Top 100 Drugs

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Royalblue_99
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283768
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Top 100 Drugs
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2015-05-07 15:12:20
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Pharmacology Top 100 Drugs
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MBBS T-Year George's Top 100 Drugs
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  1. ß2 Agonist
    • Short acting - Salbutamol; Terbutaline
    • Long acting - Salmeterol; Formoteral

    • Indications:
    • Asthma, COPD, Hyperkalemia

    • Mode of Action: 
    • Acts os ß2 receptors on smooth muscle of bronchi, GI tract, uterers and blood vessels.
    • - Stimulation of this receptor allows the muscle to relax.

    • Also acts on Na+/K+ pump
    • - K+ enters the cell
    • - must be IV to have this effect

    • Adverse Reactions:
    • Sympathetic stimulation (tachycardia; palpitations; anxiety; tremor)
    • Increased glucose and lactate in blood (stimulates glucogeolysis) 
    • Muscle cramps

    • Safety:
    • For long acting must give with corticosteroids (lesson risk of death)
    • Investigate if can give with cardiovascular disease problems

    • Interactions:
    • ß-blockers
    • Theophyline (stops cAMP --> cGMP)

    • Prescribing:
    • As required
    • Nebuliser (Air if COPD)

    • Administration:
    • Inhaled

    • Communication:
    • Explain will treat symptoms not the disease

    • Monitoring:
    • Action plan

    • Cost:
    • Cost NHS £500m each year.
  2. Template
    Indications: Mode of Action: Adverse Reactions:Safety:Interactions:Prescribing:Administration:Communication:Monitoring:Cost:
  3. Inhaled Corticosteroids
    Beclometasure; Bubesonide; Fluticasone

    • Indications:
    • Asthma (step 2)
    • COPD

    • Mode of Action: 
    • -Get through cytoplasm of cell and react with nucleus
    • -Decrease pro-inflamatory proteins (interlukins, cytokines and chemokines)
    • -Increase anti-inflamatory proteins
    • -This will widen the lamina with the decreased mucus projection

    • Adverse Reactions:
    • -Oral Candidiasis
    • -Hoarse voice
    • -Increased risk of pneumonia
    • (little systemic effect)

    • Safety:
    • -Pneumonia risk
    • -Child decrease growth

    • Interactions:
    • None

    • Prescribing:
    • Twice a day

    • Administration:
    • -Inhaled (dry powder or spacer)

    • Communication:
    • -Explain technique
    • -Will dampen down symptoms
    • -Won't get into body
    • -Rinse after taking (mouth ulcers)

    • Monitoring:
    • -Action plan
    • -Check inhaler technique

    • Cost:
    • -Cheap
  4. Anticholinergics
    • Short - Ipratropoian;
    • Long - Tiotropium; Glycopynoxcian

    • Indications:
    • COPD (short for exacibations, LAMA to prevent)
    • Asthma

    • Mode of Action: 
    • -Competitive inhibitor for ACH receptors (parasympathetic)
    • -Increase heartrate
    • -Improve smooth muscle tone
    • -Reduce seretonins
    • -Reacts on eye: pupil muscle constrictor therefore dilator. Don't use is accommodation issues

    • Adverse Reactions:
    • Dry Mouth

    • Safety:
    • Angle-closure glaucoma (will raise interoccular pressure)

    • Interactions:
    • None

    • Prescribing:
    • Short acting 4 times daily or as needed
    • LAMA once a day

    • Administration:
    • Inhaled
    • Nebulised

    • Communication:
    • Airway will relax
    • may lead to dry mouth so drink water and chew gum

    • Monitoring:
    • Check it's working
    • Check inhaler technique

    • Cost:
    • Inexpensive
  5. Oral Corticosteroid
    Prednisolone; Hydrocortisone; Dexamethasone

    • Indications:
    • Allergy
    • Auto-immune suppressant
    • Cancer
    • Hormone replacement

    • Mode of Action: 
    • -Get through cytoplasm of cell and react with nucleus-Decrease pro-inflamatory proteins (interlukins, cytokines and chemokines)-Increase inflammatory proteins

    • Adverse Reactions:
    • Increase infection risk
    • Metabolic - DM and osteoperosis
    • Muscle weakness
    • Skin - thin and bruising
    • Mood change - insomnia; confused; suicidal
    • Hypertension
    • Hyperkalemia
    • Oedema
    • Addisonian Crisis

    • Safety:
    • Not infection
    • Not children (suppress growth)

    • Interactions:
    • NSAIDs (peptic ulcers)
    • ß2 antagonists
    • Diuretics
    • Theophyline
    • Decrease cP450 Indexes
    • Prescribing:
    • Oral
    • IV
    • IM

    • Administration:
    • Oral in the morning (decreases insomnia)

    • Communication:
    • Should be better in 1-2 days
    • Don't stop suddenly
    • Explain risks (osteoporosis; fracture; diabetes)

    • Monitoring:
    • Asthma action plan
    • Side effects
    • Need a dose baseline (effected by stress)

    • Cost:
    • Not costly
  6. Tetracycline
    Doxyscyline

    Broad spectrum Antibiotic

    • Indications:
    • - Mycoplasma pneumonia
    • - Hemophilius influenze
    • - Streptaccocus pneumonia
    • - Lencoilus 
    • - Profylaxix for maleria

    • Long acting:
    • - Inhibit bacterial protein synthesis
    • - Bronchitis COPD
    • - Peridontits
    • - Urethritis / Cervitis

    • Mode of Action
    • Passes thorugh lipid bilayer
    • inhibits formation of tRNA to mRNA

    • Administration
    • Oral

    • Side effects
    • Anorexia
    • Nausia
    • Diahorrea
    • Glossitis
    • Skin irritation
    • Intercrainal hypertension
  7. Heparin
    Dalteparine; Enoxaparin (Fondaparinux)

    • Indications:
    • VTE
    • Acute Coronary Syndrome

    • Mode of Action: 
    • Inhibit Thrombin and factor Xa
    • Therefore, stop blood clots
    • LMWH works more on factor Xa (therefore we can predict what it does better)
    • UFH works on both
    • Currently, fondaparinux is being used more and only effects factor Xa

    • Adverse Reactions:
    • Bleeding
    • Injection site reaction
    • Heparin induced thrombocytopenia (rare)

    • Safety:
    • Clotting problems
    • uncontrolled hypertension
    • Surgery (don't give if possible)
    • UFH = Renal Problems

    • Interactions:
    • Warfarin
    • Don't normally combine with other thrombolytics

    • Prescribing:
    • Subcutaneous
    • VTE prophylaxis 40mg enoxaparin/5000 units Dalteparin
    • IV will have a drug protocol at hospital

    • Administration:
    • Not in abdomen

    • Communication:
    • Avoid contact spots
    • Train self administration

    • Monitoring:
    • APTR for UFHIf giving longer than 4 days then do platelet count

    • Cost:
    • UFH low cost
    • LMWH higher cost but is cost effect
  8. Warfarin
    • Indications:
    • Prevent VTE
    • Profylaxis in AFib and heart valve replacement (short term)
    • Don't use MI

    • Mode of Action: 
    • Inhibit vitamin K coagulation factors
    • Factors II; VII; IX; X; C; S

    • Adverse Reactions:
    • Bleeding

    • Safety:
    • Haemorrhage
    • Liver disease
    • DON'T USE IN PREGNANCY

    • Interactions:
    • CP450 inhibitors decrease warfarin
    • CP450 induces will increase warfarin
    • Antibiotics

    • Prescribing:
    • 5-10mg for 7 days
    • Afterwards use INR to monitor
    • Heparin for first bridging bit

    • Administration:
    • 6pm each day if once daily
    • Require constant monitoring

    • Communication:
    • Yellow book

    • Monitoring:
    • Prothrombin time (extrinsic pathway)
    • Aim for INR of 2-3 for AFib and VTE
    • Change frequency to adjust

    • Cost:
    • £1 per month
    • Others are more like £60-70 per month
  9. Digoxin
    • Indications:
    • -AFib/Atrial Flutter (decrease ventricular rate
    • -After ß-blockers or calcium channel blockers don't effect severe heart failure
    • -3rd line (ACE/ß2-antagonist) to effect the RAAS system (if patient has AFib then it's first line)

    • Mode of Action: 
    • -Negative chemotrope
    • Indirect increase of vagal tone which will decrease AV-node conduction. 
    • -Positive Inotrope
    • Inhibit Na/K pump
    • Increase Na into the cell and this increases Ca which causes a larger force

    • Adverse Reactions:
    • Bradycardia
    • GI problem
    • Rash
    • Dizzy
    • Visual disturbances
    • Proarrhythmic
    • Small therapeutic index
    • Safety:
    • Contraindicated with 2nd degree and complete heart block
    • Ventricular arrhythmia
    • Reduce renal failure
    • Electrolyte imbalance (K; Mg; Ca)
    • Don't use with AFib unless sedintary

    • Interactions:
    • Diuretics become toxic and lead to hypokalemia
    • Increase plasma (amiodesone; calcium channel blocker; spironolacture quinine)

    • Prescribing:
    • Short half life
    • Oral = 2 hours
    • IV = 30 minutes
    • Need a loading does as has a large volume of distribution
    • 500 micrograms then 250-500 micrograms
    • 125-250 micrograms daily

    • Administration:
    • IV must be given slowly

    • Communication:
    • Will slow heart rate and give you a strong heart beat. Warn of illness

    • Monitoring:
    • Monitor symptoms and heartrate

    • Cost:
    • Low dose
  10. ß-Blockers
    Bisoprolol; Atenolol; Propranolol; Metoprolol

    • Indications:
    • Ischemic heart disease (1st line)
    • Chronic heart failure (1st line)
    • AFib
    • SVT
    • Hypertension

    • Mode of Action: 
    • Block ß1 receptors in the heart which decreases the force and speed of reaction
    • Therefore decrease work and oxygen demand and increase myocardiocytes perfusion
    • Protect sympathetic nervous system
    • Used in AFib to increase the refactory period of the AV-node
    • Reacts on the ß1 receptors in the kidney

    • Adverse Reactions:
    • Fatigue
    • Cold
    • Headache
    • Nausea
    • Change in sleep
    • Impotence in men

    • Safety:
    • Not in asthma but can in COPD
    • For heart failure start on a low does and titrate up
    • Don't use if haemodynamicly instable
    • Reduce amount in hepatic failure

    • Interactions:
    • Non-dihydropyridine calcium channel blockers (Verapamol; diltiazen)
    • Leads to heart failure, bradycardia and asystole

    • Prescribing:
    • Oral in heart failure
    • Can give IV if need a rapid effect

    • Administration:
    • Oral given at regular intervals
    • Only give IV if have experience

    • Communication:
    • Warn of side-effects

    • Monitoring:
    • Symptoms
    • Heart rate

    • Cost:
    • Low cost
  11. Loop Diuretics
    Furosemide; Bumetanide (oral)

    • Indications:
    • Declining breathlessness in acute pulmonary oedema
    • Chronic heart failure (fluid overload)
    • Fluid overload

    • Mode of Action:
    • Inhibit ascending loop of Henle by stopping the Na/K/2Cl co-transporter
    • Water followed
    • In heart failure also dilates capacitance veins and which decreases the preload and increases the contractile function of overstretched myocytes

    • Adverse Reactions:
    • Dehydration
    • Hypertension
    • Electrolytes (Mg;Ca;H as well) - low state
    • Toxic does can be ototoxic and tinnitus

    • Safety:
    • Hypovolemia 
    • Hepatic encephalopathy
    • Hypokalemia
    • Hyponutraemia
    • Worsens gout
    • Interactions:
    • Effect kid excretion of drugs
    • (Lithium; Digoxin; Ototoxic; Nephrotoxic; amminoclyosides)

    • Prescribing:
    • Oral or IV

    • Administration:
    • Slowly (4mg/min)
    • Oral Morning (stop nocturia)

    • Communication:
    • You are overloaded with water so this will get rid of it

    • Monitoring:
    • Heart rate
    • Hypertension
    • Respiratory rate
    • Need Na; K and renal function tests if giving for more than 1-2 weeks

    • Cost:
    • Cheap
  12. Nitrates
    Isosorbide mononitrate; Glyceryl trinitrate

    • Indications:
    • GTN for acute angina
    • Long acting prophylactic after ß-blockers and CCB
    • IV for pulmonary oedema (with furosermide and oxygen)

    • Mode of Action: 
    • Convert to NO and increase cGMP and decrease intercellular Ca in smooth muscle
    • Therefore, venous (and some atrial) vasodilation
    • Decrease preload and left ventricular filling
    • Decrease work and O2 demand
    • Decrease resistance and therefore afterload.

