1
Q
What Chads-Vasc scores would warrant anticoagulation treatment for men & women with AF ?
A
Women = score of 2 or more Men = score of 1 or more
2
Q
What are the treatment options for rate control in AF?
A
Monotherapy 1st Line: Β Blocker OR Rate-Limiting CCB (or Digoxin if have congestive heart failure/sedentary)
Dual Therapy 2nd Line: B blocker/CCB with Digoxin (HF ideally B blocker licensed for HF with Dig)
3rd Line: Rhythm Control
3
Q
True or False, rate-limiting CCB’s are contraindicated in HF?
A
True.
4
Q
Why should you wait before doing cardio version for AF if symptoms present for > 48 hours?
A
Increased risk of stroke:
- wait and anticoagulate 3 weeks before + 4 weeks after cardio version
- give rate control in the meantime
5
Q
What are the drugs used in pharmacological cardio version?
A
Flecainide - if no structural/ischaemc heart disease
Amiodarone - if there is structural heart disease, start 4 weeks before electrical cardioversion + continue up to 12 months
6
Q
Treatment options of paroxysmal atrial fibrillation?
A
paroxysmal = episode resolves in 48 hrs without tx
- symptomatic: β blocker
- pill in pocket (infrequent episodes): flecainide/propafenone
7
Q
Treatment options for paroxysmal supraventricular arrhythmias
A
will terminate spontaneously
1st Line: Adenosine (C/I in asthma, COPD, HF)
2nd Line: Verapamil IV
8
Q
Treatment in ventricular tachycardia
A
Medical Emergency
- Direct Cardioversion + CPR
- IV Amiodarone + Cardioversion repeated
9
Q
Flecainide/Propafenone?
A
Contraindications: Heart Block, Structural Heart Disease, Heart Failure
Interactions: other anti-arrhythmias - can cause bradycardia, weaken the heart and QT prolongation (cardio-depression)
10
Q
Adenosine
A
Used for Paroxysmal Supra-ventricular Tachycardia’s - injected to restore
- Contraindicated: Asthma, COPD, Heart Failure, Heart Block
- Side Effects: once injected - bradycardia + asystole, initially get a sense of impending doom and sinking feeling in the chest (but short duration of action)
11
Q
Sotalol
A
Water-Sol Β Blocker - main thing = QT !
- Contraindicated: Long QT Syndrome
- Cautions: severe diarrhoea/prolonged - potassium changes and can cause arrhythmias
- Side Effects: life threatening arrhythmias due to QT !
- Renally Cleared - need dose reductions CrCl < 60
- Monitoring: ECG, potassium, QT
12
Q
Diltiazem/Verapamil - Contraindications
A
- Contraindications: HEART FAILURE, bradycardia, heart block
- Cautions: poor LV function - can precipitate HF
13
Q
Which CCB can be used in heart failure?
A
ONLY Amlodipine
14
Q
Diltiazem/Verapamil - Interactions
A
- Β Blockers - can cause heart failure, bradycardia, systole
- Grapefruit Juice
- Statins
15
Q
Dilitiazem/Verpamil Side Effects
A
- CONSTIPATION
- hypotension/bradycardia, cardiac failure
- other CCB side effects such as ankle swelling, flushing, headache, palpitations
Verapamil is MORE cardioselective than Diltiazem - so will have less of the other CCB side effects like ankle swelling
16
Q
Pharmacological Prophylaxis for Surgical Patients
A
LMWH/Fondaparinux/Heparin
- 7 days post-op for general surgery
- 28 days post-op for abdominal cancer surgery
- elective hip: LMWH for 10 days + Aspirin for 28 days OR LMWH for 28 days OR Rivaroxaban
- elective knee: low-dose aspirin for 14 days OR Rivaroxaban
17
Q
Pharmacological Prophylaxis in Medical Patients
A
1st Line: LMWH
2nd Line: Fondaparinux
Renal Impairment: Heparin
18
Q
Initial Treatment of DVT - doses
A
- Apixaban: 10mg BD for 7 days then 5mg BD
- Rivaroxaban: 15mg BD for 21 days then 20mg OD
- Edoxaban: 5 days of LMWH then 60mg OD
- Dabigatran: 5 days of LMWH then 150mg BD
- Warfarin: LMWH + Warfarin for 5 days/until INR at least 2 for 2 readings then continue Warfarin
19
Q
Which DOACs require dose adjustments for VTE doses?
