Upset Dry mouth, nausea, change in weight, diarrhoae or constipation CNS effects Headache, Abnormal dreams, insomnia, confusion and convulsions Hyponatremia Serotonin syndrome Suicidal thoughts and behaviours may increase Venlafaxine can increase QT interval and cause arrythmias Sudden withdrawal can cause - GI upset, neurological and infuenza-like symptoms.

Answer 115

Elderly at increased risk of adverse events Dose reduction in hepatic or renal impairment Cardiovascular disease, increased risk of arrythmias.

Answer 116

With other antidepressants can increase the risk of seratonin syndrome.

Answer 117

PO, Not 1st line. Started at a low dose Venlafaxine (37.5 mg PO, BD) increased to up to 375mg daily. Mirtazapine 15 mg PO up to 45 mg PO OD.

Answer 118

Improve over few weeks ALso psychological therapy Continue after 6 months of feeling better then discontinue over 4 weeks. May have to persist through unpleasant side effects. Seditive effect with Mirtazapine.

Answer 119

Metoclopramide Domperidone

Answer 120

(Metoclopramide, Domperidone) Prophylaxis and treatment of nausea and vomiting particulrly in the context of reduced gut motility and where this may be caused by dugs (opioids or diabetic gastroparesis) (Can be used in GORD not responding to conventional treatment)

Answer 121

(Metoclopramide, Domperidone) Reduced activation of the chemoreceptor trigger zone (CTZ) Prokinetic effect - promoting gastric emptying Effective in nausea and vomiting due to CTZ stimulation (e.g. due to drugs) and reduced gut motility (e.g. due to opioids or diabetic gastroparesis)

Answer 122

(Metoclopramide, Domperidone) Diarrhoea - most common Metoclopramide - extrapyramidal symtoms through the same mechaism as antipsychotics - acute dystonic reaction such as oculoyric crisis. (Domperidone less likely to cause these effects)

Answer 123

Extrapyramideal side effects more common in children and young adults (Metoclopramide) Due to prokinetic effect contraindicated in GI obstruction and perforation.

Answer 124

(Metoclopramide, Domperidone) Metoclopramide only: Antipsychotics - increased risk of extrapyramidal side effects CI with dopaminergic agents of Parkinson's disease as will antagonise the effects

Answer 125

(Metoclopramide, Domperidone) Starting dose 10 mg up to TDS Metoclopramide IM/IV Domperidone PO or Rectal (Oral route not suitable if actively vomiting) Should be given slowly over two minutes IV.

Answer 126

(Metoclopramide, Domperidone) Anti-sickness medicine Watch out for extra-pyramidal side effects with Metoclopramide

Answer 127

Resolution of symptoms, if prolongued should monitor for extrapyramidal features.

Answer 128

(Zine - think sounds like histamine) Cyclizine Cinnarizine Promethazine

Answer 129

(Cyclizine, Promethazine) Prophylaxis and treatment of nausea and vomitting, particulaly in the context of motion sickness and vertigo.

Answer 130

(Cyclizine, Promethazine) Histamine and acetylcholine receptors in the vomiting centre, these are blocked by these drugs reducing the communication with the vestibular centre. Effective in range of conditions (e.g. drug-induced, post-operative, radiotherapy) but most when associated with motion or vertigo

Answer 131

(Cyclizine, Promethazine) Drowsiness Dry throat and mouth Transient tachycardia noticed as palpitations Some excitation or depression

Answer 132

Sedating effect Avoided in hepatic encephalopathy and prostatic hypertrophy.

Answer 133

(Cyclizine, Promethazine) Sedation may be greated when combined with other sedating drugs e.g. benzodiazepines, opioids Avoid with 'tropiums'

Answer 134

Cyclizine 50 mg 8 hourly as required - given PO, IV, IM. PO inappropriate if actively vomitting IM injections are painful and rapid IV are unpleasant so SLOW IV is okay (2 minutes).

Answer 135

Anti-sickness medicine May not work for everyone, keep check of symptoms Advise that they can cause drowsiness and impair the ability to perform tasks such as driving which they should avoid

Answer 136

Hyoscine hydrobromide (an antimuscarinic drug) alternative and effective treatment for motion sickness.

Answer 137

Prochlorperazine Chlorpromazine

Answer 138

(Prochlorperazine, Chlorpromazine) 1. Prophylaxis and treatment of nausea and vomiting in a wide range of conditions, particularly due to vertigo. Due to side-effect profile others are usually used first-line. 2. Psychotic disorders, such as schizophrenia, where they are used as first-generation (typical) antipsychotics

Answer 139

Blockade of various receptors in the vomiting and vestibular centre. Dopamine, Histamine, Acetylcholine Useful in chemotherapy, radiotherapy and vertigo.

Answer 140

Drowsiness, postural hypotension Extrapyramidal syndromes (Same mechanism as other typical antipsychotics) - acute dystonic reactions such as oculogyric crisis. Long-term (as antipsychotic) can cause tardive dyskinesia. QT-interval prolongation (as will all antipsychotics)

Answer 141

Hepatotoxicity - avoid in severe liver disease Avoin in prostatic hypertrophy Dose reduction in the elderly

Answer 142

Extensive list of interactions - be wary with other drugs prolonguing the QT interval including - antipsychotics, amiodarone, ciprofloxacin, macrolides, quinine and SSRIs.

Answer 143

Seek senior advice as other drugs can be tried first. 20 mg PO or 12.5 mg IM then further doses IM injection into large muscle

Answer 144

Anti-sickness medicine Discuss drowsiness and diziness on standing Stop taking if any extra pyramidal side effects (muscle spasms or movement abnormalities)

Answer 145

Resolution of symptoms Monitor for extrapyramidal side effects

Answer 146

Ondansetron Granisetron

Answer 147

(Ondansetron, Granisetron) Prophylaxis and treatment of nausea and vomiting, particularly in the context of general anaesthesia and chemotherapy

Answer 148

(Ondansetron, Granisetron) Serotonin receptors in the CTZ, also released in the gut to emetogenic stimuli. Useful against nausea and vomiting due to CTX stimulation (e.g. drugs) and visceral stimuli (gut infection, radiotherapy) but not in motion sickness.

Answer 149

(Ondansetron, Granisetron) Constipation, diarrhoea and headaches can occur.

Answer 150

(Ondansetron, Granisetron) Small risk of prolonguing the QT interval, so should be avoided in patients with a long QT-interval. Also avoid in patients already taking drugs that prolongue the qt interval.

Answer 151

Ondansetron 4-8 mg, BD, PO or IV May be higher if chemotherapy induced IV \> IM as less painful - Oral should be given in advance of end of general anaesthesia

Answer 152

Ondansetron

Answer 153

Clotrimazole Fluconazole Nystatin

Answer 154

1. Treatment of local fungal infections (e.g. thrush) of the oropharyn, vagina or ski. They may be applied topically (nystatin, clotrimazole) or taken orall (fluconazole) 2. Systemic treatment of invasive or disseminated fungal infections - specialist treatment is required.

Answer 155

(Clotrimazole, Fluconazole, Nystatin) Target ergosterol on fungal cell membranes. (Resistance to antifungals can happen in long-term treatment in immunosuppressed patients)

Answer 156

(Clotrimazole, Fluconazole, Nystatin) Topical: local irritation Oral (Fluconazole): GI upset, headach, hepatitis, hypersensitivity Rarely: severe hepatic toxicity and prolonged QT interval.

Answer 157

Nystatin and Clotrimazole have no major CIs Fluconazole caution in liver disease, avoided in pregnancy.

Answer 158

Fluconazole (Check BNF): Inhibits cytochrome P450 enzymes - increase in concentration of drugs metabolised by these Increased risk of arrythmias is prescribed with drugs lengthening QT interval

Answer 159

(Clotrimazole, Fluconazole, Nystatin) Nystatin - Oral or topical thrush - check BNF Clotrimazole - Oral, topical, pessary - check BNF Fluconazole - 150mg or 50mg longer course - check BNF (Reasonably complex and depending on indication so check BNF for these)

Answer 160

After food and held in the mouth to allow good contact with lesions, dentures should be removed.

Answer 161

(Clotrimazole, Fluconazole, Nystatin) Treatment may take 1-2 weeks for skin infections after symptoms resolve If prolongued course of Fluconazole look out for signs of liver poisoining inc: nausea, loss of appetitie, lethargy or dark urine.

Answer 162

Efficacy: clinical symptoms Fluconazole: liver enzymes before and during prolongued courses of treatment to assess for hepatic toxicity

Answer 163

Elderly in hospital Antibiotics and systemic or inhaled corticosteroids Antimuscarinics reduce saliva Encourage mouth care and prescribe nystatin to promote recovery

Answer 164

Cetirizine Loratadine Fexofenadine Chlorphenamine

Answer 165

(Certirizine, Loratadine, Fexofenadine, Chlorphenamine) 1. First-line treatment for allergies inc. hayfever (seasonal allergic rhinitis) 2. To relieve itchiness (pruritis) and hives (urticaria) due to insect bites, infections (e.g. chicken pox) and drug allergies 3. Adjunct treatment in anaphylaxis with adrenaline 4. Other drugs in class may be used for nausea and vomitting (Antiemetics, histamine H1-receptor antagonisits) - Cyclizine, cinnarizine, promthazine.

Answer 166

(Certirizine, Loratadine, Fexofenadine, Chlorphenamine) Antagonist of the H1-receptor Histamine induces the features of immediate-type (type 1) hypersensitivity, they block these effects.

Answer 167

(Certirizine, Loratadine, Fexofenadine, Chlorphenamine) 1st generation (e.g. chlorphenamine) causes sedation. Newer ones (Loratadine, Fexofenadine, Certirizine) do not have such a sedetive effect.

Answer 168

Safe in most patients 1st generation - Chlorphenamine Avoid in severe liver disease (as can cause hepatic encephalopathy) and in people operating heavy machinery.

Answer 169

(Cetirizine, Loratadine, Fexofenadine, Chlorphenamine) Cetirizine 10 mg, Loratidine 10 mg, Chlorphenamine 4 mg tablets and 2mg/5ml solution - can be purchased OTC without prescription. PO, OD (Chlorphenamine 4-6 hourly) Chlorphenamine 10 mg IV or IM in anaphylaxis (with adrenaline)

Answer 170

(Cetirizine, Loratadine, Fexofenadine, Chlorphenamine) Treatment to relive allergic symptoms Chlorphenamine - may become tired and lost concentration - avoid if driving or other tasts, avoid combining with alcohol Cheaper to buy from a pharmacist over prescriptions.

Answer 171

Loperamide, Codeine Phosphate

Answer 172

(Loperamide, Codeine Phosphate) Symptomatic treatment for diarrhoea, in the context of IBS or viral gastroenteritis.

Answer 173

(Loperamide, Codeine Phosphate) Both opioids. Loperamide doesn't cross CNS so no analgesic effects, agonist of the opioid u-receptors in the GI tract. Transit of bowel contents is slowed and anal sphicter tone is increased Slower bowel transit allows more time for water absorption. (Codeine phosphate not preferable unless analgesic effect also required)

Answer 174

(Loperamide, Codeine Phosphate) GI effects - Constipation (mechnism), abdominal cramping, flatulence. If codeine phosphate is used - risk of opioid toxicity and dependence.

Answer 175

Avoid in acute unlerative colitis where inhibition of peristalsis may increase the risk of megacolon and perforation. Avoided in C.diff (diarhoea following BS antibiotic use) Avoid in acute bloody diarrhoea (dysentery) - likely bacterial infection.

Answer 176

(Loperamide, Codeine Phosphate) Loperamide may be purchased over the counter without prescription - 4 mg followed by 2 mg with each loose stool, maximum 8 mg per day. PO

Answer 177

(Loperamide, Codeine Phosphate) Will help settle diarrhoea, will not treat the underlying cause. Stop taking if they develop consipation, abdominal pain, or if taken for \>5 days. Cheaper to buy OTC.

Answer 178

High risk to inhibit peristalsis in context of C.diff colitis. Should not prescribe if devleoped in hospital or on antibiotics - unless positive viral PCR and/or negative C.difficile toxin test. Explain this is why you cannot prescribe in this context even if they would usually buy OTC.

Answer 179

Ipratropium, Tiotropium, Glycopyrronium

Answer 180

(Ipratropium, Tiotropium, Glycopyrronium) 1. In COPD, Short-acting antimuscarinics (Ipratropium) are used to relieve breathlessness e.g. brought on by exercise or during exacerbations. Long-acting antimuscarinics (Tiotropium, Glycopyrronium) are used to prevent breathlessness and exacerbations 2. In asthma SAMAs used as an adjuvant treatment for relief of breathlessness during acute exacerbations (added to a short-acting B2-agonist e.g. Salbutamol). LAMA are added to high-dose inhaled corticosteroids and long-acting B2-agnosits at step 4 in the treatment of chronic asthma.

Answer 181

(Ipratropium, Tiotropium, Glycopyrronium) Antimuscarinic drugs bind to the muscarinic receptors, where they act as a competitive inhibitor of acetylcholine. Antimuscarinics increase heart rate and conduction, reduce smooth muscle tone (in respiratory tract) and reduce secretions from glands (resp and GI tract). (In the eye they cause relaxation of the pupillary constrictor and ciliary muscles, causing pupillary dilatation and preventing accomodation respectively)

Answer 182

(Ipratropium, Tiotropium, Glycopyrronium) Little systemic absorption when inhaled, dry mouth may occur

Answer 183

Used in caution in patients susceptible to angle-closure glaucome, in whom can presipitate a dangerous rise in intraocular pressure. Mild risk in arrythmias.

Answer 184

Short-acting antimuscarinics - Ipratropium - QDS or as needed when feeling breathless. - 40 micrograms by inhalation for stable patients - 250-500 mcrorams 6hrly by nebulisation during acute attacks. (Inhaler or nebulised) Long-acting antimuscarinics - Tiotropium, Glycopyrronium are prescribed for regular administrations - OD.

Answer 185

(Ipratropium, Tiotropium, Glycopyrronium) Offering a treatment to make airways relax, should improve breathing. Treatment of symptoms, not the disease. Use of inhalers and nebulisers, may cause dry mouth.

Answer 186

(Ipratropium, Tiotropium, Glycopyrronium) Check symptoms and peak flow measurements (asthma) Check inhaler technique

Answer 187

40 micrograms (standard dose) QDS (B2-agonists, salbutamol) - can be administered more frequently (e.g 2-hourly as needed)

Answer 188

Atropine Hyoscine Butylbromide Glycopyrronium

Answer 189

(Atropine, hyoscine butylbromide, glycopyrronium) 1. **Atropine - used in the 1st line management of severe or symptomatic bradycardia to increase heart rate** 2. **Hyoscine butylbromide - 1st line pharmacological treatment option for IBS where used for antispasmodic effect.** 3. Hyoscine butylbromide - palliative care, role in reducing copious respiratory secretions.

Answer 190

(Atropine, Hyoscine butylbromide, Glycopyrronium) Antimuscarinic drugs bind to the muscarine receptor where they act as a competitive inhibitor of acetylcholine. Increases heart rate and conduction, reduce smooth muscle tone and peristaltic contractions including the gut and urinary tract Reduce secretions from glands in the respiratory and gut.

Answer 191

(Atropine, Hyoscine Butylbromide, Glycopyrronium) Tachycardia, dry mouth, constipation. Can cause urinary retention in patients with benign prostatic hypertrophy Can case blurred vision Can cause drowsiness and confusion

Answer 192

(Atropine, hyoscine butylbromide, glycopyrronium) Caution: acute-closure glaucoma Caution: Arrythmias and significant cardiovascular disease.

Answer 193

(More than for respiratory/inhaled as systemic absorption) Adverse effects more pronounced when combined with other drugs with antimuscarinic effects, such as tricyclic antidepressants

Answer 194

Atropine - Bradycardia - IV in incremental doses - 300-600 micrograms every 1-2 minutes, until acceptable HR restored (Atropine for IV administration in pre-filled syringes, check concentration) (Glycopyrronium is an alternative) Hyoscine butylbromide (Buscopan) - PO - 10 mg - 8 hourly - available without prescription Hyoscine butylbromide - Respiratory secretions - SC (Beware sounds similar to hyoscine hydrobromide - be careful)

Answer 195

(Atropine, Hyoscine Butylbromide (Buscopan), Glycopyrronium) Atropine for bradycardia - administed by specialist with high-intensity monitoring - continuous cardiac rhythm monitoring Or symptomatic for other uses

Answer 196

Oxybutynin Tolterodine Solifenacine

Answer 197

(Oxybutynin, Tolterodine, Solifenacin) To reduce urinary frequency, urgency and urge incontinence in **overactive bladder,** as a first-line pharmacological treatment if bladder training is ineffective.

Answer 198

(Oxybutynin, Tolterodine, Solifenacin) Bind to antimuscarinic drugs where they are a competitive inhibitor of acetylcholine. Contraction of the smooth muscle of the bladder is under parasympathetic control. Blocking muscarinic receptors promotes bladder relaxation

Answer 199

(Oxybutynin, Tolterodine, Solifenacin) Dry mouth Tachycardia Constipation Blurred Vision

Answer 200

Antimuscarinics are contraindicated in urinary tract infections (urinalysis before treatment) CNS side effects difficult in elderly and those with dementia Caution in angle-closure glaucoma Caution in arrythmias or at risk of urinary retention

Answer 201

Other drugs with antimuscarinic effects, such as tricyclic antidepressants

Answer 202

(Oxybutynin, Tolterodine, Solifenacin) Prescribe antimuscarinics for urge incontinence only after adequate trial of bladder retraining 5 mg - PO. 8-13 hrly Immediate release tried first, modified release only when not tolerated

Answer 203

(Oxybutynin, Tolterodine, Solifenacin) Relax the bladder, reducing the frequency and urgency with which they need to urinate Explain that dry mouth is a common side effect Elderly - may cause drowsiness and confusion

Answer 204

Chewing gum or sucking sweets (sugar-free) Increased risk of dental decay due to dry mouth.