    • Adverse Reactions:
    • Flushing
    • Headache
    • Anorexia
    • Light headed
    • Hypotension
    • Tolerance will change

    • Safety:
    • Not with severe aortic stenosis (hard to increase CO)
    • Haemodynamically instable
    • Hypotension

    • Interactions:
    • Phyosphodiesterare inhibitor
    • Prolonge effect

    • Prescribing:
    • Stable angina = sublingual
    • Infusion in heart failure (4-5 hours)
    • Can give patches or daily

    • Administration:
    • See above

    • Communication:
    • Monitory headaches and postural hypotension
    • Sitdown if there is a problem

    • Monitoring:
    • Symptoms
    • Blood pressure

    • Cost:
    • Low costs
    • No tablets after 8 weeks
  13. ACE Inhibitors
    Ramipril; Lisinopril; Perindopril

    • Indications:
    • Hypertension
    • Chronic Heart Failure
    • Ischemic Heart Disease
    • Diabetic Neuropathy (CKD)

    • Mode of Action: 
    • Inhibit Angiotensen I - Angiotensen II
    • Vasoconstrictor so inhibitor reduces after load
    • Dilate efferent gromulae arteriole 
    • Promote sodium and water excretion 
    • Reduce preload

    • Adverse Reactions:
    • Hypotension
    • Dry Cough
    • Hyperkalemia
    • Angioedema/anaphylactoid reactions

    • Safety:
    • Renal artery stenosis
    • AKI
    • Pregnant/breastfeeding
    • Reduce CKD

    • Interactions:
    • Potassium elevating drugs
    • NSAIDs (same effect on efferent arteriole)

    • Prescribing:
    • Oral
    • Titrate up

    • Administration:
    • First dose before bed

    • Communication:
    • Dizzy; dry cough; blood test monitoring; avoid NSAIDs

    • Monitoring:
    • Symptoms
    • Blood pressure
    • Renal function / electrolytes
    • eGFR shouldn't fall more than 25% or rise more than 30% - if they do STOP

    • Cost:
    • Inexpensive 
  14. Aldosterone Antagonists
    Spironolactone; Epleronone

    • Indications:
    • Ascites/Oedema due to liver cirrhosis
    • (Spironolactone = first line)
    • Chronic heart failure (with ß-blocker/ACE inhibitor)
    • Primary hyperaldosteronism

    • Mode of Action: 
    • Mineralcorticosteroid
    • Distal tubules of the kidney
    • Increase sodium and water reabsorption
    • Potassium excretion

    • Adverse Reactions:
    • Hyperkalaemia
    • Gynacomastia
    • Stevens-Johnson

    • Safety:
    • Severe renal impairment
    • Hyperkalaemia
    • Addison's disease
    • Avoid in pregnant/lactating women

    • Interactions:
    • Potassium elevating drugs (including ACE inhibitor)

    • Prescribing:
    • Only oral
    • Epleronone only one for heart failure
    • Spironolactone combine with thiazide and loop diuetic

    • Administration:
    • Spironolactone with food

    • Communication:
    • Growth and tenderness of tissue under nipples and impotence
    • Reversible
    • Blood tests important

    • Monitoring:
    • Efficacy
    • Safety
    • Cost:
    • £1.50 per month
    • Eplerenone is £40 per month
  15. Penicillins - Broad Spectrum
    Amoxicillin; Co-amoxcilan

    • Indications:
    • Pneumonia
    • UTI
    • Hospital acquired infection / abdominal sepsis (CA)
    • H. Pylori Gastric Ulcer

    • Mode of Action:
    • Inhibit enzymes that cross-link peptidoglycans
    • This causes a weak cell wall and changes to the osmotic gradient leading to lysis
    • Has a ß-lactaon ring

    • Adverse Reactions:
    • GI problems
    • Antibiotic colitis (Clostridium difficile)
    • Allergy
    • Cholestatic Jaundice (Co-amoxicilan)

    • Safety:
    • C.Difficle
    • History of penicillin allergy
    • Decrease dose if severe renal failure

    • Interactions:
    • Methotrexate - renal problems
    • Increases effect of warfarin

    • Prescribing:
    • IV 48hrs then chance to oral as this allows for less complications
    • Oral if moderate infection

    • Communication:
    • Is to get rid of the infection
    • Ask if any allergies

    • Monitoring:
    • Symptoms
    • CRP

    • Cost:
    • Use non brands of Co-amoxcillian
  16. Metformin (Biguanide)
    • Indications:
    • Type 2 Diabetes first line medication

    • Mode of Action: 
    • Increase sensitivity to insulin
    • Suppress glycogenolysis & gluconeogenesis
    • Increase glucose uptake
    • Suppress intestinal glucose absorption
    • Don't 100% understand
    • Reduce weight gain

    • Adverse Reactions:
    • GI Upset
    • Taste disturbance
    • Lactic acidosis (rare)

    • Safety:
    • Severe renal impairment (excreted in kidney)
    • Acute kidney injury
    • Severe tissue hypoxia
    • Caution hepatic impairment/acute alcohol intoxication/ chronic alcohol use

    • Interactions:
    • IV contrast media - wait 48 hours
    • Anything that impacts renal function

    • Prescribing:
    • Oral
    • Start low and titrate up
    • Long term unless issues

    • Administration:
    • With or after food with class of water

    • Communication:
    • Control sugar level
    • still make lifestyle changes
    • Vomit/stomach ach/muscle cramps/SOB = lactic acidosis
    • Tell doctor if having imagining done they are on it.

    • Monitoring:
    • HbAc1 (target < 58mmol/mol)
    • Renal function before starting then annually.

    • Cost:
    • 1p each
  17. Sulphonylureas
    Gliclazide

    • Indications:
    • Type 2 Diabetes where metformin isn't tolerated or contraindicated
    • Combination with metformin

    • Mode of Action: 
    • Stimulate pancreatic insulin secretion
    • Block ATP-dependent K channels
    • Therefore increase Ca inside the cell
    • Require some residual pancreatic function
    • Weight gain is possible with more insulin.

    • Adverse Reactions:
    • GI
    • Hypoglycaemia
    • Hypersensitivity (hepatic, rash, fever, internal organ)

    • Safety:
    • Metabolised in liver therefore reduce in hepatic impairment
    • Monitor glucose with renal impairment
    • Avoid with hypoglycaemia risk (eg elderly)

    • Interactions:
    • Hypoglycaemia risk increases with other drugs
    • Reduced with prednisolone and diuretics which elevate blood glucose

    • Prescribing:
    • Shorter action easiest to use
    • Long term

    • Administration:
    • With meals

    • Communication:
    • Still do lifestyle advice
    • Hypo management

    • Monitoring:
    • HbA1c

    • Cost:
    • 2.5p each
  18. Thiazolidinediones
    Pioglitazone

    • Indications:
    • Type 2 Diabetes
    • Others are not indicated
    • 3rd agent

    • Mode of Action: 
    • Insulin sensitiser
    • Lower blood glucose by activating PPARy
    • Increase peripheral glucose uptake
    • Reduce hepatic gluconeogenesis
    • No insulin secretion
    • Weight gain.

    • Adverse Reactions:
    • GI; Anaemia; Neurological
    • Oedema and cardiac failure
    • Small increase in the risk of bladder cancer and bone fractures
    • Severe liver toxicity (idiosyncratic reaction)
    • Only one avaliable

    • Safety:
    • CI in heart failure and bladder cancer
    • Decrease in CVD and risk of bladder cancer
    • Watch in elderly patients
    • Avoid in hepatic involvement

    • Interactions:
    • Increased with antidiabetic drugs

    • Prescribing:
    • Oral
    • 15-30mg with breakfast

    • Administration:
    • With water in morning
    • with or without food

    • Communication:
    • Lifestyle advice
    • Unexpected side effects

    • Monitoring:
    • HbAc1 - No fall then stop treatment
    • Liver enzymes baseline

    • Cost:
    • £5 per month
  19. Statin
    Simvastatin; Atovastatin; Pravastatin; Rosuvastatin

    • Indications:
    • Primary prevention of CVD (>20% risk if over 10 years if 40 years old)
    • Secondary prevention (after lifestyle advice)
    • Primary hyperlipidaemia 

    • Mode of Action: 
    • Reduce serum cholesterol levels.
    • Inhibit HMG CoA Reductase which makes cholesterol. 
    • Decrease production (liver) and increase clearance (blood) of LDL-cholesterol.
    • Reduce triglycerides indirectly.
    • Slight increase of HDL-cholesterol.
    • Slow atherosclerotic process.

    • Adverse Reactions:
    • Generally safe.
    • Headache; GI
    • Can have aches of muscle to myopathy.
    • Rare chance to raise liver enzymes and induce hepatitis.

    • Safety:
    • Caution in hepatic and renal impairment.
    • Don't use in pregnancy or breastfeeding as baby needs cholesterol.

    • Interactions:
    • CYP450 reduce metabolism so increase risk of adverse effects.
    • Amlodipine has a similar interaction.

    • Prescribing:
    • Oral
    • Simvistain 40mg
    • Amotrostain 10mg per day

    • Administration:
    • Take in evening

    • Communication:
    • Take for cholesterol
    • Avoid grapefruit juice (inhibits CYP450)

    • Monitoring:
    • Primary none is really needed.
    • Secondary check the cholesterol levels
    • LFT 3 & 12 months

    • Cost:
    • Use non-branded
  20. Proton Pump Inhibitor (PPI)
    Lansoprazole; Omeprazole; Pantoprazole

    • Indications:
    • Prevention and treatment of peptic ulcer.
    • Relieve symptoms of GORD.
    • Treatment in H.Pylori

    • Mode of Action: 
    • Inhibit the H+/K+-ase pump in the parietal cells. This reduces the amount of acid in the stomach. By working at this final stage it works better than H2-receptor antagonists by able to stop acid secretion completely.

    • Adverse Reactions:
    • Headache and gastric disturbances.
    • Can increase risk of C.dif by increasing the pH in the body.
    • Hypomagnesaemia (tetny & ventricular arrythmia)

    • Safety:
    • Can disguise the symptoms of gastric cancer.
    • Also increase fracture risk in elderly so consider OP when prescribing.

    • Interactions:
    • Can minimise the antiplatelet effect on clopidogrel (effect action of CYP450 enzymes).More of a problem with omoprazel so opt to use the others. 

    • Prescribing:
    • Dependent on drug and what it's being used for. Can be IV or oral. Start low and titrate up

    • Administration:
    • Can be taken with or without food. Usually in the morning

    • Communication:
    • Explain reason for drug.
    • Dose if H.pylori is 7 days vs proflaxis indefinitely.
    • Look out for symptoms such as weight loss, swallowing difficulty ect (gastric cancer).

    • Monitoring:
    • Treatment of ulcer = endoscopy
    • Prevention of symptoms = monitor symptoms
    • Long term use = magnesium levels

    • Cost:
    • Relatively low cost

    NOTE - H.Pylori don't prescribe for 2 weeks before testing. False negative likely.
  21. Methotrexate
    • Indications:
    • Treatment of RA.
    • Cancer treatment for lymphoma, leukaemia and some solid tumours.
    • Psoriasis

    • Mode of Action: 
    • Inhibit the enzyme dihydrofolate reductase (converts folate acid into tetrahydrofolate (FH4)). This is required for DNA synthesis. Therefore, it stops cellular replication in rapidly producing cells. 
    • In RA it also inhibits Il-1, Il-6 and TNF-alpha but the exact mechanism is unknown.

    • Adverse Reactions:
    • Mucosal damage
    • Bone marrow secretions
    • Hypersensitivity
    • Hepatic cirrhosis
    • Pulmonary fibrosis
    • Toxic effects from overdose (hepatic and renal failure or neurological symptoms) can be rectified with folinic acid + increase excretion with hydration and urinary alkinalisation.

    • Safety:
    • Teratenogenic for male and female (must wait 3 months after stopping treatment to try to conceive)
    • Not to be used in severe renal impairment
    • Avoid use in patients with impaired liver function.

    • Interactions:
    • Drugs that impact renal excretion.
    • Other folate antagonists
    • Clozapine (hepatotoxicity)

    • Prescribing:
    • Taken once a week 
    • Cancer = IV or IM
    • Auto-immune = oral (5-20mg with does adjusted as symptoms require). Take folic acid on day 6 of not taking methotrexate to reduce symptoms.

    • Administration:
    • Oral, IV or intrathecal

    • Communication:
    • For oral does prompt patient to say what day they will take the dose.
    • Look out for fever, sore throat (infection), nausea, abdominal pain (liver toxicity) or SOB (lung).

    • Monitoring:
    • Baseline LFT, renal and FBC should be done before commencing treatment. These should be monitored fortnightly until treatment is regular, then changes to every 3 months. 

    • Cost:
    • Use unbranded
  22. Bisphosphonates
    Alendronic acid; Disodium amidronate; Zoledronic acid

    • Indications:
    • High risk of osteoporosis fracture (Alendronic acid)
    • Hypercalcemia due to malignancy
    • Myloma & Breast cancer with bone metastasise (Disodium amidronate and Zoledronic acid)
    • Paget's Disease (metabolitic activated) (ALL)

    • Mode of Action: 
    • Incorporated into bone as resemble pyrophosphonate. This then gets ingested by the osteoclasts cause apoptosis. Limiting bone destruction.

    • Adverse Reactions:
    • Osteophagitis (oral) and hypophosphataemia.
    • Rare = osteonecrosis of the jaw & atypical femoral fracture. 

    • Safety:
    • Avoid with severe renal impairment
    • Avoid with hypocalcaemia
    • Contraindicated in upper GI disorders.
    • Check with dentist and avoid in smokers due to the osteonecrosis of jaw risk

    • Interactions:
    • Bind to calcium therefore absorption effected with calcium rich foods.

    • Prescribing:
    • Aledronic acid = oral
    • Other 2 IV

    • Administration:
    • When taking oral advise to take 30 minutes before breakfast and remain upright to avoid oral side-effects

    • Communication:
    • Is a medication used to strengthen bones. Follow administration advice. Look out for any GI symptoms.

    • Monitoring:
    • DEXA scan 1-2 years after commencing does for OP
    • Monitor calcium levels and symptoms for IV dose.

