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107 Cards in this Set
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ACE inhibitors e.g. Ramipril, Lisinopril, Perindopril. How do we monitor ACE inhibitors? |
- Efficacy - symptoms, BP - Safety - U+Es (aim K <6) and renal function --> check 1-2 weeks post starting treatment and after dose changes. Accept a 30% increase in creatinine or 25% decrease in eGFR - if more STOP (not reduce). |
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ACE inhibitors e.g. Ramipril, Lisinopril, Perindopril. What are the interactions of ACEi? |
- Potassium elevating drugs (including K+ supplements and diuretics). - Avoid NSAIDs. - Avoid in renal artery stenosis and AKI. - Avoid in pregnancy/child bearing women/breastfeeding. - Lower doses in CKD. |
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ACE inhibitors e.g. Ramipril, Lisinopril, Perindopril. What are the important points to communicate to a patient when prescribing ACEi? |
- Rare: hypersensitivity (face swelling/stomach pain) - STOP, seek urgent help. - Explain monitoring - ACEi can interfere with kidney function and potassium balance. - AVOID NSAIDs - risk kidney damage. |
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ACE inhibitors e.g. Ramipril, Lisinopril, Perindopril. What are the side effects of ACEi? |
- Dry cough - can give ARBs. - Dizziness (esp first dose - take at night). - Hyper K - Renal failure. - Rare: hypersensitivity anaphylactoid reactions, angioedema. |
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SSRIs Citalopram Escitalopram Sertraline Fluoxetine. How do we monitor SSRIs? |
- Sx r/v @ 1-2 weeks and 4 weeks - Change dose or drug if no effect after 4 weeks). - Otherwise adjust dose every 6-8 weeks. |
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SSRIs Citalopram Escitalopram Sertraline Fluoxetine. What are the important drug interactions of SSRIs? |
AAA - aspirin, anticoag, antipsych. - Do not give with MOAIs - Give gastroprotection if taken with aspirin/NSAIDs (increased risk GI bleed). - Increased bleeding risk if prescribed with anticoag. - Do NOT combine with drugs that prolong QT interval e.g. anitpsych. |
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SSRIs Citalopram Escitalopram Sertraline Fluoxetine. What are the side effects of SSRIs? |
-Suicidal thoughts/behaviour. - Prolongs QT - Lowers seizure threshold - Serotonin syndrome - Hypersensitivty - Hyponatraemia - esp elderly. - GIT upset/ appetite/ weight disturbance. |
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SSRIs Citalopram Escitalopram Sertraline Fluoxetine. What are the important points to be communicated to the patients when starting SSRIs? |
- Should improve symptoms over weeks - esp sleep and appetite. - D/c psych therapy. - Should continue for 6/12 even if feel better. - Do NOT stop dose suddenly = tummy upset, flu like w/d sx. |
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TCAs Amitryptilline Lofepramine (Antidepressants, neuropathic pain) What must we monitor with TCAs? |
Nil |
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TCAs Amitryptilline Lofepramine (Antidepressants, neuropathic pain) What are the side effects of TCAs? |
- Anti-muscarinic (dry mouth, constipation, urinary retention, blurred vision). - Sedation - Hypotension - Arrhythmias/ECG changes - long QT/QRS. - Convulsions, hallucinations, mania. - Gynaecomastia - Sexual dysfunction - Extra-pyramidal sx (AVOID PARKINSONS). - Dangerous in OD = all of above + coma + resp failure. |
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TCAs Amitryptilline Lofepramine (Antidepressants, neuropathic pain) What are the important drug interactions with TCAs? |
- NOT for epileptics. - NOT for elderly - Caution in constipation, BPH, raised intra-occular pressure. - Not with MOAIs |
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TCAs Amitryptilline Lofepramine (Antidepressants, neuropathic pain) What must we communicate to patients when starting TCAs? |
- Should improve symptoms over weeks- esp sleep and appetite. - D/c psych therapy. - Should continue for 6/12 even if feel better. - Do NOT stop dose suddenly = tummy upset, flu like w/d sx. |
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Lithium How must we monitor Lithium? |
- Bloods: [lithium], TFTs, cardiac function, renal function (baseline and 6 monthly). - Samples taken 12 hours post-dose - Aim: 0.4-1mmol/L |