A
- Apixaban - don’t reduce dose based on age (80) or weight (< 60kg) like you do in AF
- Dabigatran - 110-150mg BD if 75-79 years OR if there’s renal impairment OR if taking Amiodarone/Verapamil
- Edoxaban - 30mg OD if < 60kg
20
Q
How long to continue maintenance of VTE treatment?
A
3 months if provoked
> 3 months if unprovoked
21
Q
Stroke Prevention in AF - doses
A
- Apixaban: 5mg BD
- Rivaroxaban: 20mg OD
- Edoxaban: 60mg OD
- Dabigatran: 150mg BD
/Warfarin - according to INR
22
Q
Which DOACs require dose adjustments for VTE doses?
A
Apixaban: 2.5mg BD IF have any 2 of
- > 80 years
- < 60kg
- Cr > 133 (CrCl 15-30)
Rivaroxaban: 15mg OD IF CrCl 15-49
Edoxaban: 30mg OD IF
- < 60kg
- CrCl 15-50
- Concomitant tx with Dronedarone, Erythromycin, Ciclosporin
Dabigatran: 110mg BD if
- > 80 years
- Concomitant tx with Amiodarone/Verapamil
23
Q
Renal cut-offs for DOAC reduced doses
A
Apixaban = CrCl 15-30 - reduce dose
Rivaroxaban = CrCl 15-50 - reduce dose
Edoxaban = CrCl 15-50 - reduce dose
Dabigatran = CrCl 30-50 - reduce dose
24
Q
Side effects of Heparin + LMWH
A
- Hyperkalaemia - inhibits aldosterone secretion
- Skin Reactions/Injection Side Reactions
- Haemorrhages (Protamine)
- Heparin-Induced Thrombocytopenia (30% reduction in platelet counts, less likely with LMWHs)
25
Dose adjustments of LMWH
- Renal Impairment = CrCl 15-30
| - Extremes of Body Weight (< 50, > 100)
26
Interactions with DOACs
- Enzyme Inducers - reduced effectiveness
- Enzyme Inhibitors - reduced doses may be needed
- Apixaban, Dabigatran, Rivaroxaban - DON'T use SYSTEMIC azoles or HIV protease inhibitors
- Dabigatran + Rivaroxaban - DON'T use dronaderone
Dabigatran
- Verapamil + Amiodarone = dose reductions
- C/I = inducers + inhibitors (other DOACs are cautioned)
Edoxaban + NSAIDs = C/I
27
Dose reductions of Dabigatran required with these concomitant drugs
- Verapamil
| - Amiodarone
28
Dose reductions of Edoxaban required with these concomitant drugs
- Ciclosporin
- Dronedarone
- Erythromycin
- Ketoconazole
29
Aspirin Side Effects + Caution
- Bronchospasm - cautioned in asthma
| - GI Bleeds/Ulceration - contraindicated in active disease, may need PPI protection
30
Clopidogrel Interactions
Clopidogrel is a pro-drug + needs to be metabolised in order to get the active form
Inhibitors of the CYP 450s:
- Omeprazole
- Ciprofloxacin
- Erythromycin
- Antifungals
- SSRIs
31
Side Effects of Dipyridamole
Dipyridamole - alternative to Clopi/Aspirin
Causes vasodilation + tachycardia - so careful in some conditions
- diarrhoea, nausea, vomiting
- dizziness, headache, flushing
32
Stages of Hypertension
Stage 1: 140/90 to 160/100 = treat at risk patients
(< 60 yrs with a > 10% CVD risk, over 80s with BP of 150/90) + consider treatment in others at risk
Stage 2: 160/100 to 180/120 = treat all patients
Stage 3: >180/120 = severe, treat same day
33
Step-Wise Tx for Hypertension in < 55 years, not Afro-Carribbean and for Type 2 DM's
1. ACE/ARB
2. ACE/ARB + CCB (OR a TZD-like if oedema or HF)
3. ACE/ARB + CCB + TZD
4. Add in Low-Dose Spiro OR Alpha-Blocker/B Blocker
34
Step-Wise Tx for Hypertension in > 55 years, Afro-Carribbean
1. CCB
2. CCB + ACE/ARB (OR a TZD-like if oedema/HF)
3. CCB + ACE/ARB + TZD
4. Add in Low-Dose Spiro OR Alpha-Blocker/B Blocker
35
Antihypertensive option for someone with Type 1 Diabetes?
