1
Q
Acute dystonic crisis features
A
- Agitated
- Upward deviation of eyes
- Painful extension and lateral flexion of cervical spine
2
Q
Acute dystonic crises Tx
A
- Procyclidine 5-10 mg (5mg/mL injection - IV/IM)
3
Q
Hydroxychloroquine SEs
A
- Retinal toxicity
4
Q
Ciprofloxacin and methotrexate
A
- Ciprofloxacin possible reduces the excretion of methotrexate, heightens the risk of toxicity
5
Q
Tx fo scarlet fever
A
- 10 days phenoxymethylpenicillin
6
Q
Clarithromycin and warfarin
A
Clarithromycin accentuates the effects of warfarin, increasing INR
7
Q
Gemfirozil and statins
A
Gemfirozil (fibrate) increases simvastatin acid plasma concs and can lead to myopathy and rhabdomyolysis
8
Q
Hypoglycaemia Tx
A
Unconcious:
- If community: IM glucagon (Not for anticoagulated patients)
- If hospital: glucose 20% 75 mL IV (50-100 mL within 20 minutes)
- or GLUCOSE 10% 150 ml over 15 mins
- (15-20 g over 15 minutes)
- NEVER IV 50% as too viscous
- 5% would be too weak in hypoglycaemia
Conscious:
- Same as above but trial oral glucose first
9
Q
Amiodarone and potassium
A
Amiodarone can cause hypokalaemia and potassium should be monitored prior to Tx
10
Q
SSRIs monitorign
A
- No routine blood test monitoring needed
- May cause hyponatraemia and doses may need to be reduced in hepatic impairment, but routine blood monitoring not required
11
Q
Catheters and monitoring infection
A
- Catheters will usually have bacterial colonisation and therefore are not helpful for judging response to Tx
- Catheter urine specimens should not be sent unless for a specific reason such as checking for eradication of a highly resistant organism
- Blood cultures are taken at start but do not repeat unless poorly again
- Best indicator of effect of Abx is clinical improvement of symptoms
12
Q
Statins and rhabdomyolysis
A
- If symptoms resolve, restart the same statin at a lower dose
- If symptoms do not resolve, consider lower risk statin or a fibrate
13
Q
Pulmonary oedema
Furosemide Tx
A
- Use and IV formulation as PO will take too long
14
Q
Tacrolimus and potassium
A
- Can cause hyperkalaemia, probably due to reduced potassium excretion
15
Q
Allopurinol and renal function
A
Max daily dose of 100 mg until renal function improves
16
Q
Buprenorphine and other opioids
A
Has opioid agonist and antagonist properties and may precipitate withdrawal symptoms including pain in patients on other opioids!
17
Q
Fentanyl nasal spray
A
- If receiving at least 25 micrograms of fentanyl per hour, can use the nasal spray for breakthrough pain
- Max initial dose is 50 micrograms into one nostril, repeat after 10 mins with max of two sprays for each pain episode
- Min of 4 hrs between the treatment of each pain episode
- Fentanyl is rapidly absorbed from nasal mucose so acts quickly
- More expensive than morphine sulfate and not always readily available
18
Q
Breakthrough pain
A
- Generally good to use the same drug for the breakthrough as used for background pain
19
Q
Nitrofurantoin and kidney function
A
- Avoid if eGFR < 45
- Use with caution if eGFR 30-44, short-course only
20
Q
Alcohol drugs
Acamprosate
A
- Helpful for maintaining abstinence in alcohol-dependence
- Only initiated after sustained abstinence
21
Q
Alcohol drugs
Chlordiazepoxide
A
- First-line for withdrawal
22
Q
Alcohol drugs
Thiamine
A
- Vit supplementation is not given first-line for acute Tx of alcohol withdrawal
- Prophylactic thiamine should be used in a dependent drinker
23
Q
INR and surgery
A
If INR > 1.5 on day of surgery, give Vit K 1-5 mg
24
Q
Starting ACE-Is and creatinine
A
- Likely to see a small rise in creatinine when starting Tx, does not need investigating or changing prescription
25
Perindopril - measuring efficacy of Tx
- Exercise tolerance
| - NOT BNP as is expensive and not advised as a serial test
26
Ciclosporin adverse effects and monitoring
- nephrotoxicity (baseline renal function, and two-weekly until stable)
- hypertension (BP measurements often)
27
Tx of hyperglycemia on insulin
- An increase in the usual dose of 10% is a good way to manage transient rises in blood glucose caused by corticosteroids
- Preferable to adjust existing regime rather than add in additional insulin prescriptions
28
Amount of water needed per day
| Exceptions (5)
25ml/kg/day water
| 25-30 for normal, 20-25 for elderly, renal impairment, cardiac failures, malnourished or risk of refeeding syndrome