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Lithium What causes lithium toxicity and what are the symptoms? |
Toxicity caused by: NSAIDs, ACEi, Thiazides. Leukocytosis/Lethargy Intentional tremor Teratogenecity Hypothyroidism Insipidus (Diabetes) Urine Excess Metallic taste. |
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Tacrolimus/cyclosporine How must we monitor tacrolimus and cyclosporine? |
- [Trough] every 1-2 weeks for a month. - When stable, every 2-3 months. - Beware of cytochrome p450 inducers/inhibitors. |
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Acetylcysteine - Paracetamol overdose. - Prevention of contrast nephropathy. - Reduce viscosity of resp secretions. How must we monitor acetylcysteine? |
- ALT, creatinine, INR. - INR best indicator of liver function. |
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Acetylcysteine - Paracetamol overdose. - Prevention of contrast nephropathy. - Reduce viscosity of resp secretions. What are the side effects of acetylcysteine? |
- Anaphylactoid reaction - wait for them to settle then safe to restart at a lower rate of infusion. - When administered as neb (mucolytic) may = bronchospasm - give salbutamol before hand. |
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Acetylcysteine - Paracetamol overdose. - Prevention of contrast nephropathy. - Reduce viscosity of resp secretions. What are the important drug interactions? |
Nil |
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Acetylcysteine - Paracetamol overdose. - Prevention of contrast nephropathy. - Reduce viscosity of resp secretions. What must be communicated to patients when starting acetylcysteine? |
- Explain paracetamol antidote. - 21 hour drip. - May cause rash, nausea or wheeze - alert staff. - Importance of avoiding interruptions to treatment. |
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Aldosterone antagonists Spironolactone Eplerenone How must we monitor aldosterone antagonists? |
- Efficacy: symptoms - Safety: renal function (watch high K). |
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Aldosterone antagonists Spironolactone Eplerenone What are the side effects of aldosterone antagonists? |
- NOT with severe impairment - NOT with Addisons - aldosterone deficient. - NOT in pregnant or lactating women - crosses placenta. - Can cause liver impairment and jaundice. - Steven Johnson Syndrome. |
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Aldosterone antagonists Spironolactone Eplerenone What are the important interactions of aldosterone antagonists? |
- Caution with K+ elevating drug - ACEi, ARBs. - NOT with K+ supplements. |
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Aldosterone antagonists Spironolactone Eplerenone What must be communicated to patients when starting aldosterone antagonists? |
- Growth/tenderness of breast. - Sexual dysfunction - Reassure that benign and reversible. |
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Allopurinol Acute gout prevention (not for acute attack). How do we monitor allopurinol? |
Uric acid: 4 weeks after dose change (aim <300 mmol/L). |
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Allopurinol Acute gout prevention (not for acute attack). What are the side effects of allopurinol? |
- Skin rash - stop immediately, Steven Johnson syndrome. |
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Allopurinol Acute gout prevention (not for acute attack). What are the important drug interactions of allopurinol? |
MERCAPTOPURINE (cytotoxic) and pro-drug (AZATHIOPRINE) - xanthase oxidase required for metabolism. Allopurinol blocks this enzyme = toxicity. - Amoxicillin = increased risk risk skin rash. - ACEi/thiazides = increased risk of hypersensitivty reactions. |
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Allopurinol Acute gout prevention (not for acute attack). What must we communicate to patients when starting allopurinol? |
- Reduce attacks of gout. - Seek immediate medical advice if rashy. |
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Amiodarone SVT/VF treatment How do we monitor amiodarone? |
- Efficacy: HR/rhythm - Safety: if IV need constant cardiac monitoring. If chronic do baseline CXR, renal function, liver function and TFTs. Repeat liver, thyroid and renal function 6/12s. |