ACE/ARB - to prevent micro/macrovascular complications
36
Antihypertensive option for someone who is breastfeeding?
Non-Afro-Carribbean: Enalapril
Afro-Carribbean: Nifedipine/Amlodipine
Step Up: Labetalol/Atenolol
37
Patient of Afro-Carribbean origin, preferred treatment between an ACE or ARB?
ARB
ACE - not as effective + higher risk of angiooedema
38
What is the preferred thiazide to add in for treatment?
INDAPAMIDE - thiazide-like
rather than Bendro
39
Blood Pressure Targets
(incl diabetes type 2s: )
- Under 80s = 140/90
- Over 80s = 150/90
135/80
- Diabetes Type 1
- Chronic Kidney Failure + CVD
- Pregnancy
130/80
- Chronic Kidney Failure + Diabetes
40
Who should receive primary prevention with a statin?
- all those with QRISK > 10%
- all those with chronic kidney disease
- all those with diabetes type 1 > 40 years
- all those who have had diabetes for 10+ years with other risk factors
- over 85s to reduce risk of non-fatal MI
41
Β Blockers licensed for HF
- Bisoprolol
- Carvedilol
- Nebivolol (mild-moderate in > 70 years)
42
Stepwise Tx for Heart Failure (Reduced Ejection Fraction)
1. ACE/ARB + Β Blocker
2. ACE/ARB + B Blocker + Aldosterone Antagonist (monitor K !! - hyperkalaemia)
3. ACE/ARB + B Blocker + Aldosterone + Digoxin
Furosemide/Bumetanide - for SYMPTOMATIC relief
(alternative = thiazide)
--> this is the only treatment needed for preserved ejection fraction
43
Tx for HF as a result of AF
- Β Blocker + Digoxin + Anticoagulation
44
Cholesterol Targets
Healthy Adult:
- Total = < 5
- LDL = < 3
High Risk:
- Total = < 4
- LDL = < 2
Treatment Target: high-intensity statin reduce LDL-cholesterol by 40%
45
Statins Interactions
- Statins + Ezetimibe/Fibrates = AVOID due to myopathy
- Macrolides - stop taking until course completed
- Enzyme Inhibitors
- Grapefruit Juice
- Amlodipine, Amiodarone, Azoles
Dose Reductions Required For:
SIMVASTATIN - 20mg maximum with
- Amlodipine, Diltiazem, Verapamil
ATORVASTATIN - 10mg maximum with Ciclosproin
ROSUVASTATIN - 20mg maximum with Clopidogrel
46
Key Things About Statins (to learn)
Teratogenic - need protection during treatment + 1 month after, discontinue for 3 months before conceiving
LFTs - monitor before, 3 months + 12 months
Atorvastatin/Rosuvastatin = can be taken at any time of the day, the rest at NIGHT
Report Muscle Weakness/Pain - myopathy
Report SOB, Cough - interstitial lung disease
MHRA - Simvastatin 80mg = really high risk of myopathy only use in high risk patients, most doses need reducing due to concomitant meds (e.g. amlodipine)
47
Intensity of Statins
HIGH:
- Atorvastatin 80, 40, 20
- Rosuvastatin 40, 20, 10
- Simvastatin 80
MEDIUM:
- Atorvastatin 10
- Rosuvastatin 5
- Simvastatin 20 + 40
- Fluvastatin 80
LOW:
- ALL Pravastatin
- Simvastatin 10
- Fluvastatin 40 + 20
48
Stepwise Treatment for STABLE angina
Acute Attacks: always a GTN
1st Line: Β Blocker (/Rate-Limiting CCB - but only if no HF)
2nd Line: B Blocker + Normal CCB (never rate-limiting!)
