PSA Notes 1

Prescribing Safety Assessment: Notes

Table of Contents

Overview and Key Information ........................................................................................................................................... 2

Prescribing ............................................................................................................................................................................ 4

Prescription Review ............................................................................................................................................................. 5

Data Interpretation ............................................................................................................................................................... 7

Planning Management ....................................................................................................................................................... 12

Communicating Information ............................................................................................................................................. 13

Calculation Skills ................................................................................................................................................................ 14

Drug Monitoring .................................................................................................................................................................. 14

Adverse Drug Reactions ................................................................................................................................................... 16

Specific Topics ................................................................................................................................................................... 17

Intravenous (IV) Fluids ..................................................................................................................................................................17
Hypertension (HTN) ......................................................................................................................................................................18
Type 1 Diabetes (Insulin, Hypoglycaemia) ....................................................................................................................................19
Type 2 Diabetes (Medications) .....................................................................................................................................................22
Hormonal Contraceptives (COCP, POP) ........................................................................................................................................23
Hormone Replacement Therapy (HRT) .........................................................................................................................................25
Anti-emetics .................................................................................................................................................................................27
Constipation, Diarrhoea, Insomnia ...............................................................................................................................................28
Steroids .........................................................................................................................................................................................29
Statins ...........................................................................................................................................................................................30
Opiates .........................................................................................................................................................................................31
Palliative Care ..........................................................................................................................................................................31
Non-Palliative Care ..................................................................................................................................................................32
Miscellaneous ...............................................................................................................................................................................33

Mock Exams ........................................................................................................................................................................ 35

PSA Book Mock 1 (157/200; 78.5%) .............................................................................................................................................35
PSA Book Mock 2 (183/200; 91.5%) .............................................................................................................................................36
PSA Demonstration Paper (74/100; 74%).....................................................................................................................................37
Official Mock 1 (82/100; 82%) ......................................................................................................................................................38
Official Mock 2 (85/100; 85%) ......................................................................................................................................................39
Official Mock 3 (91/100; 91%) ......................................................................................................................................................39
PSA Notes 2

Overview and Key Information

• Structure of the exam:
o (1) Prescribing
o (2) Prescribing review First 2 sections are most of the marks
o (3) Data interpretation
o (4) Planning management
o (5) Communicating information
o (6) Calculation skills
o (7) Drug monitoring
o (8) Adverse drug reactions

DVT Treatment If concomitant cancer, always use LMWH

• (Option 1) à LMWH + warfarin (SC à PO and monitor)

o LMWH = dalteparin, tinzaparin, enoxaparin, (fondaparinux) Learn ONE in detail

o Enoxaparin sodium:
§ Dosing (prophylactic), SC:
• Medical 40mg/24 hours
• Surgical (moderate risk) 20mg, (2 hrs pre-surgery) à 20mg/24 hours
• Surgical (high risk) 40mg, (12 hrs pre-surgery) à 40mg/24 hours
§ Dosing (treatment), SC:
• No RFs à 1.5mg/kg/24hrs (until oral anticoagulation established) N.B. DOAC
• RFs à 1mg/kg/12hrs (until oral anticoagulation established) used now…
§ Reversal agent = protamine sulphate
§ SEs: heparin-induced thrombocytopenia (switch to danaparoid), hyperkalaemia (inhibits
aldosterone secretion), headache, hypersensitivity
§ AVOID in… eGFR <15mL/min (dose adjust if eGFR <30mL/min or weight <50kg)

• (Option 2) à DOACs (PO; no monitor) = DEAR:

o Prior LMWH (≥5 days) à DOAC dabigatran, edoxaban
o No prior LMWH required à DOAC apixaban, rivaroxaban * * take with food

o Reversal agent (dabigatran) = idarucizumab

o Reversal agent (apixaban, rivaroxaban) = andexanet alfa

o Apixaban:
§ Dosing:
• DVT, PE 10mg, BD, 7 days à 5mg, BD (3 or 6 months)
• Recurrent DVT, PE 2.5mg, BD, ongoing after 6 months treatment
§ CI: APLS (inc. risk of VTE; use LMWH à warfarin), other ABx/anti-virals (check BNF)
§ AVOID in… pregnancy, eGFR <15mL/min

Atrial Fibrillation

• Rate control (beta-blocker (not sotolol) or rate limiting CCB)

• Anticoagulation (CHA2DS2VASc à HAS-BLED score once on anticoagulation; Apixaban)

Anti-emetics

• Haloperidol Metoclopramide (narrow spectrum)

• Domperidone Cyclizine (narrow spectrum)
• Ondansetron Levomepromazine (broad spectrum)
PSA Notes 3

Diabetic Ketoacidosis (DKA)

• Diagnosis:
o Acidaemia (pH<7.3)
o Hyperglycaemia (BM>11)
o Ketonaemia (>3) or significant ketonuria

• IV fluid: 1L 0.9% saline over 1 hour à over 2 hours à over 4 hours à over 8 hours
o SBP <90 à 500ml bolus over 15 minutes + re-assess

• FRII (50 units human soluble insulin to 50ml 0.9% saline) à VRII
o Infuse continuously at 0.1 unit/kg/hr

• Monitor: glucose, potassium, pH

o Aim for fall in blood ketones (0.5mmol/L/hr)
o Glucose <14mmol/L à start 10% glucose to run alongside Saline
o Continue fixed-rate insulin until ketones <0.6mmol/L, venous pH<7.3, venous bicarbonate>15mmol/L

Hyperosmolar Hyperglycaemic State (HHS)

• Diagnosis:
o Glucose >33.3 mmol/L
o Hyperosmolar (osmolality >320 mmol/kg)
o Volume-deplete in absence of significant ketoacidosis

• Similar to DKA mx but 1⁄2 the rate of fluids requirements:

o I.E. initially, 1L NaCl 0.9% over 2 hours
o Replace K+ when urine starts to flow
o Only use insulin if BG not falling by 5mmol/L with rehydration or if ketonaemia
o Keep BG at least 10-15mmol/L for first 24h to avoid cerebral oedema

PSA Introductory Lecture Notes

• Monitoring questions – there are two types of monitoring questions:

o How do you know this drug is working? BNF and CKS not useful, use clinical judgement
o How do you monitor toxicity? BNF helpful

• Allergy and life-threatening infection (i.e. meningitis) and medications (i.e. benzylpenicillin):
o Anaphylaxis à do not give (even if a query of meningitis)
o Minor rash (immediate) or rash that occurs >72 hours after administration à give benzylpenicillin

KEY BNF SHORTCUTS

• Children BSA calculation à “Body surface area in children (image)”

• Approximate weights à “Approximate conversions and units”
• Calculating eGFR à “Prescribing in renal impairment”
PSA Notes 4

Prescribing
• Basic principles… every drug prescription must be:
o Unambiguous and specific (i.e. not a range of doses)
o An approved generic name (exception: Tacrolimus as switching brands causes toxicity)
§ Tazocin ® is NOT acceptable
o IN CAPITALS and no abbreviations 8 Q worth 10 marks each
o Signed and with bleep number 80 marks available (much more than other sections)
o If PRN, provide 2 instructions…
§ Indication
§ Maximum frequency (i.e. BD or total dose in 24 hours, i.e. paracetamol)
o If ABx, provide indication and stop/review date
o Include duration of treatment if not long-term (i.e. ABx for 7 days)

• Enzyme inducers and inhibitors to know:

o Inducers à increase p450 enzymes à decreased drug concentration
o Inhibitors à decrease p450 enzymes à increased drug concentration
§ I.E. Warfarin and Erythromycin (warfarin can accumulate and cause an acute bleed)

Inducer [PC BRAS] Inhibitor [ZAG DEVICES]

Phenytoin “-zoles” [omeprazole, ketoconazole, fluconazole]
Carbamazepine Allopurinol
Barbiturates Grapefruit juice
Rifampicin Disulfiram
Alcohol (chronic excess; days-weeks) Erythromycin, Clarithromycin (macrolides)
Sulphonylurea Valproate
Isoniazid
Ciprofloxacin
Ethanol (acute excess; hours-days)
Sulphonamides, Statins (competitive)

Drugs for Surgery

Drug to Stop When? [0 = surgery day] Replacement (if indicated)
Insulin 0 sliding scale
Lithium -1 (the day before)
Anti-coagulants/platelets * -5 (5 days)
COCP -28 (4 weeks)
ACEi, ARB, K+ sparing diuretics 0
Oral hypoglycaemics 0 Maybe VRII *

• Metformin and surgery (see here):

o ≤1 meal missed, eGFR >60, low risk AKI à continue metformin
o >1 meal missed OR AKI risk à omit metformin ± VRII (if ≥BD)

• Start VRII (Variable Rate Insulin Infusion) if…

o T1DM
o >1 missed meal
o Poor control (BM ≥12mmol/L (aim: 6-10 mmol/L); >69mmol/mol / 8.5%)
o Post-MI with diabetic mediations stopped (metformin, sulphonylureas)

• * if warfarin and…
o Stopped ≥5 days prior and INR ≥1.5 à PO phytomenadione
o Emergency surgery, can be delayed 6-12 hours à IV phytomenadione
o Emergency surgery, no delay à IV phytomenadione + IV PCC

Drug to Increase When? [0 = surgery day]

Steroids à x2 0
PSA Notes 5

Prescription Review
• Overview à 8Q [4 marks per question, 32 max marks] à identify what drug may be causing the problem…

• PReSCRIBER:
o Patient details (3 identifying factors OR addressograph)
o Reaction (allergy + reaction to drug)
o Sign the front of the chart
o check for Contraindications to each drug
o check Route for each drug
o prescribe IV fluids if needed
o prescribe Blood clot prophylaxis if needed
o prescribe anti-Emetics if needed
o prescribe pain Relief if needed

• Contraindications to know about…

o (1) Drugs that increase bleeding (aspirin, heparin, warfarin) not to be given to those…
§ Suspected of bleeding
§ At risk of bleeding
• Prolonged PT in liver disease
• Acute ischaemic stroke (haemorrhagic transformation; ≤2 months)
§ On enzyme inhibitors (i.e. erythromycin) and warfarin

o (2) Steroid side effects (STEROIDS):

§ Stomach ulcers
§ Thin skin (easy bruising)
§ (O)edema
§ Right (and left) heart failure
§ Osteoporosis
§ Infection
§ Diabetes
§ Syndrome (Cushing’s)

o (3) NSAID cautions and CIs (NSAID):

