1
Q
Renal Impairment
❌ Avoid if possible:
A
NSAIDs – reduce renal perfusion, risk of AKI
Metformin – contraindicated if eGFR <30, risk of lactic acidosis
Lithium – narrow therapeutic index; avoid in severe renal impairment
Tetracyclines – risk of accumulation; avoid unless essential
Nitrofurantoin – avoid if eGFR <45 (ineffective and toxic risk)
2
Q
contraindicated if eGFR <30,
A
Metformin
3
Q
Heart Failure
❌ Avoid:
A
Thiazolidinediones (e.g. pioglitazone) – cause fluid retention
Rate-limiting CCBs (diltiazem, verapamil) – negative inotropic effects
NSAIDs & steroids – exacerbate fluid retention
Do not initiate beta blockers in acute/unstable heart failure
4
Q
Antibiotics to avoid in Pregnancy
A
Tetracyclines – teeth discolouration
Trimethoprim and sulphonamides (e.g. co-trimoxazole) – impair folate metabolism
Aminoglycosides (e.g. gentamicin) – ototoxicity risk
Quinolones (e.g. ciprofloxacin) – cartilage toxicity
5
Q
Drugs otherthan antibiotics to avoid in Pregnancy
A
ACE inhibitors / ARBs – teratogenic, especially in 2nd/3rd trimester
Labetalol is 1st line during pregnancy
Statins – disrupt cholesterol synthesis
Warfarin – teratogenic, foetal warfarin syndrome
LMWH is 1st line anticoagulant during pregnancy
Sulfonylureas – risk of neonatal hypoglycaemia
Retinoids (including topical) – highly teratogenic
Methotrexate - teratogenic – impair folate metabolism
6
Q
1st line anticoagulant during pregnancy
A
Lmwh
7
Q
Anti-epileptics to avoidin pregnancy
A
Valproate – high teratogenic risk (neural tube defects) - avoid in all women of child bearing potential
Topiramate, phenytoin, carbamazepine, phenobarbital – all associated with congenital malformations
8
Q
Safe antiepileptics in Pregnancy
A
lamotrigine, levetiracetam
9
Q
Disulfiram
Contraindications
A
Cardiovascular disease (heart failure, CAD, stroke, hypertension)
Psychosis, suicidal risk
10
Q
Acamprosate
Contraindications:
A
Severe hepatic impairment
Renal impairment (Cr > 120 micromol/L)
Pregnancy
11
Q
Bupropion
Contraindications:
A
Eating disorders
Bipolar disorder
Seizure risk
Pregnancy
12
Q
eGFR <30 or lactic acidosis/hypoxia→ stop
A
Metformin
13
Q
Tetracyclines → avoid in
A
renal impairment + pregnancy
14
Q
avoid pioglitazone -
A
worsens fluid retention in hf
15
Q
ACEis in pregnancy →
A
foetal renal agenesis - use labetalol instead
16
Q
Valproate should be avoided in
A
all women of child bearing potential → high neural tube defect risk
17
Q
Vincristine se
A
Peripheral neuropathy (glove and stocking pattern)
18
Q
Cisplatin se
A
Nephrotoxicity
Ototoxicity (sensorineural hearing loss)
Peripheral neuropathy
Electrolyte abnormalities: hypomagnesaemia, hypokalaemia, hypocalcaemia
Pre-hydration protocols often used to reduce renal toxicity
19
Q
Bleomycin se
A
Pulmonary fibrosis
Baseline and follow-up pulmonary function tests (PFTs) are recommended
20
Q
dry cough and exertional dyspnoea in a patient post chemo
A
Bleomycin
21
Q
Doxorubicin (Anthracyclines) se
A
Acute cardiotoxicity (e.g. myopericarditis): presents with chest pain, palpitations, arrhythmia within days
Long-term cardiomyopathy
Other anthracyclines: daunorubicin, epirubicin
Baseline echocardiography is essential before treatment
22
Q
Cyclophosphamide se
A
Haemorrhagic cystitis
Caused by toxic metabolite acrolein
Prevented by co-prescribing Mesna (binds and detoxifies acrolein in urine)
23
Q
Dexamethasone (Decadron) se
A
Water retention: facial puffiness, ankle swelling
Hyperglycaemia
Also associated with mood changes, insomnia, and increased appetite with longer use
24
Q
Peripheral neuropathy =
A
vincristine or cisplatin
25
Ototoxicity + renal failure + low magnesium =
Cisplatin
26
Dry cough + SOB =
Bleomycin
27
Chest pain 2–3 days post-chemotherapy =
doxorubicin
28
Haematuria on chemotherapy =
cyclophosphamide
29
Puffy face + hyperglycaemia =
Dexa
30
PCBRASS
CYP450 Inducers
31
OAAKDEVICES
CYP450 Inhibitors
32
Cytochrome P450 Inducers
Phenytoin
Carbamazepine
Barbiturates
Rifampicin
Alcohol (chronic use)
Sulfonylureas
Smoking
St John’s Wort
33
Background of metallic heart valve on warfarin. Commenced on rifampicin for TB.