Alternatives: nitrates, nicosrandil, ranolazine, ivabradine
49
Secondary Prevention of ACS Meds
ACS BAG:
- Aspirin 75mg Lifelong
- Clopidogrel (/alt e.g. Prasugrel if PCI or Ticagrelor if low bleed risk)
- Statin - Atorvastatin 80mg
- Β Blocker (or can have rate-limiting CCB if no HF)
- ACE Inhibitor
- GTN Spray
(+ PPI for DAPT)
50
Stepwise Tx of Acute Coronary Syndromes
Community: Aspirin 300mg STAT
STEMI (complETE occlusion)
- PCI or Fibrinolysis (Clot-Buster)
NSTEMI
- Fondaparinux - then assess with GRACE score (6-month mortality - if above 3% then: )
- PCI/Angiography
- < 3% then conservative management
51
Key Points of Nitrates
GTN:
- if using MORE than 2 times a week then need some long-term prophylaxis (e.g. with a B Blocker)
- side effects: hypotension/postural hypotension causing dizziness, weakness, palpitations, headaches, flushing, nausea + vomiting = so make sure the patient is SAT DOWN
- wait 5 minutes between each dose + 3 doses = CALL 999
- GTN tabs = expire 8 weeks after opening
- SILDENAFIL etc is CONTRAINDICATED = both drugs cause marked vasodilation + hypotension
- careful when using with other antihypertensives
Nitrates:
- the ones with BD dosing - take dose after 8 hours not 12 to ensure a nitrate-free period
- patches = leave them off for 8-12 hours overnight
- AVOID abrupt withdrawal as worsens the angina on stopping
52
Key Points of Other Vasodilators
Nicorandil - main thing = ULCERS !
- GI ulceration - careful with other meds that cause this e.g. steroids, bisphosphonates, NSAIDs
- MHRA warning = skin, mucosal + eye ulcers, stop immediately if these occur
- side effects = HEADACHES, dizziness, flushing, nausea + vomiting
Ivabradine - LOW HEART RATE
- CONTRAINDICATED if HR < 70 (on initiation), stop treatment if HR < 50
- side effects: blurred vision (eye disorders), AF, QT prolongation, BRADYCARDIA
Ranolazine - prolongs QT
53
What condition are people with Coeliac disease at risk of?
Osteoporosis due to malabsorption
54
Abx to treat acute diverticulitis
1st Line: Co-Amoxiclav
| Pen Allergy: Metronidazole + Trimethoprim/Cefalexin/Ciprofloxacin
55
Management of Diverticular Disease
Symptomatic:
BULK - FORMING LAXATIVES to help with constipation
ANTISPASMODICS for abdominal cramps
56
Which drugs increase the risk of diverticular perforation?
Opioids + NSAIDs
57
Short Bowel Syndrome
shortened bowel due to a resection
nutritional deficiencies: fat-sol vitamins, B12, zinc, selenium, magnesium
diarrhoea = manage with rehydration therapy + loperamide at high doses
absorption of drug affected + EC/MR preparations are UNSUITABLE
58
Anal Fissures
tear/ulcer in the lining of anal canal
- acute < 6 weeks = just manage with bulk-forming laxative/osmotic
- chronic > 6 weeks = GTN rectal ointment
59
Pancreatin Insufficiency
due to pancreatic cancer, pancreatitis, CF, coeliac etc.