§ No urine (renal failure)
§ Systolic dysfunction
§ Asthma
§ Indigestion
§ Dyscrasia of the blood (clotting abnormality)

o (4) Antihypertensives:
§ Hypotension STOP BB IN ACUTE HF
§ Bradycardia (BB, CCBs)
§ Electrolyte disturbances (ACEi, diuretics)
§ Individual side effects:
• ACEi dry cough
• BB asthmatic wheeze, worsen acute HF (helps chronic HF)
• CCBs peripheral oedema, flushing
• Diuretics renal failure, gout (loop diuretics), gynaecomastia (spironolactone)

• Anti-emetics and the route of administration:

o Nauseated:
§ 1st line (most cases) à Cyclizine, 50mg 8-hourly, IM/IV/oral
• SE: fluid retention (not for HF)
§ 2nd line à Metoclopramide, 10mg 8-hourly, IM/IV/oral
• Avoid in Parkinson’s (DA antagonist) – use domperidone (does not cross BBB)
• Avoid in young women (risk of dyskinesia i.e. acute dystonia)
o Not nauseated, PRN:
§ Cyclizine, 50mg up to 8-hourly almost all cases prescribe this
§ Metoclopramide, 10mg up to 8-hourly if fluid retention, prescribe this
PSA Notes 6

• Blood clot prophylaxis:

o Majority = LMWH + compression stockings
o NOT if at risk of bleeding / recent ischaemic stroke (≤2m) / if patient has PAD (absent foot pulses)

• Medication side effects of note:

o Insulin is never given IV – only SC (except sliding scales with short-acting – Actrapid or Novorapid)
o BEWARE: warfarin + ciprofloxacin / erythromycin
o Addison’s disease à double hydrocortisone when sick
o Neutropenic sepsis à Piptazobactam (Tazocin) + Gentamicin
o Arrhythmia + hypotension à digoxin (no BB or non-DHP as can cause hypotension)

Medication Side Effect

Hyperkalaemia
ACEi Cough
ARF – reduces AngII à less preservation of GFR
Hyper/hypothyroid
Amiodarone
Corneal deposits
Related to iodine “amIODarone”
Skin greying

ARBs Hyperkalaemia
Beta blockers Bronchoconstriction (asthma)
Bisoprolol, 10mg OD Bradycardia (when used with a non-DHP CCB – i.e. verapamil + propranolol)
CCBs Peripheral oedema (often treated wrongly with furosemide – just stop CCB)
- DHP (amlodipine, nifedipine) Bradycardia (non-DHP when used with a BB – i.e. verapamil + propranolol)
- Non-DHP (verapamil, diltiazem) Flushing

Ciclosporin (lots of side effects) Hyperkalaemia, gingival hypertrophy, leucopenia

Ciprofloxacin tinnitus

Clozapine Agranulocytosis

COCP (Microgynon 30) Stroke (in migraines with aura) à regular check of BP and BMI

Enoxaparin (heparin) Bleeding (≤2m after a stroke)

K+-sparing diuretics Hyperkalaemia

Loop diuretics Hypokalaemia, gout

Methotrexate Neutropenic sepsis (folate antagonist)

Metoclopramide Exacerbates parkinsonism (crosses BBB, unlike domperidone)

Stomach ulcers
NSAIDs (Ibuprofen) ARF (reduces PGI2 synthesis à reduces renal artery diameter)
Max dose: 2.4g/day Bronchoconstriction (asthma; if non-sensitive, they may continue)
Peripheral oedema

Constipation
Opiates
Urinary retention

“STEROIDS” – Stomach ulcers, Thin skin, Oedema, Right- (and L-) HF,
Steroids
Osteoporosis, Infection, Diabetes, Syndrome (Cushing’s)

Thiazides Hypokalaemia, dyslipidaemia (inhibits lipoprotein lipase), gout

Thiazolidinedione fluid retention

Trimethoprim Neutropenic sepsis (folate antagonist)

PSA Notes 7

Data Interpretation
• Overview à 6Q [2 marks per question, 12 max marks]

• Haematology:
o Hb, MCV

Macrocytic Anaemia – AMHLF

Microcytic Anaemia – TAILS Normocytic Anaemia – MR I CALM
Alcoholics May Have Liver Failure
Thalassaemia Marrow failure Alcoholism
Anaemia of Chronic Disease Renal failure Myelodysplastic syndrome, Multiple myeloma
Iron deficiency anaemia Iron deficiency (early) Hypothyroidism, Haemolytic anaemia
Lead poisoning Anaemia of Chronic Disease (early) Liver failure
Aplastic anaemia, Acute blood loss
Sideroblastic anaemia (congenital) Leukaemia Folate/B12 deficiency
Myelofibrosis

o WCC
§ High neutrophils BACTERIAL, tissue damage, steroids
§ Low neutrophils VIRAL, chemo/radiotherapy, clozapine, carbimazole
§ High lymphocytes VIRAL, lymphoma, CLL

o Platelets
§ High platelets Reactive or primary
• Reactive Bleeding, tissue damage, post-splenectomy
• Primary MPD
§ Low platelets Increased destruction or reduced production
• Increased destruction Heparin, hypersplenism, DIC, ITP, HUS/TTP
• Reduced production Infection (viral), drugs (penicillamine), MDS/PMF/myeloma

• Biochemistry:
o U&Es

§ Sodium (135-145) – euvolaemic hyponatraemia SIADH causes…

• CNS pathology – stroke, haemorrhage, tumour
• Lung pathology – pneumonia (Legionella), pneumothorax
• Drugs – SSRI, TCA, PPI, carbamazepine, opiates
• Tumours
• Surgery

Hypernatraemia Hyponatraemia
PSA Notes 8

§ Potassium (3.5-5.3)
• Hyperkalaemia à ACEi, ARBs, K+-sparing diuretics; also note…
o Artefact (clotted sample – very common)
o DKA
• Hypokalaemia à loop diuretics, thiazides

Hyperkalaemia Hypokalaemia

§ AKI
• Raised urea = AKI, UGI haemorrhage (Hb digested to urea) or eat a big steak
• A raised urea with normal creatinine in a patient who is not dehydrated would prompt
you to look at the Hb (if dropped, probably = UGI bleed)

• Urea = 3-7.5 mmol/L

• Creatinine = 35-125 umol/L

• Pre-renal (70%) urea rise >> creatinine rise [i.e. U 19; Cr 110]
o Dehydration/shock
o RAS (precipitated by ACEi or NSAIDs

• Intrinsic renal (10%) urea rise << creatinine rise [i.e. U 9; Cr 342]
o “INTRINSIC”
§ Ischaemia (pre-renal AKI à ATN)
§ Nephrotoxic ABx (gentamicin, vancomycin, tetracyclines)
§ Tablets (ACEi, NSAIDs)
§ Radiological contrast
§ Injury (rhabdomyolysis)
§ Negatively birefringent crystals (gout)
§ Syndromes (glomerulonephritis)
§ Inflammation (vasculitis)
§ Cholesterol emboli
o Bladder/hydronephrosis not palpable

• Post-renal (20%) urea rise << creatinine rise [i.e. U 9; Cr 342]

o Bladder/hydronephrosis may be palpable

o Luminal (i.e. stones)

o Mural (i.e. transitional cell carcinoma)
o Extra-mural (i.e. BPH)
PSA Notes 9

• Liver Function Tests:

o AST > ALT = alcoholic hepatitis
o ALT > AST = other hepatitis

o ALP found in placenta, bone, liver and bowel wall

o Cholestatic drugs = flucloxacillin, co-amoxiclav, nitrofurantoin, steroids, sulphonylureas

o DILI anti-TB drugs = isoniazid, pyrazinamide

• Thyroid Function Tests:

o Question: change a Levothyroxine dose according to TFT result for a patient with hypothyroidism
§ Use TSH as a guide (target range: 0.5-5mIU/L)
§ Change by the smallest increment offered

• CXR:
o RIPE à ABCDE approach
o Likely scenarios: Pneumonia, pulmonary oedema

• ABG:
o 1st à check PaO2 (= FiO2 – 10):
§ Room air (FiO2 20%) à PaO2 should be ≥10 (if <10, they are hypoxic)
§ FiO2 60% à PaO2 should be ≥50 (if PaO2 <50, they are hypoxic)
PSA Notes 10

o 2nd à check for respiratory failure (if PaO2 low or inappropriately normal / high FiO2):
§ T1 RF (low/normal PaCO2, low O2)
§ T2 RF (high PaCO2, low O2)

o 3rd à acid-base balance

• ECGs – n.b. withhold digoxin in slow AF…

o QRS deflection of V1 + QRS deflection of V6 (in terms of large squares) ≥3.5 = LVH
o TWI normal in aVR and lead I [top middle 2 leads]

• Drug monitoring:
o Narrow therapeutic index drugs à require monitoring… note:
§ If low serum drug level AND inadequate clinical response – INCREASE drug level
§ If low serum drug level BUT adequate clinical response – do NOT increase drug
§ If high serum drug level AND adequate clinical response – DECREASE drug level
• Except gentamicin – the frequency of administration is decreased, not the amount

Drug Features of Toxicity

Digoxin Confusion, nausea, visual halos, arrhythmias
Early – tremor
Lithium Intermediate – tiredness
Late – arrhythmias, seizures, coma, ARF, DI
Phenytoin Gum hypertrophy, ataxia, nystagmus, peripheral neuropathy, teratogenicity
Theophylline N/A
Gentamicin Ototoxicity, nephrotoxicity
Vancomycin Ototoxicity, nephrotoxicity

o If evidence of toxicity…
§ Stop drug (± alternative)
§ Supportive measures (IV fluids)
§ Antidote (if available)

o Gentamicin monitoring:
§ Dose by patient weight and renal function (serum creatinine)
• Usual dose (high-dose regimen) = 5-7mg/kg, OD (24-hourly)
• Renal failure (<20mL/min CrCl) = 1mg/kg, BD (12-hourly)
• Infective endocarditis = 1mg/kg, TDS (8-hourly)
§ OD regimen monitoring:
• Measure levels at particular times (6-14 hours after last infusion)
• Plot on a nomogram (see below)
• Use nomogram to determine frequency of dosing (every 24, 36 or 48 hours)
§ Divided daily dosing:
• Nomogram exists but usually, daily peaks and troughs are used to guide treatment