Result: ↓ INR / subtherapeutic anticoagulation
34
Cytochrome P450 Inhibitors
Omeprazole
Amiodarone
Allopurinol
Ketoconazole
Disulfiram
Ethanol (acute use)
Valproate
Isoniazid
Ciprofloxacin
Erythromycin / Clarithromycin
Sulphonamides (e.g. sulfadiazine, sulfamethoxazole)
35
Background of metallic heart valve on warfarin. Commenced on erythromycin for infection
↑ INR → risk of bleeding
36
INR drops after starting drug =
suspect enzyme induction (PCBRASS)
37
INR rises after starting drug =
suspect enzyme inhibition (OAAKDEVICES)
38
Statins se
Deranged LFTs, myositis (↑ CK)
39
Baseline Tests Statins
Lipid profile, LFTs, HbA1c, renal function, TSH
CK if: muscle symptoms, renal impairment, hypothyroidism, or liver disease
40
Monitoring Statins
Lipid profile at 3 months
If non-HDL ↓ <40%, consider dose increase
If max dose fails, add ezetimibe (inhibits intestinal cholesterol absorption)
LFTs: at 3 months, then at 12 months
CK only if muscle symptoms
HbA1c at 3 months if diabetes risk
41
ACE Inhibitors Baseline Tests
U&Es, blood pressure
42
ACE Inhibitors titration
Recheck U&Es and BP 1–2 weeks after each dose increase
Titrate every 2 weeks until target BP achieved
43
Ongoing Monitoring
After stable: ACE Inhibitors
U&Es every 12 months unless clinical judgement indicates a requirement for more frequently.
Also if acutely unwell (e.g. D&V)
44
Acceptable changes: ACE Inhibitors
eGFR decrease from baseline < 25% or
serum creatinine level increase from baseline < 30%
K⁺ up to 5.5 acceptable
45
Sick Day Rules ACE Inhibitors
Stop temporarily during diarrhoea, vomiting, dehydration, acute illness
46
Amiodarone Baseline Tests
TFTs, LFTs, U&Es, CXR, ECG
47
AmiodaroneMonitoring
Every 6 months: TFTs, U&Es, LFTs
Yearly: ECG
48
Complications Amiodarone
Pulmonary toxicity (pneumonitis, fibrosis)
Thyroid dysfunction (hypo- or hyper-)
Hepatotoxicity
Cardiac conduction issues
Corneal deposits
Blue-grey skin discolouration
49
Levothyroxine
📆 Monitoring
TSH every 3 months until stable (2 similar results)
Then yearly TSH
50
Methotrexate
📅 Prescription
Once weekly, with folic acid 5 mg weekly on separate day
51
Methotrexate Monitoring
same as azathioprine)
FBC, U&Es, LFTs
Before starting
Every 2 weeks until dose stable × 6 weeks
Then monthly × 3 months
Then at least every 12 weeks
52
Sodium Valproate Baseline Tests
FBC, LFTs, BMI
53
Sodium Valproate Monitoring
After 6 months: FBC, LFTs, BMI
Then yearly
Valproate level only if toxicity or poor adherence suspected
54
Apixaban Baseline Tests
FBC, U&Es, LFTs, clotting screen
55
Monitoring Apixaban
Yearly: FBC, U&Es, LFTs
Every 6 months if >75 years or renal impairment
56
Glitazones (e.g. pioglitazone)
❌ Contraindications
Heart failure
Bladder cancer or macroscopic haematuria
Liver disease
57
Glitazones (e.g. pioglitazone) Baseline Tests
LFTs
Contraindicated if ALT >2.5× ULN
58
Glitazones (e.g. pioglitazone) Monitoring
LFTs periodically
Watch for signs of heart failure: oedema, weight gain
Warn about bladder cancer symptoms
59
Trastuzumab (Herceptin) Mechanism
Monoclonal antibody against HER2/neu receptor
🎯 Indication
HER2+ breast cancer
60
Adverse Effect Trastuzumab (Herceptin)
Cardiotoxicity
Echocardiogram before starting treatment
61
Trastuzumab requires
echo due to risk of cardiomyopathy
62
Typical (first-generation) antipsychotics eg
Haloperidol, chlorpromazine
63
Mechanism Typical (first-generation) antipsychotics
Dopamine D2 receptor antagonists
64
Typical (first-generation) antipsychotics se
Hyperprolactinaemia
Extrapyramidal side effects (EPSEs)
Antimuscarinic effects: dr
Impaired glucose tolerance
Lowered seizure threshold
65
Extrapyramidal Side Effects
Drug-induced parkinsonism
Akathisia
Tardive dyskinesia
Dystonias
Torticolis
Oculogyric Crisis
66
Management of acute dystonias:
Procyclidine (anticholinergic) or Benzatropine
67
Other complications Typical (first-generation) antipsychotics
Increased stroke and VTE risk in elderly
Neuroleptic malignant syndrome
QTc prolongation → risk of torsades de pointes (especially haloperidol)
68
Atypical (second-generation) antipsychotics mech
Act on multiple receptors: D2, D3, D4, 5-HT
69
Atypical (second-generation) antipsychotics se
Metabolic syndrome: weight gain, insulin resistance, dyslipidaemia
Therefore, monitoring BMI, HbA1c, lipid profile is extremely important. Patients at high risk of cardiovascular disease.