Answer 205

Haloperidol Chlorpromazine (also antiemetic - phenothiazine) Prochlorperazine (also antiemetic - phenothiazine)

Answer 206

(Haloperidol, Chlorpromazine, Prochlorperazine) 1. **Urgent treatment of severe psychomotor agitation** that is causing dangerous or violent behavior, or to calm patients to permit assessment. 2. **Schizophrenia**, particularly when the metabolic side effects of second-generation (atypical) antipsychotics are likely to be problematic. 3. **Bipolar disorder, particularly in acute episodes of mania or hypomania** 4. **Nausea and vomiting**, particulalry in the palliative care setting (**Antiemetic - Chlorpromazine, Prochlorperazine**)

Answer 207

(Haloperidol, Chlorpromazine, Prochlorperazine) Antipsychotic drugs block post-synaptic dopamine D2 receptors. All have some seditive effect.

Answer 208

(Haloperidol, Chlorpromazine, Prochlorperazine) **Extrapyramidal effects** - movement abnormalities - main drawback of 1st generation antipsychotics - oculogyric crisis **Acute dystonic reactions** - involuntary parkinsonian movements or muscle spasms **Akathisia** **Neuroleptic malignant syndrome** - rare but life-threatening - rigidity, confusion, autonomic dysregulation and pyrexia. **Tardive dyskinesia** - late effect (months - years) - movements that are pointless, involuntary and repetitive (i.e. lip smacking) - may not resolve with stopping treatment Drowsiness, hypotension, QT-interval prolongation (arrhythmias), erectile dysfunction, **hyperprolactinaemia** (menstrual disturbance, galactorrhoea, breast pain)

Answer 209

(Haloperidol, Chlorpromazine, Prochorperazine) Elderly - sensitive Avoided in demetia Avoid in Parkinson's disease - due to extrapyramidal side effects

Answer 210

Drugs also prolonguing the QT-interval (e.g. Amiodarone, Macrolides)

Answer 211

(Haloperidol, Chlorpromazine, Prochloreperazine) For schizophrenia - under guidance of Psychiatrist Single dose for acute or violent behaviour - **Haloperidol - 0.5-3.0 mg IM**) Nausea - Haloperidol - Regular PO or SC doses - e.g. 1.5mg at night or continuous SC infusion

Answer 212

(Haloperidol, Prochlorperazine, Chorpromazine) Regular administration - typical antipsychoics - taken orally or given by slow release IM 'depot' injections. In emergencies given by rapid acting IM injection and occasionally IV for rapid control of symptoms (very rare/specialist/intense side effects)

Answer 213

(Haloperidol, Chlorpromazine, Prochlorperazine) Adherence is a significant issue due to underlying psychosis and side effects (multiple) Good communication necessary Patients should report that they are taking to other healthcare professionals due to interactions.

Answer 214

(Haloperidol, Prochlorperazine, Chlorpromazine) Control of antipsychotic symptoms Antipsychotic effects may take time to be established Montoring for neurological, respiratory and cardiovascular depression. Dose-response relationshop is unpredictable

Answer 215

(Pine + Risperidone) Quetiapine Olanzapine Risperidone Clozapine

Answer 216

(Quetiapine, Olanzapine, Risperidone, Clozapine) 1. Urgent treatment of **severe psychomotor agitation** leading to dangerous or violent behaviour, or to calm such patients to permit assessment 2. **Schizophrenia**, when extrapyramidal side effects have complicated the use of first-generation (typical) antipsychotics, or when negative symptoms are prominent. 3. **Bipolar disoder,** particularly in acute episodes of mania or hypomania

Answer 217

(Quetiapine, Olanzapine, Risperidone, Clozapine) Antipsychotic drugs block post-synaptic dopamine D2 receptors. Clozapine particulalrly useful in 'treatment-resistant' schozophrenia, against negative symptoms, and have lower risk of extrapyramidal side effects. Higher affinity for other receptors and characteristic of looser binding to D2 receptors.

Answer 218

(Quetiapine, Olanzapine, Risperidone, Clozapine) Sedation Extrapyramidal effects - more common with 1st generation Metabolic distrubance - weight gain, diabetes melltus, lipid changes (more common with 2nd generation) Antipsychotics can prolongue the QT interval and cause arrythmias Risperidone - hyperprolactineamia, breast symptoms and sexual dysfunction. Clozapine - agranulocytosis and myocarditis (rare but dangerous)

Answer 219

(Quetiapine, Olanzapine, Risperidone, Clozapine) Cardiovascular disease Clozapine (not in severe heart disease or history of neutropenia - agranulocytosis)

Answer 220

Sedation may be more pronounced when used with other sedating drugs Not comined with dopamine-blocking antiemetics Drugs that prolong the QT interval - amiodarone, quinine, macrolides, SSRIs

Answer 221

(Quetiapine, Olanzapine, Risperidone, Clozapine) Decisions should be taken by psychiatrist Used for treatment of acute symptoms and prevention of subsequent attacks Daily PO or depot IM injections Clozapine when other agents ineffective or intollerable - poor side effect profile. Best taken at bedtime

Answer 222

(Quetiapine, Olanzapine, Risperidone, Clozapine) You will only deal with patients already on, a psychiatrist will establish treatment. Clozapine - regular blood test monitoring is required for agranulocytosis. Know what side-effects to look out for.

Answer 223

(Quetiapine, Olanzapine, Risperidone, Clozapine) Signs and symptoms For most - blood tests FBC, liver and renal at start and periodically For clozapine - intensive monitoring due to the risk of agranulocytosis Monitoring of metabolic and cardiovascular side efects important for second-generation ASPs - includes weight, lipid profile, fasting blood glucose (weight gain, diabetes mellitus - metabolic effects) For 1st generation the extrapyramidal side effects more likely.

Answer 224

The QT-interval on the ECG May be lengthened and may be exacerbated into arrythmias by other drugs e.g. Amiodarone, Macrolides, SSRIs

Answer 225

1. **Acute coronary syndrome and acute ischaemic stroke**, where rapid inhibition of platelet aggregation can prevent or limit arterial thrombosis and reduce mortality. 2. **For long-term secondary prevention of thrombotic arterial events in patients with cardiovascular, cerebrovascular and peripheral arterial disease.** 3. To reduce the risk of intracardiac thrombus and embolic stroke in **atrial fibrilation where warfarin and NOACs are contraindicated** 4. To control mild-to-moderate pain and fever (NSAIDs) although other drugs usually preferable

Answer 226

**Aspirin irreversibly inhibits cyclooxygenase (COX)** to reduce the production of the pro-aggregatory factor thromboxane, **reducing platelet aggregation and the risk of arterial occluision.** The antiplatelet effect of aspirin occurs at low doses and lasts for the lifetime of the platelet - it wears off as new platelets are made.

Answer 227

GI irritation - Aspirin is an NSAID Can cause gastrointestinal ulceration and haemorrhage. Hypersensitivity reactions - bronchospasm Regular high dose can cause tinnitus Aspirin is life-threatening in overdose - features include hyperventilation, earing changes, metabolic acidosis and confusion, followed by convulsions, cardiovascular collapse and respiratory arrest

Answer 228

Not given to children due to the risk of Reye's syndrome Aspirin hypersensitivity (who have had bronchospasm or other allergic symptoms triggered by exposure to aspirin or another NSAID) Avoided in third trimester of pregnancy Peptic ulceration - with gastroprotection Gout - can presipitiate an acute attack

Answer 229

Acts synergistically with other antiplatelet agents, which although therapeutically beneficial can lead to increased risk of bleeding. Caution when given with other antiplatelet drugs (clopidogrel, dipyridamole) and anticoagulants (hepain, warfarin) in some situations e.g. ACS.

Answer 230

Acute coronary syndrome - initially once-only loading dose (300mg - PO or rectal) followed by regular dose of 75 mg daily. Acute ischaemic stroke - 300 mg daily for 2 weeks, then 75 mg daily. Long-term prevention of thrombosis after acute event or in atriial fibrilation - low dose aspirin 75 mg daily. (Much higher dose in pain maximum 4 g daily) Gastroprotection e.g. Omeprazole 20 mg daily may be co-prescribed

Answer 231

Gastroprotection e.g. Omeprazole 20 mg daily should be considered for patients taking low-dose aspirin who are at increased risk of gastric complications inc: age \>65 years, previous peptic ulcer disease, comorbidities such as cardiovascular disease, diabetes and cocurrent therapy with NSAIDs or prednisilone.

Answer 232

To minimise gastric irritaton should be taken after food.

Answer 233

Warn to watch out for indigestion or bleeding symptoms.

Answer 234

Absolute risk of serious vascular events in this group is low and any potential benefits of low-dose aspirin are offset by the increased risk of serious bleeding

Answer 235

Diazepam Temazepam Lorazepam Chlordiazepoxide Midazolam

Answer 236

(Diazepam, Temazepam, Lorazepam, Chlordiazepoxide, Midazolam) 1. First line management of **seizures and status epilepticus** 2. First line management of **alcohol withdrawal reactions** 3. Common choice for **sedation for interventional procedures**, if general anaesthesia isn't used. 4. Short-term management of severe, disabling or distressing **anxiety** 5. For short-term treatment of severe, disabling or distressing **insomnia.**

Answer 237

(Diazepam, Temazepam, Lorazepam, Chlordiazepoxide, Midazolam) Target GABA receptors. GABA is the main inhibitory neurotransmitter in the brain. Benzodiazepines facilitate and enhance banding of GABA to the GABA receptors. Having a widespread depressant effect on synaptic transmission. Reduces anxiety, causes sleepiness, sedation and anticonvulsive effects.

Answer 238

Alcohol also acts on the GABA receptors and in chronic excess the patient becomes tolerant to its presence. Abrupt cessation then provokes the excitatory state of alcohol withdrawal. This can be treated by introducing a Benzodiazepine

Answer 239

(Diazepam, Temazepam, Lorazepam, Chlordiazepoxide, Midazolam) Dose-dependent drowsiness, sedation and coma. Little cardiorespiratory depression in overdose but loss of airway reflexes can lead to airway obstruction and death. Dependence can develop if taken for more than a few weeks Abrupt cessation can produce a withdrawal reaction similar to that seen with alcohol

Answer 240

(Diazepam, Temazepam, Lorazepam, Chlordiazepoxide, Midazolam) Elderly more susceptible to effects Best avoided in patients with signficant respiratory impairment or neuromuscular disease (e.g. myasthenia gravis). Should also be avoided in liver failure but if use is essential e.g. alcohol withdrawal - Lorazepam may be best choice.

Answer 241

Additive to other sedating drugs including alcohol and opioids Most depend on cytochrome P450 enzymes for elimination so concurrent use with cytochrome P450 inhibitors may increase effects

Answer 242

(Diazepam, Temazepam, Lorazepam, Chlordiazepoxide, Midazolam) (Duration of action varies) Seizures - long-acting - Lorazepam - 4mg IV or Diazepam 10mg or Diazepam - rectal solution Alcohol withdrawal - Oral chlordiazepoxide Sedation - Midazolam Insomniaa and Anxiety - Temazepam

Answer 243

Senior supervision Injected slowly

Answer 244

Only a short term measure for depression and anxiety Discuss the risk of dependence, don't take for \>4 weeks Don't drive or operate heavy machinery

Answer 245

(Diazepam, Temazepam, Lorazepam, Chlordiazepoxide, Midazolam) Close monitoring of the patient's clinical status and vtal signs are essential following IV or high dose Benzos.

Answer 246

Flumazenil (Rarely indicated - not when mixed or uncertain overdose)

Answer 247

Salbutamol Salmeterol Formoterol Terbutaline

Answer 248

(Salbutamol, Salmeterol, Formoterol, Terbutaline) 1. Asthma: short acting B2-agonists are used to relieve breathlessness. Long-acting B2-agonists are used in step 3 treatment for chronic asthma, but must always be given in combination with inhaled corticosteroids. 2. COPD: short acting B2-agonists are used to relive breathlessness. Long-acting B2-agonists are an option for second-line therapy of COPD. 3. Hyperkalaemia: nebulised salbutamol may be used as an additional treatment (alongside insulin, glucose and calcium gluconate) for the urgent treatment of high serum potassium concentration.

Answer 249

(Salbutamol, Salmeterol, Formoterol, Terbutaline) Beta2-receptors are found in smooth muscle of the bronchi. (also GI tract, uterus and blood vessels) Stimulation leads to smooth muscle relaxation This improves airflow in consricted airways. Like insulin also stimulates Na+/K+-ATPase pumps on cell serface membranes, causing a shift of K+ from the extracellular to intracellular compartment.

Answer 250

(Salbutamol, Salmeterol, Formoterol, Terbutaline) Short-acting: Salbutamol, Terbutaline Long-acting: Salmeterol, Formoterol

Answer 251

'Fight or flight' adverse effects Tachycardia, palpitations, anxiety and tremor Promote glucogenolysis so may increase serum glucose concentration Long-acting B2-agonists can cause muscle cramps

Answer 252

Long-acting B2-agonists useding in asthma only if an inhaled corticosteroid is also used. This is because without there is an increased riskof asthma deaths Caution in cardiovascular disease as the tachycardia can provoke angina and arrhythmias

Answer 253

(Salbutamol, Salmeterol, Formoterol, Terbutaline) Beta-blockers ma reduce the effectiveness of B2-agonists. Concomitant use of B2-agonists with theophylline and corticosteroids can lead to hypokalaemia so serum potassium should be monitored.

Answer 254

(Salbutamol, Salmeterol, Formoterol, Terbutaline) Short-acting - Salbutamol, Terbultaline - As required - 100-200 micrograms inhaled as required In asthma and COPD requiring hospital treatment, nebulised - salbutamol 2.5 mg nebulised 4-hourly (spacer possible) Long-actng - maintenance therapy - BD - must be with steroid in asthma so can be combined inhaler e.g. Seretide or Symbicort - improves convenience also.

Answer 255

Aerosol - Metered dose inhaler Dry powder Spacer with metered dose inhalers Inhaler technique should be checked and corrected at every consultation

Answer 256

Medicine to relax airways and improve breathing Treats symptoms not disease If they need to use freqently seek medical advice Make sure know inhaler technique

Answer 257

Symptoms and serial measurements of peak expiratory flow rate Adjust reatment with guidance from action plan COPD: severity and exacerbation rates

Answer 258

Bisoprolol Atenolol Propranolol Metoprolol

Answer 259

(Bisoprolol, Atenolol, Propranolol, Metoprolol) 1. **Ischaemic heart disease:** 1st line option to improve symptoms and prognosis associated with angina and acute coronary syndrome 2. **Chronic heart failure:** 1st line option to improve prognosis 3. **Atrial fibrillation:** 1st line option to reduce the ventricular rate and, in paroxysmal atrial fibrillaiton, to maintain sinus rhythm. 4. **Supraventricular tachycardia (SVT):** as a 1st line option in patients without circulatory compromise to restore sinus rhythm 5. **Hypertension:** may be used when other treatments: CCB, ACEi and theiazide diuretics are insufficient or inappropriate.

Answer 260

(Bisoprolol, Atenolol, Propranolol, Metoprolol) Beta1-adrenoreceptors are located mainty in the heart, Beta2-adrenoreceptors are found mostly in smooth muscle of blood vessels and airways. Via the B1-receptor, Beta-blockers reduce force of contration and speed of conduction in the heart. This relives myocaridal ischamia by reducing cardiac work and oxygen demand, and increasing myocaridal perfusion. They improve prognosis in heart failure by 'protecting' the heart from the effects of chronic sympathetic stimulation. They slow the ventricular rate in atrial fibrilation mainly by prolonguing the refractory period of the atrioventricular (AV) node. Reduce renin secretion from the kidneys to lower high blood pressure.

Answer 261

(Bisoprolol, Atenolol, Propranolol, Metoprolol) Fatigue Cold extremities Headache Nausea Sleep disturbance and nightmares Impotence in men

Answer 262

(Bisoprolol, Atenolol, Propranolol, Metoprolol) Asthma - can cause life-threatening bronchospasm - contraindicated. Caution in COPD - but use B1-selective Heart failure: gradual increase Contraindicated in heart block Reduced dose in hepatic failure

Answer 263

Not used with non-dihydropyridine calcium channel blockers (e.g. verapamil, diltiazem) as can cause heart failure, bradycardia and asystole.

Answer 264

(Bisoprolol, Atenolol, Propranolol, Metoprolol) PO - dose varies according to drug and indication. Start at lowest dose and increase IV is possible where rapid effect is required. Taken at regular intervals

Answer 265

Discuss Sfx With Heart Failure about risk of initial deterioration in symptoms COPD: stop and seek help if difficulty breathing develops

Answer 266

(Bisoprolol, Atenolol, Propranolol, Metoprolol) Dose adjust to patient's symptoms and hr in ischarmic heart disease.

Answer 267

Metoprolol (Short half-life so better to start with this at first then convert to once daily at later point)

Answer 268

Alendronic Acid Disodium Pamidronate Zoledronic Acid

Answer 269

(Alendronic Acid, Disodium Pamidronate, Zoledronic Acid) 1. **Risk of osteoporotic fragility fractures** - Alendronic acid 2. **Severe hypercalcaemia of malignancy** - Pamidronate and Zoledronic acid after IV rehydration 3. Myeloma and breast cancer with bone mets - Pamidronate and Zoledronic acid - reduces risk of pathological fractures, cord compression and need for radiotherapy and surgery 4. **Paget's disease** - 1st line treatment when metabolically active, aim of reducing bone turnover and pain.

Answer 270

Reduce bone turnover by inhibiting the action of osteoclasts, the cells responsible for bone resorption. Net effect is reduction in bone loss and improvement in bone mass.

