Extra Bits

Strains – staphylococcus, and pseudomonas aer

Staphylococcus – gram +ve, normally affects skin and nose
Staph Aureus – boils, impetigo, pimples, cellulitis
More serious infections – pneumonia, meningitis, endocarditis
Tx – Penicillin, but due to increase resistance, Flucloxacillin is 1st line

Pseudomonas aeruginosa – gram -ve, UTI, GI, Lungs
Resistant - penicillin and B-lactam Abx
Tx - quinolones, antipseud penicillin, aminoglycosides, cephalosporin

Broad Spectrum Abx

• Penicillin – ampicillin, amoxicillin
• Cephalosporin
• Chloramphenicol
• Tetracyclines
• Macrolides
• Aminoglycosides
• Carbemenems

Misc

• Aztreonam (beta-lactam) - Only active against Gram -ve , less likely to cause hypersensitivity in penicillin sensitive patients
• Polymyxins – Active against Gram -ve , can cause nephro and neurotox
• Linezolid – Only active against Gram +ve  – MRSA, alternative to vancomycin
• Clindamycin – Only active against Gram +ve, active against anaerobes, joints and bones infection
• Metronidazole – Active against anaerobes
• Aminoglycosides – Inactive against anaerobes
• Fusidic Acid – Narrow Spectrum – joints and bones infection

• Adenosine (supraventricular arrythmias)- heart transplant individuals require reduction dose of adenosine
• Beta-blocker and asthma – bronchospasm
• Labetalol – Liver damage irrespective of short or long term use
• Sotalol – limited for ventriclr arryth/prophylaxis of supravtclr arryth, not for angina, hypertension, thyrotoxicosis anymore
• Lisinopril – should not start after MI if BP < 100 mmHg
• GTN - must be kept in glass, not > 100 tabs, no cotton wool wadding, foil lined cap, discard after 8 weeks
• Diltiazem – standard formulation – no need brandspecific -tds, longer acting – must be brand specific i.e. XL, LA, SR, CR, retard (XL and LA are Once daily) , applies to Nifedipine as well
• Verapamil and BB used together can be hazardous
• Heparin – thrombocytopenia, does not develop until after 5-10days, monitoring of platelet counts recommended if given more than 4 days
• Heparin - inhibition of aldosterone secretion causes hyperkalaemia
• Statins – rhabdomyolysis rare but increase with renal impairment, hypothyroidism, or concomitant fibrate and statin use
• Bile acid sequestrant interferes with absorption of fat soluble vit A,D,E,K, require supplements
• Bezafibrate used in renal impairment –> myotoxicity
• Nicotinic acid – prostaglandin mediated symptom – flushing, reduce this by using initial low dose with meal, if takes aspirin, must be taken 30 mins before nicotinic acid

Extra bits

Diuretics

• gravitational oedema – not long term use
• thiazide – hypo K, hypo Na, hypo Mg, hyper Ca, hyperglycaemia, hyperuricaemia, gout
• loop        – hypo K, hypo Na, hypo Mg, hypo Ca, hyperglycaemia, hyperuricaemia, gout, deafness.
• hypo K –> precipitate encephalopathy in hepatic failure
• thiazide – act in 1-2 hours, duration of action 12-24 hours, loop act in 1 hour, complete in 6 hours
• metolazone – used with loop, ok in renal failure
• indapamide – less metabolic disturbance, ok in diabetes mellitus
• aldosterone antagonist – useful in ascites – liver cirrhosis
• eplerenone – suitable for use after MI

Beta Blocker

• BB not contraindicated in diabetes, but deteriorate glucose intolerance, may mask symptoms of hypo
• intrinsic sympathomimetic activity(less bradycardia and cold extremities, - oxprenolol, pindolol, acebutolol, celiprolol
• water soluble (less sleep disturbnc) – atenolol celiprolol, sotalol, nadolol
• cardioselective – atenolol, bisoprolol, metoprolol, nebivolol, acebutolol
• Labetolol – suitable for pregnancy, following MI, hypertensive crisis
• Avoid use of BB(mask symptoms of hypo) and thiazide(hyperglyc) in diabetics

ACE inhibitor

• Young Caucasians and below 55 - ACE i 1st line, over 55, afro carribean – CCB or Thiazide 1st line
• Pregnancy – contraindicated, suitable – methyldopa, hydralazine, labetalol, nifedipine
• Ace i can be used in renal impairment, but cautiously, avoid in renovascular disease
• Interactions – +NSAIDS – renal damage, +Diuretics – 1st dose postural hypo, +K-sparing diuretic – hyperK

Heart Failure

1. ACE i
2. Beta- Blocker
3. Diuretic (for fluid retention)- loop for poor renal function, thiazide for good renal function
4. Digoxin – where AF is present
5. Spironolactone can be added

Nitrates

• attack > twice a week require regular meds
• GTN subl – 20-30 min effect, 300mcg
• ISB MN – prophylaxis of angina
• ISB DN – sublingual
• GTN & ISB DN – IV injection

Calcium-channel Blocker

• Rate-limiting CCB – Verapamil and diltiazem – negative inotropic, constipation common
• CCB doesnt reduce risk of MI in unstable angina
• Nifedipine, nicardipine, amlodipine, felodipine – angina and hypertension
• Isradipin, lacidipine, lercanidipine – hypertension only
• Short acting nifedipine – not for angina or long term hypertension

Anticoagulant

• Heparin carry on for 5 days until INR stable for 2 days
• Start warfarin at the same time, it take 48-72 hours to work
• pregnancy – LMWH ok, does not cross placenta
• Heparin – side effect- osteoporosis, blood disorders, hyperK
• Warfarin – contraindicated in pregnancy – teratogenic, especially 1st and 3rd trimester
• Warfarin – avoid cranberry juice, avoid in hepatic impairment

MI

1. ACE i
2. Beta- Blocker
3. Aspirin (use with clopidogrel for 4 weeks)
4. Statin

Stroke – aspirin + dipyridamole for 2 years? to reduce risk of recurrent stroke.

