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Adverse Drug Reactions Tips for the PSA Have medicines complete/ BNF ready so you can practise the Hasaan Khan questions FOUNDATION YEAR 1 DOCTOR 1Session Format 2 Session Format • Overview of exam format • General tips • 4 different item style questions • Common drugs and their interactions • Mock exam questions (Post session resource) Quick fire section in the PSA 3Exam Format and General Tips 4 Prescribing Safety Assessment – Format Style Item Content Marks Prescribing 8 items of 10 marks 80 Prescription Review 8 items of 4 marks each 32 Planning Management 8 items of 2 marks each 16 Providing Information 6 items of 2 marks each 12 Calculation Skills 8 items of 2 marks each 16 Adverse Drug Reactions 8 items of 2 marks each 16 Drug Monitoring 8 items of 2 marks each 16 Data Interpretation 6 items of 2 marks each 12 TOTALS 60 200 Minus the prescribing, prescription review, and knowing a little bit about common emergencies, drug and opioid conversion, the PSA is a timed exam of how well you can use the BNF/medicine’s complete as a resource. 5 Prescribing Safety Assessment – Format Style Item Content Marks Prescribing 8 items of 10 marks 80 Prescription Review 8 items of 4 marks each 32 Planning Management 8 items of 2 marks each 16 Providing Information 6 items of 2 marks each 12 Calculation Skills 8 items of 2 marks each 16 Adverse Drug Reactions 8 items of 2 marks each 16 Drug Monitoring 8 items of 2 marks each 16 Data Interpretation 6 items of 2 marks each 12 TOTALS 60 200 Max spend 10 minutes on this section Prescribing, 6 minutes per question Best way to do this is 100 marks in 2 hrs. so approximately 72 seconds for every 2 marks Bulk of marks from 1 section and then second section. ADRs forms more of the general skills for PSA exam. 6 Prescribing Safety Assessment Additional construction rules Coverage of clinical settings Coverage of high risk drugs Minimum number of items At least one item on • Medicine – 8 • Opiates • Surgery – 4 • Anticoagulants • Elderly care – 8 • Insulin • Paediatrics – 4 • Antibiotics • Psychiatry – 4 • Infusion fluids • Obstetrics & Gynaecol. – 4 • General practice – 8 Each PSA will include at least one item on opiates, anticoagulants, insulin, antibiotics, and infusion fluids. These drug Groups Were Selected On The Basis That They Were Included In The List Of 8 High Risk Prescribing Categories Identified By The NPSA As Being Most Commonly Associated With Severe Harm Or death.1 Drugs In The Other 3 Categories (anaesthetics, Chemotherapy And Antipsychotics) Were Omitted On The Basis That Foundation Doctors Would Not Routinely Have responsibility For Prescribing These agents. 7Official question papers I found the most useful 8Quick summary of BNF/medicine complete Ctrl + F is your friend 9Quick summary of BNF/medicine complete Ctrl + F is your friend 10Quick summary of BNF/medicine complete Ctrl + F is your friend 11Quick summary of BNF/medicine complete Ctrl + F is your friend 12Quick summary of BNF/medicine complete Ctrl + F is your friend 13Item Styles 14 Adverse Drug Reactions • 4 types of ADR item style: • A: identifying likely adverse reactions • What is a side effect of][drug • B: identifying drugs causing specific adverse drug reactions, • What drug is causing [reaction: e.g hepatotoxicity, electrolyte abnormality] • C: identifying drug interactions • What drug is interacting with [another drug] to cause the presentation • D: managing the adverse effects of a drug • What is the most appropriate management for this drug reaction Some of this will require background knowledge but most questions it is a game of reading the buzzwords of the questions, ‘Ctrl + F’ and checking your answers. Quick fire section of PSA There are four main types of ADR questions in this chapter: ◗ Type A – asks you to identify the two most likely ADRs for specific commonly prescribed drugs, e.g. beta blockers causing bronchospasm, statins resulting in myopathy, sulfonylureas causing hypoglycaemia ◗ Type B – asks you to identify two medicines that have most likely caused an ADR presented in that question, e.g. rifampicin/isoniazid causing hepatotoxicity, antidepressants/diuretics resulting in hyponatraemia, antimuscarinics/antipsychotics causing urinary retention ◗ Type C – asks you to identify the potential drug–drug interaction between two medicines that has most likely caused the clinical presentation in that question, e.g. amiodarone and warfarin (increased anticoagulant effect), antiepileptics and SSRIs (lowered seizure threshold), digoxin and loop diuretics (increased risk of digoxin toxicity) ◗ Type D – asks you to choose the two most appropriate management options for a particular ADR, e.g. opioid toxicity, methotrexate overdose, digoxin and bradycardia. 