Answer 271

(Alendronic Acid, Disodium Pamidronate, Zoledronic Acid) Common: **Oesophagitis and hypophosphataemia** Rare but serious: **Osteonecrosis of the jaw,** more likely in high dose IV therapy Good dental care is important Rare but serious: **Atypical femoral fracture,** long-term use.

Answer 272

Avoid in severe renal impairment CI in hypocalcaemia (will increase) Oral CI in upper Gi disorders Caution in smokers and dental disease: (osteonecrosis of the jaw)

Answer 273

(Alendronic Acid, Disodium Pamidronate, Zoledronic Acid) Bind calcium Absorption is thefere reduced if taken with calcium salts (including milk) as well as antacids and iron salts.

Answer 274

(Alendronic Acid, Disodium Pamidronate, Zoledronic Acid) Osteoporosis: PO, 70mg once Weekly Severe hypercalcaemia and bone metastases: Pamidronate or Zolendronic acid: Slow IV infusions. Paget's disease: Risedronate PO or Pamidronate IV.

Answer 275

(Alendronic Acid, Disodium Pamidronate, Zoledronic Acid) 30 minutes before food or other medications Sitting upright for 30 minutes Take with plenty of water Ensure good dental health and see dentist Report any symptoms of oesophangel irritation

Answer 276

(Alendronic Acid, Disodium Pamidronate, Zoledronic Acid) In osteoporosis: check and replace calcium and vitamin D before treatment. Monitor efficacy using dual-energy X-ray absorptiometry (DEXA) scans every 1-2 years to check bone density is stable or increasing. Hypercalcaemia - calcium levels Myeloma, bone mets, Paget's disease - Bone pain, fractures Symptoms of oesophagitis, osteonecrosis of the jaw - monitor calcium and phosphate levels.

Answer 277

Calcium Carbonate Calcium Gluconate Colecalciferol Alfacalcidol

Answer 278

(Calcium Carbonate, Calcium Gluconate, Colecalciferol, Alfacalcidol) 1. Osteoporosis: Calcium and vitamin D supplements used to ensure positive calcium balance when dietary intake and/or sunlight exposure are insufficient. (+ Bisphosphonates) 2. Chronic Kidney Disease: to treat and prevent secondary hyperparathyroisism and renal osteodystrophy. 3. Severe hyperkalaemia: Calcium gluconate to prevent life-threatening arrythmias (+ insulin and glucose) 4. Severe or symptomatic hypocalcaemia 5. Vitamin D deficiency: Rickets in children and Osteomalacia in adults.

Answer 279

(Calcium Carbonate, Calcium Gluconate, Colecalciferol, Alfacalcidol) Calcium homeostasis is controlled by parathyroid hormone and vitamin D, which increase serum calcium levels and bone mineralisation, and calcitonin which reduces serum calcium levels. In severe CKD, impaired phosphate excretion and reduced activation of vitamin D cause hyperphosphataemia and hypocalcaemia. This stimulates secondary hyperparathyroisism, which leads to a range of bone changes called renal osteodystrophy. In hyperkalaemia, calcium raises the myocaridal thresshold potential, reducing excitability and the risk of arrhythmias, it does not alter the serum potassium levels.

Answer 280

Oral calcium can cause dyspepsia and constipaiton. When IV for the treatment of hyperkalaemia, calcium gluconate can cause cardiovascular collapse if administered too fast and local tissue damage if accidentally given into subcutaneous tissue.

Answer 281

(Calcium Carbonate, Calcium Gluconate, Colecalciferol, Alfacalcidol) Hypercalcaemia

Answer 282

Oral calcium reduces the absorption of many drugs including iron, bisphosphonates, tethracyclines and levothyroxine. IV calcium carbinate cannot be given with sodium bicarbonate as risk of precipitation.

Answer 283

(Calcium Carbonate, Calcium Gluconate, Colecalciferol, Alfacalcidol) Osteoporosis: 1-1.2 g of Calcium and 800 units of vitamin D per day. Adcal D2: TD (Combined prescription) Severe hyperkalaemia: 10 ml calcium gluconate 10% for administration by slow IV injection (repeat doses if ECG cahnges persist) Senior advice: Hypocalcaemia, Vit D deficiency and Severe CKD.

Answer 284

(Calcium Carbonate, Calcium Gluconate, Colecalciferol, Alfacalcidol) Oral calcium should be chewed and swallowed. Separate from interacting medicines Calcium glucontae: Slow IV injection in large vein over 5-10 minutes

Answer 285

Calcium gluconate: Severe hyperkalaemia, continuous cardiac monitoring. Repeat 12 leas EVG to confirm resolution of abnromalities. For calcium and vitamin D supplements, check serum calcium levels at regular intervals or if they develop symtoms or hypercalcaemia.

Answer 286

10 ml of calcium gluconate 10% IV over 5-10 minutes

Answer 287

Amlodipine Nifedipine Diltiazem Verapamil

Answer 288

(Amlodipine, Nifedipine, Diltiazem, Verapamil) 1. **Hypertension** - Amlodipine/Nifedipine are used for 1st or 2nd line treatment of hypertension to reduce risk of stroke, MI and death from CVD. 2. **Stable angina**: B-blockers 1st line but CCB can also be used for symptom control 3. **Supraventricular arrhythmias**: Diltiazem and verapamil are used to control cardiac rate in SVT, Atrial flutter and AF

Answer 289

(Amlodipine, Nifedipine, Diltiazem, Verapamil) CCBs decrease calcium entry into vascular and caridac cells. This causes relaxation and vasodilation in arterial smooth muscle, lowering arterial pressure. In the heart, CCBs reduce myocarial contractility and suppress cardiac conduction. All reduce oxygen demand, preventing angina.

Answer 290

(Amlodipine, Nifedipine, Diltiazem, Verapamil) Dihydropyridines: amodipine and nifedipine - selective for vasculature Non-dihydropyridines: verapamol, diltiazem - selective for the heart.

Answer 291

(Amlodipine, Nifedipine, Diltiazem, Verapamil) Dihydropyridines (Vascular selective): Amlodipine, Nifedipine: Ankle swelling, flushing, headache and palpitations - caused by vasodilatation and compensatory tachycardia. Verapamil - constipation, bradycardia, heart block rarely - cardiac failure.

Answer 292

Verapamil and Diltiazem: caution in poor left ventricular function - can precipitate or worsen heart failure. Avoided in AV nodal condiction delay - can precipitate heart block Amlodipine and Nifedipine - useful for stable angina but CI in unstable angina . Avoided in severe aortic stenosis.

Answer 293

(Amlodipine, Nifedipine, Diltiazem, Verapamil) Non-dihydropyridine (Verapamil and Diltiazem) should not be prescribed with B-blockers - can cause heart failure.

Answer 294

(Amlodipine, Nifedipine, Diltiazem, Verapamil) PO - Amlodipine - OD Ohters more frequently - 8hr or 12 hr Hypertension: Amlodipine: 5-10 mg PO, OD Angina: Diltiazem MR 90mg PO, TD Supreventricular arrythmias: Verapamil 40-120 mg PO, TDS

Answer 295

(Amlodipine, Nifedipine, Diltiazem, Verapamil) Other factors to reduce CVS risk Common side effects: Ankle oedema

Answer 296

(Amlodipine, Nifedipine, Diltiazem, Verapamil) Regular blood pressure monitoring for HTN Angina: chest pain Pulse rate, ECG 24- hour tape ECG for arrythmias

Answer 297

1. Epilepsy - 1st choice for focal seizures with and without secondary generalisation and for primary generalised seizures 2. Trigeminal Neuralgia - 1st choice to control pain and reduce frequency and severity of attacks 3. Bipolar disordeir - Option for prohylaxis in patients resistant or intolerant to other medications.

Answer 298

Appears to inhibit neuronal sodium channels, reducing neuronal excitability.

Answer 299

GI Upset (nausea and vomiting) Neurological effects (dizziness and ataxia) Hypersensitivity (10%) Antiepileptic hypersensitivity syndrome - skin reactions, ever and lymphadenopathy with systemic involvement, mortality 10% Oedema and hyponatraemia

Answer 300

Caution in pregancy - may cause defects, should have high-dose folic acid supplements before conception Prior antiepileptic hypersensitivity syndrome is a CI to carbamazepine and phenytoin Caustion with hepatic, renal or caridac disease

Answer 301

Induces P450 enzymes, reducing plasma concentration and efficacy of drugs that are metabolised by P4450 enzymes. Effects increased by cytochrome P450 inhibitors Complex interactions with other antiepeleptic durgs and drugs loweing seizure threshold (tricyclic antidepressants, antipsychotic, tramadol)

Answer 302

PO or PR Started low dose 100-200 mg OD or BD Tradually increased to up to 1.6 g/day in divided doses Treatment should be stopped slowly under medical supervision

Answer 303

Signs of severe hypersensitivity: Skin rashes, bruising , bleeding, high temp, mouth ulcers. Discuss contraception and pregnancy Must not drive unless seizure free for 12 months, shoud not drive for 6 months after changing or stopping seizures.

Answer 304

Monitored by comparing seizure frequency before and after starting treatment or dose adjustment. For safety: report symptoms hypersensitivity Plasma carbamazepine (selvct cases)

Answer 305

Lamotrigine Levetiracetam (Keppra) Choice depending on seizure type, epilepsy syndrome, co-medication, comorbidities and patient choice. Carbamazepine first choice for focal seizures and sometimes for primary focal seizures

Answer 306

Cefalexin Cefotaxime Meropenem Ertapenem

Answer 307

(Cefalexin, Cefotaxime, Meropenem, Ertapenem) 1. Oral cephalosporins are 2nd and 3rd line treatment options for UTIs and RTIs 2. IV cephalosporins and carbapenems are for the treatment of infections that are very severe or complicated, or caused by antibiotic-resistant organisms. Due to their broad antimicrobial spectrum they can be used for most indications.

Answer 308

(Cefalexin, Cefotaxime, Meropenem, Ertapenem) Antimicrobial effect due to ß-lactam ring. Weakens bacterial cell wall leading to swelling, lysis and death. More resistant to beta-lactamases than penecillins

Answer 309

(Cefalexin, Cefotaxime, Meropenem, Ertapenem) GI upset - nausea and diarrhoea Antibiotic-associated colitis - when broad spectrum antibiotics kill normal gut flora, allowing overgrowth of toxin producing c.diff. Hypersensitivity and cross-reactivity in penecillin-alergic patients CNS toxicity is possible

Answer 310

(Cefalexin, Cefotaxime, Meropenem, Ertapenem) In caution in ptts at risk of C.diff infection Allergy to penecillins, cephalosporins or carbapenems (CI if anaphylactic) Caution in epilepsy and renal impairment

Answer 311

(Cefalexin, Cefotaxime, Meropenem, Ertapenem) Can enhance the anticoagulant effect of Warfarin by killing normal gut flora that synthesise vitamin K Increase nephrotoxicity of animoglycosides Reduce plasma concentration and efficacy of valporate.

Answer 312

(Cefalexin, Cefotaxime, Meropenem, Ertapenem) Check BNF Orally or oral suspension by injection. (Ertapenem best for outpatient therapy as OD) In many hospitals cannot be prescribed without the approval of a microbiologist

Answer 313

(Cefalexin, Cefotaxime, Meropenem, Ertapenem) Check for allergy to penecillins or B-lactam antibiotics.

Answer 314

(Cefalexin, Cefotaxime, Meropenem, Ertapenem) Clinical signs of infection resolving e.g. resolution of pyrexia Blood tests: falling of C-reactive protein and WCC.

Answer 315

(Generally prescribed with aspirin, though may be used alone where aspirin is contraindicated or not tolerated) 1. For treatment of acute coronary syndrome (ACS), prevent or limit arterial thrombosis. 2. To prevent occlusion of coronary artery stents 3. For long-term 2nd prevention of thrombotic arterial events in patients with cardiobascular, cerebrovascular and peripheral arterial disease 4. To reduce the risk of intracardiac thrombus and embolic stroke in atrial fibrillation where warfarin and NOACs are contraindicated.

Answer 316

Thrombotic events occur when a platelet-rich thrombus forms in atheromatous arteries and occludes the circulation. Clopidogrel prevents platelet aggregation and reduces the risk of arterial occlusion by bindin to ADP receptors. Actions are syndergistic with aspirin.

Answer 317

Bleeding - esp if GI, Neuro or Surgical GI Upset Rare: Thrombocytopenia

Answer 318

Not with active bleeding Stopped 7 days before elective surgery Used with caution in renal and hepatic impairment

Answer 319

Pro-drug requiring metabolism by hepatic cytochrome P450 enzymes to active form Efficacy may be reduced by cytochrome P450 inhibitors Co-prescription with other antiplatet drugs (e.g. aspirin) or anticoagulants (e.g. heparin) or NSAIDs increases the risk of bleeding.

Answer 320

PO May require loading dose 300mg for ACS in once only before maintenance dose Maintenance dose of 75mg PO OD (For drug-eluting coronary stent dual antiplatelet therapy should be continued for 12 months)

Answer 321

Redudes risk of heat attacks and strokes and prolongs life. Ask about active bleeding Explain if bleeding occurs may take longer to stop.

Answer 322

Acts irreversibly for the lifespan of the platelet 7-10 days. In emergency cases, patients taking clopidogrel may require platelet transfusions to help stop bleeding.

Answer 323

Seretide Symbicort

Answer 324

(Seretide, Symbicort) 1. Asthma: control of symptoms and prevention of exacerbations, used at 'steps 3-4' in the management of chronic asthama. 2. COPD: to control symtpoms and prevent exacerbations in patients who have severe airflow obstruction on spirometry and/or recurrent exacerbations

Answer 325

(Seretide, Symbicort) Inhaled corticosteroid to suppress airway inflammation Long-acting B2-agonist (LABA) to stimulate bronchodilation Combined prescription reduces number of inhalerss and increases adherence. LABA must be taken with a corticosteroid as otherwise associated with more deaths. (Seretide - fluticasone and salmeterol) (Symbicort - budesonide and formoterol)

Answer 326

Inhaled corticosteroids - oral thrush, hoaese voice High-dose, long-time - Systemic effects - Adrenal suppression, growth retardation, osteoporosis LABAs - Tremor, tachycardia, arrythmias, muscle cramps

Answer 327

Caution in: COPD patients with Hx of pneumonia Children Cardiovascular disease - tachycardia may provoke angina or arrhythmias.

Answer 328

(Seretide, Symbicort) Beta-blockers (CI asthma) may reduce the efficaacy of B2-agonists.

Answer 329

(Seretide, Symbicort) By brand name, inhaler type and strength: no.x / no.x (in micrograms) + number of 'puffs' and frequency

Answer 330

New inhaler will prevent attacks and improve breathlessness, but must be taken without fail every morning and evening to have benefit. Rinse mouth and gargle after taking the inhaler.

Answer 331

(Seretide, Symbicort) Ask about symptoms, check worked by reviewing peak flow measurements (asthma) or exacerbation frequency (CODP and asthma)

Answer 332

Prednisolone Hydrocortisone Dexamethasone

Answer 333

(Prednisolone, Hydrocortisone, Dexamethasone) 1. Treating allergic and inflammatory disorders: e.g. anaphylacis, asthma. 2. To suppress autoimmune disease e.g. IBD, inflammatory arthritis 3. Treatment of cancers (part of chemo or reduce swelling) 4. Hormone replacment in adrenal insufficiency or hypopituitarism.

Answer 334

(Prednisolone, Hydrocortisone, Dexamethasone) Exert glucocorticoid effects Modify the immune response to reduce inflammation. Metabolic effects - increased gluconeogenesis from increased circulating amino and fatty acids, released by catabolism (breakdown) of muscle and fat. Mineralocorticoid effects - Stimulates Na+ and water retention and K+ excretion in the renal tubule.

Answer 335

(Prednisolone, Hydrocordisone, Dexamethasone) Immunosuppression - increases risk and severity of infection Metabolic effects - diabetes melitus and osteoporosis. Proximal muscle weakness, skin thinning, easy brusing and gastritis (increased catabolism) Mood and behavioral changes: Insomnia, confusion, psychosis and suicidal ideas. Mineralocordicoid actions: hypokalaemia and oedema. Adrenal atrophy and Addisonian Crisis (Long-term/withdrawal)

Answer 336

(Prednisolone, Hydrocortisone, Dexamethasone) If there is sudden withdrawal following prolongued use. Corticosteroids suppress pituitary ACTH secretion, switching off the stimulus for normal adrenal cortisone production. In prolongued treatment this causes adrenal atrophy, preventing endogenous cortisol secretion. If they are withdrawn suddely and acute Addisonian crisis with cardiovascular collapse. Slow withdrawal is necessary to allow recovery of adrenal fucntion. Symptoms of chronic glucocorticoid deficiency that occur during treatment withdrawal include fatigue, weight loss and arthralgia.

Answer 337

(Prednisolone, Hydrocortisone, Dexamethasone) In caution in people with: Infection (Immunosuppresion) Children (Growth-suppression)

Answer 338

(Dexamethasone, Hydrocortisone, Prednisolone) NSAIDS: increase the risk of peptic ulceration and GI bleeding Hypokalaema: with B2 agonists, theophylline, loop and thiazide diuretics. Efficacy can be reduced by cytochrome 450 inducers Reduce immune response to vaccines.

Answer 339

Dexamethasone - most potent - 750 micrograms Prednisolone - moderate - 5 mg Hydrocortisone - 20 mg PO, IV or IM Emergencies - cerebral oedema (cancer) - Dexamethasone Acute asthma - Prednisolone - 40 mg PO OD. Long term e.g. arthritis - Lowest dose of oral prednisolone (May require co-prescription of steroid-sparing agents e.g. azithioprine/methotrexate) Also consider the use of bisphosphonates and PPIs to reduce some of the steroid side effects.