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Amiodarone SVT/VF treatment What are the side effects of amiodarone? |
- Acute: hypotension (IV) - Chronic: pneumonitis, bradycardia, AV block, hepatitis, photosensitivity/grey skin, thyroid (high and low), corneal deposits. - Long half life - months to eliminate. |
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Amiodarone SVT/VF treatment What are the important drug interactions? |
Increases plasma [digoxin/diltiazem/verapamil] = bradycardia/AV block/HF. Therefore halve doses of these drugs if amiodarone started. |
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Amiodarone SVT/VF treatment What must we communicate with patients when starting amiodarone? |
- No grapefruit juice. - Avoid direct sunlight. |
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-Azoles e.g. fluconozole (vaginal candidiasis) cotrimazole (genital tract thrush, tinnea) nystatin (oropharyngeal candidasis, skin infections). How do we monitor -azoles? |
- Efficacy: sx - FLUCONOZOLE: liver enzymes before and during prolonged courses (hepatic toxicity). |
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-Azoles Fluconozole (vaginal candidiasis) Cotrimazole (genital tract thrush, tinnea) Nystatin (oropharyngeal candidasis, skin infections). What are the side effects? |
Topical nystatin/cotrimazole: Local irritation Fluconozole (common) - GI upset - Headache - Hepatitis - Hypersensitivty Fluconozole (rare): - Severe hepatic toxicity - Prolonged QT - Cutaneous reactions - Anaphylaxis |
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-Azoles Fluconozole (vaginal candidiasis) Cotrimazole (genital tract thrush, tinnea) Nystatin (oropharyngeal candidasis, skin infections). What are the important drug interactions? |
Fluconozole = cp450 INHIBITORS - Can cause arrhythmias if with long QT interval (antipsych, amiodarone, quinine, quinolones, macrolides, SSRIs). - NOT in pregnancy. - Lower dose in moderate renal impairment and liver disease Nystatin and cotrimazole have NO interactions |
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-Azoles Fluconozole (vaginal candidiasis) Cotrimazole (genital tract thrush, tinnea) Nystatin (oropharyngeal candidasis, skin infections). What must be communicated to patients? |
- Encourage to cont tx 1-2 weeks post sx resolution. - If on LT treatment seek medical advise if nausea, loss of appetite, lethargy or dark urine. |
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Anti-psychotics (typical - 1st generation) Haloperidol Clopromazine Prochlorperazine BLOCK POST-SYNAPTIC D2 RECEPTORS What must be monitored? |
- Efficacy: sx - Can be given as DEPOT. |
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Anti-psychotics (typical - 1st generation) Haloperidol Clopromazine Prochlorperazine BLOCK POST-SYNAPTIC D2 RECEPTORS What are the side effects? |
- Extra pyramidal effects. - Acute dystonic reactions. - Neuroleptic malignant syndrome (fever, stiffness, agitation, autonomic dysregulation). - Chronic: tardive dyskinesia, long QT, drowsiness, hypotension, erectile dysfunction, hyperprolactinaemia. |
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Anti-psychotics (typical - 1st generation) Haloperidol Clopromazine Prochlorperazine BLOCK POST-SYNAPTIC D2 RECEPTORS What are the important drug interactions? |
- Prolong QT drugs. - NOT in parkinsons. |
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Anti-psychotics (typical - 1st generation) Haloperidol Clopromazine Prochlorperazine BLOCK POST-SYNAPTIC D2 RECEPTORS What must be communicated to patients? |
- May take several weeks to work. - Adherence is important - depot. |
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Antipsychotics (atypical - 2nd generation) Clozapine Olanzapine Quetiapine Risperidone BLOCK POST-SYNAPTIC D2 RECEPTORS AND 5HT2. How do we monitor? |
- Efficacy: sx - Can be given as DEPOT. - Clozapine has own monitoring programme - Metabolic and CVS (weight, lipids, glucose baseline and intermittently). |
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Antipsychotics (atypical - 2nd generation) Clozapine Olanzapine Quetiapine Risperidone BLOCK POST-SYNAPTIC D2 RECEPTORS AND 5HT2. What are the side effects? |
- Extrapyramidal s/e (less than typicals). - Metabolic disturbance. - Prolong QT - Sexual/breast dysfunction. - Clozapine = AGRANULOCYTOSIS.- 1% clozapine patients = MYOCARDITIS. |
