Workbooks Flashcards

Question

Important SEs antipsychotics & Common SEs

Answer 1

Important side effects –Blood dyscrasias / agranulocytosis –QT prolongation, arrythmias –Worsening diabetes –Worsening Parkinson’s disease –Neuroleptic malignant syndrome Common side effects –Drowsiness, constipation, urinary retention, dry mouth, hypotension –Weight gain –Galactorrhoea, gynaecomastia, sexual dysfunction DONT STOP THE MEDICATION ABRUPTLY

Answer 2

Isotretinoin Doxycycline (& other tetracyclines) - look at medicinal forms, its on the label info Amiodarone

Answer 3

Patients should be aware of (and report) symptoms of potential toxicity –visual disturbance, persistent headaches –increased urination, muscle weakness, tremors, confusion or drowsiness Patients should be aware of (and report) potential causes of dehydration –E.g. vomiting, diarrhoea, profuse sweating with fevers –To keep well hydrated –Risk of toxicity with diuretics Will need monitoring of blood tests –Lithium, TFTs, U+Es, bone profile Avoid if possible in pregnancy (but not absolute contraindication) Should not stop treatment abruptly without medical advice

Answer 4

Patient should be aware that: –Dehydration (e.g. with diarrhoea, vomiting, infections) risks severe side effects (lactic acidosis) : **so must stop taking M if get DorV** –Gastro-intestinal side-effects are common. However, a slow increase in dose may improve tolerability Method of use –Take with or just after food –Start with low starter dose –Likely to require higher doses in the future –(Modified release tablets not to be crushed) Monitoring –Renal function (as it will influence dosing / stopping)

Answer 5

If unwell, (e.g. vomiting, diarrhoea, fevers, sweats), consider stopping the following: –Metformin (not insulin! – see later) –ACEi / ARBs / diuretics –NSAIDs (“DAMN” medications)

Answer 6

* Never omit insulin (may need increased – local guidance usually provided) * Maintain adequate (sugar-free) fluid intake * Maintain regular carbohydrate intake – if unable to take solids, in liquid carbohydrate format * Consider anti-emetic if nauseated * Consider oral electrolyte replacement in diarrhoea * If prolonged inability to keep down fluids (e.g. \>4hrs), then likely needs hospital admission * Increased blood glucose monitoring (e.g. 4hr-ly, and even more frequently if \>moderate ketones) * Ketone testing 2-4 hrly * If persistently elevated, or elevated while low blood glucose – may need hospital admission * Diabetic specialist nurse should provide individualised plan

Answer 7

1. Patients on oral medication only, not including sulphonylureas * Continue with medication as normal (except metformin if prolonged D/V) * Encourage adequate fluid and diet intake * Consider providing an oral electrolyte replacement 2. Patients taking Sulphonylureas * Minimum of daily self-blood glucose monitoring * Advice should be provided regarding the increased risk of hypoglycaemia and reinforce the importance of taking some form of regular carbohydrate * Seek advice if blood glucose persistently elevated (e.g. \> 17) 3. Patients taking insulin therapy * Never omit insulin (if regular prescription) * Emphasis on the importance of regular carbohydrate intake * Minimum twice-daily self-blood glucose monitoring * Seek advice if blood glucose persistently elevated (e.g. \> 17) * Diabetic specialist nurse should provide individualised plan

Answer 8

Sick day rules: –Likely need to increase dose if unwell or undergoing surgery Method of use: –**Do not stop steroids abruptly** –Usually taken in morning (reduce nocturnal side effects) –Taken with or just after food –Should carry steroid card Serious side effects: –Increased risk of psychological side effects –Increased risk of infections (not necessarily CI in pregnancy)

Answer 9

In "Treatment cessation" and "patient and carer advice"

Answer 10

Elective, emergency, NBM * antiplatelets/anticoagulants * diabetic meds: oral, insulin * steroids * anti-hypertensives * oral contraception/HRT [Surgery & long-term medication]

Answer 11

1. To be vigilant for worsening depressive symptoms and suicidal ideas, and to seek help promptly if they are concerned 2. It usually takes 2–4 weeks for symptoms to improve 3. Antidepressants should not be stopped suddenly due to potential for withdrawal symptoms 4. Antidepressants should be taken for at least 6 months after they have recovered, to reduce the risk of relapse 5. Antidepressants are not addictive 6. Some antidepressants potentially have sedating effects greatest in the first month, and may affect the person's ability to drive.

Answer 12

_Absolute contraindications_ –Undiagnosed vaginal bleeding –Severe liver disease –Pregnancy –Coronary artery disease –Endometrial cancer –Recent DVT or stroke _Relative contraindications_ –Migraine headaches –Personal history of breast cancer –Personal history of ovarian cancer –Venous thrombosis –History of uterine fibroids –Atypical ductal hyperplasia of the breast –Active gallbladder disease (cholangitis, cholecystitis)

Answer 13

"Sex hormones" page

Answer 14

–How to start –What to do with missed dose –Monitoring –Reasons to stop immediately –Contraindication –Interactions –Peri-operative period * Stop for combined pill * Can continue for progestogen only pill **Ethinylestradiol with desogestrel** **Levonorgestrel**