Answer 340

(Prednisolone, Hydrocortisone, Dexamethasone) OD taken in the morning, to mimic natural circadian rhythm and reduce insomnia. Do not stop treatment suddently as could make them very unwell - carry a steroid card. Discuss the long term benefits and risks.

Answer 341

(Prednisolone, Hydrocortisone, Dexamethasone) Monitoring of efficacy on conditon treated Asthma - peak flow recordings Inflammatory arthritis - blood inflammatory markers Adverse effects - HbA1c (DM) DEXA scan (Osteoporosis)

Answer 342

If on long-term corticosteroid treatment, may have atrophic adrenal galnds and be unable to increase cortisol treatment in response to stress. May need to provide artificially when there is illness (potentially double dose)

Answer 343

Beclometasone Budesonide Fluticasone

Answer 344

(Beclometasone, Budesonide, Fluticasone) 1. Asthma: to treat airway inflammation and control symptoms at 'step 2' of therapy when not controlled by a short-acting Beta2-agonist (e.g. Salbutamol) alone. 2. COPD: severe or frequent exacerbations. Usually with LABA, or LAMA. Can be combined as Seratide or Symbicort.

Answer 345

(Beclometasone, Budesonide, Fluticasone) Down regulates pro-inflammatory and uprates anti-inflammatory proteins. Reduces mucosal inflammation, widens the airways and reduces mucus secretion. Improves symptoms and reduces exacerbations in asthma and COPD.

Answer 346

(Beclometasone, Budesonide, Fluticasone) Oral thrus, hoarse voice COPD - may increase risk of pneumonia (Little systemic effect unless high doses for very long time - adrenal suppression, growth retardation and osteoporosis)

Answer 347

High dose in caustion: COPD with history of pneumonia Children

Answer 348

(Beclometasone, Budesonide, Fluticasone) Twice daily - dose dependent on drug and severity. Brand name prescribing may be required. (Aerosol or dry powder form) - Spacers can help - inahler technique should be checked at every consultation

Answer 349

(Beclometasone, Budesonide, Fluticasone) Steroid inhaler to dampen down the inflammation in the lung Rinse mouth and gargle to prevent oral thrush Show correct inhaler technique and must be reviewed at each appointment

Answer 350

(Beclometasone, Budesonide, Fluticasone) Asthma: severity and serial peak flow measurements COPD: symptom severity and exacerbation rates (review 3-6 months) (Have the potential to prevent disease progression in asthma)

Answer 351

Hydrocortisone (also oral) Betamethasone (note. not Beclometasone)

Answer 352

(Hydrocortisone, Betamethasone) 1. Used in inflammatory skin conditions e.g. **eczema** to treat disease flares or to control chronic disease where emollients alone are ineffective.

Answer 353

Immunosuppressive Metabolic Mineralocorticoid

Answer 354

Where applied topically, mostly limited to site of application. Systemic absorption can occur with potent or prolonged use. Topical: mild, moderately potent, potent and very potent. Immunosuppresive effects in topical use.

Answer 355

(Hydrocortisone, Betamethasone) Uncommon with mild or moderately potent. Potent and above: Local adverse effects: skin thinning, striae, telangiectasia, contact dermatitis. Face: perioral dermatitis, acne. Withdrawal: Rebound worseing of the underlying skin condition. Rare: systemic effects e.g. adrenal suppression.

Answer 356

(Hydrocortisone, Betamethasone) Where there is infection or facial lesions (unless very mild steroid used)

Answer 357

(Hydrocortisone, Betamethasone) Use as mild as possible for as little time as possible (max 2 weeks) Potency and name in prescription. + whether lotion, cream or ointment + amount supplied. e.g Hydrocortisone 1% (mild), cream, supply 30g (Also where and OD or BD, spaced equally)

Answer 358

(Hydrocortisone, Betamethasone) Very thinly, only where disease is active. Wash hands after use. Space applications equally.

Answer 359

(Betamethasone, Hydrocortisone) Topical therapy to improve skin problem May take 1-2 weeks Emollients should be applied 5 minutes after this Warn risk of skin damage if applied to the wrong areas of for too long. Fingertip - 1st crease should be enough for 2x palms.

Answer 360

1. AF and atrial flutter, to reduce ventricular rate. (B-blocker or non-dihydropyridine CCB (verapamil or diltiazem) usually 1st line) 2. Severe heart failure: 3rd line when already taking an ACE-inhibitor, B-blocker and either an aldosterone antagonist (spironolactone) or ARB (losartan)). At an earlier stage if have AF. (Not used particularly often anymore)

Answer 361

Effects on the heart: Reduces heart rate Increases force of contraction

Answer 362

Bradycardia, GI disturbance, Rash, Dizziness, Visual disturbance. Low theraputic index - safety margin between the theraputic and toxic doses is narrow Ride range of arrhythmias can occur in digoxin toxicity

Answer 363

May worsen conduction abnromalities - CI in heart block. Not used in ventricular arrythmias Reduced in renal failure Electrolyte abnormalities increase the risk of toxicity particularly hypokalaemia.

Answer 364

Loop and thiazide diuretics - can cause hypokalaemia increasing the risk of toxicity Some others as well can increase the risk of toxicity

Answer 365

PO ir IV Loading dose is required if a rapid effect is needed 500 micrograms followed by 250-500 micrograms 6 hours later depending on response Maintenance dose 125-250 micrograms daily IV must be given slowly

Answer 366

Treatment should slow down abnormally fast heart rate and make heart beat more strongly Common side effects: sickness, diarrhoea, headache If side effects get very bad dose may be too high

Answer 367

Efficacy: Symptoms and heart rate. Check ECG, electrolytes and renal fucntion periodically. Theraputic doses of digoxin cause ST-segment depresson - 'reverse tick' sign In acute therapy: continuous cardiac monitoring is advisable. Digoxin levels do not need to be monitored routinely - only if toxicity is suspected.

Answer 368

1. Cerebrovascular disease: **Secondary prevention of stroke:** 1st line following a TIA (alone or with aspirin) 2nd line follwing ischaemic stroke where clopidogrel is contraindicated or not tolerated. (Usually given with aspirin) 2. To induce tachycardia during a myocardial perfusion scan in the diagnosis of ischaemic heart disease.

Answer 369

Antiplatelet and vasodilatory effects Increase in intra-platelet cAMP that inhibits platelet aggregation, reducing the risk of arterial occlusions. Blocks cellular uptake of adenosine, prolonging it's effect on blood vessels to produce vasodilation.

Answer 370

Vasodilatory effects: Headache, flushing, dizziness, GI symptoms Increased risk of bleeding Rarely: Thrombocytopenia

Answer 371

In caution with: Ischaemic heart disease Aortic stenosis Heart failure

Answer 372

Inhibits cellular uptake of adenosine. Prolonguing effect on the heart and increasing the risk of cardiac arrest. Incrreased risk of bleeding with other antiplatelet agents (aspirin, clopidogrel) and anticoagulants (heparin, warfarin)

Answer 373

PO, Modified release in secondary prevention of stroke (Only if clopidogrel + aspirin is not tolerated) Dipyridamole MR - 200 mg - BD Long-term treatment Taken with food

Answer 374

Purpose is to reduce the risk of further strokes, should keep taking indefinitely. Increased risk of bleeding Side effects: headache, flushing, dizziness and GI distrubance should improve with time.

Answer 375

Furosemide Bumetanide

Answer 376

(Furosemide, Bumetanide) 1. Acute Pulmonary Oedema: For relief of breathlessness in conjunction with oxygen and nitrates 2. Chronic heart failure: Symptomatic relief of fluid overload 3. Other oedematous states: Symptomatic relief of fluid overload e.g. due to liver disease or renal failure (may be given with other diuretics)

Answer 377

(Furosemide, Bumetanide) Act on the ascending limb of the loop of Henle. where they inhibit the Na+/K+/2Cl- co-transporter. This proten transports Na+ K+ and Cl- uins from the tubular lumen into the epithelial cells and water follows by osmosis. Inhibiting this process has a potent diuretic effect. They also effect blood vessels, dilating capacitance veins, in heart failure this reduces preload and improves contractile function of the heart muscle.

Answer 378

(Furosemide, Bumetanide) Dehydration, Hypotension Inhibiting Na+/K+/Cl- increases urinary loss of sodium, potassium and chloride. This also increases the excretion of magnesium, calcium and hydrogen. They are also associated with almost **any low electrolyte state e.g. hyponatraema, hypokalaemia, hypochloraemia, hypocalcaemia, mypomagnesaemia and metabolic alkalosis.** Can cause hearing loss and tinnitus

Answer 379

(Furosemide, Bumetanide) CI in severe hypovolaemia and dehydration Caution if risk of hepatic encephalopathy Caution if hypokalaemia or hyponatraemia Can worsen gout

Answer 380

(Furosemide, Bumetanide) Can affect drugs excreted by the kidneys: e.g. lithium levels are increased, digoxin toxicity may be increased (diuretic associated hypokalaemia), aminoglycosides.

Answer 381

(Furosemide, Bumetanide) PO or IV In acute pulmonary oedema IV (once-only) then either more or regular oral maintenance doses. IV slow administration PO in the morning to avoid nocturia

Answer 382

Body is overloaded with water so medication to increase urine output. Will need to urinate more, take in the morning.

Answer 383

Efficacy in pulmonary oedema: Symptoms, tachycardia, hypertension, oxygen requirements Urine output increases more slowly than resolution of symptoms Long-term measure symptoms, signs and body weight (slow reduction) Safety: periodic moitoring of serum sodium, potassium and renal function is advisable.

Answer 384

Amiloride (as co-amilofruse, co-amilozide)

Answer 385

(Amiloride) 1. As part of combination therapy, for the treatment of hypokalaemia arising from loop or thiazide-diuretic therapy. Aldosterone antagonists (spironolactone) also have a potassium-sparing effect and may be used as an alternative.

Answer 386

(Amiloride) PSDs are relatively weak diuretics alone. However, in **combination with other diuretics** they can **counteract potassium loss and enhance diuresis.** Amiloride acts on the **distal convoluted tubules in the kidney.** **It inhibbits the reabsorption of sodium (and therefore water) by ENaC channels, leading to sodium and eater excretion and retention of potassium.** This counteracts the K+ losses of loop and thiazide diuretic therapy.

Answer 387

Amiloride alone or used as part of combination tablet with furosemide (a loop diuretic) as **co-amilofruse**, or with hydrochlorothiazide (a thiazide diuretic) as **co-amilozide.** Ratio is designed to have a neutral effect on potassium balance.

Answer 388

(Amiloride) GI Upset With other diuretics: hypotension, sizziness and urinary symptoms Electrolyte disturbances: should cancel out but still possible.

Answer 389

Severe renal impairment Hyperkalaemia (Combination therapy e.g. co-amilofruse, co-amilozide, not started in hypokalaemia, only amiloride alone) Volume depletion

Answer 390

(Amiloride) Do not use in combination with other potassium-elevating drugs including potassium supplements and aldosterone antagonists due to the risk of hyperkalaemia Renal clearance of other drugs may be affected.

Answer 391

(Amiloride, co-amilofuse, co-amilozide) Co-amilofruse most common. State the strength of the tablet/ratio if combined. Dose should match the dose of existing loop or thiazide diuretic if combination therapy

Answer 392

(Amiloride) Explain their potassium level is low due to the water tablet they are taking so you are changing water tablet to reduce this Take in the morning to minimise nocturia Sfx: Gi upset, urinary frequency Blood test monitoring to check K+ in normal range

Answer 393

(Amiloride) Efficacy: reduction in symptoms for fluid overload (co-amilofruse) or blood pressure (co-amilozide) Monitor serum potassium concentration to ensure this returns to normal (intensity of monitoring dependent on severity of imbalance)

Answer 394

Amiloride vs. Spironolactone Both inhibit sodium absorption through ENaC, and retain potassium. Amiloride may be a useful alternative to spironolactone, for examble in the treatment of hypertension due to hyperaldosteronism (Conn's syndrome) or added to loop or thiazide diuretics, particularly when the adverse effects of spironolatone (such as gynaecomastic) are unacceptable.

Answer 395

Bendroflumethiazide Indapamide Chlortalidone

Answer 396

(Bendroflumethiazine, Indapamide, Chlortalidone) 1. **Hypertension**: Alternative 1st line treatment for hypetension where a calcium channel blocker would otherwise be used but is either unsuitable (due to odema) or there are features of heart failure. 2. **Hypertension add-on:** Add on treatment for hypertension in patients whose blood pressure is not adequately controlled by a **calcium channel blocker + ACE inhibitor or ARB.**

Answer 397

(Bendroflumethiazide, Indapamide, Chlortalidone) **Thiazides (thiazide and thiazide-like diuretics) inhibit the Na+/Cl- co-transporter in the distal convoluted tubule of the nephron.** This prevents reabsorption of sodium and its osmotically associaed water. The resulting diuresis causes an inital fall in exracellular fluid volume. Long-term this is compensated so not useful for fluid overload but also have **vasodilatory** effect which means they are suitable and **long-term antihypertensives.**

Answer 398

(Bendroflumethiazide, Indapamide, Chlortalidone) **Hyponatraemia:** Preventing sodium ion reabsorption from the nephron. **Hypokalaemia --\> Cardiac arrhythmias:** Increased delivery of sodium to the distal tubule, where it can be exchanged for potassium, increasing urinary potassium losses. **Impotence in men**

Answer 399

(Bendroflumethiazide, Indapamide, Chlortalidone) Avoided in hypokalaemia, hyponatraemia May precipitate gout

Answer 400

(Bendroflumethiazide, Indapamide, Chlortalidone) Effectiveness reduced by NSAIDs Combination with other potassium lowering drugs e.g. Loop diuretics is best avodied.

Answer 401

(Bendroflumethiazide, Indapamide, Chlortalidone) Take in the morning to prevent nocturia Water-tablet to treat high blood pressure. May also help with leg oedema. Likely to need to wee more. Ibruprofen may effect the way it works Warn men about the risk of impotence.

Answer 402

(Bendroflumethiazide, Indapamide, Chlortalidone) Blood pressure and leg oedema Measure serum electrolyte before starting and 2-4 weeks into therapy

Answer 403

Thiazides can cause hypokalaemia, ACEi/ARB can cause hyperkalaemia. They have syndergistic blood pressure lowering effects Together can improve blood pressure control and maintain a neutral potassium balance.

Answer 404

Levodopa (as co-careldopa, co-beneldopa) Ropinirole Pramipexol

Answer 405

(Levodopa (co-careldopa, co-deneldopa), Ropinirole, Pramipexol) 1. **Early Parkinson's Disease:** Dopamine agonists (ropinirole, pramipexol) may be preferred over levodopa. 2. **Later Parkinson's Disease:** Levodopa (main) others may be add ons. 3. **Secondary Parkinsonism:** Parkinsonism symptoms due to a cause other than idiopathic Parkinson's disease (addressing the underlying cause is better)

Answer 406

(Levodopa (co-careldopa, co-deneldopa), Ropinirole, Pramipexol) In Parkinson's disease there is a deficiency of dopamine in the nigrostriatal pathway (substrantia nigra). Levodopa is a precursor of dopamine that can increase dopaminergic stimulation to the striatum. Ropinirole and pramipexol are agonists of the D2 receptor which predominates in the striatum.

Answer 407

(Levodopa (co-careldopa, co-deneldopa), Ropinirole, Pramipexol) **Nausea** **Drowsiness** **Confusion** **Hallucinations** **Hypotension** Levodopa: **Wearing-off effect:** Patient's symptoms worsen towards the end of the dosage interval, this gets worse as the duration of therapy increases. Increasing the dose can generate the opposide effect (dyskinesias) Together called the: **on-off effect.** Symptoms at start and end of treatment interval.

Answer 408

Cautiously in the elderly and those with existing cognitive or psychiatric disease as increase confusion and hallucinations Caution in cardiovascular disease as risk of hypotension

Answer 409

(Levodopa (co-careldopa, co-deneldopa), Ropinirole, Pramipexol) Levodopa is **always given with a peripheral dopa-decarboxylas inhibitor e.g. carbidopa** to reduce conversion to dopamine outside the brain.. This desirable interaction reduces nausea and lowers sthe dose needed for theraputic effect. Should not be combined with **antipsychotics or metoclopramide (dopamine antagonist antiemetic)** because effects on dopamine receptors are contradictory (which is why these can cause parkinsonism).

Answer 410

(Levodopa (co-careldopa, co-deneldopa), Ropinirole, Pramipexol) Starting or altering done by specialists. Tend to reserve Levodopa for later in treatment to defer the development of on-off effects. Levodopa is **ONLY AVAILABLE** combined with peripheral dopa-decarboxylast inhibitors: with benserazide (co-beneldopa) or carbidopa (co-careldopa).

Answer 411

(Levodopa (co-careldopa, co-deneldopa), Ropinirole, Pramipexol) Taken at times to achieve best symptom control for the patient. Parkinson's nurses and specialist teams.

Answer 412

(Levodopa (co-careldopa, co-deneldopa), Ropinirole, Pramipexol) Clinical efficacy and side effects Blood pressure monitoring for hypotension

Answer 413

Ensuring that a patient's therapy is maintained (dose and timing) if they are admitted to hospital. Immediate stopping can presipitate neuroleptic malignant syndrome.

Answer 414

Aqueous cream Liquid paraffin

Answer 415

(Aqueous cream, liquid paraffin) 1. Topical treatment for all dry or scaling skin disorders: Alone of with topical corticosteroids in the treatment of eczema. Can reduce cracking and dryness in psoriasis (alone or in combination)

Answer 416

(Aqueous cream, liquid paraffin) Help replace water content in dry skin. Contain oils or paraffin-based products that can help soften the skin and can reduce water loss by protecting against evaporation. Can be used as a soap substitute as soap is drying.