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Antipsychotics (atypical - 2nd generation) Clozapine Olanzapine Quetiapine Risperidone BLOCK POST-SYNAPTIC D2 RECEPTORS AND 5HT2. What are important drug interactions? |
- NOT with dopamine blocking antiemetics (metoclopramide). - Long QT drugs. |
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Antipsychotics (atypical - 2nd generation) Clozapine Olanzapine Quetiapine Risperidone BLOCK POST-SYNAPTIC D2 RECEPTORS AND 5HT2. What must be communicated to patients? |
- May take several weeks to work. - Adherence is important - depot. - Weight gain and sexual dysfunction (reversible). - Sore throat = see doctor immediately. |
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B blockers Bisoprolol Atenolol Propranolol Metoprolol How do we monitor B blockers? |
- Efficacy: sx - HR (aim 55-60). |
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B blockers Bisoprolol Atenolol Propranolol Metoprolol What are the side effects of B blockers? |
- Bradycardia - Hypotension - Fatigue - Headache - GIT disturbance - Sleep disturbance/nightmares - Impotence |
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B blockers Bisoprolol Atenolol Propranolol Metoprolol What are the important interactions? |
- NOT with non-dihydropyridine CCB (verapamil, diltiazem). - NOT for asthmatics. - NOT in heart block. - Caution in COPD. - Caution in HF. - Caution in haemodynamic instability and liver failure. |
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B blockers Bisoprolol Atenolol Propranolol Metoprolol What must we communicate with patients when starting B blockers? |
- If HF there may be initial deterioration - seek medical attention. - If obstructive airways - STOP and get help if any breathing difficulties. |
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BSP Alendronic acid Pamidronate and Zolidronic acid (decrease pathological fractures and stop cord compression) . Osteoporosis Severe HYPERCa2+ (malignant) Myeloma/breast cancer with bone mets. Pagets disease. How do we monitor BSPs? |
- In Osteoporosis: check Ca and vit D before treatment. DEXA @ 1-2 years. - In high Ca2+: levels and sx. - Monitor Ca and phosphate. |
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BSP Alendronic acid Pamidronate and Zolidronic acid (decrease pathological fractures and stop cord compression) . Osteoporosis Severe HYPERCa2+ (malignant) Myeloma/breast cancer with bone mets. Pagets disease. What are the side effects of BSPs? |
- Hypophosphataemia. - Oesophagitis. - Osteonecrosis of the jaw. - Atypical femoral fracture (proximal to femoral shaft). |
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BSP Alendronic acid Pamidronate and Zolidronic acid (decrease pathological fractures and stop cord compression) . Osteoporosis Severe HYPERCa2+ (malignant) Myeloma/breast cancer with bone mets. Pagets disease. What are the important drug interactions? |
- Antacids, Calcium and Iron supplements/salts = reduces BSP absorption. - NOT with severe renal impairment. - NOT with severe HYPOCa2+. - NOT with upper GI disorders. - Caution with smokers and jaw disease. |
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BSP Alendronic acid Pamidronate and Zolidronic acid (decrease pathological fractures and stop cord compression) . Osteoporosis Severe HYPERCa2+ (malignant) Myeloma/breast cancer with bone mets. Pagets disease. What must we communicate with patients when starting BSPs? |
- See dentist before and during. - Sore throat = see doctor. - Take before breakfast (empty stomach). - Upright for 30 minutes. - Take whole with full glass of water. |
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Calcium and Vit D. How do we monitor these drugs? |
Monitoring: - In high K+: repeat 12 lead ECG and check resolution of prolonged PR and QRS (Calcium gluconate). - Check Ca regularly. |
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Calcium and Vit D. What are the side effects? |
- Dyspepsia - Constipation - CVS collapse if too fast IV. - Local tissue damage (IV). |
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Calcium and Vit D. What are the important interactions? |
- PO reduces absorption of iron, BSP, tetracyclines, levothyroxine, levodopa, quinolones. - IV do not mix with NaCO3 as = precipitate. |
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Calcium and Vit D. What must we communicate with the patient when starting these drugs? |