OD Regimen Monitoring Divided Daily Dosing Monitoring

PSA Notes 11

o Paracetamol nomograms:
§ Paracetamol overdose:
• <1hr à activated charcoal à Ix: paracetamol level ≥4hr after ingestion à? NAC
o If below the treatment line at 4 hours post-ingestion, no NAC is required
o If staggered overdose taken or time not known of ingestion, use NAC
• >1hr à Ix: paracetamol level ≥4 hours after ingestion à? NAC
o NAC = N-acetylcysteine
o Use NAC graph to decide whether to administer
• LFTs
o ALT, AST: very high [peak at 72 hours post-ingestion]
o ALP: normal
o PT: if >180 seconds on day 4 will need transplantation
§ Fluids supportive management is also given

o Warfarin (stopped 5 days before surgery):

§ Action à inhibits vitamin K epoxide reductase which reduces levels of factors 2, 7, 9, 10
• INR = normalised version of PT (extrinsic, F7) used to overcome differences between
lab measurements and is only useful in warfarin monitoring (no other conditions)
§ Normal INR targets:
• AF, DVT, cardioversion, cardiomyopathy, MI à 2-3
• Recurrent VTE on warfarin, mechanical heart valve à 3-4
§ Warfarin ‘overdose’:
• Major bleed (à hypotension OR bleed in a confined space – i.e. skull, eye)
o Stop warfarin
o IV vitamin K (5mg, slow IV) – Phytomenadione
o IV PCC – Beriplex BNF: “oral anticoagulants”

INR Level Action

>8, minor bleeding Stop warfarin, IV vitamin K (1-3mg; repeat in 24hrs if still high), restart warfarin when INR <5

>8, no bleeding Stop warfarin, PO vitamin K (repeat in 24hrs if still high), restart warfarin when INR <5

5-8, minor bleeding Stop warfarin, IV vitamin K (1-3mg), restart warfarin when INR <5

5-8, no bleeding Withhold 1-2 doses of warfarin, consider reducing maintenance dose
PSA Notes 12

Planning Management
• Emergency / Acute Conditions:

o Cardiac disease:
§ Aspirin 300mg PO
§ Morphine 10mg IV + Metoclopramide 10mg IV
§ Clopidogrel 300mg PO + Ticagrelor 180mg PO
§ Enoxaparin 1mg/kg BD SC (NSTEMI)
§ Atenolol 5mg PO (BB in ACS – unless LVF/asthma)
§ Furosemide 40-80mg IV à if inadequate response à Isosorbide Dinitrate Infusion ± CPAP

o Anaphylaxis à ACH:
§ Adrenaline, IM 0.5mg (500mcg, 1 in 1,000)
§ Chlorphenamine, IV 10mg
§ Hydrocortisone, IV 200mg

o AE-COPD/asthma:
§ Salbutamol, Neb. 5mg
§ Ipratropium bromide, Neb. 0.5mg (500mcg)
§ Hydrocortisone, IV 100mg / PO 50mg

o Pneumonia (CURB-65 first):

§ Mild à amoxicillin
§ Severe à co-amoxiclav + clarithromycin

o Pneumothorax:
§ Primary (no lung disease):
• <2cm Air Rim à conservative
• >2cm AR à aspirate (à no success à chest drain)
§ Secondary (lung disease OR >50yo smoker):
• <1cm AR à conservative admission
• 1-2cm AR à aspirate
• >2cm AR à chest drain

o PE (NEW DOAC GUIDELINES):

§ Pain/nauseous à Morphine 10mg IV + Metoclopramide 10mg IV
§ Low BP à IV Gelofusine à noradrenaline à thrombolysis

§ Haemodynamically stable à DOAC for 3 months (or 6 months if unprovoked) ARDE

• No prior LMWH required à DOAC apixaban, rivaroxaban
• Prior LMWH (≥5 days) à DOAC dabigatran, edoxaban
§ Haemodynamically unstable à alteplase (10mg IV STAT à 90mg IV over 2 hours)

§ LMWH notes:
• N.B. LMWH, 1mg = 100 U N.B. >10,000U = treatment
• Enoxaparin, tinzaparin, dalteparin <10,000 U = prophylaxis

o AKI:
§ 1st à cannula, catheter, strict fluid monitoring
§ 2nd à 500mL fluid bolus à 1L, 4-hourly
§ 3rd à find cause…
BNF: “central nervous system infections”
o Misc. other emergencies à see main notes…
§ Meningitis à ben-pen + ceftriaxone ± ampicillin (elderly/neonate) ± aciclovir (behavioural)
§ Status epilepticus à lorazepam (0.1mg/kg à 4mg) / diazepam/midazolam (10mg)
§ DKA / HHS (see main notes)
§ Stroke (see main notes)
§ Poisoning (see main notes)
PSA Notes 13

Communicating Information
• Outline à know what drug information is relevant to patients

• No guidelines so better to be aware of the most common drugs and pertinent information:

Drug / Drug Class Information

Teratogenic
ACEi Hyperkalaemia
Extra caution with D+V

Increases risk of endometrial cancer

Tamoxifen [SERM] Increases efficacy of warfarin à high INR
Side effects: hot flushes, VTE risk

Hypoglycaemia
Sulphonylurea [i.e. Gliclazide]
Glibenclamide is a long-acting SU and so can cause long hypos

1-2 weekly blood tests (neutropoenia)

Methotrexate Taken once weekly
Folate antagonists should never be co-prescribed

Side effects: bleeding

Alcohol interaction (acute = inhibitor; chronic = inducer)
Warfarin
Colour-coded (white 0.5mg, brown 1mg, blue 3mg, pink 5mg)
Once weekly à once monthly INR monitoring

Regular BM monitoring
Steroids Gastroprotection
>3m treatment à bone protection

Initial 1-2w period of increased anxiety / suicidal ideation

SSRIs Takes up to 6w to work
Side effects: photosensitivity, dry mouth, serotonin syndrome

Higher requirements when unwell (higher BMs)

Insulin therapy Lower requirements when not eating as much
Lipodystrophy (if not rotating injection sites)

Regular U&Es required

Ciclosporin
Every 2w for first 3m à monthly

Taken with a full glass of water, remaining upright for 30 minutes

Once weekly (alendronic acid)
Bisphosphonates
Calcium salts (i.e. vitamin D3) reduce bisphosphonate absorption
Food reduces bisphosphonate absorption (avoid for 2 hours)
Alendronic acid
Side effects: osteonecrosis (EAC, jaw), oesophageal reactions
PSA Notes 14

Calculation Skills
• Calculate a dose OR rate of administration of a drug

• 1% = 10mg in 1mL

• 1 in 1,000 = 1g in 1,000mL = 1mg in 1mL

• 1 in 10,000 = 1g in 10,000mL

o I.E. how many mg is in 1mL of a 1% lignocaine solution? à 10mg

o I.E. express 250mcg/mL as a percentage à 250mcg = 0.25mg à 10/0.25 = 40 à 1/40 = 0.025%
o I.E. how much volume given in 0.5mg of 1 in 1,000 solution? à 0.5mg = 0.0005g à * 1,000 = 0.5mL

• How much NaCl to be added to an ampoule of hydralazine 20mg/2mL to make a 1mg/1mL dilution?

o (1) 20 mg in 2mL ampoule

o (2) need 20mg in 20mL
o (3) add 18mL to the 2mL to get to 20mL à 20mg in 20mL (= 1mg/mL solution)

Paracetamol IV
Weight >50kg = 1g (over 15 minutes), 4-hourly (max: 4g)
Drug Monitoring Weight <50kg = 15mg/kg (over 15 minutes), 4-hourly (max: 60mg/kg)

• 8 questions, 2 marks each à 16 marks total

• How to effectively monitor drug therapy – i.e. statin therapy à myopathy risk in those with RFs (personal/FHx
muscular disorders, history of muscular toxicity, high alcohol, renal impairment, hypothyroidism, elderly):
o RFs present à baseline CK level
o No RFs presentà baseline ALT level

Drug / Class Monitoring Notes

Creatinine Rare SEs: neutropenia, thrombocytopenia

Vancomycin
Hearing (not monitored)

Risk factors à CK CI: active liver disease, ALT/AST ≤3x normal

No risk factors à ALT
RFs: personal/FHx muscular disorders, history of
Statin Check LFTs at 3 and 12 months muscular toxicity, high alcohol, renal impairment,
hypothyroidism, elderly
Stop if taking a macrolide
Caution in CYP-i (ZAG DEVICES) Take ON (most cholesterol metabolism ON)

Nil (only check if adjusting dose, suspected Post-dose levels are not measured
Phenytoin toxicity, suspected non-adherence) After 14 days, levels do not change much

Ciclosporin Trough levels immediately before dose

Therapeutic range = 0.4-0.8mmol/L

Lithium Sample 12 hours after last dose Toxic effects >1.5mmol/L
Low Na+ à higher lithium toxicity risk
not metabolised by CYP,
Monitor weekly after 1st dose / change until
renally excreted and so is
impacted by AKI levels stable à every 3 months Anti-HTN = use CCBs* (not ACEi, thiazides, loops)
* = amlodipine; NO NSAIDs
PSA Notes 15

Report sore throats / infections

FBC, U&Es, LFTs every 1-2w until stable
FBCs, U&Es, LFTs every 2-3 months
Methotrexate No need to have a baseline CXR
Usually taken OW
CI: abnormal LFTs

Monitor 0m 1m 3m 6m Yearly
ECG RFs
Antipsychotics Prolactin
ECG only if risk factors of CVD
Lipids
Olanzapine
Weight
BMs

BP monitoring (Na+ retention)

OCP HTN à increased arterial disease risk
BMI monitoring

0m/ TFTs (TSH, T3 and T4)

Monitor 6-monthly
baseline
CXR Commence with caution in hypokalaemia due to
Amiodarone TFTs increased risk of arrhythmias

LFTs Amiodarone does not affect renal function but

K+ should be adjusted to renal function

Carbimazole FBC (neutrophils) Agranulocytosis (BM suppression)

Pre-dose
Indication 1-hour Peak
Trough
Other 5-10mg/L <2mg/L
SEs: renal toxicity, ototoxicity
Gentamicin Endocarditis 3-5mg/L <1mg/L
If high 1-hr peak à reduce dose
IV U&Es (baseline and during treatment)
If high trough à increase interval (i.e. stop)
Auditory monitoring