15 Adverse Drug Reaction 2 marks – Item style A Case Presentation ADVERSE EFFECT OPTIONS A 60-year-old woman is admitted to a general medical ward with recurrent UTI caused by extended spectrum beta- lactamase (ESBL)-producing Klebsiella. PMH. CKD (Stage 2), recurrent UTIs. DH. Amlodipine 10 mg PO daily, metoprolol Agranulocytosis tartrate 50mg PO 12-hrly, ramipril 10 mg PO daily. On Examination Temperature 38.4C, HR 90/min and rhythm regular, BP Blurred vision 102/64 mmHg, RR 21, O2 sat 98% breathing air. Urinalysis shows blood 1+, protein 2+, leucocytes 2+ Investigations Excessive sweating WCC 21.3 x 109/L (3.0-10.0), platelets 174 x 109/L (150-400). eGFR 31 mL/min/1.73 m2 (>60), CRP 165 mg/L (<10). Interstitial nephritis The consultant microbiologist advises that temocillin 1 g IV 12-hrly is started. Question Thrombocytopenia Select the adverse effect that is most likely to be caused by this treatment. 16 Adverse Drug Reaction 2 marks – Item style A Case Presentation ADVERSE EFFECT OPTIONS A 60-year-old woman is admitted to a general medical ward with recurrent UTI caused by extended spectrum beta- lactamase (ESBL)-producing Klebsiella. PMH. CKD (Stage 2), recurrent UTIs. DH. Amlodipine 10 mg PO daily, metoprolol Agranulocytosis tartrate 50mg PO 12-hrly, ramipril 10 mg PO daily. On Examination Blurred vision Temperature 38.4C, HR 90/min and rhythm regular, BP 102/64 mmHg, RR 21, O2 sat 98% breathing air. Urinalysis shows blood 1+, protein 2+, leucocytes 2+ Investigations Excessive sweating WCC 21.3 x 109/L (3.0-10.0), platelets 174 x 109/L (150-400). eGFR 31 mL/min/1.73 m2 (>60), CRP 165 mg/L (<10). Interstitial nephritis 12-hrly is started.obiologist advises ttemocillin 1 g IV Question Thrombocytopenia Select theadverse effect that ismost likely to be caused by this treatment . 17 Adverse Drug Reaction 2 marks – Item style A Feedback ADVERSE EFFECT OPTIONS The question asks which adverse effect is most likely to Agranulocytosis occur. Blurred vision (option B) and hyperhidrosis (option C) arBlurred vision not known adverse effects of penicillins such as temocillin and can therefore be eliminated. Agranulocytosis (option A) and interstitial nephritis Excessive sweating (option D) are rare or very rare adverse effects and are therefore less likely to occur. Thrombocytopenia is a common or very common adverse Interstitial nephritis effect of penicillins such as temocillin. Therefore, this the adverse effect most likely to occur. Thrombocytopenia 18Adverse Drug Reaction 2 marks – Item style A This question is quite nice because when you have an isolated drug, it requires less searching. You go to the drug and look at the side effect’s section. 19 Adverse Drug Reaction 2 marks – Item style B Case Presentation PRESCRIPTION OPTIONS A 82-year-old male is in the emergency department after becoming dizzy and experiencing a fall when going to the toilet in the evening. She reports similar ‘dizzy’ episodes on getting up from her chair. PMH. Hypothyroidism, osteoarthritis, depression, recurrent UTIs. DH. Levothyroxine sodium 50 regular prescriptions are listed (right). SH. Lives alone, walks with a stick. Ox examination micrograms PO daily Looks pale and tired. Oriented to time and place. Temperature 36Meloxicam 7.5 mg PO daily 76/min and rhythm regular (increased to 86/min during posture test). BP 120/74 mmHg (lying; 98/60 mmHg (standing). RR 16/min, HS normal, chest clear on auscultation. Tenderness and grazing on left elbow and shoulder with full range of movement. Mirtazapine 30 mg PO nightly Investigations U 6.8 mmol/L (2.5-7.0), Cr 80 μmol/L (60-100), eGFR 55 ml/min/1.73m2 (>60), serum creatine kinase 200 U/K (24-170). Paracetamol 1 g PO 6-hrly ECG shows sinus rhythm. Question Trimethoprim 100 mg PO nightly Select the prescription that is most likely to contribute to her postural hypotension. 