Stroke and VTE (especially in elderly)
Hyperprolactinaemia and EPSEs: less common but can occur
70
Clozapine indication
Treatment-resistant schizophrenia (failure of ≥2 antipsychotics for 6–8 weeks)
71
Clozapine se
Agranulocytosis: requires regular FBC monitoring
Seizures
Myocarditis: ECG required prior to starting
Constipation
Hypersalivation: may affect up to 1/3 of patients, treat with hyoscine butylbromide
72
Hypersalivation: may affect up to 1/3 of patients, treat with
Clozapine
hyoscine butylbromide
73
Neuroleptic Malignant Syndrome (NMS)
Triggers
Antipsychotics, abrupt withdrawal of Parkinson’s medications (e.g. levodopa)
74
Neuroleptic Malignant Syndrome (NMS) clinical features
Pyrexia
Muscle rigidity
Agitation and delirium
Autonomic dysfunction: tachycardia, hypertension
75
Examination findings Neuroleptic Malignant Syndrome (NMS)
Reduced or absent reflexes
Normal pupils
76
dilated pupils, myoclonus, brisk reflexes)
Serotonin syndrome
77
Complications Neuroleptic Malignant Syndrome (NMS)
Rhabdomyolysis → acute kidney injury
78
Neuroleptic Malignant Syndrome (NMS) mx
Stop antipsychotics
IV fluids
Dantrolene
Bromocriptine (dopamine agonist)
79
Selective Serotonin Reuptake Inhibitors (SSRIs) eg
Sertraline, fluoxetine, citalopram
80
Contraindications
Current mania
Poorly controlled epilepsy
Avoid citalopram/escitalopram if QT prolongation
Avoid sertraline in severe hepatic impairment
81
Cardiovascular disease safest antidepressant
Sertraline is safest
82
Side effects ssri
Common: GI symptoms (nausea, diarrhoea)
Consider PPI if co-prescribed with NSAID
83
SSRIs + NSAIDs/aspirin:
GI bleed
84
SSRIs + anticoagulants:
avoid due to bleeding risk
85
Avoid with MAOIs or triptans:
Ssri
86
Follow-up ssri
Age <30: review within 1 week
Age ≥30: review in 2 weeks
87
Duration ssri
Continue for at least 6 months after symptom improvement
88
Discontinuation syndrome if ssri stopped abruptly
Features: agitation, anxiety, diarrhoea
Gradual withdrawal over 4 weeks
Paroxetine has highest risk of withdrawal symptoms
89
Serotonin Syndrome causes
SSRIs
MAOIs
Triptans
Ecstasy, methamphetamines
St John’s Wort
90
Serotonin Syndrome clinical Features
Neuromuscular: myoclonus, hyperreflexia, rigidity
Autonomic: tachycardia, hypertension, fever
Cognitive: agitation, confusion
91
Serotonin Syndrome mx
IV fluids
Benzodiazepines
Severe cases: cyproheptadine or chlorpromazine
92
SNRIs
Examples
Venlafaxine, duloxetine
93
Monoamine Oxidase Inhibitors (MAOIs)
Example
Phenelzine
94
Maoi se
Risk of hypertensive crisis if combined with tyramine-containing foods (cheese, herring, broad beans)
95
Maoi mech
Inhibit breakdown of serotonin and noradrenaline
96
Tricyclic Antidepressants (TCAs)
Examples
Amitriptyline, dosulepin
97
Tca uses
Also prescribed for neuropathic pain and migraine prophylaxis
98
Tca se
Anticholinergic: dry mouth, blurred vision, constipation, urinary retention
Drowsiness
QT prolongation (risk of torsades)
99
Toxicity in overdose tca
Most dangerous class in overdose
Features: dilated pupils, seizures, coma, arrhythmia
ECG: prolonged QT, wide QRS, broad complex tachycardia
100
Management Toxicity in overdose tca
IV sodium bicarbonate
Indicated if QRS >100 ms or ventricular arrhythmias
101
Benzodiazepines
Mechanism
Increase GABA activity by increasing chloride channel opening frequency
102
Bzd withdrawal
Taper gradually: reduce by 1/8th every few weeks
Symptoms: anxiety, tremor, insomnia, tinnitus, seizures
Withdrawal symptoms may last up to 3 weeks
103
Lithium se
Nausea, vomiting
Fine tremor (coarse tremor = toxicity)
Nephrogenic diabetes insipidus
Hypothyroidism
Weight gain
Idiopathic intracranial hypertension
Hyperparathyroidism and hypercalcaemia
104
Monitoring Lithium
Lithium levels: 1 week after initiation and after dose changes
Once stable: every 3 months
Every 6 months: BMI, U&Es, calcium, TSH