replace pancreatic enzymes - CREON to help with nutrients
side effects:
- irritation to the mouth + skin reactions = the product is an ENZYME so will start to break down products, GI effects + colonic damage
counselling:
- don't mix with hot foods/drinks = inactivates the enzymes
- don't hold in the mouth - irritation
- hypersensitivity when handling
- GR/EC - mix with slightly acidic foods/liquids
60
Stomas
again, EC/MR preparations are UNSUITABLE
sorbitol found in liquids can have a laxative effect + increase stoma output
may need antidiarrhoeals (loperamide in high doses due to lack of enterohepatic circulation)
PPIs can be used to reduce stoma output
61
Crohn's disease Management
Acute Flare Ups:
- 1 flare/year = IV Corticosteroids OR Budesonide
- 2 flare ups or more/year = Azathioprine/Mercaptopurine AND Corticosteroids/Budesonide (or can try Methotrexate if TPMT deficient etc)
Remission:
- Azathioprine/Mercaptopurine - for everyone
- Methotrexate - only for those that had it to induce remission OR if purines not acceptable
62
Ulcerative Colitis Management
generally, aminosalicylates, applied in a formulation depending on how far the inflammation goes up the colon
suppositories --> foams --> enemas --> oral
```
mild-moderate flare ups:
non-extensive
- Topical Aminosalicylate for 4 weeks
- Then PO Aminosalicylate for 4 weeks
- Then Topical/Oral Steroids for 4-8 weeks
extensive (up to the ascending colon)
- Topical Aminosalicylate + High-Dose PO Aminosalicylate for 4 weeks
- Then corticosteroid for 4-8 weeks
```
severe flare ups = LIFE-THREATENING
- IV Steroids
- IV Ciclosporin if not working after 72 hours
remission
- just colon: rectal aminosalicylates with/without intermittent oral aminosalicylates
- ascending + descending colon: low dose aminosalicylate
63
What are the 4 aminosalicylates + class key points?
Sulfasalazine, Mesalazine/Balsalazide/Olsalazine:
side effects:
- Blood Dyscrasias (stop immediately)
- Nephrotoxic
- Salicylate Hypersensivitiy - related to aspirin (caution in asthma)
- GI discomfort, diarrhoea, N&V
- Lupus-Like Syndrome
interactions:
- other drugs that suppress the immune system (Aza/Mercaptopurine)
- drugs that affect the kidneys
-
64
Sulfasalazine specific side effects:
- pancreatitis/hepatic failure or abnormalities (monthly monitoring for 3 months)
- reversible decrease in sperm of men (oligospermia)
- sulfa allergies
- colours urine/contact lenses
- causes low folate - need adequate supplementation in pregnancy
interactions:
- folate drugs - methotrexate, trimethoprim
- meds that affect the liver
- digoxin - decreases concentrations
monitoring:
- full blood counts - baseline and 3 months
- liver - monthly checks for first 3 months
- renal
65
Mesalazine specific side effects:
90% of those intolerant to sulfasalazine can tolerate meslazine:
- headache most common
+ other aminosalicylate effects rarely
interactions - special coating so it can reach down to the colon so anything that changes the pH will change the release:
- lactulose
- PPIs
- indigestion remedies
66
IBS key points
advice;
- limit fresh fruit to 3 portions per day
- but increase soluble fibre (e.g. oats)
- DON'T have insoluble fibre e.g. bran/resistant starches
- reduce intake of caffeine/fizzy drinks
- avoid sorbitol - diarrhoea
- DON'T use lactulose as can cause bloating
67
Faecal Impaction management
Hard Stools = Macrogol (high dose)
Soft Stools = Stimulant
then enemas for both if not working
68
Constipation in Pregnancy
1st Line: Dietary
2nd Line: Bulk-Forming
avoid Senna near term - causes uterine contractions, unstable pregnancy
69
Constipation in Children
1st Line: Macrogol + Diet/Behavioural
2nd Line: Stimulant
3rd Line: Lactulose/Docusate
Faecal Impaction
- Macrogol escalating dose regimen
- stimulant + osmotic add in if doesn't help after 2 weeks
70
Red Flags of Dyspepsia
- over 55