    • Cost:
    • Alendonic acid is cheap at £1 a month
    • Others are expensive at £100+ a month
  23. Laxatives (stimulant)
    Senna; Bisacodyl; Glycerol suppositories; Docusate sodium

    • Indications:
    • Constipation
    • Faecal Impaction

    • Mode of Action:
    • Increase water and electrolyte secretion from the mucosa. This increases the content of the colon inducing peristalsis. 
    • Senna has a direct effect on peristalsis
    • Rectal suppositories are more localised to the foecal impaction
    • Docusate sodium has both a stimulatory effect and softening effect.

    • Adverse Reactions:
    • Abdominal pain (some cramping)
    • Diarrhoea 
    • Melanosis coli (reversible)

    • Safety:
    • Don't use stimulant when intestinal obstruction. Can lead to perforation
    • Don't use rectal suppository in those with haemorrhoids or anal fissure

    • Interactions:
    • No strong drug interactions

    • Prescribing:
    • For constipation usually twice a day, titrate dose for symptoms
    • For faecal impaction give once or only have maximum dose given over 24hr period

    • Administration:
    • Constipation - Oral
    • Faecal impaction - Rectal if needed

    • Communication:
    • Symptoms may not be immediate
    • Drink 6-8 glasses of water

    • Monitoring:
    • Stool chart

    • Cost:
    • 10p. Patients may save money if buy over the counter
  24. Paracetamol
    Note its presence in Co-codamol and Co-dydramol when prescribing 

    • Indications:
    • - 1st line treatment analgesic in acute and chronic conditions. (WHO pain ladder)
    • - Decrease fever and therefore other symptoms (such as shivering)

    • Mode of Action: 
    • - Not fully understood
    • - Mild COX2 inhibitor which stops prostaglandin synthesis increasing the pain threshold. 
    • - Work on hypothalamus to control perception of temperature

    • Adverse Reactions:
    • - No COX1 reactions (cardiovascular; peptic ulcer; renal impairment)
    • - Overdose can lead to liver failure. CYP450 metabolises paracetamol to NABQI which is synthesised by glutathion conjugate. If this saturates then NAPQI has high concentrations leading to heptocellular necrosis (and also nephrotoxic)
    • - Acetylcystine to treat
    • - Normally synthesised by glucuromide

    • Safety:
    • - Increased production of NABQI with chronic alcohol use
    • - Decreased glutathione stores in malnutrition, low body weight and hepatic issues

    • Interactions:
    • - CYP450 increase NABQI production

    • Prescribing:
    • - Oral over the counter medication. 0.5-1g every 4-6 hours don't exceed 4g per day
    • - Can be IV or rectal in hospital if required.

    • Administration:
    • - IV can be straight in 15mins or part of 0.9% saline or 0.5% dextrose
    • - Usually oral dose (see prescribing)

    • Communication:
    • - Pain medication
    • - Warn about overdose and it's presence in cold and flu medication

    • Monitoring:
    • - Pain
    • - If overdose monitor INR and ALT

    • Cost:
    • - 1g = 2p
    • - IV is 60 times more expensive at £1.25
  25. Naloxone
    • Indications:
    • - Used to counteract opioid toxicity in respiratory or neurological decline
    • - Palliative care 

    • Mode of Action: 
    • - Competitive antagonist of µ-receptors
    • - Offsets the opioid and reverses their effect
    • - Has no effect if there is no opioid present

    • Adverse Reactions:
    • - Withdrawal from opioid
    • - Pain / restlessness / Nausea / vomiting / dilated pupils / cold / dry skin (piloerection)

    • Safety:
    • - Withdrawal

    • Interactions:
    • - None

    • Prescribing:
    • - IV 400-1200µg
    • - If no IV access can give IM, SC on intranasally
    • - Should be given as a once only prescription and then done as required
    • - Note in palliative care start at 4µg so make up mixture of 1mL of 400µg with 9mL of saline.

    • Administration:
    • - Start small and titrate up as required

    • Communication:
    • - Warn about withdrawal effects

    • Monitoring:
    • - Effect of drug
    • - Recurrence of opioid once naloxone is used up

    • Cost:
    • - Cheap
  26. Acetylcysteine
    (N-acetylcysteine)
    • Indications:
    • - Paracetamol poisoning
    • - Prevent renal injury after radiological contrast given
    • - Mucolytic if nebuliser 

    • Mode of Action: 
    • - Replenish stores of glutathion
    • - Mechanism for renal protection is unknown but think it works as an antioxidant 
    • - Liquifies mucous in broncus making it easier to bring up

    • Adverse Reactions:
    • - Anaphylactoid (Nausia/tachycardia/rash/wheeze) but this is not IgE mediated. Therefore, once reaction under control can restart drug.
    • - Broncospasm in mucolytic use

    • Safety:
    • - Allergic reaction

    • Interactions:
    • - None

    • Prescribing:
    • - Weight adjusted IV does over 21 hours. Must consult BNF
    • - On nebs then it's 2.5-5mls 10%

    • Administration:
    • - Look up BNF
    • - 10% on nebs

    • Communication:
    • - Explain that will need to be given over 21hours despite that it is hard for the patient to be 'tied to the drip'

    • Monitoring:
    • - INR
    • - ALT
    • - Creatinine

    • Cost:
    • - Relatively cheap
  27. Activated Charcoal
    Activated refers to the fact it is heated up to increase the pore size leading to a surface area of 1000m^2/g

    • Indications:
    • - Reduce absorption of a poison (1 dose)
    • - Increase speed of elimination of poison (multiple doses)

    • Mode of Action: 
    • - Molacules are absorbed on the surface
    • - This is depended on their ionic status and solubility. If they are strongly ionic they will not bind well to the charcoal.
    • - For ones that strongly bind to the charcoal they will diffuse out to the gut
    • - This means that the blood system will not absorb the poisons substance.

    • Adverse Reactions:
    • - Aspirate
    • - Obstruction
    • - Black stools
    • - Vomiting

    • Safety:
    • - Don't use in patients with reduced consciences
    • - Warn about vomiting
    • - Decrease in GI system motility

    • Interactions:
    • - Will decrease absorption of drugs in the gut

    • Prescribing:
    • - Give 1 hour after ingestion (can be 2 hours with aspiring, opiods and tricycline antidepressants which have a longer absorption in the stomach)
    • - Oral or nasogastric
    • - Consider antiemetic or laxative 

    • Administration:
    • - Usually mixed with 250ml of water for patient to swallow

    • Communication:
    • - Doesn't taste good

    • Monitoring:
    • - Monitor if poison is causing an effect

    • Cost:
    • - Single dose is £12
  28. H2 Receptor Antagonist
    Ranitidine

    • Indications:
    • - Treatment and prevention of gastric ulcer
    • - GORD and dyspepsia
    • - Pre-operatively if risk during operation of gastric complications

    • Mode of Action: 
    • - Decrease gastric acid secretions
    • - Histamine released by paracrine cells
    • - Connect to proton pump (H+ out; K+ in) to stimulate H+ release
    • - Blocking sight decreases acidic secretions
    • - There are other stimulants for this pump so the effect is weak, however, more rapid than a PPI

    • Adverse Reactions:
    • - Rare
    • - Bowel disturbance
    • - Headache
    • - Dizzy

    • Safety:
    • - Excreted by kidneys to monitor in renal impairment
    • - Can mask symptoms of gastric cancer so still need to investigate cause of symptoms

    • Interactions:
    • - None

    • Prescribing:
    • - Over the counter
    • - Need prescription if longer than 2 weeks
    • - 150mg twice a day

    • Administration:
    • - Oral with food

    • Communication:
    • - Be clear on duration of treatment
    • - Warn about alarm symptoms

    • Monitoring:
    • - Endoscopy
    • - Patient feedback

    • Cost:
    • - Cheap
  29. Antimotility
    Loperamide; Codeine Phosphate

    • Indications:
    • - Watery diarrhoea usually in IBS or gastro

    • Mode of Action: 
    • - Is an opioid
    • - Loperamide doesn't effect receptors in the CNS therefore just works on the GI tract µ-receptors
    • - Increases non-propulsive and decreases perislatic contractions. 
    • - Slows movement and increases sphincter tone
    • - More water can be absorbed by the gut
    • - Note that codeine phosphate shouldn't be used unless will also be for analgesia 

    • Adverse Reactions:
    • - GI issues (cramping; constipation; flatulance)
    • - Opioid Toxcitiy

    • Safety:
    • - Contraindicated in Ulcerative colitis (leads to megacolon and perforation)
    • - Not in C.Diff high risk
    • - Contraindicated in dysentery as could lead to haemolytic-uraemic syndrome (E.Coli)

    • Interactions:
    • - None

    • Prescribing:
    • - Over the counter
    • - 4mg (max 8mg a day)
    • - Go down to 2mg when proper stool sample

    • Administration:
    • - Oral (can be syrup if have trouble swallowing)

    • Communication:
    • - Don't take for more than 5 days
    • - Usually not given in hospital due to issues with antibiotics

    • Monitoring:
    • - Stool samples

    • Cost:
    • - Cheap
  30. Benzodiazepine
    Diazepam; Tenazpam; Lorazepam; Chlordiazepoxide; Midazolam

    • Indications:
    • - 1st line for seizures (epileptic)
    • - Alcohol withdrawal
    • - Sedation when general anaesthetic isn't warranted
    • - Short term use for anxiety
    • - Short term use for insomnia

    • Mode of Action: 
    • - Binds to GABAa receptors which open chloride channels. This causes an influx of chloride which makes it harder to depolarise the cell in the neurotransmitter
    • - Note that alcohol also works on this transmitter, hence how they reduce withdrawal symptoms.

    • Adverse Reactions:
    • - Does dependent drowsiness, sedation and coma
    • - Low risk of cardiorespiratory depression than opiods, but can lead to airway obstruction and death
    • - Dependence so withdrawal is similar to alcohol withdrawal.

    • Safety:
    • - Elderly are more susceptible so used a reduced does
    • - Contraindicated in respiratory and neurological issues
    • - Don't use in liver failure. If need to for alcoholic withdrawal opt for Lorazepam

    • Interactions:
    • -CYP450 drug
    • - Inhibition will increase effects

    • Prescribing:
    • - Depends on duration of treatment
    • - Seizures are long term so use Lorazepam or Diazepam
    • - Alcohol withdrawal use oral Chlordiazepoxide, does dependent on symptoms
    • - Sedation uses Midazolam which is short acting
    • - For anxiety use Tenazpam, 10mg oral before bed

    • Administration:
    • - Oral except Diazepam
    • - Diazepam is rectal water solution

    • Communication:
    • - Make sure they know duration of treatment

    • Monitoring:
    • - Symptoms
    • - Side effects

    • Cost:
    • - Cheap
  31. Dipyridamole
    • Indications:
    • - Cerebrovascular disease (2nd line for ischemic stroke)
    • - First line for TIA when clopidogrel cannot be tolerated (can be given with aspirin or as a monotherapy)
    • - Induce tachycardia in myocardial perfusion scan

    • Mode of Action: 
    • - Antiplatelet. Exact mechanism isn't known but is thought to increase cAMP which stops platelet aggregation decreaseing occlusion of vessel
    • - Vasodilator. Blocks uptake of adenosine

    • Adverse Reactions:
    • - Headache (will wear off over time)
    • - Dizzy
    • - GI disturbance
    • - Bleeding risk
    • - Thrombocytopenia

    • Safety:
    • - Contraindicated in Ischemic heart disease
    • - Aortic stenosis
    • - Heart failure

    • Interactions:
    • - The blocking of adenosine can prolong effects on the heart

    • Prescribing:
    • - Oral modified release
    • - 200mg twice daily

    • Administration:
    • - Take with food
    • - Don't crush the tablet

    • Communication:
    • - Will decrease risk of stroke
    • - must be taken indefinitely 

    • Monitoring:
    • - Side effects

    • Cost:
    • - Relatively High Cost
  32. Anti-fungal
    Clotrimazol; miconazol; Nystatin; Fluconazol

    • Indications:
    • - Fungal Infection

    • Mode of Action: 
    • Works as an erosterol synthesis inhibitor. Azoles disrupt the permeability, inhibit protein synthesis. Nystatin is a polyene which is a polar pore, creating leaking.

    • Adverse Reactions:
    • - Creates androgen and cortisol synthesis
    • - Gynecomastia in men
    • - Liver dysfunction (CYP450 interactions)
    • - Prolonged QT interval

    • Safety:
    • - Monitor does if in liver problems
    • - Contraindicated in renal failure
    • - Contraindicated in pregnancy

    • Interactions:
    • - CYP450 drugs

    • Prescribing:
    • - Oral
    • - Topical

    • Administration:
    • - After food
    • - Note nystatin needs to be held in the mouth to have an effect

    • Communication:
    • - Symptom relief

    • Monitoring:
    • - Symptoms

    • Cost:
    • - Inexpensive
  33. Antimucarinics
    (GI and Cardio Use)
    Atropine; Hyosine butylbromide; Glycopynonium

    • Indications:
    • - Atropine is used in bradycardia
    • - Hyosicine butylbromide in IBS
    • - In palliative care to decrease respiratory secretions

    • Mode of Action: 
    • - Competitive inhibitor for ACh for musculinic receptors
    • - Inhibits parasympathetic stimulation
    • - Increase heart rate and conduction; decrease smooth muscle and peristaltic contractions
    • - Decrease secretions in respiratory and GI tracts.
    • - Can relax eye by dilating the pupils. This will decrease accommodation

    • Adverse Reactions:
    • - Tachycardia
    • - Dry mouth
    • - Constipation
    • - Decrease in detrusor stimulation leasts to retention in hyperplasia of the prostate
    • - Blurred vision
    • - CNS disturbance in elderly (drowsy and confused)

    • Safety:
    • - Glaucoma
    • - Arrhythmia 

    • Interactions:
    • - Antimusclinic effects in other medications (eg. tricyclics)

    • Prescribing:
    • - Atropine = IV and dose is tritated until does is increased. Can use glycopynonium, which has less CNS effects, but it's rarely found on wards
    • - For IBS oral 10mg every 8 hours. Prescription not needed
    • - Respiratory secretions is subcutaneous

    • Administration:
    • - There are atropine syringes for emergency use.