If worsening renal function, monitor lithium more frequently
105
Parkinsonism that is symmetrical and of rapid onset →
likely 1st gen antipsychotic
106
Lip-smacking and tongue protrusion in a patient on haloperidol →
tardive dyskinesia
107
Oculogyric crisis or torticollis after starting antipsychotic →
acute dystonia
Management: Procyclidine, benzatropine
108
Fever, rigidity, confusion, and autonomic instability →
neuroleptic malignant syndrome
109
Myoclonus and hyperreflexia after SSRI + triptan →
serotonin syndrome
110
Hyperprolactinaemia with antipsychotics →
especially risperidone or typicals
111
Schizophrenia resistant to ≥2 antipsychotics →
initiate clozapine (check ECG + FBC)
Risk of agranulocytosis
112
SSRI started in under-30s →
follow up in 1 week due to suicide risk
113
Restlessness, diarrhoea, agitation after abrupt SSRI withdrawal →
discontinuation syndrome
114
Hypertensive crisis after MAOI + cheese →
tyramine interaction
115
ECG: Broad complex tachycardia, dilated pupils, coma, seizures after OD →
think TCA toxicity
116
Lithium + fine tremor =
expected
117
Lithium + coarse tremor + vomiting =
toxicity
118
SSRI + NSAID →
risk of GI bleed, consider PPI
119
Benzodiazepine withdrawal after long-term use →
seizures, tinnitus, anxiety - 1/8th every 2 weeks
120
Allopurinol
🧪 Screening
Screen for HLA-B*58:01 allele in patients of Han Chinese, Thai, or Korean origin
These groups are at increased risk of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TENS)
121
Azathioprine / Mercaptopurine
🧪 Screening
Check TPMT (thiopurine methyltransferase) activity before starting
Around 1 in 300 patients have complete TPMT deficiency and are at high risk of severe bone marrow suppression
122
Gentamicin
⚠️ Complications
Ototoxicity (cranial nerve VIII damage)
Nephrotoxicity (acute tubular necrosis)
123
Contraindications Gentamicin
Myasthenia gravis - precipitates crisis
124
drugs to avoid in MG
Gentamicin precipitates crisis
Quinolones (ciprofloxacin, levofloxacin)
Macrolides (e.g. clarithromycin) – may worsen neuromuscular weakness
125
PDE5 Inhibitors eg
Sildenafil
126
PDE5 Inhibitors mech
Inhibit phosphodiesterase type V → increase cGMP → smooth muscle relaxation and vasodilation
127
PDE5 Inhibitors Contraindications
Concurrent use with nitrates (e.g. nicorandil, GTN)
Recent stroke or myocardial infarction (avoid for 6 months)
128
Adverse Effects PDE5 Inhibitors
Visual disturbance
Blue discolouration of vision
129
Blue discolouration of vision
blue pill → blue vision"
PDE5 Inhibitors
130
Combined Oral Contraceptive Pill (COCP)
✅ Benefits
Reduces risk of ovarian, endometrial, and colorectal cancer
131
Cocp risk
Increases risk of breast and cervical cancer
Increases risk of venous thromboembolism, stroke, and myocardial infarction
132
Combined Oral Contraceptive Pill (COCP) Prescribing Advice
If started in first 5 days of the cycle → immediate contraceptive protection
If started later → use additional protection for 7 days
133
UKMEC 4 Contraindications cocp
Breastfeeding and <6 weeks postpartum
<3 weeks postpartum with VTE risk
Uncontrolled hypertension (>160/100)
History of ischaemic heart disease, stroke, TIA, AF, or heart failure
Migraine with aura
History of VTE
Major surgery with prolonged immobility
Current breast cancer or known BRCA1/2 mutation
Age >35 and smoking >15 cigarettes/day
Known thrombogenic mutation
134
UKMEC 3 Conditions (risks outweigh benefits) cocp
Age >35 and smoking <15/day
BMI >35
Controlled hypertension
Family history of VTE
Gallbladder disease
Diabetes >20 years duration
Immobility (e.g. wheelchair use)
BRCA1 or BRCA2 carrier
135
Calcium Channel Blockers (CCBs)
⚠️ Adverse Effects
Constipation
Flushing
Ankle swelling
Headache
136
Cautions ccb
Avoid rate-limiting CCBs (verapamil, diltiazem) in heart failure
Do not combine rate-limiting CCBs with beta-blockers due to risk of complete heart block
137
Digoxin