Vestibular monitoring

SEs: hyperkalaemia, hyponatraemia, AKI, cough,

angioedema (months later)
ACEi U&Es (creatinine, K+)
CI: aortic stenosis

Digoxin is renally excreted and so to prevent

U&Es (creatinine, K+)
toxicity, one must check for renal dysfunction
Digoxin
Levels at least 6 hours post-dose (IV)
Hypokalaemia à digoxin toxicity

Sodium valproate LFTs (ALT; before, during first 6 months) SEs: pancreatitis

Agranulocytosis (BM suppression)

See Antipsychotics section above
All patients must be registered with a clozapine
FBC Monitoring
monitoring clinic
Clozapine
First 18 weeks à every 1 week
Stop clozapine if…
18 weeks – 1 year à every 2 weeks
leucocytes <3,000 cells/mm3
>1 year à every 4 weeks (month)
neutrophils <1,500 cells/mm3

• Thiazides à dyslipidaemia, not in eGFR <30

• Furosemide + lithium à inc. lithium concentration (as less renal excretion of lithium)
PSA Notes 16

Adverse Drug Reactions

• 8 questions, 2 marks each à 16 marks total

• Types of ADR:
o Type 1 (identify adverse effects of common drugs)
o Type 2 (recognising common reactions)
o Type 3 (identify clinically important drug interactions)
o Type 4 (recognise and manage an ADR – anaphylaxis, excessive anticoagulation, drug-induced
hyperglycaemia, diuretic-induced dehydration)

• Drugs with a narrow therapeutic index à Warfarin, Digoxin, Theophylline, Phenytoin, Lithium
• Drugs that require careful titration of dose according to effect à antihypertensives, anti-diabetic drugs
o Leads to clinically significant consequences (i.e. hypoglycaemia)
o Body’s handling of these drugs may be affected by the addition of other drugs
§ I.E. radiological contrast à AKI à metformin-induced lactic acidosis in T2DM
• Drugs that affect (or are affected by) the cytochrome p450 enzyme system:
o Enzyme induction takes days-weeks to establish
o Enzyme inhibition only take hours-days

Inducer [PC BRAS] Inhibitor [ZAG DEVICES]

Phenytoin “-zoles” [omeprazole, ketoconazole, fluconazole]
Carbamazepine Allopurinol
Barbiturates Grapefruit juice
Rifampicin Disulfiram
Alcohol (chronic excess) Erythromycin
Sulphonylurea Valproate
Isoniazid
Ciprofloxacin
Ethanol (acute excess)
Sulphonamides

• Digoxin:
o SEs: N&V, blurred vision, xanthopsia (disturbed yellow/green vision incl. ‘halo’ vision)
o MoA: antagonises K+ at myocyte Na/K-ATPase limiting Na+ influx à Ca2+ accumulates inside the
cell, prolonging the action potential à lowing of heart rate
§ Hypokalaemia à enhances digoxin effect
§ Hyperkalaemia à reduces digoxin effect
• Amiodarone (related to iodine; amIODarone) à SEs: hyper/hypothyroid, skin greying, corneal deposits
o Mx: withhold amiodarone if thyrotoxic
• Lithium à SEs: tremor à tiredness à arrhythmias, seizures, coma, AKI/CRF, DI
• BB + Verapamil à profound hypotension + asystole
• Trimethoprim + Methotrexate à BM suppression, pancytopenia, neutropenic sepsis
o Trimethoprim, methotrexate = folate antagonists
o Trimethoprim strongly CI in patients taking Methotrexate
• Alcohol leads to…
o UGIB (aspirin, NSAIDs)
o Excessive anticoagulation (acute ETOH excess and warfarin)
o Sweating, flushing, N&V (metronidazole, disulfiram)
o Lactic acidosis (metformin)
o Hypertensive crisis (MAO-I, RIMA)
o Sedation (barbiturates, opioids, BDZs)
• ACEi + NSAIDs à AKI
o ACEi à dilates efferent vessel; NSAIDs à constrict efferent vessel
o Reduces renal perfusion pressure à AKI
• ACEi (i.e. carvedilol) + K-sparing diuretic (i.e. amiloride) à hyperkalaemia
• Ciprofloxacin à tinnitus
• Thiazides à dyslipidaemia (inhibits lipoprotein lipase in capillaries à more lipoproteins), gout
PSA Notes 17

Specific Topics
Intravenous (IV) Fluids
• (1) Give all patients 0.9% Sodium Chloride (normal saline, a crystalloid) unless:
o Hypernatraemic / hypoglycaemic à 5% Dextrose
o Ascites à Human Albumin Solution (HAS)
o Bleeding shock à blood transfusion (crystalloid first if no blood available)

• (2) How much and how fast?... assess HR, BP and UO:
o HR ­ / BP ¯ à 500mL bolus over 15 minutes à further 250-500mL bolus PRN (max: 2L)
o UO ¯ (no obstruction) à 1L over 2-4 hours à reassess

o How deplete is the patient? NICE IV fluids

§ UO ¯à 500mL deplete
§ UO ¯ + HR ­ à 1L deplete
§ UO ¯ + HR ­ + BP ¯ à >2L deplete

• Resuscitation fluid:
o Sodium chloride 0.9%
o 500mL bolus à 250-500mL PRN bolus (if HF and still fluid deplete, use 500mL)
o Over 15 minutes

• Maintenance fluid (example):

o Sodium chloride 0.9% + 40 mmol K+ ± glucose (if NBM) 20mmol bags of K+ exist as well
o 1L
o Over 8-12 hours

o Requirements:
§ 25-30mL/kg/day fluid (20-25mL/kg/day if frail, obese, cardiac or renal impairment):
§ 1 mmol Na+, K+, Cl-/kg/day (all contained in Hartmann’s)
§ 50-100g glucose/day (5% dextrose = 50g glucose = enough glucose one day)

§ 70kg, healthy person:

• 2L (elderly) to 3L water 1 salty, 1 (±1) sweet
• 70 mmol each of Na, K and Cl
• 50-100 g dextrose

§ First bag, 8-hourly (or 12-hourly) = 1L 0.9% saline + 0.3% (40mmol) K+

§ Second bag, 8-hourly (or 12-hourly) = 1L 5% dextrose ± 0.15% (20mmol) K+
§ ± Third bag, 8-hourly = 1L 5% dextrose ± 0.15% (20mmol) K+

§ In reality, this regimen would be tweaked based on the presentation of the patient

§ Stroke patients: day 1: x2 1L NaCl 0.9% à day 2: 1L glucose 5%, 1L NaCl 0.9%
• Glucose can cause cerebral oedema in the acute phase of stroke

o Na+ requirement:
§ 154mmol Na+ in 1L of NaCl (it is fine to exceed the normal requirement)
§ Hartmann’s has… 131mmol Na+, 5mmol K+, 111mmol Cl-, 29mmol HCO3-

o K+ requirement:
§ Comes in bags of 20mmol or 40mmol
§ Put 20 or 40 mmol of K+ in bag 1 of NaCl and then 40mmol of K+ in bag 2
• Note; 60mmol K+ will be fine to support a 70kg person
• Even if on the high end of the normal range of K+ à still give K+
§ Infusion:
• <40mmol/L concentration (any higher will irritate veins)
• <10mmol/hour infusion (any higher will cause arrhythmias)
o >20mmol/hour needs cardiac monitoring as can cause arrhythmias
PSA Notes 18

Hypertension (HTN)

• Investigations:
o 1st à Ambulatory BP monitoring / ABPM
o 2nd (if 1st line declined) à Home BP monitoring / HBPM

Stage of HTN Criteria Treatment

1 Clinic BP ≥140/90 mmHg AND ABPM / HBPM average BP ≥135/85 mmHg Only if <80yo AND *

2 Clinic BP ≥160/100 mmHg AND ABPM / HBPM average BP ≥150/95 mmHg Yes
Severe Clinic systolic BP ≥180 mmHg OR clinic diastolic BP ≥ 110mmHg Yes
* = end-organ damage, CVD, renal disease, diabetes, QRisk ≥10%

Class Example/s Side Effects Contraindications

Angioedema
ACEi Lisinopril
New jaundice
“ACEi” (angioedema, cough, elevated K+, 1st dose low BP)
Combined with Aliskiren
ARB Losartan
Severe heart failure

Cardiogenic shock
Amlodipine (DHP) Common à peripheral oedema
CCB Aortic stenosis (severe)
Verapamil (non-DHP) Uncommon à depression, ED, gingival hyperplasia
Unstable angina

Addison’s disease
Common à constipation/diarrhoea, dry mouth, ED, high BMs Hypercalcaemia
Thiazide Indapamide
Uncommon à agranulocytosis, pancreatitis, low platelets Hyperuricaemia (symptomatic)
eGFR <30

K+-sparing diuretic Spironolactone Gynaecomastia, alopecia / hypertrichosis, agranulocytosis AKI, hyperkalaemia

Common à cough, cystitis, dry mouth, influenza-like illness, Micturition syncope (in BPH)
Alpha blocker Doxazosin
infection risk increased, oedema, vertigo Postural hypotension

Beta blocker Propranolol Common à dry eye, depression, ED, PVD, rash Many – see BNF

• General notes:
o ACEi > ARB (if both applicable 1st line)
o ACEi best given in evening (as falls risk from hypotension)
o See “Drug Monitoring” for monitoring requirements
PSA Notes 19

Type 1 Diabetes (Insulin, Hypoglycaemia)

• T1DM monitoring – adult (≥4x/day incl. before meals, before bed); child (≥5x/day):
o Waking target of 5-7mmol/L
o Other targets of 4-7mmol/L avoid acute ETOH excess à hypoglycaemia
o HbA1c = monitored once per 3-6m

Types of Insulin

Rapid Short Intermediate Long

Given at start of meal Given 15-30 minutes before meal Given OD/BD or as part of a mix Given OD

Novorapid (Aspart) Actrapid Insulatard Lantus (Glargine)

Humalog (Lispro) Humulin S Humulin I Levemir (Determir)

Apidra (Glulisine) FRII (only short-acting) Insuman basal Tresiba (Degludec)

• Mixtures (BD, pre-mixed regimens):

o Intermediate + Short (30 minutes before breakfast and dinner):
§ Humulin M3 30% short-acting
§ Insuman Comb 15/25/50 15/25/50% short-acting
o Intermediate + Rapid (at start of breakfast and dinner):
§ Novamix 30 30% rapid-acting
§ Humalog Mix 25/50 25/50% rapid-acting