29
Glucose 5%
Cautions (4)
- Impaired glucose tolerance (DM, renal failure, presence of sepsis, trauma of shock)
- Severe malnutrition (risk of precipitating refeeding syndrome)
- Thiamine deficiency (e.g. patients with chronic alcoholism), risk of severe lactic acidosis due to impaired oxidative metabolization of pyruvate
- Ischaemic stroke or severe traumatic brain injury (avoid infusion within FIRST 24 HOURS, monitor blood glucose as early hyperglycaemia is associated with poor outcomes in patients with severe traumatic brain injury)
30
Drugs that cause weight gain (7)
- SSRIs
- Anti-psychotics (clozapine, lithium, olanzapine, quetiapine, risperidone)
- Sulphonylureas (gliclazide, glimepiride, glibenclamide)
- Corticosteroids (Pred) - increases appetite
- Amitryptyline - affects hunger hormone
- Sodium valproate
- Insulin
31
Levonogestrel and norethisterone POPs
Missed pill protocol
- Missed pill if delayed for more than 3 hrs
- If missed, take as soon as you remember and carry on with next pill on time
- If pill was > 3 hrs overdue, you are not protected. Continue normal pill-taking ut use another method of contraception for next 2 days
- The Faculty of Sexual and Reproductive Healthcare recommends emergency contraception if one or more progestogen-only contraceptive tablets are missed or taken more than 3 hours late and unprotected intercourse has occurred before 2 further tablets have been correctly taken.
32
Desogestrel POP
Missed pill protocol
- If you forget a pill, take it as soon as you remember and carry on with the next pill at the right time.
- If the pill was more than 12 hours overdue you are not protected. Continue normal pill-taking but you must also use another method, such as the condom, for the next 2 days.
33
COCP
Missed pill protocol
- Critical time = missed at beginning or end of cycle
- Take missed pill as soon as possible, and then next one at normal time (even if 2 taken together)
- A missed pill is one taken 24 hrs or more late
- If she misses one pill, no extra precautions are needed
- If missed 2+ pills, extra precautions for 7 days
- If the seven days run beyond the end of the packet, start taking the next packer and omit the pill-free interval
- Emergency contraception is recommended if 2 or more combined oral contraceptive tablets are missed from the first 7 tablets in a packet and unprotected intercourse has occurred since finishing the last packet.
34
Emergency contraception
Levonorgestrel
- Within 72 hrs (3 days)
- Single dose (1.5 mg)
- Double if BMI > 26 or weight > 70 kg
- If vomit < 3 hrs, repeat dose
Ulipristal/EllaONe
- Within 120 hrs (5 days)
- Single-dose 30 mg PO
- Vomit < 3 hrs, repeat dose
- CAUTION IN ASTHMA
- Delay breastfeeding for 1 week
- Can't use hormonal contraception for 5 days (barrier)
IUD
- Within 120 hrs (5 days)
- Prophylactic Abx if increased risk of STI
35
Lactational amenorrhoea
98% effective if:
- Baby < 6 months
- Exclusively breastfeeding
- Amenorrhoeic
36
HTN first lines
If < 55 yrs/T2DM:
(a) ACE INHIBITOR or ARB
If > 55 yrs/black african or african-caribbean:
(c) calcium channel blocker
37
HTN
Step 2 Tx
(d) thiazide-like diuretics
- If already taking (a) add (c) or (d)
- If already taking (c) add (a) or (d)
In black African/Afro-Caribbean, choose thiazide-like diuretic after CCB. Then if need (a), ARB is preferred to ACE-I.
38
HTN
Step 3 Tx
Add a third drug to complete the combination
| e.g. (A + C) + D
39
HTn
Step 4 Tx
- Add a fourth drug or seek specialist advice
- First check BP, assess for postural hypotension and discuss adherence
THEN
- If K < 4.5 mmol/l, add low-dose spironolactone
- if K > 4.5 mmol/l, add alpha- or beta-blocker (doxazosin - can be a preferred Tx in BPH or propranolol/atenonol)
40
Croup
Tx
- **Single dose** of **dexamethasone** to all children, regardless of severity (150 micrograms/kg)
- Prednisolone is an alternative if not available
**Emergency treatment:**
- High-flow oxygen
- Nebulised adrenaline
41
Migraine
Acute Tx
Either: aspirin, ibuprofen or 5HT1-receptor agonist (triptan)
- Take as soon as patient knows they are developing headache
Triptans:
- Take at start of headache, not start of aura
- First line = sumatriptan
- SC sumatriptan or nasal zolmitriptan can be given if vomiting or severe attacks
- Avoid in stroke?