⚙️ Mechanism
Inhibits Na⁺/K⁺ ATPase pump → increases intracellular calcium
Positive inotropic effect
Slows AV nodal conduction → rate control
138
Digoxin Toxicity
Check
Check digoxin levels 8–12 hours after last dose
139
yellow-green vision, bradycardia, AV block
Digoxin Toxicity
140
Precipitating Factors Digoxin Toxicity
Hypokalaemia (less competition at Na⁺/K⁺ pump)
Renal failure
Drug interactions: amiodarone, verapamil, diltiazem, spironolactone, thiazides
141
Management Digoxin Toxicity
Digoxin-specific antibody fragments (Digibind)
Potassium replacement
142
Adrenaline (Epinephrine) dosing
⚡ Anaphylaxis
IM 1:1000
Adults and children >12 years: 500 micrograms (0.5 mL)
Children 6–12 years: 300 micrograms (0.3 mL)
Children <6 years: 150 micrograms (0.15 mL)
Repeat every 5 minutes if symptoms persist
143
Adrenaline (Epinephrine) dosingpersist
💓 Cardiac Arrest – IV 1:10,000
1 mg every 3–5 minutes
10 mL of 1:10,000 IV or
1 mL of 1:1000 IV (in diluted form only, administered with caution)
144
Anticipatory Medications Pain
First-line
eGFR > 30: morphine sulfate
eGFR < 30: fentanyl or alfentanil
145
Anticipatory Medications Breathlessness
First-line
eGFR > 30: morphine sulfate
eGFR < 30: fentanyl or alfentanil
146
Nausea and Vomiting Anticipatory Medications
First-line
Levomepromazine
147
Levomepromazine
Side effect: sedation
148
Nausea and Vomiting Anticipatory Medications alternative
Cyclizine – effective for drug-induced, biochemical, or obstructive nausea
Haloperidol – effective for drug-induced or biochemical causes
Metoclopramide – for gastric stasis
Hyoscine butylbromide – first-line for obstructive bowel disorders
If no improvement, consider octreotide
149
first-line for obstructive bowel disorders Anticipatory Medications
Hyoscine butylbromide – If no improvement, consider octreotide
150
effective for drug-induced, biochemical, or obstructive nausea
Cyclizine
151
for gastric stasis
Metoclopramide
152
Agitation and Anxiety
First-line
Midazolam
Alternatives
Haloperidol
Levomepromazine
153
Respiratory Secretions
First-line
Hyoscine butylbromide
Alternatives
Glycopyrronium bromide
Atropine
154
WHO Pain Ladder – Regular Analgesia step1
Paracetamol
NSAIDs
155
WHO Pain Ladder – Regular Analgesia step2
Weak opioids
Codeine
Tramadol
Do not rotate between weak opioids if ineffective — escalate to step 3
156
WHO Pain Ladder – Regular Analgesia step3
Morphine is drug of choice
Start with immediate-release morphine (e.g. sevredol, oramorph)
Typical dose: 2.5–10 mg four-hourly
Use lower doses in elderly and renal impairment
Titrate by 30–50% per day if pain poorly controlled
157
Maintenance options WHO Pain Ladder
Continue immediate-release as required
Switch to modified-release morphine (e.g. zomorph, MST)
Divide total daily dose into two 12-hourly doses
158
Breakthrough analgesia
PRN immediate-release opioid
Dose = 1/6th of total daily opioid dose
159
Side effects
Constipation –
prescribe stimulant laxative (e.g. senna)
160
opioid-induced nausea
haloperidol
161
Strong Opioids in Renal Failure
Alfentanil
Fentanyl
Buprenorphine
Oxycodone
Morphine (use with caution)
162
Opioids in Renal Failure General advice
Use lower doses
PRN preferred over regular
Immediate-release safer than modified-release
163
Opioid Regimens
A complete opioid plan should include:
Regular opioid (e.g. MST or zomorph)
Breakthrough opioid (e.g. s/c morphine, oramorph)
164
Codeine/tramadol are........ strength of morphine
1/10th
165
Oxycodone is approximately .......stronger than oral morphine
1.5x
166
Subcutaneous morphine is approximately....... more potent than oral morphine
2x
167
From To
Oral codeine/tramadol Oral morphine
Divide by 10
168
Oral oxycodone to Oral morphine
Divide by1.5
169
Oral morphine to Subcutaneous morphine
Divide by 2
170
Oral morphine to Subcutaneous fentanyl
1mg = 0.005 mg
Divide by 200 for mg
Or multiply by 5 for micro?