- Explain rationale. - Seek advice if limb or abdo pain. |
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Carbemazapine Epilepsy - FOCAL. Trigeminal neuralgia Bipolar (prophylaxis). INHIBIT NEURONAL SODIUM CHANNELS = NO DEPOLARISATION. |
- Efficacy: Seizure frequency. |
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Carbemazapine Epilepsy - FOCAL. Trigeminal neuralgia Bipolar (prophylaxis). INHIBIT NEURONAL SODIUM CHANNELS = NO DEPOLARISATION. How do we monitor carbemazepine? |
- Anti-epileptic Hypersensitivty Syndrome (SJS/TEN) - 1/5000 (also phenytoin) - 2 months of starting treatment. - Diplopia - Ataxia, dizziness - GIT upset (common). - Oedema, HYPONa+ - anti-diuretic effect. |
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Carbemazapine Epilepsy - FOCAL. Trigeminal neuralgia Bipolar (prophylaxis). INHIBIT NEURONAL SODIUM CHANNELS = NO DEPOLARISATION. What are the side effects? |
- INDUCES cp450- Do NOT give with inhibitors. - Caution with other anti-epileptics. - Do NOT give with drugs that lower seizure threshold (SSRIs, TCAs, antipsychs, tramodol). |
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Carbemazapine Epilepsy - FOCAL. Trigeminal neuralgia Bipolar (prophylaxis). INHIBIT NEURONAL SODIUM CHANNELS = NO DEPOLARISATION. What must we communicate to patients when starting carbemazepine? |
- Rash/bruising/bleeding/fever/mouth ulcers = toxicity. - Reduced appetite/abdo pain = liver toxicity. - Women: contraception and pregnancy (teratogenic). - Do NOT drive unless seizure free for 12 months - Do NOT drive for 3 years once pattern of night time only seizures. - Do NOT drive for 6 months of changing or stopping medication. |
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Digoxin POSITIVE IONOTROPE. NEGATIVE CHRONOTROPE. How do we monitor digoxin? |
Monitoring: - Efficacy: sx and HR - Safety: periodic ECG (reverse tick is normal - ST segment depression). - U+Es: low K and low Mg increases risk toxicity. |
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Digoxin POSITIVE IONOTROPE. NEGATIVE CHRONOTROPE. What are the side effects? |
- Bradycardia. - GIT upset. - Rash/dizziness - Visual disturbance: blurred/yellow. - Toxicity. |
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Digoxin POSITIVE IONOTROPE. NEGATIVE CHRONOTROPE. What are the important drug interactions? |
- Loop/thiazides increase digoxin toxicity as cause hypokalaemia.Digoxin competes for Na/K pump with K. When K is low there is increased action of digoxin. - Amiodarone, CCB, Spironolactone, Quinine increase plasma [digoxin]. - NOT in secondary HB or complete HB. - NOT in ventricular arrhythmias. - Reduce dose in renal failure. - Caution in HypoK/Mg and HyperCa. |
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Digoxin POSITIVE IONOTROPE. NEGATIVE CHRONOTROPE. What must we communicate with this patient when starting this drug? |
- Common to get sickness, diarrhoea, headache. - Progressively worse/too bad seek help - may mean too high a dose. |
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Loop Diuretics Furosemide Bumetanide How do we monitor these drugs? |
- Efficacy: sx, oedema, weight. - Safety: Na, K, renal function. |
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Loop Diuretics Furosemide Bumetanide What are the side effects? |
- Dehydration. - Hypotension. - Hypo K - Hypo Na - Hypo Cl - Hypo Ca - Hypo Mg - Metabolic alkalosis. - Higher doses = hearing loss and tinnitus. |
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Loop Diuretics Furosemide Bumetanide What are the important interactions? |
- Any drug that is renally excreted: lithium (increased levels), digoxin (increased levels) - HypoK .- Ototoxicity/Nephrotoxicity - increased aminoglycoside side effect. |
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Loop Diuretics Furosemide Bumetanide What must we communicate with patient when starting this medication? |
- Water tablet. - Frequency. - Don't take too late in the day or will be up all night peeing. |
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Ferrous sulphate/fumerate How do we monitor iron therapy? |
- Expect Hb to increase by 20g/L per month. |
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Ferrous sulphate/fumerate What are the side effects? |
- GIT upset. - Poo = black. - Constipation/Diarrhoea. - Nausea. - Epigastric pain. |