- unexplained weight loss
- GI bleeding - malaria, haematemesis
- recurrent vomiting
- dysphagia
71
Dyspepsia Management
first presentation;
1st Line: Anatacid/Alginate
2nd Line: PPI for 4 weeks max
then once investigated - use PPI at lowest effective dose
72
Those high risk of peptic ulcer disease with NSAID use
those with a hx of peptic ulcer disease
OR - those with 2 risk factors:
- over 65
- high dose NSAID
- other drugs that affect GI
- serious co-morbidity
- heavy smoker
- excessive alcohol
- prev ADR to NSAIDs
- taking NSAIDs for prolonged amount of time
73
GORD Management
uninvestigated:
1st Line: Antacid/Alginate for symptoms
2nd Line: PPI for 4 weeks
confirmed GORD:
1st Line: PPI for 4-8 weeks (/H2 antagonist if not working)
severe oesophagi's
1st Line: PPI for 8 weeks
74
Urea 13C Breath Test
for H Pylori
- don't perform within 2 weeks of PPI treatment
- don't perform within 4 weeks of Abx treatment
only re-test under specific circumstances following treatment
- take at least 4 weeks, but ideally 8 weeks after tx finishes
75
H Pylori Eradication Treatment
TRIPLE THERAPY - all BD dosing for 7 days (1st + 2nd Line, then goes to 10 days under specialist)
- a PPI + Amoxicillin 1g + Clarithromycin 500mg/Metronidazole 400mg
OR - allergy
- a PPI + Clarithromycin 500mg + Metronidazole 400mg
PPI:
- Lansoprazole 30mg BD
- Omeprazole 20-40mg BD
- Pantoprazole 40mg BD
- Esomeprazole 20mg BD
76
PPIs Key Points
MHRA Alert - SCLE, drug-induced sun-lesions + arthralgia, consider withdrawing and avoid exposure to sunlight
long-term side effects:
- osteoporosis risk
- increased risk of C diff infections
- mask symptoms of gastric cancer
- reduced absorption of nutrients
- hypomagnesia
- rebound secretion on stopping
key interactions:
- clopidogrel + omeprazole/esomeprazole
- phenytoin + omeprazole/esomeprazole - increased phenytoin
77
Loperamide Key Points
MHRA: serious cardio events when used in large doses
MHRA: symptoms of overdose can be treated with naloxone
avoid if any sign of infective diarrhoea
max 16mg per day (usually 8 per box isn't there)
OTC: for diarrhoea in OVER 12
OTC: for IBS in OVER 18
78
H2 Antagonists
Rare Side Effects:
- psychiatric reactions
- hepatitis/cholestatic jaundice
- bradycardia
- leucopenia, thrombocytopenia, pancytopenia,
- joint/muscle pain
Cimetidine - enzyme inhibitor (Warfarin, Theophylline, Phenytoin, Nifedipine)
Other Interactions - for all H2 Antagonists:
- Azole Antifungals - decreased absorption due to changes in pH
79
Laxatives
Bulk-Forming - swells to increase faecal max
- 72 hours onset
- ensure adequate water otherwise may cause obstruction/impaction
- hypersensitivity when handling
Osmotic - increases water
- Macrogol = 2-3 days
- Lactulose = 2 days - not for lactose intolerant
MHRA - macrogol, adding starch based thickeners counteracts and results in a thin liquid, fatal for dysphagia
Softeners
- Oral = 1-2 days
- PR = 20 minutes - don't use in haemarrhoids/fissures
Stimulants - MHRA = prone to abuse
- Senna = 8-12 hours, discolours urine
- Bisacodyl = 6-12 hours
- Sodium Picosulfate = 6-12 hours
80
When to step up asthma treatment?
- using salbutamol > 3x a week
- symptomatic > 3 x a week
- waking at night 1x a week
- using > 1 salbutamol a month
(SIGN - asthma attack in the last 2 years)
81
Asthma Step-Wise Treatment
both NICE/SIGN
- Salbutamol
- Low-Dose ICS
then NICE add in Montelukast
but SIGN add in LABA (as MART if needed)
then NICE add in LABA
then SIGN add in Montelukast OR med dose ICS
then NICE change to MART regime
then SIGN add in high ICS or 4th drug
then NICE change to Med dose ICS then High dose then 4th drug
same for paediatrics but lower doses of ICS
82
Acute Asthma
2-10 puffs of salbutamol via an inhaler every 10-20 minutes - ring an ambulance after 15-30 minutes
prednisolone course needed
- Children = 3 days only
- Adults = at least 5 days
