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PSA Prep Course -INR, UTI, and other abbreviations DR CHANG KIM FY1 1Disclaimer We are a group of F1 doctors preparing this course to help prepare/as a supplement for your PSA. Please do not use this as your sole source of revision. None of the patients/cases are based on real-life scenarios, and any similarities are coincidental. Some drug concentrations/preparations may have been changed for ease of calculations, and may not resemble real-life clinical practice. Always consult your university for exam-related queries and support, and the BNF/Medicines Complete for up-to-date information on drugs and prescriptions. 2 INR International Normalised Ratio 3 A 68-year-old gentleman presents to the ED with new-onset left-sided weakness, facial droop, and a GCS of 9/15. A CT head reveals an intracranial bleed. His INR is 6.3. PMHx: Atrial fibrillation, mechanical aortic valve DHx: Bisoprolol 5mg OD, warfarin 5mg OD Which of the following options is the most suitable for the patient? 1. Swap the patient onto a DOAC 2. Withhold warfarin, give tranexamic acid 3. Withhold warfarin, give IV phytomenadione 4. Reduce the warfarin dose by 2mg and review 5. Withhold warfarin, give 1 unit FFP Answer: 3. NOTE CORRECTION: recording incorrectly says PO phytomenadione for option 3. This slide as been corrected. 4Warfarin Vitamin K antagonist Target INR ◦ Prevents the formation of clotting factors II, VII, IX, X 2.5 (2-3) ◦ DVT/PE Takes 48-72h to fully anticoagulate ◦ AF ◦ Bioprosthetic heart valves 3.5 (3-4) ◦ Recurrent DVT/PE for those already on anticoagulation with INR >2 5 INR Major bleed: INR >8.0, no bleed ◦ Stop warfarin ◦ Stop warfarin ◦ Give phytomenadione PO ◦ Give phytomenadione IV ◦ Restart warfarin when INR <5 ◦ Give dried PCC INR 5-8, minor bleed ◦ Stop warfarin INR >8.0, minor bleed ◦ Give phytomenadione IV ◦ Stop warfarin ◦ Restart warfarin when INR <5 ◦ Give phytomenadione IV INR 5-8, no bleed ◦ Restart warfarin when INR <5 ◦ Withhold 1-2 doses, reduce maintenance dose PCC: prothrombin complex concentrate (II, VII, IX, X) If no PCC available, can give FFP, but is less effective Extra information on PCC vs FFP vs cryo at the end of the slides. TL;DR- any bleed, stop the warfarin and give IV phytomenadione 6Screenshot of the official wording found on BNF. 7 You’re bleeped by a nurse to review a patient’s warfarin dose. His most recent INR is 7.6. He is currently on warfarin for prophylaxis of recurrent DVTs. His target INR is 3.5. OE: HR 78, BP 150/84, RR 19, Sats 95% on RA, temp 37.1 Which of the following options is the most suitable management? 1. Stop warfarin + give phytomenadione IV + give dried PCC 2. Stop warfarin + give phytomenadione IV + restart warfarin when INR <5 3. Stop warfarin + give phytomenadione IV + restart warfarin when INR <3.5 4. Stop warfarin + give phytomenadione PO + restart warfarin when INR <3.5 5. Withhold 1-2 doses, reduce maintenance dose Answer: 5 Note that his INR is within the 5-8 range, and there are no features in the question stem suggestive of an acute major or minor bleed. 8 You’re in the clinic and one of your patients has been started on warfarin. Which of the following is the most important information that should be provided? 1. Warfarin tablets are brown 2. Warfarin should be stopped before dental procedures 3. Binge drinking alcohol should be avoided 4. Warfarin is not affected by dietary intake 5. If a dose is missed, they should take 2 tablets the next day Answer. 3 1 is true but not an important fact to relay to the patient 2 is incorrect as warfarin can be continued for most outpatient procedures 4 is incorrect as it can be affected by some foods e.g. leafy greens contain lots of vit K, cranberry juice can increase INR levels 6 is incorrect, patients should nevedouble-dosese their warfarin medication 9 UTI’s Urinary Tract Infections 10 A 24-year-old female attends her GP appointment with a 2/7 history of dysuria and offensive urine. Urine dip reveals: pH 6.0 Leukocytes ++ Bilirubin – Blood - Protein – Nitrites + Pregnancy – Ketones – Glucose – Please write a prescription for one medication to alleviate her symptoms. Nitrofurantoin 50mg QDS for 3 days or Trimethoprim 200mg BD for 3 days Make sure you state the duration of 3 days 11UTI’s Common PSA question 1 thing to consider: ◦Are they pregnant or a male? 12UTI – Non-Pregnant Females st 1 line ◦ Nitrofurantoin or trimethoprim ◦ 3 day course 13UTI – Pregnant Females 1 line ◦ Nitrofurantoin 2ndline ◦ Amoxicillin/cefalexin 7 day treatment 14UTI – Males st 1 line ◦ Nitrofurantoin or trimethoprim ◦ 7 day course 15 A 