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Ferrous sulphate/fumerate What are the main interactions? |
- Levothyroxine (reduced absorption). - BSP (reduced absorption). Therefore take 2 hours apart from iron (these tablets first as need to be on an empty stomach). |
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Ferrous sulphate/fumerate What must we communicate with patients when starting iron? |
- Poo = black. - Come back if GIT disturbance. |
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Heparins LMWH UFH Fondaparinux How do we monitor heparin? |
- LMWH: anti factor Xa, thrombin (pregnancy). - UFH: APTR/APTT (every 6 hours initially - target APTR 1.5-2.5) - Both: platelet count - Fondaparinux: anti factor Xa. |
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Heparins LMWH UFH Fondaparinux What are the side effects? |
- HITT - more common with unfractionated. - Injection site reactions. - Bleeding. |
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Heparins LMWH UFH Fondaparinux What are the important interactions? |
- Increased risk of bleeding with clotting disordered. - Severe, uncontrolled HTN. - Recent surgery/trauma. - Avoid at time of invasive procedures e.g. LP. - Renal impairment = UFH. |
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Heparins LMWH UFH Fondaparinux What must we communicate with patients when starting heparin? |
- For tx of VTE in cancer/immobilisation. - Risks vs benefits. - Avoid activities that increase bleeding - contact sports, gardening. - Caution with warfarin/clopidogrel/aspirin - Major bleeding with UFH/LMWH - give PROTAMINE. |
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Laxatives - bulk forming Ispaghula husk Methylcellulose Sterculia How do we monitor laxatives? |
Stool chart |
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Laxatives - bulk forming Ispaghula husk Methylcellulose Sterculia What are the side effects? |
- Mild abdominal distention. - Flatulence - Faecal impaction - GIT obstruction - Do NOT give to those in obstruction/impaction/ileus. |
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Laxatives - bulk forming Ispaghula husk Methylcellulose Sterculia What are the interactions? |
Nil |
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Laxatives - bulk forming Ispaghula husk Methylcellulose Sterculia What must we communicate with patients when starting laxatives? |
- Fibre supplement. - Can adjust dose depending on symptoms but must not exceed max. - Take with a meal and plenty of fluid. - Store in a dry place. |
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Laxatives - osmotic Lactulose Macrogol Phosphate enema Constipation, faecal impaction, bowel prep, hepatic encephalopathy. How do we monitor laxatives? |
- Stool chart. - Electrolytes if for hepatic encephalopathy. |
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Laxatives - osmotic Lactulose Macrogol Phosphate enema Constipation, faecal impaction, bowel prep, hepatic encephalopathy. What are the side effects? |
- Flatulence - Abdominal cramps - Nausea - Diarrhoea - Phosphate enemas: local irritation and U+E disturbances. |
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Laxatives - osmotic Lactulose Macrogol Phosphate enema Constipation, faecal impaction, bowel prep, hepatic encephalopathy. What are the interactions? |
May increase warfarin action. |
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Laxatives - osmotic Lactulose Macrogol Phosphate enema Constipation, faecal impaction, bowel prep, hepatic encephalopathy. What must we communicate with the patient when starting laxatives? |
- Must drink 6-8 glasses of liquid per day. - Side effects improve over time. - Adjust dose to maintain comfort i.e. reduce/stop if passing more than 2-3 motions a day. |
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Laxatives - stimulant Senna Bisacodyl Glycerol suppositories Docusate sodium Constipation, faecal impaction. How do we monitor laxatives? |
Stool chart. |
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Laxatives - stimulant Senna Bisacodyl Glycerol suppositories Docusate sodium Constipation, faecal impaction. What are the side effects? |
- Abdominal pain. - Cramps - Diarrhoea - MELANOSIS COLI with prolonged use. |
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Laxatives - stimulant Senna Bisacodyl Glycerol suppositories Docusate sodium Constipation, faecal impaction. What are the interactions? |