20 Adverse Drug Reaction 2 marks – Item style B Case Presentation PRESCRIPTION OPTIONS and experiencing a fall when going to the toilet in the evening. Shezy reports similar ‘dizzy’ episodes on getting up from her chair. PMH. Hypothyroidism, osteoarthritis, depression, recurrent UTIs. DH. Levothyroxine sodium 50 regular prescriptions are listed (right). SH. Lives alone, walks with a stick. micrograms PO daily Ox examination Looks pale and tired. Oriented to time and place. Temperature 36Meloxicam 7.5 mg PO daily 76/min and rhythm regular (increased to 86/min during posture test). BP 120/74 mmHg (lying; 98/60 mmHg (standing). RR 16/min, HS normal, chest clear on auscultation. Tenderness and grazing on left elbow and shoulder with full range of movement. Mirtazapine 30 mg PO nightly Investigations U 6.8 mmol/L (2.5-7.0), Cr 80 μmol/L (60-100), eGFR 55 ml/min/1.73m2 (>60), serum creatine kinase 200 U/K (24-170). Paracetamol 1 g PO 6-hrly ECG shows sinus rhythm. Question Trimethoprim 100 mg PO nightly Select the prescription that imost likely to contribute to her postural hypotension . 21 Adverse Drug Reaction 2 marks – Item style B Feedback PRESCRIPTION OPTIONS Levothyroxine sodium 50 Light-headedness is the most common presenting micrograms PO daily symptom of postural hypotension. Symptoms are worse on standing and resolve when resuming a supine positioMeloxicam 7.5 mg PO daily It is defined as a sustained drop of ≥20 mmHg in systolic blood pressure within 3 minutes of standing. Mirtazapine 30 mg PO nightly Be careful not be distracted by similar or related advParacetamol 1 g PO 6-hrly effects such as dizziness, syncope or vertigo. Postural hypotension is a common side effect of Trimethoprim 100 mg PO nightly mirtazapine. •Remember, it is asking you about postural hypotension, not the dizziness. Read the question 22Adverse Drug Reaction 2 marks – Item style B 23 Adverse Drug Reaction 2 marks – Item style C Case Presentation PRESCRIPTION OPTIONS A 68-year-old woman presents to the emergency department with headache, confusion, and severe nausea and vomiting. PMH. AF, ischaemic stroke, hypertension, vitamin D deficiency, osteoporosis, previous left neck of femur fracture. DH. Her current regular medicines, in addition to digoxinAlendonic acid 70 mg PO weekly micrograms PO daily, are listed (right). SH. Lives with husband. Ox examination Drowsy, confused, and pallid. Temperature 36.8C, HR 45/min and rhytApixaban 5 mg PO 12-hrly irregularly irregular, BP 105/72 mmHg. Investigations Na+ 140 mmol/L (137-144), K+ 3.3 mmol/L (3.5-5.3), U 10.2 mmol/L (2.5-7.0), Cr 105 μmol/L (60-100), eGFR 56 ml/min/1.73m2 (>60), Ca2+ (corrected) 2.63tatin 10 mg PO daily mmol/L (2.20-2.60). Serum digoxin 2.9 nmol/L (1.0-2.0) ECG shows atrial fibrillation and bradycardia Colecalciferol 50 000 units PO A diagnosis of digoxin toxicity is made weekly Question Ramipril 5 mg PO daily Select the prescription that is most likely to interact with digoxin to cause toxicity. 24 Adverse Drug Reaction 2 marks – Item style C Case Presentation PRESCRIPTION OPTIONS A 68-year-old woman presents to the emergency department with headache, confusion, and severe nausea and vomiting. PMH. AF, ischaemic stroke, hypertension, vitamin D deficiency, osteoporosis, previous left neck of femur fracture. DH. Her current regular medicines, in addition to digoxAlendonic acid 70 mg PO weekly micrograms PO daily, are listed (right). SH. Lives with husband. Ox examination Drowsy, confused, and pallid. Temperature 36.8C, HR 45/min and rhApixaban 5 mg PO 12-hrly irregularly irregular, BP 105/72 mmHg. Investigations Cr 105 μmol/L (60-100), eGFR 56 ml/min/1.73m2 (>60), Ca2+ (corrected) 2.63tin 10 mg PO daily mmol/L (2.20-2.60). Serum digoxin 2.9 nmol/L (1.0-2.0) ECG shows atrial fibrillation and bradycardia Colecalciferol 50 000 units PO A diagnosis of digoxin toxicity is made weekly Question Ramipril 5 mg PO daily Select the prescription that ismost likely to interact with digoxin to cause toxicity . 