171
broad-spectrum antiemetic of choice in palliative care
Levomepromazine
172
agitation and terminal restlessness
Midaz
173
death rattle
Hyoscine butylbromide
174
Always co-prescribe .......when starting opioids
stimulant laxatives (e.g. senna)
175
Paracetamol Overdose (POD) Pathophysiology
Paracetamol is usually conjugated in the liver with glucuronic acid and sulphate
In overdose, this pathway becomes saturated → paracetamol is oxidised by cytochrome P450 to form NAPQI (n-acetyl-b-benzoquinone)
Glutathione normally neutralises NAPQI
If glutathione is depleted → NAPQI accumulates → hepatocyte necrosis
N-acetylcysteine (NAC) acts as a glutathione precursor and protects the liver
176
Investigations Paracetamol Overdose (POD)
Patient weight
Paracetamol level (taken at 4 hours post-ingestion)
Bloods: LFTs, INR, U&Es, venous gas, lactate
Toxicology screen (if co-ingestion suspected, e.g. salicylates)
177
Management Paracetamol Overdose (POD) Acute Overdose
Attending < 8 hours post-ingestion
Activated charcoal if within 1 hour and dose >150 mg/kg
NAC if:
Presenting 1–4 hrs: check bloods at 4 hours
Presenting 4–8 hrs: check bloods immediately
Start NAC if paracetamol level > treatment line or liver injury present
178
Attending 8–24 hours post-ingestion Paracetamol Overdose (POD)
Check bloods immediately
If dose >150 mg/kg → start NAC while awaiting results
If <150 mg/kg → wait for levels, start NAC if above line or liver injury
179
Attending > 24 hours post-ingestion Paracetamol Overdose (POD)
Take bloods including paracetamol level
Start NAC only if:
Paracetamol detectable
ALT > 2× ULN or INR > 1.3
180
Acute overdose:
single ingestion within 1 hour
181
Staggered overdose:
taken in more than one go over >1 hour
182
Therapeutic excess:
supratherapeutic dosing for pain/fever relief
183
Staggered Overdose mx
Always start NAC immediately
Send bloods (but do not delay treatment)
184
Therapeutic Excess Paracetamol Overdose (POD)
Take bloods including paracetamol level
Start NAC if:
Dose >150 mg/kg in 24 hrs
Uncertain dosing
Symptoms (jaundice, liver tenderness)
Deranged ALT or INR
Detectable paracetamol >24 hrs after last dose
185
Adverse Reactions to NAC
Nausea, vomiting
Flushing, urticarial rash
Tachycardia, wheeze
186
Management Adverse Reactions to NAC
Pause NAC infusion
Administer antihistamines (e.g. chlorphenamine)
Nebulisers/steroids if needed
Restart NAC once symptoms settle^
187
King's College Criteria – Liver Transplant in POD
Transplant considered if:
Arterial pH < 7.3 at 24 hours post-ingestion
OR all of the following:
PT > 100 seconds
Creatinine > 300 micromol/L
Grade 3 or 4 hepatic encephalopathy
188
Activated charcoal is only useful within
within 1 hour of ingestion
189
Paracetamol Overdose (POD)Toxicity risk begins at
75 mg/kg, and is high at doses >150 mg/kg
190
Mnemonic
The 5 C’s of agranuloCytosis
Carbamazepine, valproate, phenytoin
Carbimazole
Co-trimoxazole, cephalosporins
Clozapine
Cytotoxics (e.g. methotrexate)
191
Mnemonic
MY CUSHINGOID
Myopathy
Cataracts
Ulcers
Striae
Hypertension
Immunosuppression
Necrosis of bone
Growth restriction
Osteoporosis
Increased ICP
Diabetes mellitus
192
Hypomagnasaemia causes
Aches, Cramps, Dizziness and PalPItations
Aminoglycosides (e.g. gentamicin)
Cisplatin
Diuretics (furosemide, bumetanide)
PPIs (omeprazole, lansoprazole)
193
DiaBetic Nick’s Sugar InTolerance
Diuretics (furosemide, thiazides)
Beta blockers
Nicotinic acid
Steroids (prednisolone, dexamethasone)
Interferon-alpha
Tacrolimus, ciclosporin
194
OH BETA
Beta Blockers
OH BETA!