• Regimens:
o Basal bolus regimen [left image]
o BD pre-mixed regimen [right image]
o OD intermediate morning/evening regimen (intermediate given in OM to supplement daytime oral
hypoglycaemics or ON to reduce overnight hyperglycaemia; long-acting sometimes used)
o BD intermediate regimen (less common)

Basal-Bolus Regimen BD pre-mixed Regimen

• Starting insulin:
o N.B. normal volume = 100 UNITS in 1mL
o Biphasic insulin à 0.5 - 0.8 UNITS / kg à 2/3rds in the morning, 1/3rd in the evening

• Diabetic on insulin going to surgery:

o If glucose 4-12mmol/L à proceed with surgery
o If glucose >12mmol/L, capillary blood ketones >3 or urine ketones +++ à delay surgery
§ Give variable rate insulin (VRII)
§ 1 U = ~3mmol/L glucose drop (CF: 100/total daily insulin)
o “Diabetes, surgery and medical illness” BNF topic
PSA Notes 20

• Adjusting insulin (as a rule of thumb, adjust by 10% / smallest reasonable amount available):

o [1] Add up total daily dose (TDD) of insulin (in units)

o [2] 100/TDD = decrease in blood glucose (mmol/L) with addition of 1U of insulin

o I.E. patient with a TDD of 39 U (CF = 2.5) of insulin with 18mmol/L glucose à 4 U of insulin to bring
glucose back down (2.5 mmol/L of glucose drop with each 1 U of insulin à ~8mmol/L glucose)

o If sick, continue normal insulin but with more monitoring (adjustments may be needed, see below)
§ Metformin only needs to be stopped in ‘medical’ illness if at risk of dehydration (i.e. severe)
§ Sick day rules: [Link]

o If NBM, continue basal insulin and omit bolus insulin

o Increase insulin à DKA/HHS, sepsis, steroids, missed doses, pancreatitis, dehydration

§ I.E. IE-asthma goes home with 5 days PO prednisolone à +10% to daily insulin
o Decrease insulin à ETOH, reduced renal function, reduced calories

o Adjusting basal/bolus regimens:

§ High/low before breakfast / at night à increase/decrease evening long acting
§ High/low before lunch / dinner / bed à increase/decrease rapid acting in meal before

o Adjusting BD pre-mixed / intermediate regimens:

§ High/low before bed AND before breakfast à increase/decrease evening insulin
§ High/low before lunch AND before evening meal à increase/decrease morning insulin

o Adjusting ON regimens:
§ High/low before breakfast à increase/decrease insulin

o Adjusting OM regimens:
§ High/low before lunch AND before evening meal à increase/decrease insulin
PSA Notes 21

• Variable rate infusions (VRII):

o Indication: NBM surgery patients, post FRII in DKA
o Example protocol: see below table on page prior (adjust based on CBG monitoring)
o Mix: 50 UNITS Actrapid insulin (or Humulin S) in 50mL of 0.9% sodium chloride
o Important points:
§ CBG checked every 1-2 hours and VRI adjusted accordingly
§ IV glucose given alongside VRII to maintain hydration and basal glucose
• Medical 1L 5% glucose + 0.30% K+ at 100mL/hour
• Surgical 1L 5% glucose + 0.30% K+ at 80mL/hour
§ If on basal-bolus, continue the basal long-acting insulin but omit the short-acting
o Stopping a VRII checklist:
§ E+D normally
§ Taken long-acting insulin (≥1 hour before)
§ Taken mixed/rapid insulin at usual mealtime (and wait 30 minutes before stopping VRII)
§ Monitor CBG QDS for ≥24 hours

• Prescribing rules:
o Use insulin prescribing chart
o Must write “UNITS” instead of “U”
o Specify brand name (use Novorapid instead of Insulin Aspart)
o Specify device used
o Specify time as “pre-breakfast/lunch/dinner” instead of specific times

• Hypoglycaemia:
o 15-20g glucose over 15 minutes (10% = 10g in 100mL; 20% = 20g in 100mL)

Hypoglycaemia

Treatment (after initial mx, give long-acting CHO)

BM (mmol/L) Symptoms / State
1st choice 2nd choice

Glucotabs (4-7) OR IM glucagon OR

<4 Conscious / able to swallow 150-200mL fruit juice OR
4 teaspoons sugar dissolved in water Glucose 20%, 100mL, IV, over 10 mins

IM glucagon (community, no IV) OR

<4 Unconscious / no swallow
Glucose 20%, 100mL, IV, over 10 mins

Long-acting CHO
>4 Conscious / able to swallow (two biscuits, one slice of bread, 200–300 mL of milk)
PSA Notes 22

Type 2 Diabetes (Medications)

• 1st: Changes to Diet and Exercise / CDE (lifestyle, ETOH, diet) if… HbA1c ≥42mmol/mol (≥6.0%)
o HbA1c normal = 20-42 mmol/mol
o Mx (HbA1c 42-48 / prediabetes): diabetes prevention programme (i.e. DESMOND), advice

• 1st: Medical therapy à add if HbA1c ≥48mmol/mol (≥6.5%) … OR surgical therapy (bariatric)

o RF therapy (if CVD RFs in T2DM) à Aspirin 75mg, OD, Atorvastatin 20mg, OD, anti-HTN

o (1) Metformin
§ TARGET HbA1c <48mmol/mol (<6.5%) – single drug, not hypoglycaemic
§ MoA = ­ insulin sensitivity, ¯ hepatic gluconeogenesis
§ SEs: appetite suppression, lactic acidosis, GI upset, reduced B12 absorption
• Care in dehydration or severe illness
• Metformin and surgery (see here):
o ≤1 meal missed, eGFR >60, low risk AKI à continue metformin
o >1 meal missed OR AKI risk à omit metformin ± VRII*
§ CI: eGFR <30 (CKD 4/5; mx: gliclazide, sitagliptin), tissue hypoxia (i.e. MI, surgery), iodine
contrast (stop on day and 48 hours after), alcohol abuse (relative CI), lactic acidosis

o (2) Dual therapy (if HbA1c rises to >58mmol/mol or >7.5%) …

§ TARGET HbA1c <53mmol/mol – dual drugs OR single drug, hypoglycaemic

§ 1st: Metformin + Sulphonylureas (GLIBENCLAMIDE, GLICLAZIDE)

• SEs: weight gain, hypoglycaemia
• CI: ketoacidosis; Caution: high BMI, G6PDD

§ 1st: Metformin + Thiazolidinedione (PPAR-g-R agonist, i.e. PIOGLITAZONE)

• SEs: weight gain (peripheral), abnormal LFTs, bladder cancer, osteoporosis (# risk)
• CI: HF, bladder cancer (query, past, present)

§ 1st: Metformin + Gliptins (DPP4 inhibitor, i.e. SITAGLIPTIN)

• Good addition to metformin if the patient is overweight
• CI: ketoacidosis; Caution: eGFR <45 (reduce dose, but can be used in renal failure)

§ 2nd: Metformin + SGLT-2i (EMPAGLIFLOZIN)

• SEs: euglycaemic DKA, urosepsis/infections, Fournier’s gangrene, angioedema
• CI: DKA, eGFR <60 (CKD 4, 5; mx: sitagliptin, gliclazide); Caution: complicated UTI

o (3) Triple therapy:

§ 1st: Metformin + Sulphonylurea + Gliptin
§ 1st: Metformin + Sulphonylurea + Thiazolidinedione
§ 1st: Metformin + Sulphonylurea/Thiazolidinedione + SGLT-2 inhibitors
§ 2nd: Insulin (n.b. 1mL insulin = 1,000 U à use an insulin syringe); initial therapy doses:
• ON intermediate-acting 8-10 U or 0.2 U/kg
• BD pre-mixed 6-10 U or 0.1 U/kg; BD
• Basal bolus long- and short-acting 8-10 U or 0.2 U/kg basal; 4 U bolus

o (4) Metformin + sulphonylurea + GLP-1 analogue (exenatide)

§ I/R or M/R (SC)
§ GLP-1 added if BMI >35 (as it can help with WL) or if insulin unacceptable
§ GLP-1 can cause dose-dependent hypoglycaemias but only if followed with food
PSA Notes 23

Hormonal Contraceptives (COCP, POP)

Combined Oral Contraceptive Pill (COCP) E.G. “Microgynon 30”

Hormone OESTROGEN (ethinyl oestradiol) and PROGESTERONE (progestin)

Mechanism Prevents ovulation

1. OD for 3 weeks à 4 or 7 days off (withdrawal bleed); OR

2. Tricycle: OD for 9 weeks à 4 or 7 days off (withdrawal bleed)
How to take
If started on the first 5 days of the cycle (28-day cycle) à confers immediate contraceptive protection
If starting at any other time, use additional measures for the first 7 days

+ >99% effectiveness
+ Reversible on stopping
Benefits
+ Less pain, more regular, lighter periods (used in dysmenorrhoea)
+ Reduced risk of ovarian cancer, endometrial cancer, bowel cancer [BEO]

– Easy to forget to take May cause breakthrough bleeding and spotting at first
– Does not reduce risk of STIs
– Increased risk of VTE (stroke, heart disease), breast cancer, cervical cancer [BC]
– Side effects: headache, N&V (if vomit <2hr since pill, take another), breast tenderness
– Stop 4w before surgery, restart 2w after surgery [switch to POP]

UKMEC 3 – Relative Contraindication (to any LTC containing oestrogen)

Breastfeed 6w-6m post-partum ≥35yo, smoke <15/day BMI 35-39
HTN (controlled; ≤160/95) FHx VTE (1st degree) Immobility
Disadvantages Breast mutation (BRCA1/2) Gallbladder disease Breast cancer (past)
DM + mild complications Cirrhosis (mild) Liver enzyme inducers

UKMEC 4 – Absolute Contraindications (to any LTC containing oestrogen)

Breastfeed <6w post-partum ≥35yo, smoke ≥15/day BMI ≥40
HTN (uncontrolled; ≥160/95) VTE (current, past), mutations Major surgery + immobility
IHD, stroke, TIA, CVD RFs Migraines + aura Breast cancer (current)
DM + severe complications Viral hepatitis, Cirrhosis (severe) Liver tumours