Answer 417

(Aqueous cream, liquid paraffin) Main tolerability issue is that they cause greasiness of the skin. Can exacerbate acne vulgaris and folliculitis by blocking pores.

Answer 418

Safe but fire hazard, highly flammable.

Answer 419

(Aqueous cream, liquid paraffin) Spaced out when using corticosteroids, applied after or may prevent them working.

Answer 420

(Aqueous cream, liquid paraffin) Lotions: Thin, Creams: Thicker, Ointments: Thickest More useful but harder to apply Apply at least two or three times a day Prescribe in large volumes e.g. 500g to ensure sufficient supply Continue treatment after improvement of symptoms to prevent recurrence

Answer 421

(Aqueous cream, liquid paraffin) Improve skin dryness, may taje a whikke Apply as often as possible Use insead of soap Flammable and can make surfaces slippery Apply all over and keep using when the disease is controlled Apply corticosteroids or other treatments first

Answer 422

See if effective by symptoms and if not add another topical treatment.

Answer 423

Alteplase Streptokinase

Answer 424

(Alteplase, Streptokinase) 1. **Acute ischaemic stroke** (given w/i 4.5 hours of onset) - **MAIN USE** must exclude haemorrhagic stroke first **2. Acute ST elevation myocardial infarction** (given w/i 12 hours with antiplatelet agents and anticoagulants) however PCI is usually used instead **3. Massive pulmonary embolism with haemodynamic instability**

Answer 425

(Alteplase, Streptokinase) Catalyse the conversion of plasminogen to plasmin, dissolving fibrinous clots and re-canalising occluded vessels. This allows reperfusion of affected tissue, preventing or limiting tissue infarction and cell death.

Answer 426

(Alteplase, Streptokinase) Nausea, vomitting, bruising, hypotension Stop treatment if: serious bleeding, allergic reaction, cardiogenic shock, cardiac arrest. Reperfusion of infarcted brain or heart tissue can lead to cerebral oedema and arrythmias, respectively.

Answer 427

Bleeding: Recent haemorrhage, trauma or surgery, bleeding disorders, severe hypertension, peptic ulcers. Intercranial haemorrhage/haemorrhagic stroke must be excluded with CT scan Previous streptokinase treatment - antibodies can block effect.

Answer 428

(Alteplase, Streptokinase) Risk of haemorrgae increased if taking anticoagulants and antiplatelets.

Answer 429

(Alteplase, Streptokinase) IV, under specialist supervision, in high dependency area. Check BNF

Answer 430

(Alteplase, Streptokinase) Risks and benefits, senior discussion with next of kin. Only works if given within 4.5 hours. Symptoms can get wose and 1/3 strokes are fatal. Chance of death initially increased but chance of independenced may be increased.

Answer 431

(Alteplase, Streptokinase) Should be monitored in high dependence area, with vital signs checked every 15 minutes for the first 2 hours + bleeding, anyphylaxis and neurological deterioration.

Answer 432

1. **Focal epilepsies:** with or without secondary generalisation, usually when other anti-epileptic drugs e.g. **carbamazepine** provides inadequate control 2. **Neuropathic pain:** pregabalin 2nd line after duloxetine (SNRI) for painful diabetic neuropathy and **first-line in other painful neuropathies.** **3. Generalised Anxiety Disorder**: Pregabalin

Answer 433

Structurally related to GABA but unsure of effect. Binds to **voltage sensitive Ca2+ calcium channels**, where prevents the inflow of Ca2+ and inhibits neurotransmitter release. Reduces neurotransmission and excitability.

Answer 434

Generally better tolerated than other antiepileptics Drowsiness, dizziness and ataxia, which usually improve over time.

Answer 435

Dependent on kidneys for elimination so reduced in renal impairment

Answer 436

Seditive effect may be combined with other seditive drugs e.g. benzodiazepines Otherwise few interactions so useful in combination regimes

Answer 437

PO, started at low doses Check BNF

Answer 438

Reduce fits, neuropathic pain or anxiety. May cause some drowsiness or diziness, should improve Don't operate machinery until symptoms have settled.

Answer 439

Symptom management

Answer 440

A false-positive result for the detection of protein. Can be sent for quantitative analysis.

Answer 441

Ranitidine

Answer 442

(Ranitidine) 1. **Peptic ulcer disease: 2nd line** for treatment and prevention of gastric and duodenal ulcers and NSAID-associated ulcers. though PPIs are more effective and 1st line. 2. **GORD and dyspepsia: 2nd line** for relief of symptoms. PPIs may be used instead.

Answer 443

(Ranitidine) Histamine H2-receptor antagonists **reduce gastric acid secretion.** The proton pumps in the stomach are related in part by histamine. Blocking the H2-receptors reduces acid secretion. (PPIs have a more complete suppresive effect)

Answer 444

Few side effects Bowel disturbance, headache and dizziness

Answer 445

(Ranitidine) Reduced in severe renal impairment Can disguise the symptoms of gastric cancer

Answer 446

(Ranitidine) Can be purchased OTC Prescribied if \> 2 weeks 150 mg BD is standard

Answer 447

(Ranitidine) Treatment to reduce stomach acid and relieve symptoms. Report alarm symptoms: weight loss, swallowing difficulty

Answer 448

(Ranitidine) For peptic ulcer disease, repeat endoscopy may be necessary in some cases to confirm healing For dyspepsia and gord, the reporting of reduced symptoms is best guide.

Answer 449

Rapid onset of effect In patients with GORD due to undergo GA, can help prevent reflux, can be prescribed to help prevent.

Answer 450

Enoxaparin Dalteparin Fondaparinux Unfractionated heparin

Answer 451

(Enoxaparin, Dalteparin, Fondaparinux, Unfractioned Heparin) 1. **Venous throboembolism (VTE):** LMWH is the 1st choice phramacological **VTE prophylaxis** in hospital inpatients, and for the initial treatment of **DVT and PE.** **(Usually given with warfarin)** **2. Acute Coronary Syndrome (ACS):** LMWH or fondaparinux are part of 1st line therapy to improve revascularisation and prevent intracoronary thrombus progression (ROMANC**E**)

Answer 452

(Enoxaparin, Dalteparin, Fondaparinux, Unfractioned Heparin) **Throbin and factor Ca** are key components of the coagulation pathway. **Heparins and fondaparinux inhibit their function**, preventing the formation and propagation of blood clots. (LMWH preferred over UFH in most cases)

Answer 453

(Enoxaparin, Dalteparin, Fondaparinux, Unfractioned Heparin) Bleeding (Reduced with fondaparinux) Injection site reactions Rare: heparin-induced thrombocytopenia

Answer 454

(Enoxaparin, Dalteparin, Fondaparinux, Unfractioned Heparin) Caution: Increased risk of bleeding: Clotting disorders, severe uncontrolled hypertension, recent surgery or trauma. Avoided around the time of invasive procedures (esp. lumbar puncture and spinal anaesthetia. Lower dose in renal impairment

Answer 455

Combining antithrombotic drugs increases the risk of bleeding. Should be avoided unless part of specific treatment plan.

Answer 456

(Enoxaparin, Dalteparin, Fondaparinux, Unfractioned Heparin) Protamine

Answer 457

(Enoxaparin, Dalteparin, Fondaparinux, Unfractioned Heparin) (Some have dedicated anticoagulation chart) SC Injection Prophylaxis of VTE in inpatients: enoxaparin 40mg SC or dalteparin 5000 units SC daily. VTE and ACS: Higher doses

Answer 458

SC into the subcutaneous tissue of the abdominal wall.

Answer 459

(Enoxaparin, Dalteparin, Fondaparinux, Unfractioned Heparin) VTE prophylaxis: daily injection to reduce the risk of blood clots Discuss risks and benifits, avoid activities increasing the risk of bleeding e.g. contact sports If appropriate train how to administer SC injections

Answer 460

(Enoxaparin, Dalteparin, Fondaparinux, Unfractioned Heparin) Activated partial thromboplastin ratio (APTR) for UFH - 6 hourly **Anticoagulant effects of LMWH and fondaparinux rarely require monitoring.** If required e.g. in prgnancy can be monitored by anti-Xa activity FBC and renal profile should be checked in all cases If \>4 days platelet count should be monitored for heparin-induced thrombocytopenia

Answer 461

Ferrous fumarate Ferrous sulfate

Answer 462

(Ferrous fumarate, ferrous sulfate) **1. Treatment of iron-deficiency anaemia** **2. Prophylaxis of iron-deficiency anaemia** in patients at risk due to poor diet, malabsorption, menorrhagia, gastrectomy, haemodialysis and infants with low birth weight

Answer 463

(Ferrous fumarate, ferrous sulfate) Replenish iron stores, whcih are essential for erythropoiesis (the formation of new red blood cells). Required for the synthesis of haem. (Absorbed in the duodenum and jejunum)

Answer 464

(Ferrous fumarate, ferrous sulfate) GI upset, nausea, epigastric pain, constipation and diarrhoea. Black stools Injection site irrritation and hypersensitivity reactions.

Answer 465

(Ferrous fumarate, ferrous sulfate) Oral therapy may exacerbate bowel symptoms in patients with intestinal disease.

Answer 466

(Ferrous fumarate, ferrous sulfate) Can reduce the absorption of some drugs including levothyroxine and bisphosphonates.

Answer 467

(Ferrous fumarate, ferrous sulfate) **PO or IV** **Iron-deficiency anaemia:** 100-200 mg or elemental iron, differents anoungs for two formulations, check BNF. (Once normal continue for 3 months) **Prophylaxis of iron-deficiency anemia:** Ferrous sulfare 1-2 tablets daily.

Answer 468

(Ferrous fumarate, ferrous sulfate) Improve or prevent symptoms of anaemia. May be some GI upset and stools may turn black Different salt may be useful with GI upset.

Answer 469

(Ferrous fumarate, ferrous sulfate) FBC until haemoglobin returns to normal

Answer 470

Colonoscopy Iron should be stopped 7-days before procedure

Answer 471

Ispaghula husk Methylcellulose Sterculia

Answer 472

(Ispaghula husk, Methylcellulose, Sterculia) 1. **Constibation and faecal impaction,** in patients who cannot increase diatary fibre intake 2. **Mild chronic diarrhoea** associated with diverticular disease or IBS

Answer 473

(Ispaghula husk, Methylcellulose, Sterculia) **Bulk-forming laxatives contain a hydrophilic substance which is not broken down in the gut. Like dietary fibre, this attracts water into the stool and increases its mass.** Adequate fluid intake is important in the mechanism. **Increased stool bullk stimulates peristalsis** and helps relieve constipaton. It can also help in chronic diarrhoea (IBS, DD)

Answer 474

(Ispaghula husk, Methylcellulose, Sterculia) Mild abdominat distension and flatulence Can cause fecal impaction and GI obstruction (even though used to treat this)

Answer 475

(Ispaghula husk, Methylcellulose, Sterculia) Not used with sub-acute or esteplished **intestinal obstruction or faecal impaction**, (only constipation) and in general should not be used in **ileus.** Do not prescribe for patients with new-onset constipation in patients who have just had **abdominal surgery** as they are at risk of surgical (paralytic) ileus and increased risk of obstruction.

Answer 476

(Ispaghula husk, Methylcellulose, Sterculia) Administration around meal times, common choice is ispaghula husk 1 sachet BD. Granules or powder to be disolved in water or tablets, should be taken with plenty of water as this is essential for effect.

Answer 477

(Ispaghula husk, Methylcellulose, Sterculia) Using a laxitive that works as a fibre supplement Take with a meal and plenty of fluid

Answer 478

For inpatients, stool charts can be useful.

Answer 479

Lactulose Macrogol Phosphate enema

Answer 480

(Lactulose, Macrogol, Phosphate Enema) 1. Constipation and faecal impaction 2. Bowel preparation prior to surgery or endoscopy 3. Hepatic encephalopathy

Answer 481

(Lactulose, Macrogol, Phosphate Enema) Based on **osmotically active substances** (sugars or alcohol) that are not digested or absorbed and remain in the gut lumen. They **hold water in the stool** maintaining the colme and **stimulating peristalsis.** (Also helpful in liver failure/hepatic encephalopathy as inhibit thr proliferation of ammonia-producing bacteria)

Answer 482

(Lactulose, Macrogol, Phosphate Enema) Flatulence, abdominal cramps, nausea Diarrhoea Phosphate enemas can cause local irritation and electrolyte distrubances.

Answer 483

(Lactulose, Macrogol, Phosphate Enema) CI: Intestinal obstruction: risk of perforation Can cause fluid shits so with caution in: heart failure, ascites and electrolyte distrubances.

Answer 484

(Lactulose, Macrogol, Phosphate Enema) Example: Lactulose 15 ml PO, BD (Titrate to reponse, may take a few days to see effect) Phosphate enema for faecal impaction, once only or as required. Hepatic encephalopathy: Lactulose 30-50 mL TDS.

Answer 485

(Lactulose, Macrogol, Phosphate Enema) Laxitive to make stool softer and easier to pass. Must drink plenty of water. Cramps and flatulence may occur.

Answer 486

Can try a rectally administered glycerol suppository (stimulant laxitive) then if this doesn't work a phosphate enema (osmotic laxitive - may case electrolyte disturbance and more uncomfortable)

Answer 487

Senna Docusate Sodium Bisacodyl Glycerol Suppositories

Answer 488

(Senna, docusate sodium, bisacodyl, glycerol suppositories) 1. Constipation - (particularly useful in the elderly in opioid use where consiptation can cause confusion) 2. As glycerol suppositories for faecal impaction

Answer 489

(Senna, docusate sodium, bisacodyl, glycerol suppositories) Stimulant laxatives **increase water and electrolyte secretion from the colonic mucose, thereby increasing the volume of colonic content and stimulating peristalsis.** Direct pro-peristaltic action. Docusate sodium has stimulant and faecal softening actions

Answer 490

Abdominal pain and cramping Diarrhoea Melanosis coli (reversible pigmentation of the intestinal wall)

Answer 491

(Senna, docusate sodium, bisacodyl, glycerol suppositories) Intestinal onstruction: risk of perforation Rectal preparations: avoided in haemorrhoids or anal fissure

Answer 492

(Senna, docusate sodium, bisacodyl, glycerol suppositories) DB, e.g. 1-2 tablets of senna Titrate to effect For faecal impaction, rectal stimulant lacatives should be prescribed once only in a 24 hour period

Answer 493

(Senna, docusate sodium, bisacodyl, glycerol suppositories) Help stool pass Glood fluid intake necessary May take a few doses before effect seen Adjust dose or comfort Abdominal pain and flatulence may occur

Answer 494

1. 1st choice local anaesthetic in urinary catheterisation and minor producedures (e.g. suturing) (Can be used as an antiarrhythmmic drug for VT and VF: Refractory to electrical cardioverstion (amiodarone) preferred)

Answer 495

Inside cells **blocks voltage-gated sodium channels** on surface membranes. **Prevents initiation and propagation of action potentials in nerves and muscles, inducing local anaestesia in the area** supplied by blocked nerve fibres. (Role in heart in slowing conduction and increasing refractory period, terminating VT and improving chances treating VF)

Answer 496

Initial stinging locally Systemic (intentiaonal or accidental intravascular administration): Drowsiness, restless, tremor, fits. Overdose: hypotension, arrhythmias.

Answer 497

Dose reduced in states of reduced cardiac output.

Answer 498

When used with locally administered adrenaline/epinephrine can prolongue action of anaesthetic effect.

Answer 499

Urinary catheterisation: Instillagel Minor procedures: 1% (10mg/ml) solution of lidocaine hydrochloride. Maximum dose 200 mg or 3mg/kg whatever is lower (more if combined with adrenaline). On deal body weight. Use enough to produce adequate anaesthesia. (Not systemic administration at Foundation level)

Answer 500

Around 5 minutes, do not test before this.

Answer 501

Clarithromycin Erythromycin Azithromycin

Answer 502

(Clarithromycin, Erythromycin, Azithromycin) 1. Treatment of **respiratory and skin and soft tissue infections** as an alternative to a penicillin. 2. In **severe pneumonia** added to a penicillin to cover atypical organisms including Legionella pneumophilia and Mycoplasma pneumonia. (evidence of consolidation on chest x-ray) 3. Eradication of **Helicobacter pylori** (for example causing **peptic ulcer disease)** in combination with a PPO and either amoxicillin or metronidazole.

Answer 503

(Clarithromycin, Erythromycin, Azithromycin) **Inhibit bacterial protein synthesis**'bacteriostatic' which assists in the immune system killing and removing the bacteria from the body.

Answer 504

(Clarithromycin, Erythromycin, Azithromycin) Irritant: can cause nausea, vomiting, GI upset, diarrhoea IV: throbophlebitis Allergy and antibiotic-associated colitis Liver abnormalities: cholestatic jaundice Prolongation of the QT interval --\> arrhythmias Ototoxicity at high doses

Answer 505

(Clarithromycin, Erythromycin, Azithromycin) Macrolide hypersensitivity (but useful in Penecillin allergy) CI in severe renal and hepatic impairment

Answer 506

(Clarithromycin, Erythromycin, Azithromycin) Inhibit cytochrome P450 enzymes increasing plasma conc of drugs metabolised by P450 enzymes. Warfarin and statins Caution in drugs increasing QT interval: amiodarone, antipsychotics, quinine, quinolone antibiotics, SSRIs

Answer 507

(Clarithromycin, Erythromycin, Azithromycin) Clarithromycin most common PO or IV if CI to PO (e.g. vomiting) Usual dose Clarithromycin 250-500 mg BD 7-14 days Include indication and duration in prescription: antibiotic stewardship. IV Clarithromycin must be given as an infusion over at least 60 minutes not IV or IM bolus to reduce the risk of arrythmias. PO much cheaper than IV so do this as soon as possible

Answer 508

(Clarithromycin, Erythromycin, Azithromycin) Getting rid of infection and improving symptoms. Encourage to complete prescribed course Check for no allergy to Macrolides Seek medical adice if signs of allergy: e.g. rash ect and don't take in future.