Answer 15

**Azathioprine** 1. Should be warned to report immediately any signs or symptoms of bone marrow suppression e.g. inexplicable bruising or bleeding, infection 2. There is a risk of hypersensitivity reactions, which calls for immediate withdrawal **Methotrexate** 1. Weekly dosing 2. Requires folic acid also weekly on a separate day to methotrexate 3. Should be warned to report immediately any signs or symptoms of bone marrow suppression e.g. inexplicable bruising or bleeding, infection 4. Should be warned to report if stomatitis develops (may be first sign of gastro-intestinal toxicity) 5. Should be warned to report to seek medical attention if dyspnoea, cough or fever (risk of pneumonitis) 6. Contraception recommended for both women and men for at least 3 months after treatment 7. Patients should be advised to avoid self-medication with over-the-counter aspirin or ibuprofen **In general** Requires regular blood monitoring (esp. FBC, LFT)

Answer 16

Methotrexate Cyclophosphamide and many other strong IS Some chemotherapy (some antifungals and some antivirals)

Answer 17

5.1 - 5.6 kPa

Answer 18

patients at risk of hypercapnic respiratory failure, which is more likely in those with: * COPD * advanced cystic fibrosis; * severe non-cystic fibrosis bronchiectasis; * severe kyphoscoliosis or severe ankylosing spondylitis; * severe lung scarring caused by tuberculosis; * musculoskeletal disorders with respiratory weakness, especially if on home ventilation; * opioids OD, benzodiazepines, or other drugs causing respiratory depression. Until blood gases can be measured, initial oxygen should be given using a controlled concentration of **24% or 28%,** titrated towards a target oxygen saturation of **_88–92%_** or the level specified on the patient's oxygen alert card if available. The aim is to provide the patient with enough oxygen to achieve an acceptable arterial oxygen tension without worsening carbon dioxide retention and respiratory acidosis. Patients with COPD and other at-risk conditions who have had an episode of hypercapnic respiratory failure, should be given a **24% or 28% Venturi mask and an oxygen alert card endorsed with the oxygen saturations required during previous exacerbations.** Patients and their carers should be instructed to show the card to emergency healthcare providers in the event of an exacerbation.

Answer 19

Look on drug & allergy and cross-sensitivity e.g. avoid if history of immediate hypersensitivity reaction to beta-lactam antibacterials

Answer 20

Which insulin to adjust depends on timing of hypo/hyperglycaemia –Typical target of 4-10 mmol/L Ideally review pattern over 48 hours (might not always be possible) Typically adjustments by 10% of dose (varies with experience), e.g. –Reducing from 24 units à new dose 22 units –Increasing from 16 units à new dose 18 units

Answer 21

Do not prescribed stat doses of rapid acting insulin to ‘correct’ hyperglycaemia –Can precipitate hypoglycaemia. –Needs clinical experience Do not change the total daily dose of insulin into one night-time dose –Dangerous Do not specify changes in calorific content of meals

Answer 22

starts within days of starting antipsychotic: ## Footnote pyrexia muscle rigidity autonomic lability: typical features include hypertension, tachycardia and tachypnoea agitated delirium with confusion Ix: raised CK Rx: fluids, stop antipsychotic, dantrolene

Answer 23

BNF medicinal forms * 1-in-1 = 1 g/mL * 1-in-1000 = 1g/1000mL * 1-in-10000 = 1g/10000mL

Answer 24

Conversions * 100% = 1 g/mL * 1% = 1g/100mL * (Or however you prefer to remember) • •But if you cannot remember on the day, the BNF sometimes has a conversion for the specific drug

Answer 25

ANSWER: dabigatran (direct thrombin inhibitor), metrofmin and naproxen KEY MESSAGE – Need to recognise the difference between medications that: Require dose adjustments / cessation with reduced renal function * The aim of this question * E.g. metformin, NSAID in this question May cause a reduction in renal function •See below Both of the above HIGHEST RISK OF NEPHROTOXICITY: * Diuretics, especially loop diuretics * ACEi/ARBs/mineralocorticoid antagonists * NSAIDs

Answer 26

Hyoscine hydrobromide

Answer 27

Activated charcol 50mg PO BNF: "poisoning, emergecny treatment"

Answer 28

Anti-factor Xa assay

Answer 29

D. REGULAR dose 60mg x2/day = 120mg/24hr AS REQUIRED dose 7.5mls of morphine solution 10mg/5ml = 15mg/dose Four doses in 24hours = 60mg morphine/24hrs. Therefore total 180 mg morphine /24 hours Dosing for breakthrough pain is typically 1/6th f the total daily dose = 30mg morphine sulfate orally (D) Oral morphine sulfate (aka oramorph) is appropriate formulation - no indication for intravenous (C) as still no evidence cannot drink - nasal (A) may be reserved for those who cannot take oral meds - should be immediately active for breakthrough pain, so not modified release (B) - tramadol (E) would be insufficient, particularly at that dose

Answer 30

Pain score

Answer 31

**Extrapyramidal symptoms** (esp. first generation antipsychotics, e.g. haloperidol, chlorperazine) * Parkinsonian symptoms * Acute dystonia managed with procyclidine 10mg IV (or IM if no IV access) * Procyclidine also useful for acute dystonic reactions to metoclopramide **Neuroleptic malignant syndrome** * Hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with pallor, tachycardia, labile blood pressure, sweating, and urinary incontinence * Discontinuation of the antipsychotic drug is essential because there is no proven effective treatment * But bromocriptine and dantrolene have been used

Answer 32

* (Q17) Most syringe drivers can be as precise as 0.1mL/hr * (Q18) Precision for other volumes is dependent on overall volume * In the case of question 18, would be reasonable to be 7.5mL * Paediatric volumes are less likely to be rounded * Tablet doses in mg more likely to be rounded * E.g. 350.5mg à 350mg

Answer 33

25-30 mol/kg/day 1mmol/kg/day each of K, Na and Cl ~ 50-100g of glucose per day to limit starvation ketosis

Answer 34

10 mmol / hr

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