• 1 pill missed: take last pill and current pill (even if 2 in 1 day) à no further action needed
• 2 pills missed: take last pill and current pill (even if 2 in 1 day) à further action:
Missed dose
o Use condoms until pill has been taken correctly for 7 days in a row
o 2 Missed in Week 1: consider emergency contraception
Week 4 = pill-free
o 2 Missed in Week 2: no need for emergency contraception
o 2 Missed in Week 3: finish current pack, start new pack immediately (no pill-free break)

• Follow-ups (COCP) = annual follow-up appointments:

o Check eligibility again
o BP (Na+ (and fluid) retention à rise in BP à monitor BP regularly; stop HRT if BP >160/95)
o BMI

• Surgery (stop COCP 4 weeks before, restart 2 weeks after; use POP in interim)
PSA Notes 24

Progesterone Only Pill (POP)

Hormone PROGESTERONE (progestin) à levonorgestrel, norethisterone, desogestrel (cerazette)

Mechanism Thickens cervical mucus (desogestrel/cerazette primarily stops ovulation)

• OD at the same time every day (no pill-free week)

How to take If started on the first 5 days of the cycle (28-day cycle) à confers immediate contraceptive protection
If starting at any other time, use additional measures for the first 2 days
If switching over from the COCP, it provides immediate protection

Benefits + No oestrogen pill risks (n.b. ABx has no effect on POP)

– Very easy to forget to take

– Initial irregular bleeding (which may continue) = most common complaint:
20% à amenorrhoeic 40% à bleed regularly 40% à bleed irregularly
Disadvantages
– Osteoporosis and ovarian cyst risks
– SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache

– CI: breast cancer

• Traditional POPs (Micronor, Noriday, Nogeston, Femulen)

o <3 hours late: continue as normal
o 3+ hours late: take missed pill ASAP, continue with rest of pack, extra precautions (condoms) until
pill taking re-established for 48 hours
§ If missed 2 pills, take last missed pill and next pill, and use barrier methods until pill-taking
Missed dose has been re-established for 48 hours
§ Emergency contraception needed if UPSI during this interval
• Cerazette (Desogestrel)
o <12 hours late: continue as normal
o >12 hours late: take missed pill ASAP, continue with rest of pack, extra precautions (condoms) until
pill taking re-established for 48 hours

• “Contraceptives, interactions”:
o COCP:
§ Short-courses (≤2 months) enzyme inducer:
• + condoms (during + up to 4 weeks after stopping)
§ Long-course (>2 months) enzyme inducer:
• ­ dose oestrogen (≥50mcg OD) + tricycling (during + up to 4 weeks after stopping)
§ Long-course (>2 months) rifampicin:
• IUD
o POP:
§ Short-courses (≤2 months) enzyme inducer:
• + condoms (during + up to 4 weeks after stopping)
§ Long-course (>2 months) enzyme inducer:
• Alternative contraception (during + up to 4 weeks after stopping)
PSA Notes 25

Hormone Replacement Therapy (HRT)

• Consider HRT for… vasomotor S/S, urogenital atrophy, low mood, altered sexual function, osteoporosis
o Great website for HRT prescribing

Oestrogen only (POST-HYSTERECTOMY)

HRT Delivery Dose (Oestrogen) Indication

Elleste solo PO 1 / 2 mg, OD 1st line PO

1st line transdermal

Evorel Transdermal 25 / 50 / 75 / 100 mcg, twice weekly
BMI >30 (lower VTE risk)

Skin allergy to patches

Sandrena PV (gel) 0.5 / 1.0 / 1.5 mg/g, OD
BMI >30 (lower VTE risk)

• Adjunct progesterone (used alongside PO or transdermal oestrogen for endometrial protection):

o IUS (Mirena) – for 4 years
o Medroxyprogesterone acetate (Provera), PO:
§ SCT (10mg OD, last 12 days of 28-day cycle)
§ CCT (2.5 – 5 mg OD)
o Utrogestan (micronized progesterone), PO:
§ SCT (200mg ON, last 12 days of 28-day cycle)
§ CCT (100mg ON)

Oestrogen and Progesterone (Cyclical / Sequential Combined, SCT – PERI-MENOPAUSAL) – monthly bleed

HRT Delivery Dose (Oestrogen / Progesterone) Indication

Elleste duet PO 1 mg / 1 mg, OD 1st line PO

Oestradiol, Norethisterone

Evorel sequi Transdermal 50 mcg / 170 mcg, twice weekly 1st line transdermal
Oestradiol, Norethisterone

• Method:
o Monthly: oestrogen for 28 days + progesterone for the last 14 days
§ Indication = regular periods and menopause symptoms
§ Evorel 50mcg transdermal, 14d à Evorel Sequi 50mcg/170mcg transdermal, 14d
o 3-monthly: oestrogen for 3 months + progesterone for last 14 days
§ Indication = irregular periods and menopause symptoms

• Unscheduled vaginal bleeding (common in first 3 months of HRT)

o Sequential > continuous HRT
o Investigate if it continues past 6 months (or after a spell of amenorrhoea)

Oestrogen and Progesterone (Continuous Combined, CCT – POST-MENOPAUSAL) – cycle free

HRT Delivery Dose (Oestrogen / Progesterone) Indication

Kilovance PO 1 mg / 0.5 mg, OD 1st line PO

Oestradiol, Norethisterone

Evorel Conti Transdermal 50 mcg / 170 mcg, twice weekly 1st line transdermal
Oestradiol, Norethisterone
PSA Notes 26

• Stopping HRT:
o Stop after the menopause symptoms stop (usually after a few years)
o Stop gradually (to reduce the side effects)

• Side effects:

Oestrogen Side Effects

Breast tenderness
Wait (side effects settle in <3 months)
Nipple sensitivity
Bloating
If severe, reduce dose
Leg cramps
Nausea/heartburn
Change route from PO to transdermal
Headaches

Progesterone Side Effects

PMS symptoms
Change type of progestogen
Mood changes
Breast tenderness
Change route from PO to transdermal
Bloating
Headache
Change regime (long cycle SCT, CCT, ± IUS)
Acne/greasy skin

• Risks:
o Cancer:
§ Oestrogen-only = breast cancer, endometrial cancer
§ Combined = breast cancer (more so than for oestrogen alone)
o VTE (2-4x higher; 2 per 1,000 taking HRT over 7.5 years)

• HRT / COCP à Na+ (and fluid) retention à rise in BP à monitor BP regularly; stop HRT if BP >160/95

• Alternatives = Non-Hormonal Therapy

o Vasomotor symptoms:
§ 1st line (SSRIs) à fluoxetine
§ 2nd line à citalopram, venlafaxine
§ 3rd line (ongoing research) à gabapentin
§ Alpha agonists (clonidine) are licenced but there are lots of anti-ACh side effects…
o Vaginal dryness:
§ Lubricants
o Osteoporosis treatments (e.g. bisphosphonates)

• Contraception requirement:
o Until >1-year amenorrhoeic if >50yo
o Until >2-years amenorrhoeic if <50yo
PSA Notes 27

Anti-emetics

Drug Class Examples Indications Side Effects

Antihistamines / Mixed Receptor

- Motion sickness - Dizziness
- Promethazine
- Labyrinth disorders - Fatigue
H1 > M > D2
- Hyperemesis gravidarum - Tinnitus
- Cyclizine
- Pre- and post-operatively - Sedation
Acts on CTZ, vestibular, VC

CNS
D2 receptor antagonist - EPSE
- Metoclopramide - GI motility disorders
- Drowsiness, dizziness,
Avoid in bowel obstruction (pro-kinetic) - Uraemia
D2 >> H1 >>> M anxiety
- Radiation sickness
Endocrine
- Domperidone - Cancer chemotherapy
Acts on CTZ - Hyperprolactinaemia
- Galactorrhoea

M receptor antagonist - Hyoscine / Scopolamine Antimuscarinic

- Pre-operative medication - Dry mouth
M >>> D2/H1 - Diphenhydramine - Mydriasis
- Motion sickness - Constipation
Acts on CTZ, vestibular, VC Little effect once nausea established - Drowsiness

5-HT3 receptor antagonist - Ondansetron - Chemotherapy sickness

- Headache
5-HT2 Mild nausea à use alone - Radiotherapy sickness - Flushing
- Constipation
Acts on CTZ, peripheral signals Severe nausea à combine with steroids - Post-op N&V

• Bowel obstruction nausea:

o 1st à ‘Drip & suck’
§ Relieves nausea effectively if pressure build-up is present
o 2nd à IV cyclizine, ondansetron
§ Metoclopramide is contraindicated
PSA Notes 28

Constipation, Diarrhoea, Insomnia

• Constipation à laxative agents (see “Constipation” in BNF):

o Bulk-forming (ispaghula husk, methylcellulose):

§ Action: retain fluid in stool and increase bulk, stimulating peristalsis; soften stool

o Osmotic (lactulose, polyethylene glycol / Movicol, phosphate enemas):

§ Action: draw fluid in stool and increase bulk, stimulating peristalsis; soften stool
§ N.B. Movicol contains a high level of sodium
§ CI: bloating

o Stimulant (senna1, bisacodyl2, sodium picosulphate2, docusate):

§ Action: stimulate the colonic nerves1 or both the colonic and rectal nerves2
• Docusate wets the surface of stool reducing the surface tension, allowing water
penetration (also has a weak stimulatory effect on the bowel)
• Sodium picosulphate is quite extreme and used more for bowel prep
§ CI: colitis, cramps, bowel obstruction

o Pro-kinetic (prucalopride, metoclopramide):

§ Action: 5-HT4-R agonist to promote intestinal motility
§ Contraindicated in bowel obstruction (may cause a perforation)

o I.E. post-operative TKR lady who hasn’t opened bowels in 4 days and had soft stool loading on DRE
and no signs of bowel obstruction à prescribe Senna

• Diarrhoea:
o Infective à treat cause
o Chronic, non-infective:
§ Loperamide 2mg PO 3-hourly must be taken after each loose movement
§ Codeine 30mg PO 6-hourly

• Insomnia: n.b. some drugs cause this (i.e. corticosteroids NOT to be given ON, only as OM)

o CAUTION in elderly (causes falls at night – i.e. going to the toilet)

o Zopiclone 7.5mg ON
PSA Notes 29

Steroids

• Steroid strength (G = glucocorticoid; M = Mineralocorticoid):

o Hydrocortisone à G 1, M 1
o Prednisolone à G 4, M 0.8
o Fludrocortisone à G 15, M 150
o Aldosterone à G 0, M 500 strongest M
o Dexamethasone à G 40, M 0 strongest G, used in raised ICP as weakest MR activity