Answer 509

Check resolution of infection by: Resolution of symptoms Examination: resolution of pyrexia, lung crackles Blood tests: falling C-reactive protein and WCC

Answer 510

1. **Disease-modifying treatment for rheumatoid arthritis** **2. Chemotherapy:** as part of regimens for cancers, leukaemia, lymphoma and some solid tumours. 3. **Severe** **Psoriasis** (and **psoriatic arthritis)** that is resistant to other therapies

Answer 511

Inhibits dihydrogolate reductase, preventing formation of FH4 and so **preventing cellular replication.** Actively dividing cells are particularly sensitive to the effects of methotrexate accounting for it's efficacy in **cancer.** (Also highly teratogenic) It also has **anti-inflammatory and immunosuppresive effects** - **inhibiting IL-6, IL-8 and TNF-a**.

Answer 512

**Mucosal damage** (sore mouth, GI upset) **Bone marrow suppression** (neutropenia and increased risk infection) **Hypersensitivity reactions:** cutaneous, hepatitis, pneumoniitis **Hepatic cirrhosis and pulmonary fibrosis** - long-term Once weeky: **risk of overdose if OD accidentally:** Severe renal and hepatotoxicity. Headaches, seizures and coma.

Answer 513

**Teratogenic - pregnancy** **Men and women must use effective contraception during and 3 months after stopping treatment** CI in severe renal impairment Avoid in abnormal liver function

Answer 514

Toxicity more likely with drugs that inhibit renal excretion e.g. NSAIDs penecillins. With other folate antagonists e.g. Trimethoprim and phenytoin increases the risk of haematological abnormalities.

Answer 515

Autoimmune disease: PO 7.5-20 mg **Once WEEKLY** Adjust according to response and adverse effects (**Folic acid 5mg** can be prescribed to days Methotrexate isn't to reduce adverse effects) For cancer, methotrexate can be given IV, IM or intrathecal routes to induce remission, then orally: specialist only. (FY1 Doctors should not start a Methotrexate prescription)

Answer 516

Improve swollen painful joints or psoriasis, may take some time To be taken ONCE A WEEK Urgent medical advice if develops sore throad, fever, brusing or bleeding (neutropenia - bone marrow suppression), nausea, abdominal pain, or dark urine (liver poisoning) or breathlessness (pulmonary fibrosis). Give advice regarding contraception (at time and 3 months after).

Answer 517

Symptoms and clincal examination Blood tests (inflammatory markers) Safety monitoring: symptoms. FBC, liver and renal function - before starting and 1-2 weeks in on establishing then every 2-3 months thereafter. Stop immediately if any side-effects.

Answer 518

Anaerobic bacterial infections in: 1. **Antibiotic-associated colitis** caused by **Clostridium difficile,** a gram-positive anaerobe. 2. **Oral infections (e.g. abscess) or aspiration pneumonia** caused by gram-negtive anaerobe from the mouth 3. **Surgical and gynaecological** infections caused by gram-negative anaerobes from the colon, for example Bacteroides fragilis. 4. **Protozoal infections:** trichomonal vaginal infection, amoebic dysentery, giardiasis

Answer 519

**In anaerobic bacteria,** reduces DNA synthesis causing widespread damage, DNA degradation and cell death. (Doesn't work in aerobes)

Answer 520

GI Upset: nausea and vomitting (most abx.) Immediate and delayed hypersensitivity reactions Long-use: Peripheral and optic neuropathy, seizures, encephalopathy

Answer 521

Metabolised by P450 so reduced in severe liver disease. Alcohol should not be drunk as can cause 'disulfiram-like' reactiion including, headache, flushing, nausea and vomiting.

Answer 522

Inhibitory effect on cytochrme P450 enzymes, increasing wardarin and phenytoin levels. Reverse interaction can heppen with inducer. Increased risk of toxicity with Lithium.

Answer 523

PO for GI infection (C.diff) - 400 mg PO, 8 hourly IV 500 mg IV, 8 hourly systemic/ PO not available/ severe Metronidazone gel or topical for bacterial vaginosis

Answer 524

Complete course Check no allergy DON'T DRINK ALCOHOL Look out for signs of allegy

Answer 525

Resolution of infection (same all abx.) Treatment \>10 days FBC and LFTs for adverse effects

Answer 526

1. Treatment of **opioid toxicity** associated with respiratory and/or neurological depression

Answer 527

Binds to opioid receptors inc. opioid u-receptors, acts as a **competitive antagonist** Has little/no effect in the absence of an exogenous opioid (e.g. morphine, heroin). If one is present it displaces it's receptors and reverses effects. Will restore consciousness and respiratory state.

Answer 528

When given to opioid-dependent individual, an **opioid withdrawal reaction** may occur. This presents with pain (if underlying), restlessess, nausea and vomiting, dilated pupils and cold dry skin with piloerection (cold-turkey). No other adverse effects

Answer 529

In caution in opioid dependence: may trigger withdrawal Lower doses in the palliative care setting to reduce the risk of complete reversal of analgesia

Answer 530

Usually effective: 400-1200 micrograms IV, titrated (small incremental doses) to effect, smaller increments in palliative care Can be given IM, C or intranasally. (Can be written immediately after in emegency)

Answer 531

Explain given antidote to counteract the effect of too much opioid. May need to discuss how it happened to try to prevent future occurances.

Answer 532

Closely monitored as the dose is titrated to effect. Once adequate reversal is achieved keep monitoring for an hour. The duration of action (about 20-60 min) is shorter than most opioids - so toxicity can recur when the effect has dissipated.

Answer 533

1. Prevention and treatment of chest pain in people with **stable angina.** 1st choice is B-blockers (or CCBs), individually or in combination. (Not the Non-Dyhydropyridine Ones - Verapamil, Diltiazem) Nicorandil (or a long acting Nitrate) can be used if these drugs are insufficient or not tolerated. (Actual treatment and management, not just symptomatic relief of GTN spray)

Answer 534

**Causes arterial and venous vasodiatation** through the action as a **nitrate and by activating K+-ATP channels** (causing relaxation and vasodilatation) This reduces cardiac preload and systemic and coronary vascular resistance. This **improves myocardial perfusion** and **decrreases myocardial work** and **oxygen demand**. This **reduces the frequency and severity of angina attacks.**

Answer 535

Unwanted effects of vasodilatation: **flushing, dizziness and headache.** Nausea, vomiting and hypotension. Rarely: GI, skin or mucosal ulceration

Answer 536

Caution: Poor left ventricular function, hypotension, pulmonary oedema

Answer 537

Hypotensive effects enhanced with **phosphodiesterase inhibitors e.g. sildenafil** (Not prescribed together)

Answer 538

PO, 5-10 mg BD, increased up to 20-30 mg BD (Develops tolerance to vasodilatory adverse effects)

Answer 539

Reduce attacks of chest pain Discuss other measures to reduce cardiovascular risk Do not drive or use heavy machinery until angina and hypotension adverse effects have settled

Answer 540

Symptoms Blood pressure: For the adverse effect of hypotension

Answer 541

Patients whose symptoms are not controlled on 2 anti-anginal drugs (e.g. Beta-blocker and CCB) need referral to consider angiographhy and revascularisation.

Answer 542

Nicotine Varenicline Bupropion

Answer 543

(Nicotine, Varenicline, Bupropion) Smoking cessation to control physical replacement of nicotine withdrawal.

Answer 544

(Nicotine, Varenicline, Bupropion) In CNS nicotine **activates nicotinic acetylcholine receptors,** increasing neurotransmitter levels and causing euphoria and relaxation. **Nicotine replacement** therapy **prevents withdrawal symptoms by maintaining receptor activation.** **Varenicline:** partial agonist, reduces withdrawal and reduces rewarding effects of smoking. **Bupropion:** increases noradrenaline and dopamine in synaptic cleft.

Answer 545

(Nicotine, Varenicline, Bupropion) Better than continuing smoking Local irritation, GI upset (oral) Palpitations and abnormal dreams Varenicline: Same + nausea, headache, insomnia. Rare: suicidal ideation. Bupropion: Dry mouth, GI upset, neurological and psychiatric adverse effects. Hypersensitivity.

Answer 546

(Nicotine, Varenicline, Bupropion) Caution if haemodynamically unstable Bupropion, Varenicline: risk of seizures, psychiatric disease Hepatic and renal impairment

Answer 547

(Nicotine, Varenicline, Bupropion) Only Bupropion - metabolised by cytochrome P450, so plasma levels increased by P450 inhibitors

Answer 548

(Nicotine, Varenicline, Bupropion) Nicotine replacment therapy - continous-release patch to reduce or prevent cravings and/or an immediate-release preparation to control the acute urge to smoke. Treatment starts either before attempt or when stopiing. Varencline or Bupropion should start 1-2 weeks BEFORE the target quit date. Continued for 9-12 weeks.

Answer 549

(Nicotine, Varenicline, Bupropion) Applied in the morning to an area of dry, airless skin and taken off at night to prevent insomnia Different site each day to reduce skin irritation Immediate-release: as and when the urge to smoke strikes

Answer 550

(Nicotine, Varenicline, Bupropion) Medicine to help reduce the cravingfor a cigarette and irritability. Need a plan + offer support and counselling, such as smoking cessation clinic.

Answer 551

(Nicotine, Varenicline, Bupropion) Monitoring of success of quit attempt and side effects of treatment by patient report, reviewed monthly.

Answer 552

(Nicotine, Varenicline, Bupropion) Prescribed on NHS with clear plan Stop if attempt fails and don't repeat within 6 months unless exceptional circumstances.

Answer 553

Isosorbide Mononitrate Glyceryl Trinitrate

Answer 554

(Isosorbide mononitrate, Glyceryl trinitrate) 1. **Short-acting nitrates (GTN)** are used in the treatment of **acute angina** and chest pain associated with **acute coronary syndrome.** 2. **Long-acting** **nitrates (e.g. isosorbide mononitrate)** are used in the **prophylaxis of angina** where B-blocker and/or a calciu channel blocker are insufficient or not toleated. 3. Intravenous nitrates are used in the treatment of **pulmonary oedema,** usually combination with **furosemide and oxygen**

Answer 555

(Isosorbide mononitrate, Glyceryl trinitrate) Converted to nitric oxide (NO). NO increases cGMP synthesis, which reduces intracellular Ca2+, relaxing vascular smooth muscle tone. **Caues venous and some arterial vasodilatation.** **Relaxation of venous capacitance vessels reduces cardiac preload and left ventricular filling. These effects reduce cardiac work and myocardial oxygen demand, relieving angina and cardiac failure.**

Answer 556

(Isosorbide mononitrate, Glyceryl trinitrate) Flushing,headaches, light-headedness and hypotension. Sustained use can lead to tolerance, with reduced symptom relief dispite continued use.

Answer 557

(Isosorbide mononitrate, Glyceryl trinitrate) CI: Severe aortic stenosis; cadiovascular collapse. Avoided in haemodynamic instability and hypotension.

Answer 558

Phosphodiesterase inhibitors (e.g. sildenafil) because prolongue hypotensive effects. Caution with other hypotensive medications

Answer 559

(Isosorbide mononitrate, Glyceryl trinitrate) Stable angina, GTN sublingually as tablets or spray for immediate relief of chest pain. In ACS or heart failure, GTN as continuous IV infusion. Recurrrent angina, (not treated w/ BB or CCB) isosorbide mononitrate (ISMN) is prescripted 2-3 times daily as immediate release tablets (also available as MR tablets or transdermal patches)

Answer 560

(Isosorbide mononitrate, Glyceryl trinitrate) Nitrate to relieve chest pain and/or breathlessness May develop short headache Should use sublingual GTN BEFORE tasks that usually bring on their angina May be good to sit and rest for 5 minutes to counteract hypotension. Remove patch/dont take at nighttime to prevent tolerance (tachyphylaxis)/ in periods of inactivity.

Answer 561

Symptoms (e.g. chest pain, breathlessness) When administering by IV infusion, blood pressure shoudl be monitored frequently.

Answer 562

1. **Uncomplicated lower urinary tract infection (UTI)**, as a 1st line. Alternatives are trimethoprim or amoxicillin.

Answer 563

Metabolised in bacterial cells to active metabolites which damage bacterial DNA and cause cell death. Active against the gram -ve and +ve bacteria commonly causing UTIs.

Answer 564

GI Upset (nausea and diarrhoea) Immediate and delayed hypersensitivity Can turn urine dark yellow or brown Rarely: pneumonitis and fibrosis, hepatiits and peripheral neuropathy, haemolytic anaemia of the newborn.

Answer 565

Not in pregnant women 3rd trimester/towards term or for babies in 1st 3 months of life Renal impariment Not for long-term prevention of UTIs as increased risk of chronic adverse effects.

Answer 566

PO - maximum urinary concentrations 2-4 hours after dosing Treatment of acute UTI: 50-100 mg 6-hrly. Treatment duration depends on severity, usually 3 days in women and 7 days in men. Prevention of recurrent UTIs, nightly dose 50-100 mg up to 6 months (requires monitoring) Take with food to minimise GI side effects

Answer 567

Complete course Check for allergy Urine may become dark Watch out for pins and needs (neuropathy) or breathlessness (pneumonitis and fibrosis) for harmful side effects

Answer 568

Efficacy: Treatment of UTI, resolution of symptoms or sterility of urine. Report any symptoms of neuropathy or respiratory side effects

Answer 569

Not suitable for pyelonephritis or complicated UTIs, suitable is co-amoxiclav or gentamicin

Answer 570

Naproxen Ibuprofen Etoricoxib

Answer 571

(Naproxen, Ibuprofen, Etoricoxib) 1. PNR for **mild-to-moderate pain** and/or paracetamol. Paracetamol preferred in those at risk of adverse effects. 2. Regular treatment for pain **related to inflammation** particularly of the MSK system e.g. MSK injury, RA, osteoarthritis or gout

Answer 572

Inhibit sythesis of prostaglandins from arachidonic acid by **inhibiting cyclooxygenase (COX).** (The theraputic effects are principally medicated by COX-2 inhibition and adverse effects by COX-1 inhibition. Selective COX-2 inhibitors e.g. etoricoxib are developed to try to reduce adverse effects)

Answer 573

(Naproxen, Ibuprofen, Etoricoxib) **GI toxicity:** Peptic ulcers **Renal impairment** **Increased risk CV events**: MI and stroke (Different onces have different AE profiles) Hypersensitivity reactions: bronchospasm, angioedema Fluid retention: Can worsen hypertension and heart failure

Answer 574

CI: Severe renal impairment, heart failure, liver failure, known NSAID hypersneitivity In peptic ulcer disease, GI bleeding, CVD, renal impariment - if unavoidable use the lowet effective dose for the shortest possible time.

Answer 575

(Naproxen, Ibuprofen, Etoricoxib) Drugs inc risk GI ulceration: Aspirin, Corticosteroids GI Bleeding: Anticoagulants, SSRIs, Venlafaxine, Warfarin Renal impariment: ACE inhibitors, diuretics, Reduce theraputic effects of antihypertensives and diuretics

Answer 576

(Naproxen, Ibuprofen, Etoricoxib) PO, topical, suppositories, injectable e.g. RA, naproxen 500 mg PO, 12 hrly Regular treatment for at least 3 weeks is necessary before full anti-inflammatory effect is seen. Acute pain: naproxen 250 mg PO, 6-8 hrly as needed (Different tollerance and AE profile with different drugs) Take with food to minimise GI upset

Answer 577

(Naproxen, Ibuprofen, Etoricoxib) Anti-inflammatory drug to help pain, swelling and/or fever Most common SFx is indigestion - stop and seek medical advice if this occurs For acute pain, do not use \> 10 days Chronic use/renal impairment: Stop if become acutely unwell or dehydrated to reduce the risk of damage to the kidneys.

Answer 578

(Naproxen, Ibuprofen, Etoricoxib) Efficacy: control of symptoms Renal function monitored in those with existing renal impairment

Answer 579

(Naproxen, Ibuprofen, Etoricoxib) Should be considered for all patients prescribed NSAIDS who are at increased risk of GI complications: Age \> 65 years, previous peptic ulcer disease, comorbidities (e.g. diabetes), concurrent therapy with other drugs with GI sfx (esp, aspirin and prednisolone) **Use with PPI (Lansoprazole 15 mg OD)**

Answer 580

Hypromellose Carbomers Liquid and white soft paraffin

Answer 581

(Hypromellose, Carbomers, Liquid and white soft paraffin) **1st line** symptomatic treatment of **dry eye conditions** (including keratoconjunctivitis sicca and Sjogren's syndrome, alongside environmental coping strategies and avoiding precipitants)

Answer 582

(Hypromellose, Carbomers, Liquid and white soft paraffin) **Soothing effect and help protect the eye surfaces from abrasive damage.** Increasing thickness and duration but may cause blurred vision.

Answer 583

(Hypromellose, Carbomers, Liquid and white soft paraffin) Mild stinging and temporary blurring of vision (increased with ointments) May cause mild allergic reaction in some patients (No warnings and ICs and no interactions)

Answer 584

(Hypromellose, Carbomers, Liquid and white soft paraffin) Most can be purchased OTC (Sjoren's needs supervision/medical intervention) Liquid \> Gel \> Paraffin Paraffin usually only at night due to blurring effect

Answer 585

(Hypromellose, Carbomers, Liquid and white soft paraffin) Artificial tears in the hope of improving dry eyes. Can sting when applied, advice on how to apply With continued use the previous abrasive damage may be repaired, they will probably need to take treatment indefinitely to reduce new damage.