Orthostatic Hypotension
Bronchospasm
Erectile dysfunction
Trouble sleeping and vivid dreams
AV block and arrhythmias
195
Urinary Retention
Mnemonic
Terminate DAN’s (urine) Output
Causing drugs
Tricyclic antidepressants
Disopyramide
Anticholinergics (e.g. atropine)
NSAIDs
Opiates
196
Pulmonary Fibrosis
Mnemonic
Check if your patients with fibrosis have NESCARs on their lungs..
Causing drugs
Nitrofurantoin
Ergot-derived dopamine agonists (bromocriptine, cabergoline, pergolide)
Sulfasalazine
Cytotoxics (especially bleomycin)
Amiodarone
Rheumatoid drugS(methotrexate)
197
Photosensitivity
Mnemonic
STan’s TAN
Causing drugs
Sulfonamides (sulfamethoxazole, sulfasalazine, co-trimoxazole)
Thiazides and loop diuretics
Tetracyclines and quinolones
Amiodarone
NSAIDs (naproxen, piroxicam)
198
Thrombocytopaenia
Causing drugs
Quinine
Quinidine
Co-trimoxazole
Vancomycin
199
Drug-Induced Urticaria Common causes
ACE inhibitors (ramipril, lisinopril, captopril)
Aspirin, NSAIDs
200
Amiodarone is a BITCH
Blue skin discolouration
Interstitial lung disease
Thyroid dysfunction (hypo- or hyperthyroidism)
Corneal microdeposits (causing glare, night vision issues)
Hepatotoxicity
201
Quinolones adr
Tendon rupture (especially in elderly)
Lower seizure threshold – avoid in epilepsy
202
Cyproterone Acetate
Synthetic antiandrogen for prostate cancer
Side effect: hepatotoxicity, liver failure
203
Mefloquine
Antimalarial started 2–3 weeks pre-travel
Adverse effects: neuropsychiatric (hallucinations, abnormal behaviour)
Contraindicated in patients with psychiatric illness or seizures
204
Sore throat in a patient on carbimazole or clozapine →
stop drug, check FBC immediately
205
Blue skin, interstitial lung disease, thyroid issues →
think amiodarone
206
New drug started → urticaria develops →
Consider ACEi or NSAIDs
207
Hallucinations after starting malaria tablets →
suspect mefloquine
208
Pulmonary fibrosis?
Think nitrofurantoin or methotrexate
209
Beta blockers and ... → classic side effect
nightmares
210
Tendon pain on antibiotics
Likely ciprofloxacin!