25 Adverse Drug Reaction 2 marks – Item style C Feedback PRESCRIPTION OPTIONS Alendonic acid 70 mg PO weekly High dose cholecalciferol treatment is the most likely cause of this patient’s digoxin toxicity. Apixaban 5 mg PO 12-hrly There is an increased risk of toxicity according to the BNF. This is thought to be due to colecalciferol-induced hypercalcemia and the resultant positive inotropic effecAtorvastatin 10 mg PO daily this may cause. The other options do not interact with digoxin to cause Colecalciferol 50 000 units PO toxicity. weekly Ramipril 5 mg PO daily 26Adverse Drug Reaction 2 marks – Item style C 27Adverse Drug Reaction 2 marks – Item style C 28 Adverse Drug Reaction 2 marks – Item style D Case Presentation PRESCRIPTION OPTIONS A 24-year-old woman on the surgical emergency unit is being prepared for emergency surgery. During the anaesthetic induction with sevoflurane 1% INH and suxamethonium chloriDantrolene sodium 140 mg IV 70 mg IV, he develops malignant hyperthermia. SH. Works as a pharmacist. once only Ox examination Lorazepam 4 mg IV once only Patient intubated and ventilated. Temperature 41.3C, HR 120/min and rhythm regular, BP 101/52 mmHg, RR 14/min, O2 and non-tender. Muscle rigidity throughout. Weight 70kg.soRocuronium bromide 40 mg IV once only He is receiving sodium chloride 0.9% as IV fluid resuscitation. Sodium bicarbonate 1.26% 500mL IV over 4 h Question Zoledronic acid 4 mg once only Select the most appropriate option for the management of this adverse drug reaction. 29 Adverse Drug Reaction 2 marks – Item style D Case Presentation PRESCRIPTION OPTIONS A 24-year-old woman on the surgical emergency unit is being prepared for emergency surgery. During the anaesthetic induction with sevoflurane 1% INH and suxamethonium chlorDantrolene sodium 140 mg IV 70 mg IV, he developsignant hyperthermia . SH. Works as a pharmacist. once only Ox examination Lorazepam 4 mg IV once only Patient intubated and ventilated. Temperature 41.3C, HR 120/min and rhythm regular, BP 101/52 mmHg, RR 14/min, O2 sat 100% on 50% oxygen. HS normal, chest clear, abdomen sRocuronium bromide 40 mg IV and non-tender. Muscle rigidity throughout. Weight 70kg. once only He is receiving sodium chloride 0.9% as IV fluid resuscitSodium bicarbonate 1.26% 500mL IV over 4 h Question Zoledronic acid 4 mg once only Select themost appropriate option for the management of this adverse drug reaction. 30 Adverse Drug Reaction 2 marks – Item style C Feedback PRESCRIPTION OPTIONS Dantrolene sodium 140 mg IV The BNF has a treatment summary for anaesthetic once only emergencies. Lorazepam 4 mg IV once only Even if it didn’t, when searching about dantrolene, it appears as a drug used in the management of malignant hyperthermia. The other drugs listened mention Rocuronium bromide 40 mg IV susceptibility to the condition as a contra-indicationonce only Sodium bicarbonate 1.26% 500mL Malignant hyperthermia has a mortality of up to 80%. Proper recognition and prompt administration of IV over 4 h dantrolene reduces this mortality to approximately 5%. Zoledronic acid 4 mg once only 31Adverse Drug Reaction 2 marks – Item style C Treatment summary: has list of conditions and treatments Drugs from the question step One of the answer options… 32Adverse Drug Reaction 2 marks – Item style C 33Adverse Drug Reaction 2 marks – Item style C 34Adverse Drug Reaction 2 marks – Item style C 35 Common drugs Each PSA will include at least one item on opiates, anticoagulants, insulin, antibiotics, and infusion fluids. These drug Groups Were Selected On The Basis That They Were Included In The List Of 8 High Risk Prescribing Categories Identified By The NPSA As Being Most Commonly Associated With Severe Harm Or death.1 Drugs In The Other 3 Categories (anaesthetics, Chemotherapy And Antipsychotics) Were Omitted On The Basis That Foundation Doctors Would Not Routinely Have responsibility For Prescribing These agents… …But actually they are fair game in the mocks at least (like how you are apparently “supposed” to know procyclidine is given for extrapyramidal side effects from antipsychotic medications) 36 Common interacting drugs Enzyme inducers (PC BRAS) Enzyme inhibitors (AODEVICES) Phenytoin Allopurinol Carbamazepine Omeprazole Barbiturates Disulfiram Rifampicin Valproate Alcohol (chronic) Isoniazid Sulphonylureas (e.g gliclazide) Ciprofloxacin Ethanol (acute intoxication) Sulphonamides (e.g sulfamethoxazole) 37 Analgesia Drug class Examples Side effect profile Noteworthy interactions Thrombocytopenia • Alcohol (heavy drinkers): (Rare) hepatotoxicity Paracetamol • Flucloxacillin: metabolic acidosis • Warfarin: increased INR NSAIDs Ibuprofen Dyspepsia, diarrhoea • SSRIs, Warfarin/DOACs, Naproxen