Answer 586

Co-codamol Co-dydramol

Answer 587

(Co-codamol, Co-dydramol) **1. Mild-to-moderate pain:** as second-line agents when simple analgesics, such as paracetamol, are insufficent. Second 'rung' if the WHO pain ladder.

Answer 588

(Co-codamol, co-dydramol) Paracetamol: **Weak inhibitor of cyclooxygenase (COX)** Opiods metabolised to **morphine/morphine related metabolites - agonists of opioid u-receptors.**

Answer 589

(Co-codamol, co-dydramol) Opioids: Nausea, consitpaiton and drowsiness Paracetamol OD: hepatotoxicity Opioid OD: Neurological and respiratory depression

Answer 590

(Co-codamol, Co-dydramol) Significant respiratory depression Reduced doses in real and hepatic impairment (opioid excretion) Caution in the elderly

Answer 591

(Co-codamol, Co-dydramol) Not used with other sedating drugs: antipsychotics, benzodiazepines, tricyclic antidepressants. (Close monitoring if combination required)

Answer 592

(Co-codamol, Co-dydramol) PO All tablets contain 500 mg of paracetamol and dose of opioid varies. Opioid x mg/ Paracatamol x mg (Go for one with 1g paracetamol 6 hrly)

Answer 593

A stimulant laxative, for example senna.

Answer 594

Painkiller which is a weaker version of morphine To be taken at regular intervals Side effects and laxitive if required Avoid driving or operating heavy machinery if they become drowsy or confused whilst taking medication

Answer 595

(Co-codamol, Co-dydramol) Efficacy: Pain relief No special monitoring

Answer 596

Morpine Oxycodone

Answer 597

(Morphine, Oxycodone) 1. Rapid relief of **acute severe pain (inc. post-operative and acute MI)** 2. **Chronic pain: 3rd rung** - when paracetamol, NSAIDs and weak opioids are insufficient 3. **Breathlessness in end-of-life care** 4. To relieve breathlessness and anxiety in **acutre pulmonary odema with oxygen, furosemide and nitrates**

Answer 598

(Morphine, Oxycodone) **Activation of opioid u (mu) receptors in the CNS, reducing neuronal excitability and pain transmission.** By relieving pain, breathlessness and anxiety, opioids **reduce sympathetic nervous system activity.** Thus in MI and acute pulmonary oedema they reduce cardiac work and oxygen demand as well as symptoms.

Answer 599

(Morphine, Oxycodone) **Respiratory depression** by reducing respiratory drive Euphoria and detachment and **neurological depression** **Nausea and vomitting (usually settles)** **Pupillary constriction** **Constipation** Itching, urticaria, vasodilation and sweating Continued use: **tolerance and dependence** If dependent: **withdrawal reaction**

Answer 600

(Morphine, Oxycodone) Liver and kidney elimination: reduced in hepatic failure and renal impairment Elderly Respiratory failure Not in biliary colic

Answer 601

(Morphine, Oxycodone) Close monitoring if used with other sedating drugs: Antipsychotics, Benzodiazepines, Tricyclic antidepressants

Answer 602

(Morphine, Oxycodone) **Acute severe pain (high-dependency):** Morphine IV for rapid onset (2-10 mg) (If general ward: IM and SC is prefered) **Chronic pain: PO e.g. Oramorph 5 mg PO 4 hourly** (When optimum dose found, converted to a modified release form e.g. MST Continus 15 mg 12 hrly - make sure equivalent) **Breakthrough analgesia: Prescribe immediate-release morphin at a dose of 1/6th total daily dose e.g.** Oramorph 5 mg 2 hourly in as required section

Answer 603

(Morphine, Oxycodone) Addiction not usually issue when used for pain relief Dose may need to be increased due to tolerance Take slow release tablets for 'background pain' then fast acting for 'background pain'. Nausea settles over a few days but can offer antiemetic **Metoclopramide** For consitpation **senna** and hydration Do not drive or operate heavy machinery if drowsy or confused

Answer 604

(Morphine, Oxycodone) Pain relief, respiratory and neurological depression.

Answer 605

Anxiety Pain and breathlessness Dilated pupils Dry and cool skin with piloerection (Cold-turkey)

Answer 606

Tramadol Codeine Dihydrocodeine

Answer 607

(Tramadol, Codeine, Dihydrocodeine) Mild-to-moderate pain, incuding post-operative pain, as 2nd line agents when simple analgesics such as paracetamol are inappropriate (2nd rung)

Answer 608

(Tramadol, Codeine, Dihydrocodeine) Metabolised in liver to morphine and related metabolites **Agonists of the u (mu) opioid receptors** (10% of caucasians may find less effective) Tramadol is more moderate in strength

Answer 609

(Tramadol, Codeine, Dihydrocodeine) **Nausea** **Constipation** **Dizziness** **Drowsiness** **Neurological and Respiratory Depression** **Codeine and Dihydrocodien MUST NOT be given IV** as can have severe reaction similar to anapylaxis.

Answer 610

(Tramadol, Codeine, Dihydrocodeine) Caution in: significant respiratory disease. Reduced doses in renal and hepatic impairment and elderly Tramadol - caution in epilepsy

Answer 611

(Tramadol, Codeine, Dihydrocodeine) Ideally not used or strict monitoring with other sedating drugs: Antipsychotics, Benzodiazepines, Tricyclic antidepressants Tramadol not with drugs lowering the seizure threshold: SSRIs and tricyclic antidepressants

Answer 612

(Tramadol, Codeine, Dihydrocodeine) PO where possible IM in operating theatre - DO NOT GIVE IV Regular preferable to as-redquired e.g. Codeine or dihydrocodeine 30 mg PO 4-ourly Co-prescribe a stimulant laxitive such as Senna

Answer 613

(Tramadol, Codeine, Dihydrocodeine) Painkiller weaker mophine Take at regular intervals Laxitives for constipation Avoid driving or operating heavy machinery if drowsy or confused.

Answer 614

Anaesthetists sometimes give IM towards end NOT IV CAUSES REACTION May leave rede mark on lateral aspect of leg due to local reaction

Answer 615

1. 1st line analegis for acute and chronic pain - 1st rung of pain ladder 2. Antipyretic anc can reduce fever and shivering

Answer 616

**Weak inhibitor of cyclooxygenase (COX)** the enzyme involved in prostaglandin metabolism. Increases pain threshold and reduces prostaglanding concentration. (Weak anti-inflammatory)

Answer 617

Treatment doses: Safe (Lack of COX-1 inhibition means doesn't cause NSAID Sfx) In overdose, causes hepatotoxicity (NAPQI accumulation cauing hepatocellular necrosis - can be treated with acetylcysteine)

Answer 618

Reduced in those at increased risk of liver toxicity Chronic excessive alcohol use, malnutrition, blow body weight and severe hepatic impariment

Answer 619

Cytochrome P450 incudes increase rate of NAPQI producion and increase risk of liver toxicity in overdose

Answer 620

PO, IV or rectal 0.5-1 g every 4-6 hours, maximum 4 g daily Can be regular or as required (must state daily maximum dose)

Answer 621

Aim of reducing or relieving pain, effects in 30 mins Take 6 hourly if regular of 4-6 hourly if PRN At review check if step-up is required Overdose: blood tests INR, ALT to see if acetylcystine treatment is required.

Answer 622

Co-codamol or Co-dydramol as this would mean they are already having paracetamol

Answer 623

Benzylpenicillin Phenoxymethylpenicillin

Answer 624

(Benzylpenicillin, Phenoxymethylpenicillin) 1. Strep infections including tonsillitis, pneumonia (with macrolide if severe), endocarditis and skin and soft tissue infections (added to flucloxaxillin if severe) 2. Clostridal infection, e.g. tetanus 3. Meningococcal infection, e.g. meningitis, septicaemia

Answer 625

(Benzylpenicillin, Phenoxymethylpenicillin) Weaken cell walls, causing cell swelling, lysis and death Penicillins contain a B-lactam ring, which is responsible for antimucrobal activity. Bacteria producing B-lactamases are resistant to treatment with Penicillins.

Answer 626

(Benzylpenicillin, Phenoxymethylpenicillin) Penicillin allergy: 1-10% people Skin rash 7-10 days after exposure or 1-2 days after repeat exposure (dubacute IgG-mediated reaction) less commonly a life threatening (minutes to house) IgE anaphylactic reaction may occur: Hypotension, bronchial and laryngeal spasm/oedema and angioedema. CNS toxicity can occurr where there are high doses or severe impairment.

Answer 627

(Benzylpenicillin, Phenoxymethylpenicillin) Reduced dose in renal impariment CI: History of penicillin allergy

Answer 628

Increase methotrexate toxicity

Answer 629

(Benzylpenicillin, Phenoxymethylpenicillin) Benzylpenicillin IM or IV only (severe infections) Phenoxymethylpenicillin PO (less severe infections) 4-6 hourly Include indication and duration of treatment in prescription

Answer 630

Complete course Check for allergy

Answer 631

(Benzylpenicillin, Phenoxymethylpenicillin) Symptom reduction: Pyrexia, lung crackles Blood markers: Falling C-reactive protein and WCC

Answer 632

Phenoxymethylpenicillin Amoxicillin when due to EBV can cause a rash which may lead to a lifetime of avoidance of penicillin.

Answer 633

Piperacillin with Tazobactam e.g. Tazocin

Answer 634

(Piperacillin with Tazobactam e.g. Tazocin) For severe infection, where there is a broad spectrum of potential causative pathogens inc: Pseudomonas aeruginosa, where antibiotic resistance is likely (hospital-aquired infection) or patients are immunocompromised. 1. LRTI 2. UTI 3. Intra-abdominal sepsis 4. Skin and soft tissue infection

Answer 635

(Piperacillin with Tazobactam e.g. Tazocin) Weaken cell walls, leading to cell swelling, lysis and death Penicillins contain a B-lactam ring. Addition of tazobactam (a B-lactamase inhibitor, canfers antimicrobilal activity against B-lactamase-producing bacteria e.g. Staph aureus, Gram-neg anaerobes, Pseudomonas aeruginosa

Answer 636

(Piperacillin with Tazobactam e.g. Tazocin) GI upset: nausea and diarrhoea Antibiotic-resistant colitis (due to broad spectrim - overgrowth of C.diff) Delayed or immediate hypersensitivity reactions

Answer 637

(Piperacillin with Tazobactam e.g. Tazocin) Caution in at risk of C.diff CI: History of penicillin allergy Reduced in moderate-severe renal impariement

Answer 638

(Piperacillin with Tazobactam e.g. Tazocin) Reduce excretion of methotrexate increasing toxicity Antipsuedomonal penicillins can enhance the anticoagulation effect of warfarin

Answer 639

(Piperacillin with Tazobactam e.g. Tazocin) IV. 5-14 days. 4.5g containing 4 g piperacillin and 500 mg tazobactam 6-8 hourly . (Include indication and duration in prescription) Pweder diluted in water and sodium chloride + glucose

Answer 640

(Piperacillin with Tazobactam e.g. Tazocin) Check for allergy and warning signs. Advice will be in hosptial for a while (5-14 days) IV treatment

Answer 641

Amoxicillin Co-amoxiclav

Answer 642

(Amoxicillin, Co-amoxiclav) 1. Empirical treatment of **pneumonia**, which may be cause by gram-positive (strep pneumonia) or gram-negative pathogens (haemophilus influenzae) 2. Empirical treatment of **UTI** most likely caused by e.coli, can use Nitrofurantoin 3. Combination treatment (co-amoxiclav) for **hospital-aquired infection or intra-abdominal sepsis.** 4. As part of combination treatment for **H/pylori-assocaited peptic ulcers**

Answer 643

(Amoxicillin, co-amoxiclav) Weaken cell walls leading to cell, swelling lysis and death. Penicillins contain a B-lactam ring, which is responsible for their antimicrobial activity. (**Co-amoxiclav contains clavulanic acid,** which increases the spectrum of antimicrobial activity to include **B-lacamase-producing bacteria** such as Staph aureaus and gram-negativ anaerobes)

Answer 644

(Amoxicillin, co-amoxiclav) GI Upset: Nausea and diarrhoea Antibiotic-associated colitis: C.diff overgrowth (can lead to colonic perforation and/or death) Penicillin allergy: Rash or anaphylaxis Anaphylactic reaction: Hypotension, bronchospasm and angioedema Cholestatic jaundice: co-amoxiclav

Answer 645

(Amoxicillin, Co-amoxiclav) Caution in those at risk of C.diff infection CI: Penicillin allergy Reduced dose in severe renal impairment

Answer 646

(Amoxicillin, Co-amoxiclav) Increasee plasma concentration of Methotrexate Enhance anti-coagulant effect of warfarin.

Answer 647

(Amoxicillin, Co-amoxiclav) Severe infection: Amoxicillin (high-dose 1g 8-hrly) IV should be switched to oral after 48hrs if clinically indicated and patient is improving. Mild-to-moderate infection: PO lower dose amoxicillin (250-500 mg 8hrly) co-amoxiclav (co-amoxiclav 500/125 indicated amoxicillin/clavuanic acid) (Include indication and dose of treatment)

Answer 648

(Amoxicillin, Co-amoxiclav) Oral: Complete prescribedcourse Ceck for allergy Warnings if allergy develops

Answer 649

Flucloxacillin

Answer 650

(Flucloxacillin) Staphylococcal infection: 1. Skin and soft tissue infections such as cellulitis (in combination with benzylpenicillin for more severe infections) 2. Osteomyelitis and septic arthritis 3. Other infections, including endocarditis

Answer 651

(Flucloxacillin) Weaken cell walls, causing cell swelling, lysis and death. Penicillins contain a B-lactam ring, which is responsible for antimicrobial activity. Flucloxacillin has side chain which makes effective against B-lactamase producing staphylococci. (MRSA is resistant)

Answer 652

(Flucloxacillin) GI upset: Nausea and vomitting Allergy: Rash (delayed IgG) anaphylaxis (IgE) Liver toxicity CNS toxicity - high dose or severe renal impairment

Answer 653

(Flucloxacillin) Renal failure: reduced dose CI: History of penicillin allergy CI: Previous flucloxacillin realted hepatotoxicity

Answer 654

(Flucloxacillin) Flucloxacillin: High-dose IV for severe infection, where systemically unwell (up to 6 weeks may be required for osteomyelitis or endocarditis) Less severe: PO 250-500 mg 6 hrly (Include duration and indication in prescription)

Answer 655

(Flucloxacillin) Complete course Check for allergy (note nausea may not be a reaction but instead a dose related adverse effect)

Answer 656

1. To control seizures in **status epilepticus** where benzodiazepines are ineffective 2. Reduce frequency of **generalised or focal seizures in epilepsy,** though drugs with fewer adverse effects and interactions eg. Valproate, lamotrigine, levetriacetam are usually preferred.

Answer 657

**Reduces neuronal excitability and electrical conductance among brain cells.** Seems to bind to Na+ neuronal channels. (Similar effect in cardiac Purkinje fibres may account for antiarrythmic and cardiotoxic effects)

Answer 658

Long term: **Change in appearance -** skin coarsening, acne, hirsuitism and gum hypertrophy. **Neurological effects:** Cerebellar toxicity (e.g. nystagmus, ataxia and discoordination) and impaired cognition or consciousness **Haematological disorders and osteomalacia** by incuding folic acid and vitamin D metabolism **Hypersensitivity** **Phenytoin toxicity**: cardiovascular collapse and respiratory depression (can be fatal)

Answer 659

**Hepatic impairment:** Metabolised in liver with zero-order kinetics and with low theraputic index - dose reduced in hepatic impairment. **Teratogenic:** Craniofacial deformity and reduced IQ, women with epilepsy planning pregnancy should take HIGH DOSE folic acid before conception

Answer 660

Enzyme inducer so reduces plasma concentrations of drugs metabolised by P450 enzymes. Concentration increased by cytochrome P450 inhibitors Complex interactions with other antiepileptic drugs Efficacy reduced by drugs lowering the seizure thereshold

Answer 661

**Status epilepticus: IV phenytoin** loading dose of 20mg/kg (max 2g) followed by maintenance dose of 100 mg 6-8 hourly. **Long term Oral phenytoin** for chronic epilepsy is commenced at 150-300 mg daily, in 1-2 divided doses. Phenytoin dosage is adjusted according to **plasma concentations**. Treatment should not be stopped suddenly but should be withdrawn gradually to reduce risk of recurrence. (Slow IV, flushed and need resus facilities)

Answer 662

To reduce frequency of seizures Advice to take regularly with food and don't miss doses Seek medical advice for rashes, bruising or signs of infection For women: discuss contraception and preganncy DVLA - Don't drive uness seizure free for 12 months and for 6 months after changing or stopping treatment

Answer 663

**Plasma phenytoin concentrations** are measure immediately before the next dose and should be 10-20 mg/L. Make small changes in dose due to zero-order kinetics. **Efficacy:** Compare seizure frequency before and after starting or changing treatment. **IV treatment:** BP, ECG, Respiratory rate, oxygen saturations

Answer 664

Sildenafil

Answer 665

(Sildenafil) 1. Erectile dysfunction 2. Primary pulmonary hypertension

Answer 666

(Sildenafil) Selective for **PDE type 5** which is found predominantly in the smooth muscle of the **corpus cavernosum** of the penis and arteries of the lung. For an erection to occur, sexual simulation is required. As PDE5 is responsible for the breakdown of cGMP, inhibition of this enzyme by **sildenafil increases cGMP concentrations, improving penile blood flow and erection quality.** In primary pulmonary vasculature, sildenafil causes arterial vasodilatation by similar mechanisms so is used to treat **primary pulmonary hypertension.**

Answer 667

(Sildenafil) Flushing, headache, dizziness, nasal congestion Hypoension, tachycardia and palpitations Small risk of vascular events: MI, stroke Priapism (Urgent medical review) Visual disorders (Urgent medical review)

Answer 668

(Sildenafil) Recent stroke or ACS Significant CVD Severe renal or hepatic impairment

Answer 669

(Sildenafil) Not with **nitrates**: can cause cardiovascular collapse: Nitrates or Nicorandil **Caution with a-blockers and CCBs** - increased risk hypotension Concentrations increased by cytochrome P450 inhibitors. Do not take with amyl nitrate (poppers) as may cause collapse

Answer 670

(Sildenafil) Viagra: erectile dysfunction 50 mg PO, 1 day maximum Revatio: primary pulmonary hypertension.