    • Communication:
    • - Side effects

    • Monitoring:
    • - Heart rate

    • Cost:
    • - Inexpensive
  34. Cephalosporins & Carbapens
    Cefalexin; Cefotaxine; Meropenem; Enteperum

    • Indications:
    • - Second and third UTI and respiratory tract infection
    • - IV for severe and complicated infections

    • Mode of Action: 
    • - ß-lactan
    • - Increase in generations become more gram negative and less oral use

    • Adverse Reactions:
    • - GI upset (nausea and vomiting)
    • - Hypersensitivity
    • - Seizures (CNS - Rare)
    • - Alcohol Disulfide-like reaction with cefotelam and cefotaxime

    • Safety:
    • - C.Diff warning
    • - Watch in renal failure
    • - Carbapens warning in epilepsy

    • Interactions:
    • - Warfarin (can disrupt bacteria needed for vitamin K synthesis)
    • - Nephrotoxic change the nitrogen
    • - Decrease effect of valporvant

    • Prescribing:
    • - Does within 6-12 hours

    • Administration:
    • - Oral, injection or IV

    • Communication:
    • - Allergy risk

    • Monitoring:
    • - Symptoms
    • - Blood test (CRP)

    • Cost:
    • - More expensive than penicillin
  35. Allopurinol
    • Indications:
    • - Prevention of acute gout attacks
    • - Uric acid and calcium oxilate renal stones
    • - Prevent hyperurtemia and toxic lymphodema syndrome

    • Mode of Action: 
    • - Anthine oxidase inhibitor
    • - This is needed for the production of uric acid
    • - Therefore decrease deposits

    • Adverse Reactions:
    • - Usually well tolerated
    • - Skin rash
    • - Steven-Johnson Syndrom or Toxic Erythroderma Necrosis
    • - Rare anaphylaxis
    • - Worsen an acute attack 

    • Safety:
    • - Contraindicated in acute attack and skin rash
    • - Contraindicated if hypersensitive
    • - Reduce in renal or hepatic failure

    • Interactions:
    • - Meraptopurine and azathioprine need anthine oxidase to metabolise
    • - Amoxicillin increases chance of skin rash
    • - ACE inhibitors and thiazides increase risk of hypersensitivy reaction.

    • Prescribing:
    • - Oral 100mg and titrate up
    • - Give with NSAIDs
    • - Give before chemotherapy

    • Administration:
    • - Oral
    • - After meals

    • Communication:
    • - Check rash

    • Monitoring:
    • - Symptoms
    • - After 4 weeks see if can lower dose

    • Cost:
    • - Cheap
  36. Thyroid Hormones
    Levothyroxine; Liothyronine

    • Indications:
    • - Primary hypothyroidism
    • - Secondary hypothyroidsm due to pituritay

    • Mode of Action: 
    • - Levothyroxine is synthetic T4. Takes 24-48 hours to work
    • - Liothyronine is synthetic T3 with a shorter half-life and acts quicker

    • Adverse Reactions:
    • - Excessive does effects (hyperthyroid symptoms)

    • Safety:
    • - Will increase heart rate and metabolism
    • - Contraindicated in coronary artery diseases
    • - Don't use in pituritay failure as this will need corticosteroid 

    • Interactions:
    • - Absorption is decreased in GI if antacids, calcium or iron supplements given
    • - Increase CYP450
    • - Metabolism of insulin can change

    • Prescribing:
    • - Oral 50-100µg (elderly have 25µg)
    • - Liothyronine is available as IV in emergency

    • Administration:
    • - Only avaliable in 25, 50 and 100µg tablets

    • Communication:
    • - Synthetic replacement
    • - Will take for life
    • - Might need calcium and iron supplements

    • Monitoring:
    • - TFT

    • Cost:
    • - £4 per month
  37. Insulin
    Insulin aspart; Insulin glargine; Biphasic insulin; Soluble Insulin

    • Indications:
    • - Type 1 Diabetes
    • - Type 2 Diabetes where hypoglycaemic agents are intollerated or don't work
    • - IV use in emergency in DKA or HHS
    • - Hyperkaleamia (needs to be with glucose)

    • Mode of Action: 
    • - Replaces insulin
    • - Brings potassium into the cells
    • - Insulin aspart (Novogusil) = rapid acting
    • - Soluble insulin (Actrapril) = short acting
    • - Isophran (Humulin) = intermediate acting
    • - Insulin glargine (Levemir/Lantan) = Long acting
    • - Biphasic (novomax) is a combination of insulin aspart and insulin aspart protamine

    • Adverse Reactions:
    • - Hypoglycemia
    • - Lipohypertrophy (can be uncomfortable)

    • Safety:
    • - In renal failure can have a higher risk of hypoglyceamia

    • Interactions:
    • - Corticosteroids can increase the need for insulin

    • Prescribing:
    • - Self administered by SC injection. Usually 30-50units but is dependent on diet, weight and activity level
    • - In emergancy DKA give 50 units Actrapid
    • - For hyperkaleamia give 10 units with 20% glucose in 100mls for 15 minutes

    • Administration:
    • - SC self administration is done with a 'Pen'

    • Communication:
    • - Lifestyle advice
    • - Watch for hypoglyceamia side-effects

    • Monitoring:
    • - HbA1c

    • Cost:
    • - Cost NHS more than £300million each year
  38. Vitamins
    Folic Acid; Thiamine; Hydroxocobalamin; Phytomenadine

    • Indications:
    • - Thiamine = B12. This is for Wernicke's encephalopathy and Korsaboff's psychosis
    • - Folic acid = B9. Megoblastic anaemia and for first trimester of pregnancy for neural tube defects.
    • - Hydroxocobalamin = cobulamin/B12. Megoblastic anaemia and subacute combined degeneration on the cord
    • - Phytomenadine = Vitamin K. Newborn babies and to reverse warfarin

    • Mode of Action: 
    • - Do what they say

    • Adverse Reactions:
    • - IV Thiamine can cause anaphylaxis 

    • Safety:
    • - B12 and folate deficiency must both be corrected
    • - Phytomexadine is less effective in liver failure

    • Interactions:
    • - Warfarin with Phytomexadine

    • Prescribing:
    • - Thiamine is given to reduce risk in hospital. Normally as a combination of Vitamins B and C (Pabrinex) for 12 hours IV over 3 days
    • - For neural tube defects, folate acid is given in 400µg until week 12. If high risk of defect or anaemia then 5mg is given
    • - Vitamin B12 is IM (as issue is normally it's not being absorbed)
    • - 1mg of Vitamin K is given to newborns. To reverse warfarin 10mg are given

    • Administration:
    • - Pabrinex is usually given in 2 ampules and mixed in with sodium chloride over 30min
    • - Phytomenadine must be injected slowly

    • Communication:
    • - Will replace

    • Monitoring:
    • - Clinically
    • - FBC
    • - INR

    • Cost:
    • - Usually quite cheap
  39. Vancomycin
    • Indications:
    • - Gram positive infections when penicillin resistant.
    • - 2nd line for C.Diff

    • Mode of Action: 
    • - Inhibit cell wall of bacteria
    • - Cannot work on gram positives
    • - Resistance is increasing

    • Adverse Reactions:
    • - Infection at inflammation site (thrombphlebitis)
    • - Red man syndrome (erythema, hypotension and broncospasm). Not antibody mediated
    • - Nephrotoxic
    • - Ototoxic
    • - Blood disturbance

    • Safety:
    • - Caution if renal failure
    • - Caution in elderly

    • Interactions:
    • - Anything that combines the adverse reactions

    • Prescribing:
    • - Is hydrophilic so must be given IV

    • Administration:
    • - Oral
    • - IV (must be given slowly)

    • Communication:
    • - Look out for ototoxic problems

    • Monitoring:
    • - Plasma levels
    • - Infection

    • Cost:
    • - Metronidazol is £3 compared to £200 for vancomycin
  40. Metronidazole
    • Indications:
    • - C.diff first line
    • - Oral gram negative 
    • - Surgery GI infections with gram negative anerobes
    • - Protozoal

    • Mode of Action: 
    • - Diffuse into the bacteria
    • - Broken down to nitroso free radical in anaerobes
    • - Stops DNA synthesis
    • - Resistance has been reported

    • Adverse Reactions:
    • - GI upset
    • - Hypersensitivity
    • - Peripheral neuropathy
    • - Optic neuropathy
    • - Seizures
    • - Enchephalopathy

    • Safety:
    • - CYP450 reacts so watch sever liver
    • - no alcohol

    • Interactions:
    • - Inhibit CYP450 metabolism

    • Prescribing:
    • - For GI infection is oral, 400mg over 8hrs (can give rectal)
    • - For IV give 500mg 

    • Administration:
    • - Oral
    • - IV over 20min

    • Communication:
    • - Watch infection
    • - Don't drink alcohol

    • Monitoring:
    • - FBC

    • Cost:
    • - 400mg tablets £1.50
    • - 500mg tablets £36
  41. Quinine
    • Quinine Sulfate
    • Indications:
    • - Leg cramps (20% work)
    • - Malaria

    • Mode of Action: 
    • - For leg cramps is thought to decrease the excitability at the motor end
    • - Don't understand mechanism for malaria but kills the schizont (in the liver)

    • Adverse Reactions:
    • - Tinnitus
    • - Deafness
    • - Blindness
    • - GI upset
    • - Hypersensitivity
    • - Prolonged QT interval
    • - Hypoglycemia (when treated for malaria)

    • Safety:
    • - Don't use in hearing and vision loss
    • - Can be teratogenic but the benefits outweigh the risks
    • - Don't use in G6PD deficiency

    • Interactions:
    • - Anything that also increases the QT interval

    • Prescribing:
    • - Leg cramps 200-300mg
    • - Malaria oral or IV if complicated condition

    • Administration:
    • - Slow

    • Communication:
    • - Help leg cramp

    • Monitoring:
    • - Only use for 4 weeks then stop if no improvement

    • Cost:
    • - Cheap
  42. Antipsychotics (1st Generation)
    • Haloperidol; Chlorpromazine; Prochlorperazine
    • Indications:
    • - Urgent psychomotor agitation
    • - Schizophrenia
    • - Bipolar disorder
    • - Nausea and vomiting

    • Mode of Action: 
    • - Block the post-synaptic D2 receptors
    • - Mesolimbic/mesocortical pathway is thought to be the antipsychotic path
    • - Nigrostriated
    • - Tuberohypophyseal (hyperthalamus to pituritay)
    • - D2 receptors also exist in the chemoreceptor trigger zone
    • - Also have a sedation effect, especially chlorpromazine

    • Adverse Reactions:
    • - Acute sytonic and atathesal
    • - Tardive dyskineasia
    • - Drowsy
    • - Hyotension
    • - Erectile dysfunction

    • Safety:
    • - Elderly, dementia and Parkinson's patients should be started on a lower dose

    • Interactions:
    • - Anything that prolongs QT interval

    • Prescribing:
    • - Oral
    • - Subcutaneaous

    • Administration:
    • - Slow infusion
    • - Can give rapid if an emergancy

    • Communication:
    • - Meh

    • Monitoring:
    • - Symptoms

    • Cost:
    • - Can be expensive
  43. Adenosine
    • Indications:
    • First line for super-ventricular tachycardia

    • Mode of Action: 
    • - Adenosine agonist that in the heart reacts to G-protein coupled receptors.
    • - Decreases the frequency of spontaneous 
    • - Increase resistance of AV-node
    • - Can break the re-entry and regain control of the heart.
    • - If the AV-node is not involved with the SVT then there will be no cardioversion (for example AF) but you will be able to make a better diagnosis on the ECG
    • - Has a half life of 10 seconds

    • Adverse Reactions:
    • - Bradycardia and asystole
    • - Gives unpleasant sinking feeling with impending sense of doom but should only be felt for a short time.

    • Safety:
    • - Don't use in hypotension, ischaemia, heart failure
    • - Caution in COPD and those with transplants

    • Interactions:
    • - Dipyridamole can potentiate the effect so give half a does
    • - Competitive antagonists are theophyline, caffeine and aminophyline

    • Prescribing:
    • - IV once only
    • - First does 6mg then 12 mg if doesn't work
    • - If in central line give 3mg

    • Administration:
    • - Must have experience to administer
    • - Have resus equipment on hand
    • - Use large bore cannular (18 gague)
    • - Takes 10-15seconds to show effect and lasts 30-60 seconds

    • Communication:
    • - Is to 'reset' the heart

    • Monitoring:
    • - ECG

    • Cost:
    • - Cheap
  44. Adrenaline
    • Indications:
    • - Cardiac arrest
    • - Anaphylaxis 
    • - Local vasoconstriction (such as endoscopy to reduce bleeding. Normally given with lidocaine to prolong analgesia)

    • Mode of Action: 
    • - Potent agonist to sympathetic nervous system receptors
    • - Vasoconstriction
    • - Increase heart rate
    • - Increase force of heart contraction and myocardial excitability
    • - Vasodilator for the heart
    • - Therefore changes the blood flow to the heart
    • - Also stops mast cells which leads to bronchodilation

    • Adverse Reactions:
    • - For cardiac arrest can lead to adrenaline induced hypertension
    • - Anxiety; tremor; headache; palpitations
    • - Angina; MI; Arrhythmia especially if pre-existing condition

    • Safety:
    • - Don't use local if heart disease
    • - Not for end-artery areas

    • Interactions:
    • - Effect changed if on ß-blocker

    • Prescribing:
    • - Act first, prescribe later
    • - Cardiac arrest that is shockable then give 1mg IV after the 3rd shock and repeat after 3-5min
    • - Cardiac arrest that isn't shockable give 1mg ASAP then repeat after 3-5min
    • - Anaphylaxis give 500µg IM and repeat in 5min if needed. 