• Steroid ladder – Help (hydrocortisone) Every (Eumovate) Busy (Betnovate) Dermatologist (Dermovate)
o Hydrocortisone Low potency
o Clobetasone butyrate
o Betamethasone Medium potency
o Mometasone furoate
o Clobetasol propionate High potency

• Steroid rules:

o Sick days à double steroid dose

o Do not stop abruptly; gradual withdrawal required for…

§ received >40 mg prednisolone (or equivalent) OD for >1 week N.B. abrupt withdrawal in
§ received >3 weeks’ treatment IE-COPD/asthma is okay!
§ recently received repeated courses
§ taken a short course within 1 year of stopping long-term therapy
§ other possible causes of adrenal suppression

o Physiological steroids = ~7.5mg prednisolone / day

Withdrawal Protocol
Circumstance Suggested change in daily dose
Problem resolved, and treatment has [1] reduce by 2.5 mg every 3–4 days, down to 7.5 mg per day,
been given for only a few weeks [2] reduce by 2.5 mg every week, fortnight, or month
Uncertainty about disease resolution [1] reduce by 2.5 mg every fortnight or month down to 7.5 mg per day
and/or therapy given for +++ weeks [2] reduce by 1 mg every month

Symptoms of the disease are likely to

[1] reduce by 1 mg every month
recur on withdrawal (for example
In PMR this is more complex – see PMR treatment summary
polymyalgia rheumatica [PMR])
PSA Notes 30

Statins

• Statins:
o Time of day:
§ Atorvastatin à taken at the same time each day (morning or evening)
§ Simvastatin à taken in the evening (most cholesterol metabolism is at night)
o Stop taking them when you take macrolides (clarithromycin, erythromycin)
o SE: myositis

• Monitoring:
o Baseline bloods:
§ Full lipid profile (non-fasting)
§ LFTs
§ TSH
§ U&Es
§ CK (only if persistent, generalised, unexplained muscle pains à if ≥5x ULN, repeat after 7/7):
• RFs: CKD, hypothyroid, FHx/PMHx of hereditary muscular disorders, history of
unexplained muscle pain, liver disease, ETOH excess, ≥70yo w/ polypharmacy
• If still ≥5x ULN, do not offer statin
• If <5x ULN, offer statin at a reduced dose
§ HbA1c (for high risk of DM patients)
o 3 months:
§ Full lipid profile (non-fasting)
§ LFTs
§ HbA1c (for high risk of DM patients)
o 6 months:
§ LFTs

o LFT results (AST/ALT):

§ ≥3 ULN à stop statin (35 x 3 i.e. ≥105)
§ <3x ULN à continue statin (unless muscle pains evident)

o Statin myopathy:
§ Statin is suspected cause of myopathy + CK markedly elevated (≥5x ULN), OR
§ Severe muscular symptoms

§ Mx: discontinue treatment and if CK returns to normal à reintroduce at a lower dose

o Statin therapy (secondary prevention); ‘Cardiovascular disease risk assessment and prevention’:
§ 3m after starting therapy à ≥40% reduction in non-HDL cholesterol OR ≤2.5mmol/L non-HDL
• Adherence
• Lifestyle modifications
§ All à annual review (adherence, lifestyle modification, CVD RFs, non-HDL (non-fasting))

• Warfarin + statins à high INR (competitive inhibition of CYP by statins; only in some people)
PSA Notes 31

Opiates

Palliative Care

• Starting treatment (opioids in palliative care): Total morphine Side Effects

o 15mg MR morphine (MST), PO BD 30mg nausea (transient)
o 5mg IR oromorph, PO PRN drowsiness (transient)
o Laxatives constipation (persistent)

o Can start with oromorph (IR) only and then once pain is controlled, convert to the MR version

o Opioids in CKD: Codeine à constipation

§ GFR 30-60 à oxycodone Tramadol à hallucinations, agitation
§ GFR <30 à alfentanil, fentanyl, buprenorphine

• Ongoing treatment: Diamorphine preferred in palliative care

o Starting doses for oromorph is 2.5-5mg, 4-hourly
o Increase by 1/3rd (30-50%) if pain not 90% relieved
o Breakthrough doses = 1/6th of total morphine in 24 hours

o Example:
§ Person on 30/500 co-codamol (codeine + paracetamol), 8x a day with some pain
§ 30mg codeine, 8x a day = 240mg codeine = 24mg morphine
§ Increase to 30mg morphine à 15mg MST, BD
• I.E. modified/sustained release = half the immediate release dose of morphine
§ Add breakthrough immediate release medication = 1/6th of 30mg = 5mg (6mg) oromorph

• WHO analgesic ladder:

o (1) Non-opioid (NSAID, paracetamol)
o (2) Weak opioid (codeine, tramadol, buprenorphine)
§ Codeine
§ Tramadol
§ Morphine (MST, oromorph, sevredol, MXL) Bony metastasis pain:
• Immediate release (IR; ≤4 hours): 1st: Analgesia
o Oromorph (liquid) 2nd: Bisphosphonates
o Sevredol (tablet) 3rd: Radiotherapy
o Morphine injection
• Modified release (MR): Paracetamol =dose 1g (max 4g)
o MST / zomorph (BD) NSAID = dose 400mg (max 2.4g)
o MXL (OD)
§ Oxycodone
o (3) Strong opioid + non-opioid (morphine, diamorphine, fentanyl, oxycodone, alfentanil)

• Morphine conversion/equivalence: Opioid Conversion Table

Conversion Example
From To
Factor From To
PO codeine PO morphine /10 100mg codeine 10mg morphine
PO tramadol PO morphine /10 100mg tramadol 10mg morphine
PO morphine PO oxycodone /2 10mg morphine 5mg oxycodone
PO morphine SC morphine /2 10mg PO morphine 5mg SC morphine
PO morphine SC diamorphine /3 10mg PO morphine 3mg SC diamorphine
PO oxycodone SC diamorphine /1.5 6mg PO oxycodone 3mg SC diamorphine
PO morphine PO alfentanil /30 30mg PO morphine 1mg PO alfentanil
PO morphine Fentanyl 100 patch /100 (over 24 hrs) 240mg PO morphine 2.4mg SC fentanyl
PSA Notes 32

Non-Palliative Care

• Starting treatment:

o Opioid dosing (non-palliative care)

§ 1st: oromorph 2.5-5mg, 4-hourly à ≥24 hours, increase +1/3rd if pain not 90% relieved
• Once well controlled pain, switch to long-acting preparations BD
• N.B. SC dose is half the PO route dose
§ Co-prescribe immediate release for breakthrough pain (dose 1/6th morphine in 24 hours)
• PRN given every 4-6 hours for pain

o Example:
§ Person on 30/500 co-codamol (codeine + paracetamol), 8x a day with some pain
§ 30mg codeine, 8x a day = 240mg codeine = 24mg morphine
§ Increase to 30mg morphine à 15mg MST, BD
• I.E. modified/sustained release = half the immediate release dose of morphine
§ Add breakthrough immediate release medication = 1/6th of 30mg = 5mg (6mg) oromorph

o Pain from STEMI / pleuritic chest pain / bowel perforation (yes, you can give morphine):
§ MORPHINE SULPHATE
§ 5-10mg Acute pulmonary oedema 5-10mg IV (2mg/min)
§ IV (slow) STEMI 5-10mg IV (1-2mg/min)
§ STAT Acute pain 5mg IV

• Side effects [most common] = vomiting hence, give with metoclopramide in acute settings

• Analgesia prescriptions:

Situation Regular Prescription PRN

No pain Nil Paracetamol, 1g, up to 6-hourly
Mild pain Paracetamol, 1g, 6-hourly Codeine, 30mg, up to 6-hourly
Severe pain Co-codamol, 30/500, 2 tablets, 6-hourly Oromorph 4mg, up to 6-hourly *
* 1/6th daily co-codamol morphine equivalent, can be increased dependant on pain
PSA Notes 33

Miscellaneous

• Aggression treatment:
o (1) Verbal de-escalation
o (2) Oral lorazepam
o (3) IM Lorazepam

o Delirium aggression à IM haloperidol (use lorazepam in Parkinson’s)

• Alcohol:
o Liver disease:
§ Pain management à 500mg paracetamol, QDS [lower dose]
§ Avoid:
• NSAIDs [clotting abnormalities may be present and these precipitate bleeding]
• Opiates [precipitate hepatic encephalopathy]
o Alcohol avoidance on…
§ ABx (metronidazole, doxycycline) Benzodiazepines, sedating antihistamines
§ Fluoxetine Disulfiram
§ Statins (must stay within limits) Warfarin
o Pabrinex = thiamine / B1, vitamin C, other B vitamins

• Medications to state by brand name (rather than generic chemical):

o Adrenaline pre-filled syringes Aminophylline
o Buprenorphine patches Carbamazepine
o Ciclosporin Fentanyl patches
o Lithium Methylphenidate MR
o Morphine MR MMF
o Phenytoin Tacrolimus, Theophylline

• Neuropathic pain prescriptions:

o Pain from nerve damage/disease; described as ‘shooting’, ‘stabbing’ or ‘burning’
o N.B. acute phase shingles requires paracetamol – only post-herpetic neuralgia requires the below
o 1st line neuropathic pain:
§ Amitriptyline (10mg oral nightly)
§ Pregabalin (75mg oral 12-hourly)
o 1st line diabetic neuropathy à duloxetine (60 mg oral daily)

• Avoid in heart failure:

o Thiazolidinediones (pioglitazone) à fluid retention
o NSAIDs/glucocorticoids caution: fluid retention [75mg aspirin exception]
o Verapamil à negative inotropic effect
o Class I antiarrhythmics (flecainide) à negative inotropic and proarrhythmic effects

• Take at night, ON:

o Statins (most cholesterol metabolism occurs at night)
o Amitriptyline (SE: drowsiness)

• Insomnia:
o 1st line: Z-drugs (Zopiclone)
o 2nd line / severe insomnia: BDZ (Nitrazepam; 2-4w)

