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PSA session 3 Prescriptionreview& Adverse Drug Reactions Research survey 23 January 2025 Dr Milena Nossen, Dr Aeron AlvaradoLearning Outcomes Prescription review ✔ Learn how to systematically review drug prescriptions, including dosing errors, contraindications, withholding medications, nephrotoxic medications and identify which medication is causing the complication Adverse drug reactions ✔ Learn how to identify adverse drug reactions, such as drug interactions, side effects, toxicities, CYP450 inducers/ inhibitors and how to treat ADRs.Prescription ReviewPrescription review 8 items, 32/200 marks Suggested is 2.5 min/ question1. A 33-year-old woman comes to the GP with palpitations. As part of her work up, the GP requests an ECG (findings below.) PMH. Recurrent thrush, hypothyroidism, depression, anxiety. DH. See below. NKDA ECG: sinus rhythm, rate 68 bpm, PR 0.12s, QRS narrow, QTc 0.52s Which drug is most likely responsible for this patient’s ECG findings? Medicine Dose Route Frequency A Co-codamol 8/501 – 2 tabletsPO PRN B Fluconazole 150 mg PO weekly C Levothyroxine 100 microgramPO OD D Propranolol 40 mg PO OD E Sertraline 150 mg PO OD1. A 33-year-old woman comes to the GP with palpitations. As part of her work up, the GP requests an ECG (findings below.) PMH. Recurrent thrush, hypothyroidism, depression, anxiety. DH. See below. NKDA ECG: sinus rhythm, rate 68 bpm, PR 0.12s, QRS narrow, QTc 0.52s Which drug is most likely responsible for this patient’s ECG findings? Medicine Dose Route Frequency A Co-codamol 8/501 – 2 tabletsPO PRN B Fluconazole 150 mg PO weekly C Levothyroxine 100 microgramPO OD D Propranolol 40 mg PO OD E Sertraline 150 mg PO ODTips ⮚ Appendix 1 has tables for many abnormal findings ⮚ CTRL + F for ‘QT’ , then look for all drugs ⮚ Sometimes drugs or specific reason might not be listed, in that case look up drugs individually and CTRL + F for side effect ⮚ For co-codamol, use individual drug sections (codeine /paracetamol)2. You are reviewing a drug chart of a 78-year-old gentleman, that was completed on clerking by the on-call doctor. PMH. Myocardial infarction 2 years ago, ischaemic heart disease, hypothyroidism. DH. See below. Allergies. Penicillin (rash) Please select the 2 drugs that most likely contain a serious dosing error Medicine Dose Route Frequency A Atorvastatin 20 mg PO OD B Bisoprolol 2.5 mg PO OD C Furosemide 40 mg PO OD D Levothyroxine50 mg PO OD E Ramipril 5 mg PO OD2. You are reviewing a drug chart of a 78-year-old gentleman, that was completed on clerking by the on-call doctor. PMH. Myocardial infarction 2 years ago, ischaemic heart disease, hypothyroidism. DH. See below. Allergies. Penicillin (rash) Please select the 2 drugs that most likely contain a serious dosing error Medicine Dose Route Frequency A Atorvastatin 20 mg PO OD B Bisoprolol 2.5 mg PO OD C Furosemide 40 mg PO OD D Levothyroxine50 mg PO OD E Ramipril 5 mg PO ODTips ⮚ Know common drugs and their doses ⮚ Always check for units!3. A 45-year-old male patient presented to A&E with haematemesis. During his stay, he acquired pneumonia. PMH. Gastric ulcer, hypertension, T2DM. DH. See below. Allergies. Penicillin (anaphylaxis) Observations: HR 115, RR 22, BP 95/55, temp 39C Which 2 drugs are most important to stop? Medicine Dose Route Frequency A Atorvastatin 20 mg PO OD B Ceftriaxone 1 g IV BD C Lisinopril 20 mg PO OD D Metformin 500 mg PO BD E Tranexamic Ac1 g IV TDS3. A 45-year-old male patient presented to A&E with haematemesis. During his stay, he acquired pneumonia. PMH. Gastric ulcer, hypertension, T2DM. DH. See below. Allergies. Penicillin (anaphylaxis) Observations: HR 115, RR 22, BP 95/55, temp 39C Which 2 drugs are most important to stop? Medicine Dose Route Frequency A Atorvastatin 20 mg PO OD B Ceftriaxone 1 g IV BD C Lisinopril 20 mg PO OD D Metformin 500 mg PO BD E Tranexamic Ac1 g IV