    • Administration:
    • - There are pre-filled syringes
    • - Then flush
    • - If obese ensure giving IM and not SC

    • Communication:
    • - Just give it

    • Monitoring:
    • - Symptoms
    • - Haematology 

    • Cost:
    • - Not relevant to treatment
  45. Alginates and Antacids
    Gaviscon; Peptac

    • Indications:
    • - GORD
    • - Dyspepsia (short term)

    • Mode of Action: 
    • - Taken as a compound
    • - Antacids can be calcium, magnesium or aluminium carbonate which buffer the acid
    • - Alginates increase viscosity of stomach contense which create a raft. It is also thought they inhibit pepsin.

    • Adverse Reactions:
    • - Magnesium can lead to diarrhoea
    • - Aluminium can cause constipation

    • Safety:
    • - Is fine when pregnant 
    • - Properties can change when had with thick milk
    • - watch salt if renal failure or sucrose if diabetic 

    • Interactions:
    • - Can bind to some drugs - ACE inhibitors; Antibiotics; Bisphosphonates; digoxin; lerothysime; PPI
    • - Can increase effect of aspirin and lithium 

    • Prescribing:
    • - Oral or chewable
    • - Can use brand names
    • - Take for symptoms

    • Administration:
    • - Take after a meal, before bed or with symptoms

    • Communication:
    • - Should feel better after 20min and the effects should last for hours. 
    • - Lifestyle changes will have a better effect
    • - Don't take another dose for at least 2 hours

    • Monitoring:
    • - Symptoms
    • - Red flag symptoms

    • Cost:
    • - Cheap and over the counter
  46. Alpha Blocker
    Doxazosin; Tamsidosin; Alfuzosin

    • Indications:
    • - First line for BPH when lifestyle changes don't work
    • - Can add to hypertension medications

    • Mode of Action: 
    • - Alpha-1 selective which act on smooth muscles of blood vessels and urinary tract
    • - Cause them to relax and vasodilator
    • - Reduces peripheral resistance

    • Adverse Reactions:
    • - Postural hypotension
    • - Dizzy
    • - Syncope

    • Safety:
    • - Reduce does if postural hypotension

    • Interactions:
    • - Other hypertension medications

    • Prescribing:
    • - Doxazosin can be used for both indications and give 1mg every 1-2 weeks
    • - Tamsidosin is oral for BPH only. Give 400mg

    • Administration:
    • - Take at bedtime at first

    • Communication:
    • - Symptoms
    • - Start at bedtime

    • Monitoring:
    • - Symptoms
    • - Lying and standing BP

    • Cost:
    • - Cheap
    • - Can get moderate release ones which are more expensive
  47. Aminoglycosides
    Gentamicin; Amibacin

    • Indications:
    • - Severe infection for gram negative aerobes including pseudomonus aeruginosa
    • - Can give in sepsis when questioning cause
    • - Pyelonephritis; Severe UTI; Biliary infection; intra-abdominal sepsis
    • - Doesn't work on streptococci and anaerobes so give with penicillin or metrandiazole if don't know the organism

    • Mode of Action: 
    • - Block 30S ribosomal subunit
    • - Therefore there is no protein synthesis and are bacteriacidal
    • - Enter bacteria through oxygen dependent transport system

    • Adverse Reactions:
    • - Nephrotoxic
    • - Ototoxic

    • Safety:
    • - Watch plasma concentration in neonates and elderly
    • - Change does in myasthesia gravis

    • Interactions:
    • - Ototoxic more likely if on loop diaretics
    • - Nephrotoxic with other antibiotics and platinum chemo

    • Prescribing:
    • - Not oral as cannot cross lipid membranes
    • - Give IV daily

    • Administration:
    • - IV administration slowly (over 30 minutes)

    • Communication:
    • - Fight infection
    • - Ask about red flag symptoms

    • Monitoring:
    • - Symptoms
    • - CRP

    • Cost:
    • - Not considered if needed for treatment
  48. Aminosalicylates
    Mesalazine; Sulfasalazine

    • Indications:
    • - Mesalazine first line for Ulcerative colitis
    • - Sulfasalazine is a DMARD for rheumatoid arthritis

    • Mode of Action: 
    • - Drugs release 5-ASA (aminosalicylic acid)
    • - Mechanism of 5-ASA is unknown but it seems to give an anti-inflammatory response and immunosuppression
    • - It seems to have a topical GI effect rather than systemic therefore Mesalazine is given a coating and Sulfasalazine linked to sulfapyridine so it can work on the gut.
    • - Sulfapyridine can increase the side effects so not used in UC anymore

    • Adverse Reactions:
    • - Mesalazine has few reactions that include GI upset (nausea) and headaches
    • - Both have blood abnormalities (rare) such as leucopenia and thrombocytopenia
    • - Both can have renal complications
    • - Sulfasalazine can reversibly decrease sperm count
    • - Both can yield a serious hypersensitivity reaction

    • Safety:
    • - Not given if patient has aspirin hypersensitivity

    • Interactions:
    • - Coatings can effect pH of the stomach so effects of PPI can change
    • - Other changes to pH in stomach can impact the 5-ASA release

    • Prescribing:
    • - Ulcerative colitis given rectally or rectalsigmoidal as an enema or suppositary
    • - Acute phase is given 1-2 times daily for 4-6 weeks
    • - For RA consult rheumatologist (oral)

    • Administration:
    • - Must get written consent from patient
    • - Asacol foam enema must be shaken for 15 seconds twice
    • - Oral make-ups must NOT be chewed or crunched

    • Communication:
    • - Written!

    • Monitoring:
    • - Symptoms
    • - In RA can look at RA
    • - If oral does then get renal function

    • Cost:
    • - Dependent of make
  49. Amiodarone
    • Indications:
    • - Tachyarrhythmia when other management options such as DCCV or medications don't work

    • Mode of Action: 
    • - Block Na, Ca and K channels as well as antagonist for alpha and ß receptors
    • - Therefore decrease depolarisation (automatic) and slow velocity
    • - Increase resistance of depolarisation (refractoriness) such as the AV node
    • - Can also breakdown re-entry arrhythmia 

    • Adverse Reactions:
    • - Hypotension if giving IV (acute situations)
    • - Chronic situations lead to pneumonitis; bradycardia; AV block; Hepatitis; photophobia; grey pigmentation; thyroid (contain iodine)

    • Safety:
    • - Cautions only
    • - Severe hypotension
    • - Heart block
    • - Active thyroid disease

    • Interactions:
    • - Too many to list

    • Prescribing:
    • - Ask for help
    • - Cardiac arrest is only time F1 may act if VF or pulseless VT
    • - Give 300mg IV then 20ml saline or 5% glucose

    • Administration:
    • - In cardiac arrest use bolus
    • - If IV administration use central line

    • Communication:
    • - Not relevant

    • Monitoring:
    • - Heart rate and rhythem
    • - ECG if IV
    • - Long term get baseline CXR, thyroid, liver and renal function tests

    • Cost:
    • - Cheap
  50. Angiotensin Receptor Blockers
    Losartan; Candesartan; Irbesatan

    • Indications:
    • - Hypertension when ACE cause cough
    • - Chronic heart failure
    • - Decrease risk of event in ischamic heart disease
    • - Slow progression of renal failure in diabetic nephropathy or CKD with protein secretion

    • Mode of Action: 
    • - Block the angiotensin effect on the AT1 receptor
    • - Stops the secretion of aldosterone and vasoconstriction
    • - Decreases afterload and dilates efferent gromular arteriol which slows CKD progression
    • - Promotes sodium and water excretion decreasing the preload

    • Adverse Reactions:
    • - Hypotension
    • - Hyperkalemia
    • - Renal failure (need efferent arteriol constricted to maintain proper pressure)
    • - No cough or angioedema like in ACE

    • Safety:
    • - Not to be used in renal artery stenosis or acute kidney injury
    • - watch use in pregnancy, breast feeding and monitor kidney function

    • Interactions:
    • - Other hyperkaleamic drugs
    • - NSAIDs increase renal failure

    • Prescribing:
    • - Oral, start low and titrate up

    • Administration:
    • - Take first does before bed

    • Communication:
    • - Look out for feeling dizzy
    • - Don't take NSAIDs

    • Monitoring:
    • - Blood pressure, electrolytes and renal function for 1-2 weeks and when does is increased
    • - Creatinine should not be raised more than 30% or lowered more than 25%
    • - Potassium over 6 means STOP THE DRUG

    • Cost:
    • - Cheap
  51. Selective Serotonin Re-uptake Inhibitors
    Citalopram; Fluoxetrine; Sertraline; Excitalopram

    • Indications:
    • - First line treatment in moderate-severe depression
    • - Panic disorders
    • - OCD

    • Mode of Action: 
    • - Inhibit re-uptake of serotonin in synaptic cleft
    • - Increases availability 
    • - Found to increase mood and relieve panic and OCD
    • - Doesn't inhibit NOR as tricyclics do

    • Adverse Reactions:
    • - GI upset; appetite and weight changes; hypersensitivity (rash)
    • - Hyperneutriema
    • - Increase suicidal thoughts
    • - Decrease seizure threshold; Increase QT interval and cause arrhythmia
    • - Bleeding risk
    • - Serotonin syndrome (hyperactive; altered mental state; neuromuscular excitation)
    • - Withdrawal = GI upset; neurological and flu-like symptoms; Sleep disturbance

    • Safety:
    • - Epileptic
    • - Peptic ulcer
    • - Young people
    • - Liver problems

    • Interactions:
    • - DO NOT GIVE WITH MOI
    • - Gastric protection is needed if patient also on aspirin or NSAIDs
    • - Bleeding risk increases if on anticoagulants
    • - Don't give with other drugs that increase QT interval

    • Prescribing:
    • - Oral
    • - Once a day and titrate up

    • Administration:
    • - Tablet or droplet form

    • Communication:
    • - Don't stop suddenly
    • - Will take for 6 months then start lowering does for 4 weeks

    • Monitoring:
    • - After 1-2 weeks
    • - If no effect seen in 4 weeks then change treatment.

    • Cost:
    • - Fine
  52. Tricyclics & Related Antidepressants
    Amitriplyline; Lofepramine

    • Indications:
    • - 2nd line after SSRI for moderate-severe depression
    • - Neuopathic pain (not licensed for this)

    • Mode of Action: 
    • - Inhibit uptake of serotonin (5-HT) and NOR
    • - Increased avbaliablity
    • - Block musclarinic receptors; H1; alpha-adenergic and D2

    • Adverse Reactions:
    • - Antimucularinic = Dry mouth; constipation; urinary retention; blurred vision
    • - H1 and A1 = Sedation and hypotention as well as arrhythmia and ECG changes
    • - Brain = Convulsions; Hallucinations; Mania
    • - Breast changes and sexual dysfunction
    • - Extrapyramidal symptoms (tremor and dyskinesia)
    • - Overdoes can be fatal
    • - Withdrawal flu like symptoms

    • Safety:
    • - Caution in elderly; CVD; epilepsy; prostate hypertrophy and raised intraoccular pressure

    • Interactions:
    • - NOT WITH MOI

    • Prescribing:
    • - Need supervision

    • Administration:
    • - Oral

    • Communication:
    • - Question other therapy
    • - Don't stop taking it
    • - Will reduce over 4 weeks when time to do so

    • Monitoring:
    • - Symptoms after 1-2 weeks (used to say 2-4 but found they work quicker than originally anticipated previously)

    • Cost:
    • - Fine
  53. Antidepressants (Other)
    Venlafaxine; Mirtazapine

    • Indications:
    • - Major depression where SSRI don't work
    • - Venlafaxine for generalised anxiety disorder

    • Mode of Action: 
    • - Venlafaxine are an serotonin and noradrenaline re-uptake inhibitor (SNRI)
    • - Mirtazapine is and antagonist of inhibitory pre-synaptic a2-adrenoceptors
    • - Both increase monamine availability which improves mood (though not in mild depression)
    • - Venlafaxine is a weak antagonist for musculinic and H1 receptors (less than tricyclics)
    • - Mertazapine is more potent for H1 receptors leading to sedation

    • Adverse Reactions:
    • - GI upset
    • - CNS disturbance (Headache; strange dreams; insomnia; confusion; convulsions)
    • - Hyponatreamia
    • - Serotonin syndrome
    • - Withdrawal (GI upset; neurological and flu-like symptoms; sleep disturbance)

    • Safety:
    • - Caution in elderly, hepatic and renal problems
    • - Venlafaxine should be avoided in those with CVD as it can increase the risk of arrhythmia 

    • Interactions:
    • - Other antidepressants

    • Prescribing:
    • - Oral
    • - Seek help 

    • Administration:
    • - Take at night

    • Communication:
    • - Symptoms should improve over the next few weeks
    • - Consider other treatment
    • - Take for at least 6 months and don't stop suddenly or will go through withdrawal
    • - Mirtazapine can lead to blood disorders

    • Monitoring:
    • - Symptoms over the next 1-2 weeks
    • - If no improvement after 4 weeks then change treatment