GI ulceration steroids: increased risk of bleeding (GI mainly with Worsens asthma, and steroids) contraindicated in AKI • ACE-i: hyperkalaemia • Diuretics: AKI 38 Analgesia Drug class Examples Side effect profile Noteworthy interactions Opioids Tramadol Constipation, dry • Alcohol: CNS depressant Morphine mouth, confusion, • SSRI, St John's wort, Codeine dizziness, withdrawal Sumitriptan: serotonin syndrome syndrome Overdose symptoms: LOC, difficulty breathing  Naloxone 39 Steroids Drug class Examples Side effect profile Noteworthy interactions Steroids Hydrocortisone Cushing's syndrome, • Aspirin: GI bleeds Dexamethasone fluid retention, GI • Digoxin: digoxin toxicity ulceration, osteoporosis, • Erythromycin, citalopram: (fungal) infections, hypokaelmia hyperglycaemia, • Antifungals glaucoma, hypertension, (ketoconazole): increased alkalosis hypokalaemic exposure of steroid 40 Antihypertensive agents Drug class Examples Side effect profile Noteworthy interactions ACE inhibitors Ramipril Dry cough, Hypotension, • Can contribute to an AKI renal impairment, when given with NSAIDs hyperkalaemia • Spironolactone: severe hyperkalaemia ARBs Losartan Hypotension, hyperkalaemia CCBs Amlodipine Peripheral oedema, • Grapefruit (very mild), flushing increases exposure • Verapamil and beta- blockers: will cause bradycardia and asystole 41 Antihypertensive agents Drug class Examples Side effect profile Noteworthy interactions (aldosterone Spironolactone Hyperkalaemia, • Dalteparin, ACE-I, ARBs, receptor gynaecomastia, NSAIDs, Ciclosporin, antagonists) hypotension heparins, other potassium-sparing diuretics, tacrolimus, trimethoprim/ sulfamethoxazole: hyperkalaemia (Beta-blockers) Bisoprolol Worsens asthma and • Worsens hypotension acute HF, masks • Verapamil: bradycardia, hypoglycaemia asystole. 42 Disulfiram Reaction • A disulfiram-like drug causes an ADR to alcohol leading to nausea, vomiting, flushing, dizziness, abdominal discomfort, and general hangover-like symptoms • Reaction may occur following exposure to small amounts of alcohol (e.g perfume, aerosol sprays) Key drugs: • Ketoconazole • Metronidazole 43 Adverse Drug Reactions Tips for the PSA Hasaan Khan FOUNDATION YEAR 1 DOCTOR 44 Bonus Content Based on popular demand :) See notes Hasaan Khan FOUNDATION YEAR 1 DOCTOR Hey everyone! Hope you are well. Thanks for attending the session and filling in the feedback. As requested I have provided some extra information that should help you on searching for items in the BNF below: - Warfarin dose adjustments under Oral anticoagulants - Info on heparin under Parenteral anticoagulants - Opioid dose conversions under Prescribing in palliative care - Benzodiazepine dose conversions under Hypnotics and anxiolytics - Steroid dose conversions under Glucocorticoid 45 therapy - Acute asthma Mx under Asthma, acute - Missed pill rules for contraception can be found on the page for the drug itself under Patient and carer advice e.g. for the combined pill, you could go to the page for Ethinylestradiol with desogestrel and CTRL+F for "missed dose" - Treating hyperkalemia under Fluids and electrolytes - Menorrhagia is not called by its medical term, and is under Heavy menstrual bleeding - The vaccine schedule is under Immunisation schedule - Management guidelines for MI under Acute coronary syndromes - Info on what drugs to stop before surgery under Surgery and long-term medication - Loads of info on ACE inhibitors under Drugs affecting the renin-angiotensin system - For overdoses and poisoning (e.g. paracetamol), see Poisoning, emergency treatment - Medical emergencies in the community – good for GP stuff and hypoglycaemia - Glucocorticoid replacement during stress – adrenal insufficiency - Diabetes, surgery and medical illness. - surgery in 45 diabetic patients - Pneumonia Mx under Respiratory system infections, antibacterial therapy - Infective endocarditis under Cardiovascular system infections, antibacterial therapy - There's also Gastro-intestinal system infections, antibacterial therapy - Diabetes insipidus management under Posterior pituitary hormones and antagonists All the best with your revision! I look forward to having each of you as my colleague in the future. 