Nil |
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Laxatives - stimulant Senna Bisacodyl Glycerol suppositories Docusate sodium Constipation, faecal impaction. What must we communicate to patients when starting laxatives? |
- Drink 6-8 glasses of water a day. - Do not work immediately - may need several doses. - Can be adjusted as needed. - If >2-3 motions a day - reduce/stop. - Side effects should improve over time. |
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Metformin BIGUANIDE How do we monitor metformin? |
- Safety: Renal function before and then annually. Measure twice annually if deteriorating renal function/ risk impairment. - Efficacy: HbA1c (aim <58). |
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Metformin BIGUANIDE What are the side effects? |
- GIT upset (nausea, vomiting, taste disturbance, anorexia, diarrhoea = weight loss). - Lactic acidosis - precipitated by intercurrent illness. |
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Metformin BIGUANIDE What are the interactions? |
- NOT in severe renal impairment (<30 eGFR).- Reduce in moderate impairment (<45). - Withhold in: AKI, severe tissue hypoxia. - Caution in hepatic impairment (reduced lactate clearance).- Withhold during acute alcohol intoxication. - Caution in chronic alcohol overuse where there is a risk of low glucose. - Withhold before for 48 hours after IV contrast media when increased risk of renal impairment/accumulation/lactic acidosis. - Caution with other drugs that may cause renal impairment - NSAIDs, ACEi, diuretics. - Prednisolone, thiazide/loops elevate blood glucose = reduce efficacy of metformin. |
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Metformin BIGUANIDE What must we communicate to patients when starting metformin? |
- Prescribed to control blood sugar and reduce risk of complications. - Do not replace lifestyle measures. - Seek urgent medical advice if vomiting/abdo pain/ muscle cramps/ SOB/ severe tiredness (=LACTIC ACIDOSIS). - Must tell doctors they are taking metformin as need to be stopped before X ray or operation. |
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Methotrexate How do we monitor methotrexate? |
- Efficacy: symptoms, examination, inflammatory markers. - Renal, FBC and liver function - 1-2 weekly then 3/12ly. - Patients to report side effects. - STOP immediately if any abnormal bloods or patient SOB. |
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Methotrexate What are the side effects? |
DOSE RELATED: - mucosal damage - sore mouth, GIT upset. - BM suppression - neutropenia, increased infection. - Hypersensitivity - cutaneous, hepatitis, pneumonitis. LONG TERM: - Hepatic cirrhosis - Pulmonary fibrosis. RISK: accidental overdose if taken DAILY. TOXICITY: Causes renal impairment, hepatotoxicity, headache, seizures, coma. Treat with FOLINIC ACID + hydration + urinary alkalinisation. |
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Methotrexate What are the interactions? |
- AVOID in pregnancy (teratogenic) - Renally excreted so avoid in severe renal impairment. - Avoid if abnormal LFTs as = liver hepatotoxicity. - Toxicity more likely if prescribed with drugs reducing renal function e.g. NSAID, penicillins. - Co-prescription with other folate antagonists (TRIMETHOPRIM, PHEYTOIN) increases risk of haematological abnormalities. - High risk of neutropenia if combined with CLOZAPINE. |
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Methotrexate What must we communicate to patients when starting methotrexate? |
- May take time to reach maximal effect. - Take ONCE A WEEK - Seek urgent help if sore throat/fever, bleeding/bruising, nausea, abdominal pain, dark urine (liver toxicity) or SOB (lung toxicity). - Men and women should use contraception up to 3 months post treatment. |
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Phenytoin How do we monitor phenytoin? |
- Plasma [phenytoin] measured immediately before the next dose (N = 10-20mg/L) - If needed, make small dose changes at a time - zero order kinetics makes it difficult to predict. - After dose change, wait 7/7s before checking concentration. - Efficacy: seizure frequency. - Monitor BP, rhythm, resp rate and O2 sats during IV treatment. Measure trough doses if: - Adjusting dose - ? toxicity - ? adherence |