    • Cost:
    • - Fine
  54. Anti-emetic Dopamine Blockers
    Metoclopramide; Domperidone

    • Indications:
    • - For nausea and vomiting, particularly if is due to reduced gut motility

    • Mode of Action: 
    • - Vomiting is said to be controlled by the vomit centre of the medulla. 
    • - Input from chemoreceptor trigger zone (CTZ) senses the emetogenic substance
    • - These drugs, along with neurotransmitters of the gut relax the stomach and lower oesophageal sphincter which inhibit gastroduodenal coordination
    • - Therefore we have a prokinetic effect and emptying

    • Adverse Reactions:
    • - Diarrhoea
    • - Metoclopramide can give extrapyamidal symptoms (Domperidone cannot cross the blood brain barrier)
    • - Short-term effects can be acute dystonic reaction

    • Safety:
    • - Caution in children and young adults
    • - Watch if GI tract is obstructed
    • - Don't give if GI tract perforated

    • Interactions:
    • - Not with dopaminergic Parkinson's medication
    • - Not with antipsychotics

    • Prescribing:
    • - Both are 10mg 3 times a day
    • - Metoclopramide is given IM or IV
    • - Domperidone is given rectally

    • Administration:
    • - IV administration needs to be over 2 minutes

    • Communication:
    • - Anti-sickness
    • - Watch out for side-effects like muscle spasms

    • Monitoring:
    • - Symptoms
    • - If taking long term monitor extrapyramidal side effects

    • Cost:
    • - Cheap
    • - Rectal domperidone is expensive
  55. Antiemetic, Histamine H1-receptor antagonist
    Cyclizine; Cinnarizine; Promethazine

    • Indications:
    • - Nausea and vomiting particularly in motion sickness or vertigo

    • Mode of Action: 
    • - The vomit centre of the brain is located in the medulla and is communicated via the chemoreceptor trigger zone (CTZ).
    • - H1 and muscalrinic receptors (Ach) are mainly part of the pathway and with the vestibular system
    • - These block these receptors but cannot cross the blood brain barrier.

    • Adverse Reactions:
    • - Sedation (less in Cyclizine)
    • - Dry mouth due to anticholinergic
    • - IV can lead to transient tachycardia and the patient may feel palpitations
    • - Excitation/depression

    • Safety:
    • - Caution in hepatic encephalopathy and
    • - prostatic hypertrophy

    • Interactions:
    • - Don't use with other drugs that cause sedation
    • - Other drugs may potentiate the anticholinergic effect

    • Prescribing:
    • - Oral, IM or IV
    • - 5mg 8-hrly

    • Administration:
    • - IV must be given slowly over 2min

    • Communication:
    • - Anti-sickness medication
    • - Not always good for everyone so can swap if needed (Hyosine hydrobromid for instance)

    • Monitoring:
    • - Symptoms

    • Cost:
    • - In expensive
  56. Phenothiazines - Antiemetic
    Prochlorperazine; Chlorpromazine

    • Indications:
    • - Prophylaxis and treatment of nausea and vomiting but as has higher side-effects this is not first line
    • - 1st generation antiphycotic drug used in schizophrenia and other psycosis

    • Mode of Action: 
    • - Vomiting triggers converge on the vomit centre in the medella which converge on the chemoreceptor trigger zone (CTZ)
    • - These block D2 receptors in the CTZ and the gut
    • - To a lesser extent they block H1 and Ach between the vomit centre and the vestibular system
    • - Therefore, a wider range of uses

    • Adverse Reactions:
    • - Drowsiness 
    • - Extrapyramidal symptoms, especially acute dystonia which can sometimes present as occulogic crisis due to the D2 blockade
    • - Tartive dyskinesia is also common
    • - Prolonged QT interval

    • Safety:
    • - Don't use if sever liver disease
    • - Caution in prostatic hypertrophy
    • - Use a lower does in the elderly

    • Interactions:
    • - Always consult the BNF as there are a lot of interactions 
    • - Don't use with other drugs that prolong QT interval

    • Prescribing:
    • - Get help from senior staff
    • - If for nausea and vomiting then 20mg oral or 12.5mg IM
    • - This is for acute attack

    • Administration:
    • - IM must be deep

    • Communication:
    • - Anti-sickness medication
    • - If dizzy come and see
    • - Stop if not effective

    • Monitoring:
    • - Symptoms
    • - Extrapyramidal symptoms that are not always obvious

    • Cost:
    • - Buccal forms are available but these are more expensive
  57. Antiemetic, serotonin 5-HT3 Receptor Angonist
    Odansetron; Granisetron

    • Indications:
    • - Profylaxis or treatment of nausea and vomiting particularly in anaesthesia or chemotherapy
    • - Not licensed for but evidence shows good for morning sickness in pregnancy

    • Mode of Action: 
    • - 5HT3 receptors in the CTZ
    • - High amount of serotonin in the gut that engages emetogenic stimuli
    • - Vagus nerve transmits this to the vomit centre
    • - Few vestibular connections

    • Adverse Reactions:
    • - Rare
    • - Diarrhoea
    • - Constipation
    • - Headache

    • Safety:
    • - Very high doeses have been shown to result in an increased QT interval

    • Interactions:
    • - Don't use with other drugs that prolong QT interval

    • Prescribing:
    • - Ondansetron usually 4-8mg over 12 hours oral or IV
    • - Give higher does in chemotherapy
    • - Can take regularly or as required. 
    • - If profylaxis then take 1 hour before anticipated reaction

    • Administration:
    • - No special considerations

    • Communication:
    • - Anti-sickness
    • - Might not work for everyone so can change if not tolerated 

    • Monitoring:
    • - Symptoms

    • Cost:
    • - More expensive than other medications
  58. Atypical Antipsycotics
    Quetiapine; Olanzapine; Risperidone; Clozapine

    • Indications:
    • - Urgent psychomotor agitation
    • - second line for schizophrenia, especially those suffering extrapyramidal symptoms on first line
    • - Bipolar in acute mania

    • Mode of Action: 
    • - Block post synaptic D2 receptors
    • - Better results in medication resistant schizophrenia

    • Adverse Reactions:
    • - Sedation
    • - Extrapyrimidal symptoms
    • - Metabolic (weight gain; diabetes; lipid change)
    • - Increase QT-interval and lead to arrhythmia
    • - Risperidone effect the tuberohypophyseal pathway leading to an increase in prolactin. This causes breast changes and sexual dysfunction
    • - Clozapine can lead to low neutrophils and very rarely myocarditis

    • Safety:
    • - Caution in CVD
    • - Not in severe heart disease
    • - Not if history of neutropenia

    • Interactions:
    • - Other sedatives
    • - Other drugs that prolong QT interval

    • Prescribing:
    • - Need a specialist
    • - Can be Oral or IM (depot)
    • - Clozapine is a last resort
    • - As an F1 just know not to stop the medication

    • Administration:
    • - Oral does should be taken at bedtime

    • Communication:
    • - Tell patients to inform medical professionals if on the drug
    • - If on clozapine then regular blood tests

    • Monitoring:
    • - Signs and symptoms

    • Cost:
    • - Can be expensive
  59. Calcium & Vitamin D
    Calcium carbonate; Calcium gluconate; Colecalciferol; Alfacalcidol

    • Indications:
    • - Osteoperosis
    • - CKD
    • - Hyperkaleamia
    • - Hypocalcemia
    • - Low vitamin D

    • Mode of Action: 
    • - Calcium is needed in normal function of musculoskeletal system and clotting. It is controlled by vitamin D and PTH. Increase of Calcium in the serum increases it on bone mineral.s

    • Adverse Reactions:
    • - Oral have little side-effects. Could be some dyspepsial or constipation
    • - IV can lead to hyperkaleamia if too fast resulting in CVD and local tissue damage

    • Safety:
    • - Hypercalceima

    • Interactions:
    • - Iron biphosphyates
    • - Trycyclics
    • - Terothyroxe
    • - Don't use calcium carbonate with sodium bicarbonate as can precipitate

    • Prescribing:
    • - Oral 1-1.2g of calcium and 800g of vitamin D per day
    • - If for hyperkalemia then 10mL 10% IV

    • Administration:
    • - Oral and don't chew

    • Communication:
    • - Normal
    • - Might need to take blood

    • Monitoring:
    • - ECG
    • - Calcium levels

    • Cost:
    • - Inexpensive
  60. Calcium Channel Blocker
    Amlodiprine; Nifedipine; Diltiagen; Verapramil

    • Indications:
    • - Hypertension
    • - Angina (though ß-blocker is better)
    • - Superventricular arrhythmia

    • Mode of Action: 
    • - Decreases the amount of calcium ions in the cell which allow for relaxation and vasodilation aretial in smooth muscles. This decrease afterload.
    • - Dihydropyvidines more with vasculitis
    • - Non-dihyropyridine are verapramil and heart directed

    • Adverse Reactions:
    • - Ankle swelling
    • - Flushing
    • - Headache
    • - Palpations
    • - Verapramil leads to constipation and bradycardia with heart block or failure
    • - Diltiazen gives a mix of problems

    • Safety:
    • - Not in poor left ventricular function
    • - AV nodal condution delay
    • - not in unstable angina
    • - not in severe aortic stenosis

    • Interactions:
    • - Not with ß-blocker

    • Prescribing:
    • - Oral

    • Administration:
    • - swallow whole

    • Communication:
    • - CVD 
    • - watch out for side effects

    • Monitoring:
    • - Blood pressure
    • - ECG

    • Cost:
    • - Fine
  61. Carbamazepine
    • Indications:
    • - Epilepsy
    • - Trigeminal neuralgia
    • - Bipolar

    • Mode of Action: 
    • - Mechanism not really known.
    • - Inhibit sodium ion channels which stabilise the resting membrane potential
    • - Inhibits the spread of the seizure
    • - Blocks pain
    • - Temporal lobe and limbic lobe are effected which can impact on the mood.

    • Adverse Reactions:
    • - GI upset
    • - Neurological including dizziness and ataxia
    • - 10% have hypersensitivity of a maculopapular rash
    • - 1 in 5000 have anti-epileptic hypersensitivity syndrome (Steven-Johnstons syndrome; Fever; Lymphadeopathy)
    • - Oedema
    • - Hyponatremia

    • Safety:
    • - Neural tube defects
    • - Can have some renal and hepatic impairment
    • - Not if history of antiepileptic hypersensitivity syndrome

    • Interactions:
    • - cP450 inducer
    • - Other epileptic medications
    • - drugs that lower seizure threshold

    • Prescribing:
    • - Oral or rectal
    • - max does is 1.6g/day

    • Administration:
    • - Try to stick to oral which can have different release and are available in chewable form

    • Communication:
    • - Shall lower the frequency of seizures
    • - Watch for hypersensitivity
    • - Caution about pregnancy

    • Monitoring:
    • - Compare frequency to before taking medication

    • Cost:
    • - Cheap
  62. Clopidogrel
    • Indications:
    • - Acute coronary syndrome
    • - Prevent occlusion of coronary artery stent
    • - Prevent MI/stroke
    • - AF if anticoagulation is contraindicated

    • Mode of Action: 
    • - Prevent platelet aggregation by binding to the ADP receptors (P2T12) on the surface of the platelet
    • - No effect on COX pathway

    • Adverse Reactions:
    • - Bleeding
    • - GI upset
    • - Thrombocytopenia

    • Safety:
    • - Not if bleeding
    • - Stop 7 days before elective surgery (This is the lifetime of the platelet)
    • - Renal and hepatic problems

    • Interactions:
    • - Pro-drug so requires P450

    • Prescribing:
    • - Oral
    • - Needs a week to take effect
    • - Loading does of 300mg is given then maintainence does of 75mg
    • - If a stent then must be taken for a year

    • Administration:
    • - Nothing special

    • Communication:
    • - Decrease risk factor for MI
    • - Increase lifespan
    • - Watch for bleeding

    • Monitoring:
    • - Side effects

    • Cost:
    • - Cheap
  63. Gabapentin & Pregablain
    • Indications:
    • - Focal epilepsy with or without generalisation (usually and add-on treatment)
    • - Neuropathic pain profylaxis for diabetic neuropathy
    • - Gabapentin can be used for migraine profylaxis
    • - Pregabalin can be used for generalised anxiety disorder

    • Mode of Action: 
    • - Gabapentin looks like GABA but actually doesn't seem to act like it. Mechanism is largely unknown.
    • - Thought to bind to voltage sensitive calcium channels stopping the inflow and therefore neurotransmitter release
    • - Pregablain is a structural analogue so probably works the same

    • Adverse Reactions:
    • - Not really any
    • - Drowsy
    • - Dizzy
    • - Ataxia
    • - Can have false positives of protein in urine dipstick

    • Safety:
    • - Warning in renal impairment

    • Interactions:
    • - Sedating drugs
    • - Very few compared to other drugs like this

    • Prescribing:
    • - Oral, start at low dose

    • Administration:
    • - No special things

    • Communication:
    • - Will decrease severity of symptoms

    • Monitoring:
    • - Symptoms
    • - Serum levels are not helpful

    • Cost:
    • - Avoid brands
  64. Ocular Lubricant (Artificial Tears)
    Hypromellose; Carborners; Liquid and white soft paraffin

    • Indications:
    • - Dry eyes
    • - Keratoconjuctivitis sicca
    • - Sjogren's
    • - Environmental

    • Mode of Action: 
    • - Soothing effect and protection that tears normally provide

    • Adverse Reactions:
    • - Mild stinging on application
    • - Blurred vision
    • - Local inflammatory reaction if allergic