TDSTips ⮚ Never forget about allergies! ⮚ Always review medications if status changes, e.g. BP drop, bleeding etc.4. A 28-year-old woman presents to A&E with a sudden onset of right heel pain. PMH. Pelvic inflammatory disease (diagnosed 1 week ago), hayfever, fibromyalgia DH. See below. NKDA On examination, she is limping and visibly in pain. Her left heel and leg are bruised, swollen and poorly defined. Which drug has most likely caused her symptoms? Medicine Dose Route Frequency A Duloxetine 60 mg PO OD B Metronidazole400 mg PO BD C Moxifloxacin 400 mg PO OD D Pregabalin 100 mg PO TDS E Promethazine 20 mg PO BD4. A 28-year-old woman presents to A&E with a sudden onset of right heel pain. PMH. Pelvic inflammatory disease (diagnosed 1 week ago), hayfever, fibromyalgia DH. See below. NKDA On examination, she is limping and visibly in pain. Her left heel and leg are bruised, swollen and poorly defined. Which drug has most likely caused her symptoms? Medicine Dose Route Frequency A Duloxetine 60 mg PO OD B Metronidazole400 mg PO BD C Moxifloxacin 400 mg PO OD D Pregabalin 100 mg PO TDS E Promethazine 20 mg PO BDTips ⮚ If unsure, check BNF for safety information, contraindication, caution ⮚ CTRL + F for key phrases like MSK, tendon etc. ⮚ Can always use search function in general!5. A 55-year-old patient has review bloods done. PMH. Gout, rheumatoid arthritis, T2DM, ischaemic heart failure DH. See below. NKDA Investigations: GFR 80 2 weeks ago, GFR 35 today (AKI stage 2) Which 3 drugs should be stopped? Medicine Dose Route Frequency A Allopurinol 100 mg PO OD B Atorvastatin 20 mg PO OD C Ketoprofen 100 mg PO OD D Metformin 1 g PO BD E Methotrexate 15 mg PO weekly F Prednisolone 7.5 mg PO OD G Spironolacton50 mg PO OD5. A 55-year-old patient has review bloods done. PMH. Gout, rheumatoid arthritis, T2DM, ischaemic heart failure DH. See below. NKDA Investigations: GFR 80 2 weeks ago, GFR 35 today (AKI stage 2) Which 3 drugs should be stopped? Medicine Dose Route Frequency A Allopurinol 100 mg PO OD B Atorvastatin 20 mg PO OD C Ketoprofen 100 mg PO OD D Metformin 1 g PO BD E Methotrexate 15 mg PO weekly F Prednisolone 7.5 mg PO OD G Spironolacton50 mg PO ODTips ⮚ Appendix 1 ⮚ Look up individual drugs as some drugs might not be on the tableAdverse Drug ReactionsAdverse drug reaction 8 items, 16/200 marks Suggested is 1 min/ question6. A 55-year-old man is being prepped for surgery. His regular medications are listed below. The anaesthetist is considering to use propofol. Which of his regular medications is most likely to interact with propofol? Medicine Dose Route Frequency A Atorvastatin 20 mg PO OD B Finasteride 1 mg PO OD C Methotrexate 7.5 mg PO weekly D Sodium 2 g PO OD Valproate E Verapamil 240 mg PO BD6. A 55-year-old man is being prepped for surgery. His regular medications are listed below. The anaesthetist is considering to use propofol. Which of his regular medications is most likely to interact with propofol? Medicine Dose Route Frequency A Atorvastatin 20 mg PO OD B Finasteride 1 mg PO OD C Methotrexate 7.5 mg PO weekly D Sodium 2 g PO OD Valproate E Verapamil 240 mg PO BDTips ⮚ Highly recommend MC interaction checker – ensure correct spelling! ⮚ On BNF, select main drug, then CTRL + F for other drugs ⮚ Sodium valproate has a theoretical interaction7. A 40-year-old woman has presented with irregular periods. Her regular medications are listed below Which drug is most likely to be responsible for her symptoms? Medicine Dose Route Frequency A Colchicine 500 microgramPO BD B Desogestrel 75 mg PO OD C Lansoprazole30 mg PO OD D Risperidone 2 mg PO OD E Sumatriptan 50 mg PO PRN7. A 40-year-old woman has presented with irregular periods. Her regular medications are listed below Which drug is most likely to be responsible for her symptoms? Medicine Dose Route Frequency A Colchicine 500 microgramPO BD B Desogestrel 75 mg PO OD C Lansoprazole30 mg PO OD