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Prescribing Safety ExamStructure ▪ It is made up of 8 sections totaling 200 marks. 1. Prescribing 2. Prescription review 3. Planning management 4. Providing information 5. Calculation skills 6. Adverse drug reactions 7. Drug monitoring 8. Data interpretationTips •The time given to complete this is 120 minutes (2hours). •Do all the practice papers on PSA website – remember they are only half papers so should be done in 60minutes (1hour). – ”Paper 3” = full length. ▪Use the search function ‘Ctrl + F’ to speed up your searches e.g..▪ Be familiar with the “treatment summaries” section in the BNF If you are unsure about the medication used to treat a condition such asan acute dystonic reaction. The best solution is to search “poisoning” under treatment summaries which would tell you that procyclidine or diazepam can be used in this scenario.1.Prescribing ▪ 8 x 10 mark questions – 5 marks for drug choice, 5 marks for choice of dose/route/frequency ▪ You should allocate around 45mins to this section ▪ You will be asked to write a prescription for ONE drug that can be used to treat a condition ▪ ALLERGIES ▪ Check if any cautions/interactions in past medical history. ▪ There can be a range of scenarios such as treatment ofacute conditions (e.g. acute asthma attack, acute heart failure), chronic conditions (e.g. depression, GORD), fluid prescription and important symptoms such as pain. ▪ Use the list of important treatment summaries on previous slide to help you in this section.Prescribing The approach: •For example: ‘What would you prescribed to treat acute pulmonary oedema secondary to left ventricular systolic dysfunction?’ •You decide on → e.g Furosemide – now check BNF for route, dose, interval etcPrescribing fluids ▪ If chronic renal failure, heart failure or signs of fluid overload – give 250ml bolus (usually 500ml bolus of saline in resus) for low BP i.e. shock) ▪ Use Parkland criteria for burns - %BSA burn x weight(kg)x 4ml = total fluid requirementfor first24hours ▪ Use Hartmann’s – 50% in first 8hours since time of burn and remaining50% over next 16 hours ▪ Types of fluids: ▪ Sodium chloride 0.9% ▪ Hartmann’s solution ▪ 5% dextrose ▪ 0.18% sodium chloride / 4% dextroseN.B ▪ ▪Antiemetic Prescribing ▪ https://youtu.be/zD_CWMlrb5s ▪ ▪ ▪ ▪ ▪NI Palliative Care Guidelines ▪Laxatives ▪ ▪ ▪ ▪ ▪ ▪ ▪https://www.northoftyneapc.nhs.uk/wp-content/uploads/2023/01/Constipation-guideline-January-2023.pdf2.Prescription review • 8 questions = 8 medications to review. You should allocate ~20mins to this section. ▪ ▪ ▪▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Use short acting insulin e.g., novorapid ▪ 1 unit of insulin reduces blood glucose by 2- ▪ 3mmol/L ▪ ▪ ▪Pre-op medication reviewAntipsychotic side effects▪ • • • • • • • • • • • • • • •▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪3.Planning management •8 items ~10 minutes •Typically, you will be provided with 5 options and tasked with deciding which treatment would be most appropriate in the management of the given clinical scenario. st Almost MCQ like - need knowledge to make decisions on 1 line medication choices etc or…4.Communicating information ▪6 items ~ 7 minutes ▪Typically, you will be provided with 5 pieces of information and tasked with selecting the most important option to provide to the patient. ▪Examples of the medicines that might be the focus of discussion include insulin, warfarin, salbutamol inhaler, methotrexate, or an oral hypoglycaemic medication.