    • Safety:
    • - Look if absorbed

    • Interactions:
    • - None

    • Prescribing:
    • - 1 to 2 drops 0.3 solution

    • Administration:
    • - Self administration

    • Communication:
    • - Normal

    • Monitoring:
    • - Self

    • Cost:
    • - Cheaper over the counter than prescription
  65. Female Sex Hormones
    Combined ethinytstradiol products; Desogestrel

    • Indications:
    • - Hormone contraception
    • - Acne
    • - HRT

    • Mode of Action: 
    • - Oestrogen and progenstrogen exert negative feedback on the LH and FSH hormones stopping ovulation.
    • - Also decrease pain and bleeding of periods
    • - Can reduce acne symptoms
    • - Provide relief of menopause problems

    • Adverse Reactions:
    • - Irregular bleeding
    • - Mood change
    • - Don't effect weight gain
    • - VTE risk doubles
    • - Increased risk of CVD and cancer

    • Safety:
    • - Contraindicated in breast cancer

    • Interactions:
    • - Drugs that impact cP450 might decrease efficiacy

    • Prescribing:
    • - Oral
    • - Consult BNF

    • Administration:
    • - If started on day 6 of menstrual cycle then no other contraception is needed. If not use barrier methods until end of next cycle
    • - 21 days on then 7 days off
    • - Can usually miss 1 but if miss 2 must have 7 days off
    • - Unlicensed for continuous use but usually fine

    • Communication:
    • - Discuss all contraception options
    • - Explain that the bleeding is no longer a period
    • - Rules of missing one

    • Monitoring:
    • - Check blood pressure
    • - Follow up after 3 months of starting

    • Cost:
    • - Check local policy
  66. Opioid Compound Preparations
    Co-Codamol; Co-dydramol

    • Indications:
    • - Mild to moderate pain (2nd rung on the WHO pain ladder)

    • Mode of Action: 
    • - Paracetamol is a COX inhibitor which is required for prostoglandin synthesis. This increases the pain threshold (mechanism not entirely known)
    • - Codine and dihydrocodine are opioids that are synthesised to morphine by p450
    • - This binds to µ-receptors to stop potentiation of cells
    • - Combination of the drugs gives better pain control

    • Adverse Reactions:
    • - Nausea
    • - Constipation
    • - Drowsyness
    • - Overdoes risk as with both. Paracetamol can lead to hepatoxic symptoms while opioids lead to neurological stress and respiratory depression

    • Safety:
    • - Cautions only
    • - Respiratory distress
    • - Renal impairment
    • - Hepatic impairment
    • - Elderly

    • Interactions:
    • - Other sedating drugs

    • Prescribing:
    • - Oral
    • - 500mg of paracetamol then usually 8/500 co-codamol and 10/500 of co-dydramol
    • - 15mg ones are available and can take 2 every 6 hours
    • - Consider a laxative

    • Administration:
    • - Take at regular intervals with or without food

    • Communication:
    • - Avoid heavy machinery
    • - Laxative?

    • Monitoring:
    • - Acute pain check in 1-2 hours, chronic check in 1-2weeks
    • - Monitor symptoms, maybe using the pain score

    • Cost:
    • - Can be cheaper over the counter than on presciption
  67. Strong Opioids
    Morphine; Oxycodone

    • Indications:
    • - Acute severe pain
    • - Chronic pain (rung 3 on WHO pain scale)
    • - Breathlessness
    • - Acute pulmonary oedema

    • Mode of Action: 
    • - Binds to µ-receptors which decrease neuron excitability and therefore they cannot potentiate pain
    • - Blunt hypoxic and hypercapnoea drive in brain
    • - This can decrease the flight/fight response

    • Adverse Reactions:
    • - Respiratory depression
    • - Euphoric mood or in high doses neurological depression
    • - Effects CTZ so can induce nausea and vomiting
    • - Constrict pupils (Edinger-Westphal)
    • - Constipation as slow down motility of small intestine
    • - Histamine in skin therefore itching
    • - Tolerance can build up

    • Safety:
    • - Caution in hepatic, respiratory, elderly and biliary colic
    • - Avoid in respiratory failure

    • Interactions:
    • - Other sedating drugs

    • Prescribing:
    • - IV rapid administration of 2-10mg (tailored to patient)

    • Administration:
    • - Only in high dependancy areas

    • Communication:
    • - Many patients fear addiction
    • - Not a problem if used correctly for pain control

    • Monitoring:
    • - Symptoms
    • - Acute check after 1-2 hours
    • - Chronic check after 1-2 weeks

    • Cost:
    • - Synthetic types are more expensive
  68. Non-Steroidal Anti-Inflammatories
    (NSAIDs)
    Naproxen; Ibuprofen; Etoricoxib

    • Indications:
    • - As needed for mild-to-moderate pain
    • - Responce to inflammation

    • Mode of Action: 
    • - COX inhibitor that synthesis prostaglandins 
    • - COX1 = constitutive and needed for gastric mucosa, renal function and inhibit thrombus. This is usually the side-effects
    • - COX2 = Indurable and is the inflammation response. Etoricoxib is COX2 specific

    • Adverse Reactions:
    • - GI toxic
    • - Renal toxic
    • - Increase of cardiovascular risk
    • - Hypersensitivity reaction
    • - Fluid retention

    • Safety:
    • - Not in those with severe renal, hepatic or heart failure
    • - Not those with past hypersensitivity reaction
    • - Avoid if have ulcer, are bleeding, have cardiovascular disease or mild renal complications

    • Interactions:
    • - Side effects increase with aspirin, corticosteroids, anti-coagulants, SSRI, venlafauc, ACE-inhibitors and diuretics
    • - Use decreased in anti-hypertensives and diruetics

    • Prescribing:
    • - Normally oral but can get gels, suppositories or IM injections

    • Administration:
    • - Take with food

    • Communication:
    • - If indigestion then stop taking and come in
    • - If take for more than 10 days need to look at stopping side-effects

    • Monitoring:
    • - Pain

    • Cost:
    • - Over the counter can be cheaper
  69. Opioids for Moderate Pain
    Tramadol; Codine; Dihydrocodine

    • Indications:
    • - Mild to moderate pain
    • - Second rung on the WHO pain ladder

    • Mode of Action: 
    • - Metabolise to morphine and then bind to µ-receptors
    • - Note that 10% of caucasians have less of the enzyme p450 2D6 which does this
    • - Tramadol is a synthetic of codine and is also serotonergic and adrenergic

    • Adverse Reactions:
    • - Nausea
    • - Constipation (less with tramadol)
    • - Dizzy
    • - Drowsy
    • - Neurological and respiratory depression
    • - IV --> anaphylaxis

    • Safety:
    • - Not in respiratory disease, renal disease, hepatic complications and reduced in elderly
    • - Can lower the seizure threshold in epileptics 

    • Interactions:
    • - Other sedating drugs
    • - Other drugs that lower seizure threshold

    • Prescribing:
    • - Oral
    • - IM
    • - Consider a laxative

    • Administration:
    • - Take at regular intervals

    • Communication:
    • - Weak version of morphine
    • - Take at regular intervals

    • Monitoring:
    • - Acute pain check in 1-2 hours
    • - Chronic pain check after 1-2 weeks

    • Cost:
    • - Avoid moderate release versions unless that are absolutely necessary
  70. Phenytoin
    • Indications:
    • - Status eplieptius when benzodiazapine doesn't work
    • - Decrease frequency of seizures but not the best treatment

    • Mode of Action: 
    • - Mechanism not entirely known
    • - Bind to Na channels
    • - Decrease neuronal excitability & conductance

    • Adverse Reactions:
    • - Change in appearance (Coarse; acne; hirsutism; gum problems)
    • - Neurological effects (nystagumus; ataxia)
    • - Haematoligical disorders
    • - Induce folic acid and vitamin D metabolism which can lead to osteomilitus
    • - Hypersensitivity
    • - Toxic does lead to cardiac and respiratory distress.

    • Safety:
    • - Zero-order kinetics so there is a low theraputic index
    • - Caution in hepatic problems and pregnancy (fetal hydantion syndrome)

    • Interactions:
    • - Enzyme inducer of p450
    • - Other epileptic

    • Prescribing:
    • - IV 20mg/kg in status epilepticus
    • - Oral 150-300mg daily and don't stop suddenly

    • Administration:
    • - IV slowly or infusion

    • Communication:
    • - Decrease frequency of seizures
    • - Take with food
    • - Don't miss a does

    • Monitoring:
    • - Monitor concentration
    • - symptoms

    • Cost:
    • - Varys
  71. Oxygen
    • Indications:
    • - Hypoxaemia
    • - Pneumothorax
    • - Carbon-monoxide posening

    • Mode of Action: 
    • - Increase the PO2 which increases the O2 in tissues
    • - In pneumothorax decreases the nitrogen fraction

    • Adverse Reactions:
    • - Discomfort of the delivery device
    • - Dry mouth (use humidifier)

    • Safety:
    • - Type II respiratory failure

    • Interactions:
    • - None

    • Prescribing:
    • - Have a target range
    • - Resivouir, venturi mask and nasal cannula 

    • Administration:
    • - Resiviour mask = 15L/min
    • - Venturi mask has a fixed ration
    • - Nasal can be 2-6L (facemask can be used but usually uncomfortable)

    • Communication:
    • - Continous O2

    • Monitoring:
    • - Monitor O2Sats
    • - ABG

    • Cost:
    • - Not considered when prescribing
  72. Aspirin
    • Indications:
    • - Acute coronary syndrome and stroke
    • - Secondary prevention of ACS
    • - AF where warfarin is contraindicated
    • - Pain & fever relief

    • Mode of Action: 
    • - Inhibit COX from production of thromboxane which decreases platelet aggregation
    • - Lasts for the lifetime of the platelet

    • Adverse Reactions:
    • - GI upset
    • - Ulcer or bleed
    • - Hypersensitivity can lead to bronchospasm
    • - Tinnitus
    • - Overdose is life threatening

    • Safety:
    • - Not in those under 16 (Reye's syndrome)
    • - Hypersensitive
    • - 3rd trimester of pregnancy (stop closure of ductus arteriosis)
    • - Caution in peptic ulcer and gout

    • Interactions:
    • - Antiplatelets 
    • - Anticoagulants 

    • Prescribing:
    • - During ACS once only loading does 300mg
    • - 75mg daily
    • - Give PPI for gastro-protection

    • Administration:
    • - Take after food
    • - Can take enteric coated but not if rapid effect is desired

    • Communication:
    • - Watch out for bleeding

    • Monitoring:
    • - Nill

    • Cost:
    • - Cheap and can get over the counter
  73. Penicillins, Antipseudomonal
    Piperacillin + Tazobactam (Tazocin)

    • Indications:
    • - Severe infections and broad spectrum pathogens
    • - High resistance and immunocompromised patients
    • - LRTI, UTI and intrabdominal sepsis
    • - Skin and soft tissue issues

    • Mode of Action: 
    • - Destroy cell wall which changes the osmotic gradient
    • - Mainly against pseudomonas aeruginosa
    • - Active against ß-lactamase producing bacteria

    • Adverse Reactions:
    • - GI upset
    • - Colitis
    • - Hypersensitivity

    • Safety:
    • - History of C.diff
    • - Not if allergy
    • - Caution in renal failure

    • Interactions:
    • - Methotrexate decrease excretion
    • - Increased warfrin

    • Prescribing:
    • - IV 5-14 days 4.5g (4g Piperacillin and 500mg tazobactam) over 6-8 hours

    • Administration:
    • - IV over 30 minutes

    • Communication:
    • - Question allergy
    • - Get rid of infection

    • Monitoring:
    • - CRP
    • - WCC

    • Cost:
    • - Can be expensive
  74. Penicillins, Penicillinase-resistant
    Flucloxacillin

    • Indications:
    • - Against staph

    • Mode of Action: 
    • - Inhibit cell wall
    • - Has Acyl side chain
    • - ß-lactamase producing staph
    • - MRSA is resistance to the binding

    • Adverse Reactions:
    • - GI upset
    • - Allergy (rash)
    • - Liver toxic
    • - CNS toxic with renal failure

    • Safety:
    • - Renal failure
    • - Penicillin allergy
    • - Hepatotoxic

    • Interactions:
    • - Methotrexate

    • Prescribing:
    • - High does IV over 6 weeks
    • - Note it has a 45-60min half life

    • Administration:
    • - Oral
    • - IV

    • Communication:
    • - Watch out for allergy

    • Monitoring:
    • - CRP
    • - WCC

    • Cost:
    • - Cheap
  75. Bulk Forming Laxatives
    Ispaghula Husk; Methylcellulose; Sterculia

    • Indications:
    • - Constipation & Faecal impaction if cannot increase fibre intake
    • - Mild chronic diarrhoea with diverticular disease or IBS

    • Mode of Action: 
    • - Contain hydrophilic substance (polysaccharide or cellulose)
    • - Not absorbed by bowel
    • - Attacks water to stool
    • - Increased bulk stimulates peristalsis
    • - Can help with chronic diarrhoea

    • Adverse Reactions:
    • - Well tolerated
    • - Minimal distension and flatulence
    • - Rarely cause faecal impaction and GI Obstruction

    • Safety:
    • - Subacute or established intestinal obstruction
    • - Feacal impaction
    • - Not with ileus

    • Interactions:
    • - None

    • Prescribing:
    • - Around meal times

    • Administration:
    • - Powder dissolved in water
    • - Tablets (methylcellulose)

    • Communication:
    • - Works as a fibre supplement
    • - Don't exceed maximum dose
    • - Store in dry place