• Iron deficiency management:

o Blood transfusion:
§ Indications:
• Severely symptomatic
• Hb <70g/L
§ Raises Hb by 10g/L per unit given
o 1st line: ferrous sulphate, 200mg, PO, TDS [take with food]
§ Given until Hb normal + further 3 months to replace stores
§ Consider SE as a cause of non-compliance if Hb not rising (constipation, black tarry stools)
§ Reduce to BD if side effects are prominent and reassess in 2-4 weeks
PSA Notes 34

• Liver injury and drugs:

o ALT : ALP >5 hepatocellular picture

§ Paracetamol
§ NSAIDs
§ Statins
§ Amiodarone

o ALT : ALP <2 cholestatic picture

§ Co-amoxiclav
§ Erythromycin
§ Chlorpromazine
§ Hormonal contraception

o ALT : ALP 2-5 mixed picture

§ Phenytoin
§ Sulphonamides
§ Carbamazepine
PSA Notes 35

Mock Exams
PSA Book Mock 1 (157/200; 78.5%)
Notes below – answered in textbook

• Thiazides à gout (stop if the patient has a PMHx of gout)

• Lithium interactions à excretion is significantly reduced by…

o NSAIDs
o ACEi, thiazides if a diuretic must be given à use furosemide

• Metformin should NOT be used if eGFR <30mL/min/1.73m2 à use a sulphonylurea or DPPG-4 inhibitor

• “ACEi” SEs = Angioedema (~4w), Cough, Elevated K+, I (1st dose low BP)

• Calculation:
o A drug comes in 10mL ampules containing 5g of medication (20mmol). You need 8mmol of drug.
o Calculate how much dilutant is required to give a 200mg/mL solution
§ 8mmol = 8/20 * 5 = 2g drug = 2000mg drug (= 4mL solution)
§ Need 200mg/mL, currently 2000mg in 4mL (500mg/mL)
§ 500/200 * 4 = 10mL

• Heartburn (immediate relief):

o Short-term relief à Magnesium carbonate, 10mL, PO, TDS
o Long-term relief à Omeprazole, 10mg, PO

• Pneumonia à see “Respiratory system infections, antibacterial therapy”:

o CAP:
§ Mild Amoxicillin
§ Severe Co-amoxiclav + clarithromycin
o HAP:
§ Non-severe (NICE) Co-amoxiclav / doxycycline
§ Severe (NICE) Piperacillin/tazobactam
o Generally, review all ABx after 3 days (when MC&S is usually back by)

• Monitoring therapeutic effect:

o Clinical effect > biochemical effect
o DKA resolving = check ketones are going down (not glucose)
o ACEi = check serum creatinine first
o NORMAL pre-dose ‘trough’ vancomycin = 10-15mg/L
o Anti-muscarinic side effects = cyclizine

• Digoxin toxicity (suspected):

o Digoxin level
o ECG
o U&Es (must be interpreted in light of K+ level)
§ Hypokalaemia à increased digoxin effect
§ Hyperkalaemia à reduced digoxin effect
PSA Notes 36

PSA Book Mock 2 (183/200; 91.5%)

Notes below – answered in textbook

• Parkinson’s disease – anti-emetic = domperidone (does not pass BBB and so is appropriate)
o CI: metoclopramide

• Diuretics à take in the MORNING (as taking in the evenings makes you get up all night to urinate)
• Anti-hypertensives à take in the EVENING (less falls risk as sleeping)
• Beta-blockers à take in the MORNING

• Hypernatraemia (nephrogenic DI) à lithium, hypercalcaemia, hypokalaemia

• Hyponatraemia (SIADH) à carbamazepine, SSRI, TCA, opiates, PPI
• Hyperkalaemia à ACEi, ARB, aldosterone antagonists
• Hypokalaemia à thiazides, loop diuretics

• Caution in asthmatics:
o Absolute CI: beta-blockers
o Relative CI: NSAIDs > aspirin

• Leucocytosis + normal CRP à are they on steroids? (benign leucocytosis)

• Hyperkalaemia:
o 10mL, 10% calcium gluconate
o 125mL, 20% dextrose (equiv. 25mL pure glucose)
o 10U insulin
o Salbutamol nebulisers
o Calcium Resonium (CALCIUM POLYSTYRENE SULFONATE), 15mg, 8-hourly
§ Takes some days to work (use dialysis if immediate need)

• Enoxaparin is dose-adjusted in…

o Low eGFRs (<30mL/min)
o Weight <50kg

• Length of course and reviewing of ABx:

o Review at 3 days (time for MC&S to come back)
o PO course = 7 days (unless for UTI)
o IV course = 5 days
• Oral candidiasis mx:
o Nystatin, 100,000U, QDS, 7 days
o Miconazole oral gel, 2.5mL, QDS, 7 days

• Hypoglycaemia management:
o Glucagon:
§ Not used in… prolonged fast, adrenal insufficiency, chronic/ETOH-induced hypoglycaemia
§ Less effective in those taking a sulphonylurea (use IV glucose instead)
o If an insulin injection is due, it should not be omitted but a review may be required

• Ibuprofen should be avoided in pregnancy if possible but esp. in the third trimester as the NSAID can cause
early closure of the ductus arteriosus and remove the shunting ability of the heart too early
PSA Notes 37

PSA Demonstration Paper (74/100; 74%)

• COPD/asthma exacerbation:
o Salbutamol, 1mg/mL nebuliser liquid
o 5mg (or 5mL)
o Nebulised (not inhalational) If INH instead of NEB, you would only get 5/10…

• If dehydrated (Na is a little high) AND the glucose is high (7.2mmol/L), then prioritise giving NaCl over
glucose, as glucose can exacerbate any cerebral injury (such as if they had just had a stroke)

• Morphine SEs:
o Confusion, drowsiness
o Constipation, urinary retention, dry mouth
o Flushing

• SE: urinary retention:

o Morphine / other opioids think low UO in post-operative patients on opioids
o Anticholinergics
o GA
o Alpha adrenoceptor agonists
o Benzodiazepines
o NSAIDs
o CCBs
o Antihistamines
o ETOH

• SE: confusion / disorientation:

o Morphine
o Metoclopramide
o Anti-cholinergics, -psychotics, -depressants, -convulsants

• Folic acid (pre-conceptual, 1st trimester):

o 400mcg
o 5mg (special groups – can see BNF):
§ Previous child with NTD Diabetes mellitus Epileptic woman
§ Obesity HIV +ve on co-trimoxazole SCD
§ IBD Thalassaemia

• Monitoring dehydration and response to fluid therapy:

o BP > UO (as UO may not recover as quickly as the BP would)

• Gentamicin dosing: even if both the peak is high and pre-dose is high,
o Peak dose high à reduce dose then extend the interval AND reduce the dose
o Pre-dose / trough high à increase interval
PSA Notes 38

Official Mock 1 (82/100; 82%)

• Hyperkalaemic contributor medications:

o Dalteparin inhibition of aldosterone synthesis
o Tacrolimus reduced potassium excretion

• Aspirin, despite being an NSAID, does not need to be stopped in AKI; consider stopping…
o ACEi
o ARB
o Diuretics, incl. loop diuretics
o Allopurinol

• Confusion commonly from… BDZ, morphine, prednisolone

• Drugs that cause hyponatraemia (through SIADH):

o SSRI, TCA PPI
o Carbamazepine Sulphonylureas
o Vincristine, cyclophosphamide Opiates

• If on ≥25mcg/hour fentanyl patches à breakthrough pain is via nasal fentanyl sprays, i.e.:
o Fentanyl, 50 micrograms/h transdermal patch, one patch per 72 hours
o Fentanyl, 50 micrograms / actuation nasal spray to one nostril, repeated after 10 minutes
§ Maximum of 2 sprays per pain episode
§ Every 4 hours, PRN

• UTI:
o Nitrofurantoin (CI: eGFR <45; eGFR 30-45 okay if <7 days course)
o Trimethoprim (Caution: eGFR <30, half doses)

• Warfarin and surgery (‘oral anticoagulants’):

o Stop 5 days before surgery (as it is an anticoagulant / antiplatelet)
o If INR >1.5 on the day of surgery, give Phytomenadione (vitamin K), PO (using IV reparation)
o Can be resumed at normal dose in evening / next day (if adequate haemostasis)

• Always check eGFR guidelines if they give you an eGFR in the question, i.e.:
o Nitrofurantoin (CI: eGFR <45; eGFR 30-45 okay if <7 days course)
o Trimethoprim (Caution: eGFR <30, half doses)

• Co-amoxiclav jaundice:
o Common, very common
o Only occurs with co-amoxiclav and not with just amoxicillin
o If this has happened before, it is an absolute CI to having co-amoxiclav again

• Hypertension management – ACEi and monitoring:

o ACEi (U&Es before ACEi, and during treatment)
o ARB (U&Es during treatment to monitor K+)
o A small rise (≤20%) in creatinine is expected with new ACEi/ARB à do nothing, remeasure in 1 week

• Clinical monitoring >>> biochemical monitoring (esp. early)

• Ciclosporin – lots of side effects, but monitor esp. for… (mediated by vasoconstriction on renal arterioles)
o Nephrotoxicity (baseline U&Es and every 2 weeks until stable)
o Hypertension (regular BP monitoring)

• IDDM on prednisolone (i.e. asthmatic exacerbation, T1DM) à +10% insulin dosing during steroid window:
o Humulin M3, 20U, SC, BD (BM 6mmol before breakfast, 18mmol before dinner)
o Humulin M3, 22U, SC, BD

o It’s preferable to adjust the existing insulin than add say, a short-acting insulin for the evening meal
PSA Notes 39

Official Mock 2 (85/100; 85%)

• Beta blockers:
o Reduce hypoglycaemic awareness
o Contraindicated in…
§ asthma cardiogenic shock
§ hypotension bradycardia
§ metabolic acidosis 2nd AV block, 3rd AV block
§ uncontrolled HF severe peripheral arterial disease

• Exacerbate heart failure:

o Steroids (MR effect of steroids à sodium retention à increased fluid retention à CCF)
§ “STEROIDS” – Stomach ulcers, Thin skin, Oedema, Right- (and L-) HF, Osteoporosis,
Infection, Diabetes, Syndrome (Cushing’s)… and confusion
o CCBs (verapamil, diltiazem, nifedipine [not amlodipine] à reduce contractility, peripheral oedema)

• Scarlet fever à phenoxymethylpenicillin for 10 days (BNF says 5-10 days but this serious so 10 days)

• An INR ±0.5 either side of a target is acceptable

Official Mock 3 (91/100; 91%)

• Nil – incorporated into notes above