26-year-old female attends her GP appointment with a 4/7 history of stinging sensation when passing urine. She is currently emptying her bladder 7-8 times a day, which she states is unusual for her. She is currently 17 weeks pregnant. PMH: Migraines with aura, endometriosis DHx: paracetamol, ibuprofen Allergies: nitrofurantoin A mid-stream urine sample is collected and sent off to the labs for MCS. Please write a prescription for one medication to alleviate her symptoms. Cefalexin 500mg BD for 7 days for full marks Amoxicillin 500mg TDS for 7 days would not be full marks as you do not know the susceptibility 16 NTD’s Neural Tube Defects 17 A 26-year-old female attends her GP appointment asking for pregnancy advice. She wants to try for a baby and says that one of her friends had to take tablets to prevent the baby from being born without a hole in its spine. PMH: haemorrhoids, alopecia areata DH: nil Which of the following is the most suitable prescription? 1. Folic acid 400 micrograms PO OD until week 12 2. Folic acid 400 micrograms PO OD until birth 3. Folic acid 5mg PO OD until week 12 4. Folic acid 5mg PO OD until birth 5. Reassure her Answer: 1 18Neural Tube Defects Occurs when the neural tube doesn’t At risk patients: close properly during embryonic development Previous child with NTD ◦ Spina bifida Antiepileptic medication ◦ Anencephaly Diabetes Sickle cell disease 19NTD prevention Prevention (low risk) Folic acid 400 micrograms PO OD until week 12 Prevention (high risk) Folic acid 5mg PO OD until week 12 Prevention (sickle cell) Folic acid 5mg PO OD until birth 20 A 29-year-old female attends her GP appointment asking for pregnancy advice. She is currently 6 weeks pregnant and states her mother told her to come to the GP for advice about taking nutritional supplements to support the baby’s development. PMH: orthostatic hypotension, sickle cell disease, Factor V Leiden deficiency DH: nil Allergies: aspirin Please write a prescription for one medication to prevent a neural tube defect. Note that the patient has a history of sickle cell disease, hence the correct prescription would be folic acid 5mg PO OD until birth. 21 ACEi’s ACE inhibitors 22 An 85-year-old gentleman comes into the GP clinic for a routine review 1 week after increasing his ramipril from 5mg to 10mg PO OD. Below are his recent blood test results: 12/11/22 15/09/22 Which of the following is the most suitable Na+ 137 (135-145) Na+ 135 management option? K+ 4.9 (3.5-5.3) K+ 4.2 1. Carry on the ramipril at 10mg Urea 6.8 (2.0-7.0) Urea 4.9 2. Stop the ramipril completely Creatinine 117 (55-120) Creatinine 86 3. Switch back to 5mg PO OD eGFR 86 eGFR 93 4. Re-assess the BP 5. Re-check bloods in 2 weeks Answer: 3. As the creatinine has increased by 36% (even though it is within normal range), the NICE CKS recommendation is that you cut back to the last tolerated dose and monitor. 23 ACEi Management If eGFR drops by <25% or creatinine If eGFR drops by >25% or creatinine increases by <30% increases by >30% Do not modify ACEi dose Investigate other causes e.g. volume depletion Re-check levels in 2 weeks Consider drugs which may contribute to renal function drop Stop the ACEi dose OR Reduce dose to previously tolerable dose & re-check in 5-7/7 Example drugs: NSAIDs, vasodilators (CCB, nitrates), K sparing diuretics, diuretics. 24 PCC vs FFP vs CPT Prothrombin Complex Concentrate vs Fresh Frozen Plasma vs Cryoprecipitate 25 PCC (Beriplex/Octaplex) Fresh Frozen Plasma Cryoprecipitate Contents: Contents: Contents: • Factors II, VII, IX, X • All clotting factors • Factors VIII, XIII, • Protein C & S Slower administration fibrinogen, vWF Fast administration Needs thawing Indicated in: Corrects the INR in <5 Needs to be blood group • Fibrogen deficiency (vWD, mins specific haemophilia) Virally inactivated Often not virally • dysfibrinogenaemia due inactivated to: • Critical bleeding • Invasive procedures • Trauma • DIC PCC- prothrombin complex concentrate vWF- von Willebrand factor vWD- von Willebrand disease Takeaway message from this slide: In acute warfarin-related bleeds, evidence based medicine suggests that the use of PCC provides better outcomes and quicker responses than FFP. NICE recommends PCC, but if not available, FFP is a suitable alternative for INR reversal Viral inactivation: the process when viruses in a sample are either removed or rendered non-infectious. 26Important BNF Pages Treatment summaries ◦ Oral anticoagulants ◦ Urinary Tract Infections ◦ Neural Tube Defects ◦ Hypertension (NICE CKS) 27 NextWeek Feedback Data Interpretation & Drug Monitoring (09:00-11:15) with Dr Sa-Bin Hong 28