D Risperidone 2 mg PO OD E Sumatriptan 50 mg PO PRNTips ⮚ CTRL + F for side effect on all drugs ⮚ Always check all drugs to look for highest frequency ⮚ On Medicines complete try ADR checker8. A 55-year-old woman is due to be started on warfarin after a metallic mitral valve replacement. PMH. Epilepsy, tinea pedis, TB contact. DH. See below. NKDA Which of the following is most likely to interact with warfarin to cause an increased INR? Medicine Dose Route Frequency A Carbamazepine500 mg PO BD B Fluconazole 50 mg PO OD C Griseofulvin 1 g PO OD D Phenobarbital120 mg PO OD E Rifampicin 600 mg PO OD8. A 55-year-old woman is due to be started on warfarin after a metallic mitral valve replacement. PMH. Epilepsy, tinea pedis, TB contact. DH. See below. NKDA Which of the following is most likely to interact with warfarin to cause an increased INR? Medicine Dose Route Frequency A Carbamazepine500 mg PO BD B Fluconazole 50 mg PO OD C Griseofulvin 1 g PO OD D Phenobarbital120 mg PO OD E Rifampicin 600 mg PO ODTips Can be found under Substrate Inducers – CRAP Inhibitors – SICKFACES.COM interactions of warfarin GPSs CYP450 inducers/ inhibitors are worth remembering! Statin Carbamazepine Sodium Valproate Sulphonamides ⮚ P450 metabolises the Theophylline Rifampicin Isoniazid Ciprofloxacin drug ⮚ Inducers will increase Phenytoin Alcohol (chronic) Cimetidine Omeprazole metabolism, leading to lower drug levels Warfarin Phenytoin Ketoconazole Metronidazole ⮚ Inhibitors cause higher drug levels due to SSRI Griseofulvin Fluconazole inhibited drug Amitriptyline Phenobarbital Amiodarone, Alcohol Grapefruit juice metabolism (acute) Codeine Sulfonylureas Chloramphenicol Caffeine St John’s Wort Erythromycin9. A 29-year-old male inpatient on a psychiatric ward has been found drowsy. This is untypical for him, just 2 hours ago he was aggressive and threatening towards staff and had to be restrained. PMH. Schizophrenia DH. Clozapine 200 mg OD, lorazepam 2mg PRN, paracetamol 1g PRN. NKDA. On examination, nystagmus is present, and his RR is 6. Which drug should be given? Medicine Dose Route Frequency A Acetylcysteine 8 g IV stat B Charcoal 50 g PO stat C Flumazenil 200 micrograms IV stat D Lorazepam 2 mg IM/IV stat E Naloxone 400 micrograms IV stat9. A 29-year-old male inpatient on a psychiatric ward has been found drowsy. This is untypical for him, just 2 hours ago he was aggressive and threatening towards staff and had to be restrained. PMH. Schizophrenia DH. Clozapine 200 mg OD, lorazepam 2mg PRN, paracetamol 1g PRN. NKDA. On examination, nystagmus is present, and his RR is 6. Which drug should be given? Medicine Dose Route Frequency A Acetylcysteine 8 g IV stat B Charcoal 50 g PO stat C Flumazenil 200 micrograms IV stat D Lorazepam 2 mg IM/IV stat E Naloxone 400 micrograms IV statTips ⮚ Poisoning treatment summary10. A 32-year-old gentleman is started on clozapine. PMH. Schizophrenia. DH. Clozapine. NKDA. What monitoring should this patient have at 6 months? Monitoring A Lipids, fasting blood glucose, FBC, prolactin, LFTs B Lipids, weight, fasting blood glucose, FBC C Lipids, weight, fasting blood glucose, FBC, LFTs, U&Es D Lipids, weight, fasting blood glucose, FBC, prolactin E Lipids, weight, fasting blood glucose, FBC, prolactin, LFTs10. A 32-year-old gentleman is started on clozapine. PMH. Schizophrenia. DH. Clozapine. NKDA. What monitoring should this patient have at 6 months? Monitoring A Lipids, fasting blood glucose, FBC, prolactin, LFTs B Lipids, weight, fasting blood glucose, FBC C Lipids, weight, fasting blood glucose, FBC, LFTs, U&Es D Lipids, weight, fasting blood glucose, FBC, prolactin E Lipids, weight, fasting blood glucose, FBC, prolactin, LFTsTips ⮚ Monitoring requirement section for most drugs ⮚ Read it carefully! Questions? Research survey Feedback SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! 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