- Antiemetics: Metoclopramide or prochlorperazine (PO or SC)
- Other NSAIDs (Naproxen/diclofenac) can be used in place of ibuprofen
- Mefenamic acid can be used for menstrual migraine in women using it for dysmenorrhea or menorrhagia
- Tx with paracetamol can be considered in patients who are unable to take other acute Tx options
- If fail to respond to monotherapy → combine sumatriptan and naproxen
42
Migraine
Prophylaxis
First line: **Propranolol hydrochloride**
- Alternative beta-blockers: metoprolol tartrate, atenolol, nadolol, timolol, bisoprolol fumarate (especially in patients already taking for cardiac reasons)
- If beta-blocker not suitable → **Topiramate**
- In women of child-bearing age → use highly effective contraception
- Amitriptyline hydrochloride
- Unlicensed drugs: candesartan, sodium valproate
- Preventative treatment should be tried for at least 3 months at the maximum tolerated dose, before deciding whether or not it is effective
- A good response to treatment is defined as a 50% reduction in the severity and frequency of migraine attacks
- Review after 6-12 months
- SSRIs may be used if co-existing depression
43
Sumatriptan drug profile
- CIs: IHD, **mild uncontrolled HTN, mod-sev HTN**, peripheral vascular disease, previous cerebrovascular accident, previous MI, previous TIA, Prinzmetal’s angina
- Cautions: Predisposing coronary artery disease factors, elderly, Hx of seizures, mild controlled HTN, risk factors for seizures
- SEs: Dizziness, drowsiness, dyspnoea, flushing, myalgia, nausea, vomiting, pain, skin reactions, temp sensation altered
- Pregnancy: best to avoid if possible due to limited evidence
- Consider dose reduction to 25–50 mg in mild to moderate hepatic impairment
44
Propranolol drug profile
- CIs: **Asthma, COPD, hypotension, bradycardia**, metabolic acidosis, 2nd or 3rd degree AV block, severe peripheral arterial disease, sick sinus syndrome, uncontrolled HF, pheochromocytoma, Prinzmetals angina
- Cautions: DM, myasthenia gravis, portal hypertension, psoriasis, may mask hypoglycaemia or thyrotoxicosis
- Elderly STOPP criteria:
- In combo with verapamil or diltiazem
- With bradycardia (HR<50bpm)
- DM with frequent hypoglycaemia episodes
- History of asthma requiring
- SEs: abdo discomfort, confusion, depression, diarrhoea, dizziness, dry eye, dyspnoea, **erectile dysfunction**, fatigue, headache, HF, nausea, paraesthesia, PVD, rash, sleep disorder, syncope, visual impairment, vomiting
- May reduce response to adrenalin
- Avoid abrupt withdrawal (especially in IHD) → rebound worsening of myocardial ischaemia
45
Topiramate drug profile
- ENZYME INDUCER
- Risk of suicidal thoughts and behaviour
- Cautions: acute porphyria's, risk of metabolic acidosis
- Pregnancy: Use of highly effective contraception and fully informed of risks or avoid altogether
- **Breastfeeding: AVOID**
- Renal impairment: **half dose if creatinine clearance < 70**`
46
HF Tx
First-line = **ACE-INHIBITOR** and **BETA-BLOCKER**
- Beta-blockers licenses for HF: bisoprolol, carvedilol, nebivolol
- Use an **ARB** if ACE-I is not tolerated/appropriate
Second-line = **ALDOSTERONE ANTAGONIST**
- Spironolactone or eplerenone
- ACE-I and aldosterone antagonists both cause hyperkalaemia so monitor potassium
Third-line (SPECIALIST):
- Ivabradine
- Sacubtril-valsartan
- Digoxin
- Hydralazine in combination with nitrate
- Cardiac resynchronization therapy
Vaccines:
- Annual influenza vaccine
- One-off pneumococcal vaccine
47
Aminophylline adverse effects
- Tachycardia (toxicity) - stop drug
48
Aminophylline monitoring
- Target serum aminophylline (measured as theophylline) is 10 - 20 nanograms/ml
- Level should be taken 18 hours after commencing Tx unless concerns re toxicity
- Is not a marker of efficacy though
49
Ways to judge improvement of chest infection
- Best = ABG or O2 sats
- 2nd best = resp rate
- CXR: would take 6 weeks to clear
- Creps on auscultation could take days to change
50
Measuring response to DKA Tx
- Best = serum ketones!