45Mock (8 questions) Best of luck! 46 Adverse Drug Reaction 2 marks Case Presentation ADVERSE EFFECT OPTIONS A 62-year old woman on the elderly care ward is having frequent ‘off’ periods with increased jerky movements, DH. Co-careldopa 25/100 mg one tablet PO at 06:00 h, 14:00 h, and 22:00 h, co-careldopa 50/200 m/r one tablet PO at Blurred vision 08:00 h and 20:00 h, ropinirole m/r 8 mg PO daily, fluoxetine 40 mg PO daily, lactulose 10 ml PO 12-hrly, senna 15 mg PO nightly. On examination Hypertension HR 64/min and rhythm regular, BP 108/72 mmHg. Investigations Rash Hb 122 g/L (115-165), Na+ 139 mmol/L (137-144), K+ 4.2 mmol, , U 6.5 mmol/L (2.5-7.0), Cr 58 μmol/L (60-100), eGFR 56 ml/min/1.73m2 (>60). Treatment with entacapone 200 mg PO at 08:00 h, 14:00 h Urine discolouration and 20:00 h is added to her prescription. Question Weight loss Select the adverse effect that is most likely to be caused by this treatment. 47 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS Feedback Blurred vision Entacapone is a catechol-O-methyltransferase (COMT) inhibitor which prevents the breakdown of levodopa in Hypertension the peripheral circulation, allowing it to reach the brain. It is used in advanced Parkinson’s disease. Rash Some adverse effects are incorrect and can be eliminated immediately. Amongst the options that remain, you must check to see which of the potential adverse effects hasUrine discolouration the greatest reported frequency. Weight loss In this case, urine discolouration is the most likely adverse effect to be caused by this treatment. 48 Adverse Drug Reaction 2 marks Case Presentation ADVERSE EFFECT OPTIONS A 19-year-old man presents to the emergency department with a fracture of his right forearm sustained whilst mountain biking. SH. Works as an apprentice electrician.Circumoral tingling Weight 50kg. His fracture is to be reduced using regional anaesthesiaAgitation (Bier’s block) with lidocaine hydrochloride 150 mg IV. Paranoia Seizure Question Select the adverse effect that is most likely to be the Ventricular tachycardia sign of systemic lidocaine toxicity in this patient. 49 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS The systemic toxicity of local anaesthetics mainly involvescumoral tingling the central nervous and cardiovascular systems. Agitation The BNF isn’t has helpful for this question because the symptoms of toxicity are not covered. In which case, you may be required to know this fact beforehand but in the Paranoia off chance you are unsure, the ARDs questions are not the make-or-break of the PSA exam as much as the earlier sections are. Seizure If we assume they are all side effects that occur, the less severe signs of toxicity will precede the more serious onestricular tachycardia (like ventricular tachycardia or seizures) 50 Adverse Drug Reaction 2 marks Case presentation ADVERSE EFFECT OPTIONS A 30-year-old woman presents to the emergency department with jaundice and right upper quadrant pain. PMH. Obesity, lymphoedema, chronic cellulitis, osteoarthritis. DH. Her regular prescriptions are listed codeine phosphate 30 mg (right). SH. Works in social care. PO 6-hrly Investigations desogestrel 75 mg PO daily Hb 120 g/L (115-165), WCC 13.0 x 109/L (3.0-10.0), platelets 250 x 109/L (150-400). Na+ 141 mmol/L (137- 144), K + 4.0 mmol/L (3.5—5.3), U 6.4 mmol/L (2.5- 7.0), flucloxacillin 1 g PO 6-hrly cr 73 pmol/L (60-110), eGFR 90 mL/min/1.73 m2 (>60), ALT 2146 U/L (5- 35), alk phos 1337 U/L (45-105). ibuprofen 400 mg PO 8-hrly Question Select the prescription that is most likely to be paracetamol 1 g PO 6-hrly contributing to the acute hepatitis. 51 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS information provided in the case presentation regarding theer indication for the drugs prescribed in addition to the relativeine phosphate 30 mg frequency of reported adverse effects. As the patient has PO 6-hrly chronic cellulitis, this implies that she may have taken flucloxacillin long-term, rather than as a short course. Thdesogestrel 75 mg PO daily is a section in the BNF monograph for flucloxacillin headed 'Important safety information’. rare adverse effects of flucloxacillin. However, they can occurloxacillin 1 g PO 6-hrly up to 2 months following treatment and are more common in people who have received treatment with flucloxacillin for more than 2 weeks. . However, the information from the case study indicating a long-term course ibuprofen 400 mg PO 