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PrescribingSafety Assessment Part1 Prescribing // Prescription reviews// Adverse drug reactions carolamaria.bigogno1@nhs.net48min 19min 12sec 9min 36sec 7min 12sec 9min 36sec 9min 36sec 9min 36sec 7min 12secGeneraltips • Do all the official practice papers • Practice under time pressure (give yourself even less time!) • Be familiarwith the BNF (& Medicines Complete), so you can move quickly! • CTRL +“F” • Be familiarwith treatment summaries Treatment summaries • MEDICAL EMERGENCIES IN THE COMMUNITY • ACS, asthma, croup, anaphylaxis, meningitis,hypoglycaemia, seizures • Anxiety/OCD  ANTIDEPRESSANTS • Overdose POISONING,EMERGENCY TREATMENT • Smoking  SUBSTANCE DEPENDANCE • Opioidconversion  PALLIATIVECARE • HRT  SEX-HORMONES • INR ORALANTICOAGULANTS • Excess bleeding ANTIFIBRINOLYTICS • Laxatives  COSTIPATION6 • B12deficiency/anaemia MEGALOBLASTICANAEMIA • Steroid conversion  GLUCOCORTICOID THERAPY Treatment summaries • Gentamicin  AMINOGLYCOSIDES • Derm conditions  SKININFECTIONS/ SKIN CONDITIONS • Endocarditis  CARDIOVASCULAR INFECTIONS • Shigella  GASTRO-INTESTINAL SYSTEM INFECTION, ANTIBACTERIALTHERAPY • Cholecystitis  GALL STONES • Osteomyelitis  MUSCULOSKELETAL INFECTION • Pneumonia  RESPIRATORY INFECTIONS • UTI URINARY-TRACT INFECTIONS • ENT EAR INFECTIONS/ NOSE INFECTIONS/ ORAL INFECTIONS/ OROPHARYNGEAL INFECTIONS COMMON ACUTE CONDITIONS FLUID PRESCRIPTIONS - acute asthma attach - emergency resus - COPD exacerbation - maintenance - acute heart failure (- paediatric ) - ACS IMPORTANTSYMPTOMS COMMON CHRONIC CONDITIONS - depression - pain - reflux - Constipation - COPD/Asthma - N&V COMMONACUTECONDITIONS - acute asthma attach - COPDexacerbation - acute heart failure • Oxford - ACS Handbook COMMON CHRONIC CONDITIONS • Finals revision - depression - reflux • Treatment - COPD/asthma summaries on BNF IMPORTANTSYMPTOMS - pain - constipation - N&V• Enoxaparin sodium40mgSCOD • Apixabam 2.5mg(1tablet) POBD • Dabigatran 220mgPOOD • Tinzaparin 4500USCOD • Rivaroxabam 10mg(1Tablet)POOD • Dalteparin 5000U/ 0.5mlSCODPain Treatment Summary “Pain, chronic” “Lower back pain and sciatica” “Neuropathic pain” “Urological pain” • Pain ladderFluidprescriptions • Resus if haemodynamically unstable • 500ml sodium chloride over 15 min • Replacement if D&V , DKA • Look at electrolytes 80kg patient • Maintenance if NBM • Water 25—30 ml/kg/day - water2-2.5L/day • Na/K/Cl 1mmol/kg/day - electrolytes80mmol/day • Glucose 50-100g/day - glucose 50-100g/day • 1L 5% dextrose= 50gThe traditional regime = “1 salty + 2 sweet”: • Saline 0.9% + 20mmol potassium chloride (over 8 hours) • Dextrose 5% + 20mmol potassium chloride (over 8 hours) • Dextrose 5% + 20mmol potassium chloride (over 8 hours)Hypoglycaemia –IVglucose • 10% glucose • First line • 100-200ml  delivers 10-20g of glucose • Infuseup to 20min • 20% glucose • 50-100ml  delivers 10-20g of glucose • Infuseup to 20min • 50% glucose hypertonic,shouldnot beused • 5% glucose too weak,too much of a largevolumewouldbeneededPrescriptionsreview–hard!! • Drugsto stop orcouldcausea problem eg impairedrenalfunction • Important drug interactions • Verapamil& beta-blockers • Erythromycin& warfarin • Interactionsofmedications andcondition • Asthma & beta-blockers • Dosingerrors • Bisphosphonatesand methotrexate are prescribed weekly (notOD!) • Levothyroxineand digoxinareprescribed inmicrograms(notmilligrams!) • Commondrugs eg Paracetamol max 1g QDS.Beaware ifco-prescriptionsofco-codamol andadd them up • Pregnancy/breastfeeding/hepaticimpairement/renalimpairement Delirium/ acute confusion • Sedative hypnotics(benzos eg diazepam) • Zopiclone • Analgesics (opioids) • Anticholinergics(atropine,oxybutynin) Prescription • Anticonvulsants (pregabalin) • Antidepressants reviewin • Antipsychotics • Metoclopramide • Electrolyte imbalance (eg low Na, also caused by thiazide diuretics) Elderly Dehydration patients • Diuretics (furosemide, spironolactone,bendroflumethiazide Renal impairement • eGFR<30 • Eg withheldmetformin Liver impairement • NSAIDs, corticosteroids, worsening oedema/ascites • RifampicinPrescribinginPaeds • Prescribing:allergies, infections(otitismedia,epiglottitis,croup),reflux • Prescription reviews: rare • Planning management:asthma,anaphylaxis,DKS, dehydration • Providing information:vaccinations,insulin,cysticfibrosis, acne • Calculations:fluid replacement,dosing by weight • Adverse drug reactions:hypoglycaemia,vomiting,substance abuse • Drug monitoring:asthma therapy,diabetes • Drug interpretation:PEFR, paracetamolpoisononingPaediatric fluids Interactiontabisgold Severity Evidence If not there, no interaction! Minor Anecdotal  Moderate  Theoretical  Severe  StudyAdverseDrug Reactions • CTRL + F is your best friend • Generalvs specific • Common/very commonvsrare/veryrare • Ifindoubt,commonisthesaferoption • Be awareof frequencynot known • Therecanbe differentreactionsbasedondifferentdrug forms • Pregnancy/breastfeeding/hepaticimpairement/renalimpairementMostcommonandmost seriousADRs • ACEi • Amlodipine • Amiodarone • Carbamazepine • Clozapine • Gliclazide • Metformin • StatinsMostcommonandmost seriousADRs • ACEi COUGH,HYPERKALAEMIA • Amlodipine OEDEMA • Amiodarone PULMONARY FIBROSIS, THYROID DYSFUNCTION • CarbamazepineHYPONATRAEMIA • Clozapine AGRANULOCYTOSIS • Gliclazide HYPOGLYCAEMIA • Metformin  LACTIC ACIDOSIS • Statins  MYALGIA Management ofADRs Common High INR/ Anaphylaxis overdoses eg bleeding on Hypoglycaemia …. paracetamol anticoagulant  MEDICAL  POISONING,  ORAL THECOMMUNITYN ETREATENT ANTICOAGULANTS  HYPOGLYCAEMIAAnyquestions? carolamaria.bigogno1@nhs.net Please don’tforget tofill in thefeedback! Next sessions: • Monday 29 Jan 2024– Drug Monitoring & Interpretation& Reactions • Wednesday 31 Jan 2024– Planning Management,Providing Information & Calculations