▪ The approach: • Search for the medication in question. • The information that is important can often be found in “important safety information” ( e.g Rivaroxaban not being effective on an empty stomach ), “patient and carer advice” (e.g advice regarding missed contraceptive doses) or “monitoring requirements”. Tip From experience these tended to be the more “holistic” pieces of advice or pertaining to side effects/ efficacy relevant to patient moreso than biochemical side effects for example. A lot of these will have more than one right answer – need to pick the one you feel is most relevant to the patient.5.Calculation skills •8 items ~10 minutes •You will be tasked with calculating the dose or rate of administration of a medication. Theapproach: •Work through calculations of a question twice to double checkyour answers. (or work backwards once you get your answer) •Be familiar with unit conversions. •And preparations: 1% = 1g in 100mL; 1 in 1000 = 1g in 1000mL •X% v/v = x ml dissolved in 100ml 1% 1g in 100ml Diagram showing conversionsbetween common units for medications 1% = If you know this you can 1g/100ml = answer any PSA calculation question 1000mg/ml= (well most of them)!!! 10mg/ml Question 1 – How much amphotericin do we need? 36x5 = 180mg Question 2 – how many ml of reconstituted Amph do Lesson – there’s often lots of extra info we need? in these stems – be selective in what you use! 180/4 = 45mlHow much Vanc in mg?? = 1000mg 1000mg → 5mg = / by 200 Therefore need 200ml diluent1st bag – 20mmol/ L in 500ml = 10mmol nd 2 bag = 20mmol/L in 1L= 20mmol 2 hours left so 1/4 final bag will run → 40/4 = 10mmol 10+20+10 = 40mmol6.Adverse drug reactions • 8 items ~10 minutes • Often relevant adverse drugreactions (ADRs) can be found in either the “side effect”, “interactions” or “cautions” section of the medication. • If you were interested in finding out whether the combined oral contraceptive pill (COCP) increases blood pressure,use the ‘Ctrl F’ function to search for “blood pressure” on the BNF page for the particular COCP. • Sometimes, several drugs may list the relevant ADR in itsside-effect profile, you should then pick the drug for which the side-effect is most common.7.Drug monitoring ▪ 8 items ~ 10minutes ▪ This section will task you with selecting the most suitable plan of monitoring for either beneficial or harmful effects of a newly started medication. • It is importantto elicit which one of these is being tested as different tests are often required. (e.g., weightis the best monitoring measure for the beneficial effects of furosemide in someone with fluid overload, however, to monitor for harmful effects – renal function) The approach: • Search up the medications “monitoring requirements”, “important safety information” or “pre-treatment screening” on the BNF.Tip → in a lot of these, the most non- invasive test that is directly impactful of QoL, is often the right answer, Eg. Weight,Exercise tolerance, number of loose stoolsImportant drug monitoring Clozapine ▪ • Weekly FBC 18/52 • • 2 weekly for a year • • Monthly thereafter • Baseline lipidsand weight ▪ ▪ ▪ ▪ ▪ ▪8.Data interpretation • You will be provided with a clinical scenario and some investigation results and tasked with determining the most appropriate course of action forward with regard to prescribing. (e.g withdrawing a medication, reducing its dose, no change, increasing its dose or switching to a new medication). • Asked to interpret blood tests, drug levels or graphical data (e.g., nomograms) • For INR search ‘oral anticoagulants’ • Abnormal test results don’t always alter the management plan • Transaminases can be raised by x3 upper limit of norms before statins should be discontinued • Steroids can raise WCC (non-infective)The approach: • As the scope of testing for this section can be quite broad, knowledge of some common scenarios will be very helpful: • Switch patients not tolerating an ACEi to ARBs • Know how to prescribe gentamicin and how to use the gentamicin chartto determine next prescription timing • Know how to use the treatment nomogram in paracetamol overdoses. • For someone with BD mixed insulin, the morning insulin should be adjusted according to evening BMs and evening insulin adjusted according to morning BMs. (e.g for a patient on Humulin M3 BD, with high morning BMs, evening Humulin M3 should be increased) • Oxycodone/fentanylis preferrable to morphine in impaired renal functionTherapeutic drug monitoring▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Questions? omcgilly01@qub.ac.uk