8-hrly As a general rule, antibiotics like flucloxacillin are culpparacetamol 1 g PO 6-hrly hepatic impairment in the PSA exam. 52 Adverse Drug Reaction 2 marks Case Presentation ADVERSE EFFECT OPTIONS An 82-year-old woman attends her GP, with her daughter, to discuss the results of recent blood tests. She initially presented 2 days ago with a 2-week history of worsening confusion but no obvious cause was found. PMH. Amlodipine 10 mg PO daily Hypertension, GORD, nocturnal leg cramps, osteoarthritis. DH. Her regular medicines are listed (right). SH. Lives with husband, carers attend twice daily. Omeprazole 40 mg PO daily Investigations Hb 138 g/L (115-165), WCC 3.3 x 109/L (3.0-10.0). Na+ 122 mmol/L (137-144), K + 3.9 mmol/L (3.5-5.3), U 4.2 Paracetamol 1 g PO 6-hrly mmol/L (2.5-7.0), Cr 108 pmol/L (60-110), TSH 2.8 mU/L (0.4-5.0), serum T4 101 nmol/L (58-174), serum T3 2.14 nmol/L (1.07-3.18), CRP mg/L (<10). Quinine sulfate 200 mg PO nightly Question Select the prescription that is most likely to be Simvastatin 20 mg PO nightly contributing to the hyponatraemia. 53 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS Proton-pump inhibitors (PPIs) have been associated with a number of electrolyte disurbances including Amlodipine 10 mg PO daily hyponatraemia, hypokalaemia, and hypocalcaemia. Hyponatraemia is listed as a rare adverse effect of omeprazole but this is the most likely cause in this Omeprazole 40 mg PO daily patient. Paracetamol 1 g PO 6-hrly The question asks which prescription is most likely to contribute to hyponatraemia. Although this is a rare adverse effect of omeprazole, it is not listed as an adverse effect of the other drugs listed (amlodipine, paracetamol,inine sulfate 200 mg PO nightly quinine sulfate or simvastatin) so all other distractors can be eliminated. Simvastatin 20 mg PO nightly 54 Adverse Drug Reaction 2 marks Case Presentation ADVERSE EFFECT OPTIONS department with a 2-week history of headache, visual disturbance and intermittent vomiting. She describes her headache as pulsatile in quality and it has not responcetirizine hydrochloride 10 mg PO to paracetamol or ibuprofen. PMH. Acne vulgaris, epilepsy, medicines, in addition to isotretinoin 60 mg PO daily, aredaily listed (right). SH. Lives with her boyfriend. doxycycline 100 mg PO daily On examination Temperature 37. IOC. Ophthalmoscopic examination shows papilloedema. Investigations folic acid 5 mg PO daily Opening pressure 270 mmH20 (120—250). CT scan head shows no evidence of a space-occupying lesion. lamotrigine 200 mg PO 12-hrly Question Select the prescription that is most likely to interact with isotretinoin to increase her risk of developing benign levonorgestrel (Mirena@) 20 intracranial hypertension. micrograms/ 24 hours intrauterine device replaced every 5 years 55 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS Concomitant use of isotretinoin with tetracyclines (e.g. demeclocycline hydrochloride, doxycycline, lymecycline, cetirizine hydrochloride 10 mg PO minocycline, oxytetracycline, tigecycline) is contraindicated. Other retinoids (e.g. acitretin) are daily expected to interact similarly. doxycycline 100 mg PO daily The signs and symptoms of benign intracranial hypertension include headache, nausea and vomiting, visual disturbances and papilloedema. This patient folic acid 5 mg PO daily describes these signs and symptoms. Benign intracranial hypertension is a very rare (21/10 000 to < 1/1000) adverse effect of isotretinoin. lamotrigine 200 mg PO 12-hrly levonorgestrel (Mirena@) 20 micrograms/ 24 hours intrauterine device replaced every 5 years 56 Adverse Drug Reaction 2 marks Case Presentation ADVERSE EFFECT OPTIONS A 78-year-old woman is on the neurosurgery ward with a right acute subdural haemorrhage which was evacuated by craniotomy 2 days ago. PMH. Schizophrenia. DH. Her current regular medicines, in addition to morphine 5 mg levetiracetam 500 mg PO 12-hrly IV 6-hrly as required and ondansetron 4 mg IV 8-hrly as required, are listed (right). SH. Lives at home, mobiliselorazepam 500 micrograms PO 12- with a stick, independent with activities of daily livinghrly as required Investigations quetiapine 300 mg PO 12-hrly K+ 3.4 mmol/L (3.5-5.3). QTc 480 ms (>460). senna 15 mg PO nightly Question Select the prescription that is most likely to have zopiclone 7.5 mg PO nightly interacted with ondansetron to cause a prolonged QT- interval. 