Answer 671

(Sildenafil) Will help have and maintain an erection but will not work without sexual stimulation Should be taken an hour befre sex to allow sufficient time for absorption Seek medical advice if the erection does not subside within two hours after sexual activity has finished Be aware of any eyesight changes

Answer 672

Only where erectile dysfunction is secondary to chronic disease or trauma or if causing significant psychological or social distress. Now available without prescription.

Answer 673

Potassium Chloride Potassium Bicarbonate

Answer 674

(Potassium Chloride, Potassium Bicarbonate) 1. Treatment and prevention of **potassim depletion/hypokalaemia.** (Where this is caused by a loop or thiazide diuretic, addition of a potassium sparing diuretic is preferable. IV potassium chloride is preferreed in the initial treatment of hypokalaemia that is severe (\<2.5 mmol/L), symptomatic or causing arrythmias.

Answer 675

(Potassium Chloride, Potassium Bicarbonate) Causes of hypokalaemia: diarrhoea, vomiting, secondary hyperaldosteronism. - **Supplement is treatment** Where caused by loop or thiazide diuretic, **requires potassium-sparing diuretic or aldosterone antagonist.** Redistribtive hypokalaemia: total body potassium is normal but serum concentration is low because of distribution into cells (insulin or salbutamol) MANAGEMENT ADDRESS UNDERLYING CAUSE

Answer 676

(Potassium Chloride, Potassium Bicarbonate) Oral: Unpalatable and cause **GI disturbance:** nausea, vomiting, pain, diarrhoea, flatulence. Modified release: GI obstruction, ulceration and bleeding Overtreatment: **Hyperkalaemia and resultant risk of arrhytmias.**

Answer 677

(Potassium Chloride, Potassium Bicarbonate) Caution in renal impairment and avoided in severe renal impairment

Answer 678

(Potassium Chloride, Potassium Bicarbonate) Additive effect with IV potassium, aldosterone antagonists, potassium-sparing diuretics, ACE inhibitors and ARBs.

Answer 679

(Potassium Chloride, Potassium Bicarbonate) Treat if \<2.5-3.5 depending on risk of arrythmias (inc. in digoxin) Sando-K or Kay-Cee-L syrup Dose adjusted to response Dissolved in water, may be more palpable with food.

Answer 680

(Potassium Chloride, Potassium Bicarbonate) Low level of potassium blood could upset heart rhythm. Blood test monitoring will be required SFx may be reduced if combined with meal or snack Do not consume salt substitutes as these have high potassium concent and count interact with treatment.

Answer 681

(Potassium Chloride, Potassium Bicarbonate) Baseline: ECG to confirm the absence of hypokalaemia changes: IV over oral treatment. Potassium concentration should be monitored during therapy.

Answer 682

Latanprost Bimatoprost

Answer 683

(Latanoprost, Bimatoprost) 1. 1st line agent to lower intraocular pressure in **open-angle glaucoma** and **ocular hypertension.** Usually prefered over topical B-blocker (the main alternative class) as they cause fewer systemic side effects.

Answer 684

(Latanoprost, Bimatoprost) Ocular hypertension is a risk factor for open-angle glaucoma **Prostaglandin analogue eye drops reduce intraocular pressure by increasing outflow of aqueous humour via the uveoscleral pathway.** (Glaucoma is characterised by progressive optic nerve damage associated with visual field loss and eventually blindness, it is usually though not always associated with elevated intraocular pressure)

Answer 685

(Latanoprost, Bimatoprost) Blurred vision, conjunctival redening and ocular irritation and pain May cause permanent ch.ange in eye colour

Answer 686

(Latanoprost, Bimatoprost) Eyes in which the lens is absent or artificial In patients with or at risk of iritis, uveitis or macular oedema (Topical beta-blockers risk of bronchoconstrction)

Answer 687

(Latanoprost, Bimatoprost) Specialist decision with ocular hypertension **Open-angle glaucoma** all offered treatment with specialist involvement - usually Latanoprost 1 drop daily, in the evening.

Answer 688

(Latanoprost, Bimatoprost) Aim of treatment is to reduce the risk of sight loss. Advice how to administed Explain the risk of eye colour change Gently compress the medial canthus (nasal corner) of the eye for a minute after adminstration to reduce systemic absorption of the drug.

Answer 689

Lansoprozole Omeprazole Prantoprazole

Answer 690

(Lansoprazole, Omeprazole, Pantoprazole) 1st line for: 1. Prevention and treatment of **peptic ulcer disease,** including **NSAID-associated ulcers** 2. Symptomatic relief of **dyspepsia and GORD** 3. Eradication of **Helicobacter pylori infection**, where they are used with antibiotics

Answer 691

(Lansoprazole, Omeprazole, Pantoprazole) Reduce gastric acid secretion by **irreversibly inhibiting H+/K+-ATPase in gastric parietal cells.** This is the proton pump responsible for secreting H+ and generating gastric acid. (More complete action than H2-receptor antagonists)

Answer 692

(Lansoprazole, Omeprazole, Pantoprazole) **GI disturbance and headache** May increase risk of C.diff in some people Prolongued treatment: **hypomagnesaemia** (tetany and ventricular arrhythmia)

Answer 693

(Lansoprazole, Omeprazole, Pantoprazole) PPIs may disguise symptoms of gastric cancer, so check **red flags** before and after treatment. May increase risk of **fracture, so caution in Osteoporosis**

Answer 694

(Lansoprazole, Omeprazole, Pantoprazole) May reduce antiplatelet effect of **clopidogrel.**

Answer 695

(Lansoprazole, Omeprazole, Pantoprazole) PO or IV, dose on drug and indication. Lowest possible for shortest period of time, take in morning.

Answer 696

(Lansoprazole, Omeprazole, Pantoprazole) Hopefully reduce discomfort and help ulcers to heal. Ensure clear on duration on therapy and how success will be judged. Red flags: Weight loss, swallowing difficulty

Answer 697

(Lansoprazole, Omeprazole, Pantoprazole) Symptomatic response Healing of peptic ulcers judged by endoscopic examination/appearance. If \>1 year, check serum magnesium levels due to risk of hypomagnesaemia.

Answer 698

Witheld for 2 weeks as increases the risk of a false negative result

Answer 699

1. **Nightime leg cramps** (when disturb sleep and non-pharmacological methods have failed) 2. **Plasmodium falciparum malaria**

Answer 700

Reduces excitability of motor end plates, reducing frequency of muscle contraction - **Leg cramps** Kills P.falciparum parasites in the blood - **Malaria**

Answer 701

Safe at recommended doses Overdose: Tinitus, deafness, blindness, GI upset and hypersensitivity reactions. Prolongued QT interval - arrythmias Hypoglycaemia

Answer 702

Caution: existing hearning or visual loss Teratogenic: not in 1st trimester of pregnancy Avoid in G6PD deficiency

Answer 703

Other drugs prolonging the QT interval: amiodarone, antipsychotics, quinolones, macrolides and SSRIs.

Answer 704

Leg cramps: 200-300 mg PO, at night. Malaria: Higher doses, PO or IV (with doxycycline)

Answer 705

Leg cramps: trial for 4 weeks. Report: Hearning loss, visual disturbance and palpiations immediately (ears, eyes and heart)

Answer 706

Review at 4-weeks and stop if no improvement. Try to stop at 3-months due to risk of serious side effects.

Answer 707

Ciprofloxacin Moxifloxacin Levofloxacin

Answer 708

(Ciprofloxacin, Moxifloxacin, Levofloxacin) 2nd and 3rd line for: 1. UTIs 2. Severe GI Infection 3. LRTI infection 4. **Pseudomonas aeruginosa**

Answer 709

(Ciprofloxacin, Moxifloxacin, Levofloxacin) Kill bacteria by **inhibiting DNA synthesis.** **Bacteria rapidly develop resistance to quinolones.**

Answer 710

(Ciprofloxacin, Moxifloxacin, Levofloxacin) GI Upset: nausea and diarrhoea (all Abx) Immediate and delayed hypersensitivity reactions Neurological effects: Lowering seizure threshold and hallucinations Inflammation and rupture of muscle tendons Quinolones: Prolong the QT interval - increase risk arrythmias Promote C.diff infection

Answer 711

(Ciprofloxacin, Moxifloxacin, Levofloxacin) Caution in those at risk of **seizures, children, QT prolongation.**

Answer 712

(Ciprofloxacin, Moxifloxacin, Levofloxacin) Multiple, check BNF.

Answer 713

(Ciprofloxacin, Moxifloxacin, Levofloxacin) PO if possible but IV is possible 12-24 hours

Answer 714

(Ciprofloxacin, Moxifloxacin, Levofloxacin) Complete course, check for allergy.

Answer 715

(Ciprofloxacin, Moxifloxacin, Levofloxacin) Severe traveller's diarrhoea: shigella, salmonella, campylobacter. (Reserved for systemic involvement)

Answer 716

Simvastatin Atorvastatin Pravastatin Rosuvastatin

Answer 717

(Simvastatin, Atorvastatin, Pravastatin, Rosuvastatin) 1. **Primary prevention of cardiovascular disease:** to prevent cardiovascular events in people over 40 years of age with a 10-year cardiovascular risk \>20% 2. **Secondary prevention of cardiovascular disease:** first line alongside lifestyle changes, to prevent further cardiovascular events in those who have evidence of cardiovascular disease 3. **Primary hyperlipidemia:** 1st line in primary hypercholesterolemia, mixed dyslipedaemia and familial hypercholesterolemia.

Answer 718

(Simvastatin, Atorvastatin, Pravastatin, Rosuvastatin) **Reduce serum cholesterol levels by inhibiting HMG CoA reductase.** An enzyme involved in making cholesterol. Slow the alterosclerotic proccess.

Answer 719

(Simvastatin, Atorvastatin, Pravastatin, Rosuvastatin) Headache and GI disturbances Muscle: can cause aches, myopathy or (rare) rhabdomyolysis. Liver: rise in liver enzymes (ALT), (rare) drug induced hepatitis.

Answer 720

(Simvastatin, Atorvastatin, Pravastatin, Rosuvastatin) Caution: Hepatic impariment Dose reducedd in renal impairment Avoided in pregnancy and breastfeeding

Answer 721

(Simvastatin, Atorvastatin, Pravastatin, Rosuvastatin) Accumulation with cytochrome P450 inhibitors. Amlodipine

Answer 722

(Simvastatin, Atorvastatin, Pravastatin, Rosuvastatin) PO, OD, e.g. 40 mg daily Simvastatin or 10 mg daily Atorvastatin Taken in the evening

Answer 723

(Simvastatin, Atorvastatin, Pravastatin, Rosuvastatin) Medicine to lower cholesterol and reduce the risk of heart attack or stroke in the future. Seek help if experience muscle symptoms Blood tests in 3 and 12 months Teep alcohol intake to a minimum and avoid grapefruit juice.

Answer 724

(Simvastatin, Atorvastatin, Pravastatin, Rosuvastatin) Primary prevention: lipid profilebefore treatment. Secondary prevention: efficacy by serial lipid profiles to meet targets. Safety: liver enzymes ALT at 3 and 12 months. Creatinine kinase if muscle symptoms are reported.

Answer 725

Thyroid function as hypothyroidism is a reversible cause of hyperlipidaemia and should be corrected instead of statin treatment.

Answer 726

Doxycycline Lymecycline

Answer 727

(Doxycycline, Lymecycline) 1. **Acne vulgaris** **2. LRTIs including:** Infective COPD, Pneumonia and atypical pneumonia. 3. **Chlamydial infection including pelvic inflammatory disease (PID)** **4. Typhoid, anthrax, malaria, Lyme disease**

Answer 728

(Doxycycline, Lymecycline) **Inhibit bacterial protein synthesis -** bacteriostatic and kills bacteria.

Answer 729

(Doxycycline, Lymecycline) GI upset: Nausea, vomtting and diarrhoea Hypersensitivity reactions Immediate and delayed Specific to tetracyclines: Oesophageal irritation, ulceration and dysphagia, photosensitivity, discolouration or hypoplasia of tooth enamel. Intracranial hypertension.

Answer 730

(Doxycycline, Lymecycline) Bind to teeth and bones during foetal development and childhood: Pregnancy, breastfeeding, Children \<12 Renal impairment

Answer 731

(Doxycycline, Lymecycline) Enhance anticoagulant effect of warfarin (many Abx can)

Answer 732

(Doxycycline, Lymecycline) PO Only Vaires between drugs Duration depending on indication Include indication and duration on prescription (With water whilst upright as can otherwise cause ulceration of the oesophagus) Take with food as can cause nausea and vomitting if not but not with dairy products as can interact with them

Answer 733

(Doxycycline, Lymecycline) Complete course Check for allergy

Answer 734

(Doxycycline, Lymecycline) Resoution of infection and blood marers (reduced inflammatory markers)

Answer 735

(Levothyroxine, Liothyronine)

Answer 736

(Levothyroxine, Liothyronine) 1. Primary hypothyroidism 2. Hypothyroidism secondary to hypopituitarism

Answer 737

(Levothyroxine, Liothyronine) The thyroid gland produces thyroxine (T4) which is converted to the active triiodothyronine (T3) in target tissues. Thyroid hormones regulate metabolism and growth. Hypothyroidism is treated by long-term replacement of thyroid hormones, most usually as levothyroxine (synthertic T4) or liothyronin (synthetic T3). **Liothyronine** is used for emergency treatment of severe or acute hypothyroidism.

Answer 738

(Levothyroxine, Liothyronine) **Excessive doses: hyperthyroidism** - GI (diarrhoea, vomiting, weight loss), cardiac (palpitations, arrhythmias, angina) and neurological (e.g. tremor, restlessness, insomnia), manifestations.

Answer 739

(Levothyroxine, Liothyronine) Increase heart rate and metabolism: can prescipitate cardiac ischaemia in people with **coronary artery disease.** **In hypopituitarism** - corticosteroid therapy must be initiated before thyroid hormone replacement to avoid precipitating an addisonian crisis.

Answer 740

(Levothyroxine, Liothyronine) Multiple Cytochrome P450 inducers can decrease dose Can alter insulin and glycaemic requirements in diabetes

Answer 741

(Levothyroxine, Liothyronine) Levothyroxine PO only (25-100 micrograms) Write MICROGRAMS Liothyronine IV: for emergencies only

Answer 742

(Levothyroxine, Liothyronine) Replacing a natural hormone that their body has stopped making - may take months to feel back to normal Lifelong treatment Look out for signs of too much: hyperthyroidism Don't take with calcium and iron supplements

Answer 743

(Levothyroxine, Liothyronine) Return patients to euthoroid state **Thyroid function tests measured at 3 months after starting treatment or change in dose** **In primary hypothyroidism, thyroid stimulating hormone (TSH) is the main guide to dosing.** It is elevated due to loss of negative feedback of T4 on the pituitary. **With adequate levothyroxine replacement, TSH should return to normal or low-normal concentratons.** Stable patients should have annual clinical review and thyroid function tests.

Answer 744

(Trimethoprim, Co-trimoxazole)

Answer 745

(Trimethoprim, Co-trimoxazole) 1. Trimethoprim 1st choice for uncomplicated UTIs (or nitrofurantoin and amoxicillin) 2. Co-trimoxazole is used for the treatment of prevention of **pneumocystis pneumonia** in people with immunosuppression e.g. due to HIV infection

Answer 746

(Trimethoprim, Co-trimoxazole) **Inhibits bacterial folate synthesis** (There is widespread bacterial resistance limiting clinical utility)

Answer 747

(Trimethoprim, Co-trimoxazole) GI Upset (Nausea, vomiting, sore mouth) Skin rash Hypersensitivity A folate antagonist so can impair haematopoiesis, causing **haematoloical disorders** - megaloblastic anaemia, lecopenia, throbocytopenia. Can cause hyperkalaemia and elevation of plasma creatinine concentrations.

Answer 748

(Trimethoprim, Co-trimoxazole) CI 1st trimester of pregnancy as folate antagonist Caution: folate deficiency Renal impairment Reduced: Neonates, elderly and HIV infection

Answer 749

(Trimethoprim, Co-trimoxazole) Can cause hyperkalaemia and more likely when used with potassium elevating drugs (aldosterone antagonists, ACE inhibitors, ARBs) Folate antagonists: Methotrezatte and increase risk of adverse haematological effects. Can enhance anticoagulation effect of arfrin by killing normal gut flora synthesising vitamin K

Answer 750

(Trimethoprim, Co-trimoxazole) PO Only 200 mg 12 hourly Otherwise variable by indication: check BNF. Co-trimoxazole is suitable for IV and PO administration

Answer 751

(Trimethoprim, Co-trimoxazole) Acute infection: resolution of symptoms, signs and investigations (urine culture in some cases) Long-term treatment: FBC monitoring may aid early detection and treatment of haematological disodders.

Answer 752

Can lead to a small, reversible risk in serum creatinine concentraton. eGFR remains the same. Less effective for treatment of UTI in renal impairment though.

Answer 753

(Sodium Valproate, Valproic Acid)

Answer 754

(Sodium Valproate, Valproic Acid) 1. **Epilepsy** 1st choice for control of generalised or abscence seizures and option for focal seizures 2. **Bipolar disorder** acute treatment of manic episodes and prophylaxis against recurrence.

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