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Phenytoin What are the side effects? |
LONG TERM: - Skin coarsening - Acne - Hirsuitism - Gum Hypertrophy DOSE RELATED: - Cerebellar toxicity - Impaired cognition/consciousness. S/E: - Megaloblastic anaemia - Osteomalacia - Hypersensitivity - Teratogenic - Drug induced SLE - Hepatitis - Peripheral neuropathy. TOXICITY: death from CVS collapse and resp depression |
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Phenytoin What are the interactions? |
- Narrow therapeutic index - Reduce dose in hepatic impairment. - Contraception in pregnancy = Fetal HYDANTOIN SYNDROME. - High dose folic acid (5mg) given in unplanned pregnancy. - CYP450 inducer. - Phenytoin increased by CYP450 inhibitors. - Interactions with other anti-epileptics. - Efficacy reduced by drugs lowering seizure threshold e.g. SSRI, TCA, antipsych, tramadol. |
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Phenytoin? What must we communicate to patients when starting phenytoin? |
- Aim to reduce seizure frequency. - Take regularly with or after food. - Do not miss doses. - Seek urgent help if rashes, bruises, signs of infection. - Contraception for women. - Do NOT drive unless seizure free for 12 months (or 3 years of sleep only seizures). - Do NOT drive for 6/12s after changing/stopping treatment. |
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Statin How do we monitor statins? |
- Primary: lipid profile before treatment. - Thereafter not routinely checked as no target. - Secondary: Check target cholesterol levels. - Aim for 40% decrease in non-HDL cholesterol, otherwise increase dose. - Safety: LFT baseline and again at 3 and 12 months. - A rise in ALT up to 3 times upper limit of normal is acceptable. - If higher, stop statin and wait. Once reduced can start statin again at a lower dose. - Do NOT need to check CK regularly but ask to report muscle sx. |
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Statins What are the side effects? |
- Headache - GIT disturbance - Aches --> myopathy --> rhabdomyolysis. - Rise in liver enzymes (ALT) - Drug induced hepatitis. |
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Statins What are the interactions? |
- Caution in hepatic impairment. - Reduce dose in renal impairment. - Avoid in pregnancy/breastfeeding - cholesterol important for normal fetal development. |
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Statins What must we communicate to patients when starting statins? |
- Aim to lower cholesterol. - Ask for help if muscle symptoms arise. - Ask for repeat bloods at 3 and 12 months. - Keep alcohol to a minimum. - Avoid grapefruit if on atorvastatin/simvastatin. |
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Sulfonylureas Gliclizide Chlopropramide (long acting) How do we monitor sulfonylureas? |
- HbA1c (aim <58) - Monitor renal and hepatic function (identify patients who may not be suitable). |
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Sulfonylureas Gliclizide Chlopropramide (long acting) What are the side effects? |
- GIT upset - Hypoglycaemia - more likely with high doses, reduced metabolism or other hypoglycaemic agents co-prescribed. Can last many hours. - Hypersensitivty - hepatic toxicity (cholestatic jaundice), haematological abnormalities (agranulocytosis). |
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Sulfonylureas Gliclizide Chlopropramide (long acting) What are the interactions? |
Metabolised in the liver - 10-12 hour half life. Unchanged metabolites excreted in urine. - Dose reduction in patients with hepatic impairment. - Monitor glucose levels in those with renal impairment. - Caution in patients with increased risk of hypoglycaemia: --> hepatic impairment (reduced gluconeogenesis). --> Malnutrition --> Adrenal/pituitary insufficiency (lack of counter regulatory hormones). --> Elderly. - Hypoglycaemia more likely with other hypoglycaemics e.g. metformin, pioglitazone. - Efficacy reduced by drugs increasing blood glucose e.g. prednisolone, thiazide and loops. |
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Sulfonylureas What must we communicate to patients when starting sulfonylureas? |
- Aim to control BMs - Tablets are not a replacement for lifestyle measures. - Warn of hypoglycaemia and symptoms. - Should take something sugary e.g. glucose tablet/sugary drink and then something starchy. - Seek help if recur. |