57 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS Most psychotropic drugs are associated with ECG changes and some may be causally linked with serious ventricularevetiracetam 500 mg PO 12-hrly arrhythmias and sudden cardiac death. Some antipsychotics are known to block cardiac potassium channels, leading to a prolonged QT-interval. lorazepam 500 micrograms PO 12- hrly as required This is a risk factor for torsades de pointes, a serious and quetiapine 300 mg PO 12-hrly potentially fatal ventricular arrhythmia. This patient is taking quetiapine and QT-interval prolongation is listed as a common/very common adverse effect in the BNF. senna 15 mg PO nightly zopiclone 7.5 mg PO nightly 58 Adverse Drug Reaction 2 marks Case Presentation ADVERSE EFFECT OPTIONS A 70-year-old woman on a medical ward is receiving treatment for community acquired pneumonia. She reports feeling weak with blurred vision and soon afterwards, becomes uncooperative. PMH. Depression, Give her a slice of bread type 1 diabetes. DH. Amoxicillin 1g IV 8-hrly, Insulin aspart 5 units SC three times daily (with meals), insulin detemir 18 units SC nightly, sertraline 50mg PO daily. Glucagon 5 mg IV over 1-2 mins On examination Appears sweaty and confused. Conscious and able to swallow. Glucose 20% 100 ml IV Investigations Random capillary glucose 3.0 mmol/L (<11.1) Glucose 50% 50 ml IV Question Glucose monohydrate 40% gel two Select the most appropriate option for the management of this adverse drug reaction. tubes bucally 59 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS Give her a slice of bread ‘Medical emergencies in the community’ has a good treatment summary on managing hypoglycaemia. Glucagon 5 mg IV over 1-2 mins If a patient is conscious and can swallow, oral administration of a fast-acting carbohydrate is preferred. Alternatives to the gel include 200ml of pure fruit juicGlucose 20% 100 ml IV 3-4 teaspoonfuls of sugar dissolved in water. After 15 minutes, if the blood glucose is >4 mmol/L, the patient can then be given a long-carbohydrate snack like a slice of bread or 2 digestive biscuits. Glucose 50% 50 ml IV Insulin should not be omitted if it is due, but the doseGlucose monohydrate 40% gel two regime will likely require a review. tubes bucally 60 Adverse Drug Reaction 2 marks Case Presentation ADVERSE EFFECT OPTIONS A 26-year old man is brought to the emergency department by his boyfriend after taking an overdose of paracetamol about 11 hours ago. There were 3 empty Acetylcysteine 200mg/mL 42 mL packets of 16 paracetamol 500 mg tablets in his PMH. Depression. DH. Sertraline 20 mg PO daily.d twice.by IV infusion over 1 hr. On examination Acetylcysteine 200mg/mL 47 mL Temperature 36.9C, HR 78/min and rhythm regular, BP by IV infusion over 1 hr. 123/66 mmHg, RR 13/min, weight 78kg Acetylcysteine 200mg/mL 57 mL Investigations Plasma paracetamol concentratrion (on admission) 42 by IV infusion over 1 hr. mg/L Acetylcysteine 200mg/mL 64 mL by IV infusion over 1 hr. Question Select the most appropriate option for the initial Acetylcysteine 200mg/mL 72 mL management of this adverse drug reaction. by IV infusion over 1 hr. 61 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS Acetylcysteine 200mg/mL 42 mL ‘Emergency treatment of poisoning.’ has a good treatmenby IV infusion over 1 hr. summary on managing paracetamol overdoses. Acetylcysteine 200mg/mL 47 mL Brush up on this section before the PSA to familarise by IV infusion over 1 hr. yourself with the subsections and where to find information. But if you are unsure on the day, focus onAcetylcysteine 200mg/mL 57 mL patient’s weight, the hrs since ingestion, whether it wby IV infusion over 1 hr. scattered dose and the plasma concentration. Acetylcysteine 200mg/mL 64 mL Use the Paracetamol overdose treatment graph to help by IV infusion over 1 hr. you. For our patient’s weight (70-79), they would require 200mg/mL 57 mL by IV infusion over 1 hr. Acetylcysteine 200mg/mL 72 mL by IV infusion over 1 hr. 62 Template I’ve made a templquestions! can have a crack at making your own 63 Adverse Drug Reaction 2 marks Case Presentation ADVERSE EFFECT OPTIONS [Insert text here] Question [Insert text here] 64 Adverse Drug Reaction 2 marks Feedback ADVERSE EFFECT OPTIONS [Insert text here] 65