- Serum glucose normalized rapidly but does not necessarily suggest resolution of DKA
- Urinary glucose will also improve but not useful in measuring resolution of symptoms
51
Drugs that cause urinary retention
- Anticholinergics (antipsychotics, antidepressants, detrusor relaxants)
- General anesthetics
- Alpha-adrenoreceptor agonists
- Benzos
- NSAIDs
- CCBs
- Antihistamines
- Alcohol
52
Drugs that can cause confusion
- Anticholinergics
- Antipsychotics
- Antidepressants
- Anticonvulsants
- Benzos/opioids
- Dopamine receptor antagonists (metoclopramide)
Less common causes:
- Histamine H2 receptor antagonists
- Digoxin
- Beta-blockers
- Corticosteroids
- NSAIDs
- Abx
53
Statins and ALT
When to measure ALT?
Level to stop statins?
Measure ALT at baseline, 3 months and 12 months
< 3x baseline: continue at normal dose
> 3x baseline: stop statins
54
Statins SEs
- Myalgia
- Liver function
- GI disturbances
- Sleep disturbances
- Headache
55
Statins
| Cardiovascular risk
If 10-year cardiovascular risk is > 10% then use 'primary prevention of CVS events in patients at high risk of first CVS event'
56
Anticholinergic examples
- Oxybutynin
- Tiotropium and ipratropium
- Atropine
- Tolterodine
- Solifenacin
57
CIs of IV sedation with benzos
- Confusion and disorientation
- Neonates
- CNS depression
- Compromised airway
- Respiratory depression
58
CIs of benzodiazepines
- Acute pulmonary insufficiency
- Marked neuromuscular respiratory weakness
- Obsessional states
- phobic states
- Sleep apnoea
- Unstable MG
59
IV Vit B (Pabrinex)
- Indicated in patient with long history of alcohol abuse and disorientation (risk of WE)
- Do not be persuaded that presence of thiamine tablets mean he is OK
60
Features of adrenal crisis
- K+ normal or increased
- Na+ normal or decreased
- Creatinine may be raised
- Calcium may be raised
- Hypoglycaemia in children
- Blood for cortisol and ACTH should be taken (high ACTH, low cortisol)
61
Tx of adrenal crisis
- IV or IM hydrocortisone
- Normal saline rehydration
- Electrolyte monitoring
62
Calcium resonium
- If persistent hyperkalaemia despite salbutamol/insulin/dextrose Tx
- Takes several days to work so if Tx-resistant hyperkalaemia needs urgently fixing then dialysis is the next treatment
63
When is Vit K indicated in pregnancy?
- If cholestatic jaundice in later stages
| - Would be menadiol sodium phosphate
64
Folic acid in pregnancy
- 400 micrograms if low risk, daily before conception and until week 12 of pregnancy
- 5 mg daily for those at high risk (e.g. family Hx, personal Hx, antiepileptic meds, diabetes or sickle cell)
65
Alendronic acid
MoA
Fracture risk
STOP?
- Reduce rate of bone turnover
- Adsorbed onto hydroxyapatite crystals in bone and inhibits osteoclasts
- Calcium still required for health of bone if poor delay intake
- Reduces fracture rates
- STOP if heartburn/oesophagitis risk
66
Diabetes and illness
- Antidiabetic drugs are not normally effective at restoring glycaemic control during stress responses (surgery, infection, MI, coma, trauma) so need to transfer to insulin
67
Furosemide and vestibular nerve damage
- Can damage vestibular nerve
- More common with IV administration or renal impairment
- Unlikely at low oral dose
68
Drugs that can cause anaphylaxis
- NSAIDs
- Penicillin's and cephalosporins
- Aspirin
- Chemotherapy
- Vaccines
- Parenteral iron injections
- Herbal preparations
- Vancomycin
- Morphine
- XR contrast media
69
Clinical features of anaphylaxis
- increased vascular permeability
- vasodilation
- hypotension
- tachycardia
- bronchospasm
- interstitial pneumonitis
- urticaria
- angioedema
- tissue oedema
70
Gout
Measure of successful Tx
Other things that would be raised
- Serum urate (would reduce)
Raised: WCC, CRP, ESR
71
measuring success of fluid replacement
- Earliest and best sign = BP improvement
| - Urine output is less reliable in early stages
72
When should diuretics be taken?
Not at night or no sleep due to passing urine
73
Antiemetics that should NOT be used in parkinsons?
Dopamine receptor antagonists
- Metoclopramide
- Prochlorperazine
- Chlorpromazine
- Droperidol
- Promethazine
74
What should you look at if leucocytosis and normal CRP?
- Steroids
75
When might you use FFP?
FFP is usually used to correct deranged clotting (where PT/aPTT is >1.5 times the normal limit)
76
Define mild and severe flair of UC and Tx
- Mild = < 6 times bowel opening per day and no other symptoms
- Severe = > 6 times bowel opening per day and systemically unwell
77
Indicators for fluid resus?
- Systolic BP < 100
- HR > 90
- Cap refill > 2 seconds
- Cold peripheries
- RR > 20
- NEW > 5
- Passive leg raise fluid responsiveness
PSA
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