211
Diuretics + PPIs → risk of
hypomagnesaemia
212
Terminate DAN →
drugs that cause urinary retention
213
Salicylate (Aspirin) Overdose
Clinical features
Mixed respiratory alkalosis and metabolic acidosis
Hyperventilation
Tinnitus
Nausea and vomiting
Hypo- or hyperglycaemia
214
Salicylate (Aspirin) Overdose
Mx
Activated charcoal
Urinary alkalinisation with IV bicarbonate
Haemodialysis if severe
215
Benzodiazepine Overdose
Clinical features
CNS depression
Ataxia, slurred speech
Respiratory depression
Coma
216
Benzodiazepine Overdose
Mx
Supportive care
Flumazenil in severe or iatrogenic cases (with caution due to seizure risk)
217
Opioid Overdose
Clinical features
Respiratory depression
Pinpoint pupils (miosis)
Decreased level of consciousness
218
Opioid Overdose
Mx
Support airway and breathing
Naloxone – opioid receptor antagonist
219
Tricyclic Antidepressant (TCA) Overdose
Dangerous TCAs
Dosulepin
Amitriptyline
220
Tricyclic Antidepressant (TCA) Overdose
Clinical Features
Early: dry mouth, dilated pupils, blurred vision
Later: arrhythmias, metabolic acidosis, seizures, coma
221
ECG findings tca Overdose
Sinus tachycardia
QRS > 100 ms (seizure risk), > 160 ms (arrhythmia risk)
Prolonged QTc
222
Management tca Overdose
IV sodium bicarbonate
Dialysis is not effective
223
Lithium Overdose
Clinical features
Coarse tremor
Ataxia, hyperreflexia
Nystagmus
Acute kidney injury
224
Lithium Overdose mx
Mild/moderate: IV 0.9% NaCl
Haemodialysis if:
Lithium > 5 mmol/L
Lithium > 4 mmol/L + renal failure
Severe symptoms (↓ GCS, seizures, arrhythmia)
225
Quinine Toxicity – Cinchonism
Clinical features
Tinnitus, flushing
Nausea, vomiting
ECG
Widened QRS
Prolonged QTc
226
Complications cinchonism
Arrhythmias
Hypoglycaemia (↑ insulin secretion)
Flash pulmonary oedema
227
Heparin Overdose
Management
Protamine sulphate
228
Beta-blocker Overdose
Clinical features
Bradycardia
Hypotension, syncope
Hypoglycaemia
Hypothermia
229
Beta-blocker Overdose mx
Glucagon
230
Ethylene Glycol Poisoning
Source
Found in antifreeze and industrial products
231
Ethylene Glycol Poisoning
Mx
Fomepizole (ADH inhibitor)
232
Ethylene Glycol Poisoning
Clinical Features
Alcohol-like 'drunk' features (slurred speech, ataxia)
High anion gap metabolic acidosis
Acute renal failure
233
Methanol Poisoning
Clinical features
Intoxication
Optic neuritis → blindness
234
Methanol Poisoning mx
Fomepizole
Folinic acid
235
Organophosphate Poisoning
Mechanism
Inhibits acetylcholinesterase → ↑ acetylcholine
236
SLUDS
Op Poisoning
Salivation
Lacrimation
Urination
Diarrhoea
Small pupils
237
Organophosphate Poisoning
Mx
Atropine
238
Iron Overdose
Management
Desferrioxamine (iron chelation)
239
Carbon Monoxide (CO) Poisoning clinical Features
Headache, nausea
Pink/cherry-red skin
240
Carbon Monoxide (CO) Poisoning investigations
Pulse oximetry may be falsely normal
ABG: measure carboxyhaemoglobin
Normal < 3%
Smokers < 10%
241
Carbon Monoxide (CO) Poisoning mx
100% oxygen via non-rebreathe mask for 6 hours
Hyperbaric oxygen in severe cases
242
Tinnitus + hyperventilation + mixed acid-base picture →
salicylate overdose
243
Pinpoint pupils + diarrhoea + bradycardia →
think SLUDS → organophosphate poisoning
244
Cherry-red skin + headache →
carbon monoxide poisoning
245
Anticholinergic signs + widened QRS on ECG →
TCA overdose
246
Coarse tremor + AKI + nystagmus →
lithium toxicity
247
Blindness after alcohol ingestion →
methanol poisoning
248
Bradycardia + hypotension + hypoglycaemia →
beta-blocker overdose
249
Flash pulmonary oedema + hypoglycaemia + tinnitus →
quinine toxicity
250
Drowsiness + ataxia →
benzodiazepine overdose
251
Falsely normal SpO2 + red skin →
CO poisoning → confirm with ABG
252
Seizures + QTc prolongation + arrhythmias →
suspect quinolones, TCAs, or quinine
253
Hypersalivation is a common, recognised adverse effect of
Clozapine
254
Pmol potentially hepatotoxic dose
>150 mg/kg)
MSRA
flashcards
Decks in class (27)
# Cards
-
MEDICINE228
-
Antibiotics31
-
Ent149
-
Psychiatry59
-
Contraception49
-
Gynae95
-
Ortho1
-
Cardio304
-
Resp120
-
Derma278
-
Ophthal180
-
Endocrine322
-
Metabolic58
-
Gastro343
-
Surgery168
-
Infectious Diseases269
-
Hematology242
-
Rheumat + Musculoskeletal497
-
Rheumat + Musculoskeletal 264
-
Pediatrics389
-
Pharma254
-
Psychiatry168
-
Respiratory247
-
Uro101
-
Renal175
-
Obgyn340
-
Neuro269