    • Monitoring:
    • - Stool chart

    • Cost:
    • - Over-the-counter cheaper than prescription
  76. Osmotic Laxatives
    Lactulose; Macrogol; Phosphate enema

    • Indications:
    • - Constipation & Faecal impaction
    • - Bowel preparation
    • - Hepatic encephalopathy

    • Mode of Action: 
    • - Based on osmotic active substances (sugar or alcohol) that are not digested
    • - Hold water in the stool, maintaining volume and stimulating peristalsis. 
    • - Lactulose stops ammonia absorption by acidifying stool (good for liver failure)

    • Adverse Reactions:
    • - Flatulence
    • - Abdominal Cramps
    • - Nausea
    • - Diarrhoea
    • - Local irritation
    • - Electrolyte disturbance

    • Safety:
    • - Not in intestinal obstruction
    • - Heart failure
    • - Ascites
    • - Electrolyte disturbances

    • Interactions:
    • - Warfain could be slightly increased

    • Prescribing:
    • - Oral
    • - Enema

    • Administration:
    • - With or without food
    • - Enema should stay there until need to open bowels

    • Communication:
    • - Make stool softer and easier to pass
    • - Have 6-8 glasses of fluid a day
    • - Stop if more than 2-3 soft stools a day

    • Monitoring:
    • - INR
    • - Electrolytes

    • Cost:
    • Cheap so buy over the counter
  77. Thiazide and related diuretics
    Bendroflumethiazide; indapamide; chlortalidone

    • Indications:
    • - Hypertension where ACE and CCB are not able to be used
    • - 3rd line add-on for hypertension

    • Mode of Action: 
    • - Inhibit the Na/Cl co-transporter in the distal convoluted tubule on the nephron
    • - Prevents reabsorption of sodium and osmotically associated water so there is a fall in ECF

    • Adverse Reactions:
    • - Preventing sodium ion reabsorption can cause hyponatraemia
    • - As sodium is exchanged for potassium can lead to hypokalaemia and cardiac arrhythmia
    • - Increase plasma glucose, LDL-cholesterol and triglycerides (however, net effect on CVD is protective)
    • - Can cause impotence in men

    • Safety:
    • - Avoid with hypokalaemia
    • - Caution hyponatraemia
    • - Avoid in gout

    • Interactions:
    • - Reduced by NSAIDs
    • - Avoid drugs that lower potassium

    • Prescribing:
    • - Oral part of regular medication
    • - Bendrofluethiazide 2.5mg

    • Administration:
    • - Take in morning so not to disrupt sleep

    • Communication:
    • - 'water tablet'
    • - Warn about leg swelling
    • - Find if easy access to toilet 
    • - Ibuprofen can interact
    • - Ask about impotence at review

    • Monitoring:
    • - Measure blood pressure
    • - Oedema
    • - Electrolytes before and at 2-4 weeks to pick up any changes

    • Cost:
    • Cheap
  78. Potassium-Sparing Diuretics
    Amiloride (Co-amilofruse or co-amiloride)

    • Indications:
    • - Part of combination therapy to treat hypokalaemia.

    • Mode of Action: 
    • - Weak diuretic alone
    • - With another they can counteract potassium loss and enhance diuresis
    • - Acts on distal convoluted tubule in the kidney
    • - Inhibits reabsorption of sodium at the epithelial sodium channels
    • - So there is sodium and water excretion and retention of potassium
    • - Co-amilofruse is combination with furosemide
    • - hydrochlorothiazide combination is called co-amilozide
    • - Neutral effect on potassium balance.

    • Adverse Reactions:
    • - GI upset
    • - Hypotension and urinary symptoms
    • - Electrolyte disturbances

    • Safety:
    • - Avoid in renal impairment
    • - Avoid in hyperkalaemia
    • - Combination not used for hypokalaemia (unpredictable effect)
    • - Avoid in states with volume depletion

    • Interactions:
    • - Don't use with potassium-elevating drugs
    • - Alter digoxin and lithium

    • Prescribing:
    • - Tablet
    • - Give strength of ratio on prescription
    • - Then give number of tablets to take daily

    • Administration:
    • - Best to take in the morning

    • Communication:
    • - Potassium is low cause the water tablet being taken
    • - Change to a different one and prevent potassium loss
    • - Will need blood test monitoring until potassium returns to normal

    • Monitoring:
    • - Watch for fluid overload
    • - Monitor serum potassium

    • Cost:
    • - Cheap
  79. Class I Antiarrhythmics
    Lidocaine

    • Indications:
    • - First choice local anaesthetic in urinary catheterisation and minor procedures

    • Mode of Action: 
    • - Enters cells in its uncharged form
    • - Accepts proton and then becomes positively charged
    • - This blocks voltage-gated sodium channels
    • - In heart can terminate VT and improve chance of successfully treat VF (slows down conduction velocity)

    • Adverse Reactions:
    • - Common side effect is an initial stinging sensation
    • - Drowsy
    • - Restless
    • - Tremor
    • - Fits
    • - Hypotension
    • - Arrhythmia

    • Safety:
    • - Safe

    • Interactions:
    • - Adrenaline and vasoconstrictors can prolong the effect

    • Prescribing:
    • - Instillagel for urinary catheterisation (6-11mL)
    • - For minor procedures usually 1% 200mg or 3mg/kg

    • Administration:
    • - Gel for catheterisation
    • - Superficial layer injection

    • Communication:
    • - Explain that it will numb the pain
    • - It could sting but then should go away

    • Monitoring:
    • - Clinically

    • Cost:
    • - Cheap 10-20p per tube
  80. Nicorandil
    • Indications:
    • - Prevention and treatment of stable angina if ß-blockers and CCB are not sufficient or tolerated

    • Mode of Action: 
    • - Causes both arterial and venous vasodilation as a nitrate
    • - Activate K-ATP channels
    • - Causes hyperpolarisation of cell and inactivation of voltage-gated channels
    • - Increased calcium in cells causes vasodilation
    • - Reduces cardiac preload and vascular resistance

    • Adverse Reactions:
    • - Flushing
    • - Dizziness
    • - Headache
    • - Nausea
    • - Vomiting
    • - Hypotension
    • - GI, skin or mucosal ulceration

    • Safety:
    • - Avoid with poor left ventricular function
    • - Hypotension
    • - Pulmonary oedema

    • Interactions:
    • - Enhanced by phosphodiesterase inhibitors

    • Prescribing:
    • - Oral only
    • - Start low (5-10mg twice daily) and increase to 20-30mg as patient becomes tolerant

    • Administration:
    • - Tablets

    • Communication:
    • - To reduce chest pain
    • - Reduce other cardiovascular risks
    • - Don't drive until angina controlled

    • Monitoring:
    • - Regular review of symptoms
    • - Blood pressure monitored

    • Cost:
    • - Prescribe as generic name so pharmacist can give non-proprietary form
  81. Fibrinolytic/Thrombolytic Drugs
    Alteplase; Streptokinase

    • Indications:
    • - Acute ischaemic stroke if given within 4.5 hours of onset
    • - Acute STEMI within 12 hours with onset of symptoms with antiplatlets

    • Mode of Action: 
    • - Catalyse the conversion of plasminogen to plasmin
    • - Dissolve fibrin clot
    • - Re-canalise occluded vessel

    • Adverse Reactions:
    • - Nausea
    • - Vomiting
    • - Bruising at injection site
    • - Hypotension
    • - Stop if serious bleeding, allergic reaction, cariogenic shock and cardiac arrest

    • Safety:
    • - Not if recent haemorrhage, bleeding disorder, severe hypertension or peptic ulcer
    • - Ensure so intracranial haemorrhage in CT
    • - No previous streptokinase

    • Interactions:
    • - ACE increase risk of anaphylactoid reaction
    • - Increased risk in anticoagulant and antiplatlets

    • Prescribing:
    • - Fibrinolytic drugs only if experienced

    • Administration:
    • - In an high dependency area

    • Communication:
    • - Senior

    • Monitoring:
    • - Vital signs every 15 minutes for 2 hours

    • Cost:
    • - £80-£600
  82. Compound Bronchodilators
    Seretide; Symbicort

    • Indications:
    • - Asthma steps 3-4
    • - COPD

    • Mode of Action: 
    • - Suppress airway inflammation
    • - LABA stimulate broncodilation
    • - Seretide = fluticasone and salmetrol
    • - Symbicort = budesonide and formoterol

    • Adverse Reactions:
    • - Oral thrush
    • - Hoarse voice
    • - ? increase pneumonia risk
    • - Tremor, tachycardia, arrhythmias, muscle cramps

    • Safety:
    • - ? COPD with history of pneumonia
    • - ? children

    • Interactions:
    • - B-blockers can reduce effectiveness

    • Prescribing:
    • - By brand name and strength

    • Administration:
    • - Seretide is formulated as pressurised metered dose. 
    • - Both can be dry powder

    • Communication:
    • - Take EVERY morning
    • - No systemic steroid effects

    • Monitoring:
    • - Asthma and COPD review

    • Cost:
    • - Huge drain on budget
  83. Valporate
    Sodium Valporate; Valporic Acid

    • Indications:
    • - Epilepsy (first choice for control of generalised or absence seizures and as treatment for focal seizures)
    • - Bipolar disorder (acute for manic episodes)

    • Mode of Action: 
    • - Unsure
    • - Weak sodium channel inhibitor in neuronal sections
    • - Stabilise membrane potentials
    • - Increase brain content of y-aminobutyric 

    • Adverse Reactions:
    • - GI upset
    • - Neuro and psychiatric effects
    • - Thrombocytopenia (increase liver enzymes)
    • - Hair loss
    • - Life-threatening idiosyncratic liver injury, pancreatitis, bone marrow failure, antiepileptic hypersensitivity syndrome

    • Safety:
    • - Avoid in women who can have kids
    • - First trimester
    • - Caution hepatic and renal impairment

    • Interactions:
    • - CYP450 inhibitor

    • Prescribing:
    • - 2 formulations
    • - 600mg epilepsy
    • - 750mg for bipolar disorder

    • Administration:
    • - Oral
    • - IV can be used temporarily

    • Communication:
    • - Reduce frequency seizures
    • - Take with food
    • - Seek urgent medical advice if lethargy, loss of appetite, vomiting, abdominal pain

    • Monitoring:
    • - Efficacy
    • - Plasma concentrations don't corrolate with effect

    • Cost:
    • - £9 per 100-pack of 500mg tablets
  84. Z-Drugs
    Zopiclone; Zolpidem

    • Indications:
    • - Short term treatment for insomnia which is debilitating or distressing

    • Mode of Action: 
    • - Similar to benzos
    • - GABAa receptor
    • - Allows chloride to flow into cell therefore cannot depolarise

    • Adverse Reactions:
    • - Daytime sleepiness which may affect ability to drive
    • - Rebound insomnia (when stopped)
    • - CNS effects: Headache; confusion; nightmares; amnesia
    • - Zipiclone = taste disturbance
    • - Zolpidem = GI upset
    • - After 4 weeks can have dependence and withdrawal when stopping
    • - Overdose = coma

    • Safety:
    • - ? Elderly
    • - Not in OSA
    • - Not if respiratory muscle weakness or depression

    • Interactions:
    • - Metabolised by P450

    • Prescribing:
    • - Short term
    • - Halve dose in elderly

    • Administration:
    • - Oral

    • Communication:
    • - Short-term
    • - Only if needed
    • - Don't drive or operate heavy machinery

    • Monitoring:
    • - Clinical

    • Cost:
    • - Inexpensive
  85. 5-a Reductase Inhibitors
    Finasteride

    • Indications:
    • - Second line to BPH

    • Mode of Action: 
    • - Stop testesterone to DHT
    • - Can take months to have an effect

    • Adverse Reactions:
    • - Impotence, reduced libido and gynaecomastia
    • - Can allow hair growth

    • Safety:
    • - Not if partner trying to get pregnant or is pregnant

    • Interactions:
    • - None

    • Prescribing:
    • - Oral (5mg)

    • Administration:
    • - Don't allow women to touch it

    • Communication:
    • - Explain BPH
    • - Could take 6 months
    • - Warn of side-effects

    • Monitoring:
    • - 3-6 month follow-up
    • - Then every 6-12 months

    • Cost:
    • - Inexpensive
  86. Phosphodiesterase (Type 5) Inhibitors
    Sildenafil

    • Indications:
    • - Erectile dysfunction
    • - Primary pulmonary hypertension

    • Mode of Action: 
    • - PDE type-5 are in smooth muscle of corpus cavenosum of penis and arteries of lung
    • - Erection: Nitric oxide -> cGMP -> smooth muscle relaxation -> vasodialtation -> enlargement

    • Adverse Reactions:
    • - Flushing
    • - Headache
    • - Dizzy
    • - Nasal congestion
    • - Visual disorders
    • - Priapism

    • Safety:
    • - Not for patients with vasodilation
    • - Not in recet CVD
    • - ? hepatic and renal

    • Interactions:
    • - Nitrates
    • - Nicorandil
    • - Metabolised by P450

    • Prescribing:
    • - Viagra
    • - Revatio for pulmonary hypertension

    • Administration:
    • - Absorption of oral sildenafil and onset of effect is delayed with food

    • Communication:
    • - Still need sexual stimulation
    • - Take 1 hour before sex
    • - Don't take with amyl nitrate (poppers)

    • Monitoring:
    • - Review

    • Cost:
    • - Expensive
  87. iii
    Indications: Mode of Action: Adverse Reactions:Safety:Interactions:Prescribing:Administration:Communication:Monitoring:Cost:

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