•  Sucralfate – Bezoar formation pg 47
• Misoprostol – avoid in pregnancy, only used if contraceptive measures taken, it causes uterus contraction –> miscarriage
• Aminosalicylates – Blood disorder
• Methotrexate – Blood disorder, liver toxicity, respiratory effects
• High strength pancreatin – fibrosing colonopathy in children with cystic fibrosis age 2-13yrs
• Dantron (Co-danthromer) – carcinogenic, only use if terminally ill

Extra bits

Antacid

Many antacids contain sodium, avoid in salt restricted individual – Peptac, Gaviscon, Rennie, Topal. The magnesium and alluminium antacids are suitable for them – Asilone, Maalox (low sodium)

Antimuscarinics

 Antimuscurinic drugs are contraindicated in – prostate enlargement, angle closure glaucoma, urinary retention, constipation, Common drugs involved – TCA, Antihistamine, Antispasmodics, Antipychotic, Parkinson drugs, some bronchodilators

Laxatives

Stimulant laxative can cause hypokalaemia
Lactulose (lowers pH) – prevent release of mesalazine
                                              – also a treatment for hepatic encephalopathy
Movicol sachets - after reconstitution, keep in the fridge, discard after 6 hours
Movicol Paeds plain – discard after 24 hours

Colestyramine

Binds with bile acid forming insoluble complex, used for pruritus in biliary obstruction
It affects the absorption of many drugs, other drugs taken 1 hour before or 4-6 hours after

Other practitioners – can obtain by wholesale from pharmacy – with restrictions

Midwives 

- Sell & Supply –> GSL , P, POM (lists pg18)
- Administer  (lists pg18)

*can administer Promazine Hcl, Lignocaine, Lignocaine Hcl – woman in child birth

Chiropodist

- Sell & Supply –> GSL  external use,  P external use (list pg 18)
- Administer (list pg 19)

Optometrist

- Sell & Supply –> GSL, P, POM (not parenteral-pg19)
- Administer  (list pg20)

* Can supply directly to patient, record in POM reg

Additional Supply Optometrist

- Sell & Supply –> (lists pg20) – not for parenteral

Shipping Personnel

- Supply          –> GSL, P, POM including CD
- Administer –> POM for parenteral admin

* Check ID, company can be contacted

Occupational Health Schemes (OHS)

- Supply          –> GSL, P, POM
- Administer –> POM -parenteral

*order must be signed by doctor

Offshore Installation – 1st aid personnel

- Supply         –> GSL, P, POM
- Administer –> POM – parenteral

Drug Tx Services

- Supply –> ampoules of sterile water for injection, not > 2ml

Royal National Lifeboat Institution

- Supply –> GSL, P, POM

First Aid Organisations

- Supply –> GSL, P

Paramedics (NHS/Private)

- Administer –> (lists pg22)

* Certificate issued by secretary of state

• Wholesale dealing requires license
• Pharmacists can wholesale if no more than 5% of total meds trade
• Provided that purchaser is authorised to sell, supply, administer meds to human in their business
• Pharmacists must not wholesale to holders of wholesale dealer’s licenses
• Supply whole pack, should not label
• Entry in POM book, or keep copy of invoice/order for 2 years

Hopefully I have not missed anything important.

But despite all these pressure, today was a great day. It was my final day at work before the exam. Im still a little overwhelmed when my collegues surprised me with flowers, as a gesture of ‘GOOD LUCK’ . My collegue bought me an Ice cream which made my day even better ;) Eventhough my tutor isn’t around (In Scotland holiday-ing ), she rang up yesterday to give a word of encouragement as well!! Such a thoughtful bunch eh?

Needless to say more, I am touched and thankful. Thank you everyone at 5563!!

Phenobarbitone – Schedule 3 CD

Both are exempted from safe custody

Eventhough Emergency Supply is not allowed for Schedule 2 and 3 CD, Phenobarbitone is exempted from that restriction if it is for epilepsy. Note : Not Quinalbarbitone.

Quinalbarbitone (a.k.a Secobarbital) still requires CD reg entry

Indications : Epilepsy, Insomnia

I have not seen it in the pharmacy so far, according to my collegues, they did see that long long time ago, but not anymore now. If you refer to MEP CD table, only Phenobarbitone for the treatment of epilepsy can be requested as an emergency, nothing said about Quinalbarbitone.

 - urine, saliva and other body secretions coloured orange-red

Triamterene

- Urine may look slightly blue in some lights

Co-danthramer (Dantron)

- Urine may be coloured Red

Sulphasalazine

- urine may be coloured orange, some soft contact lense may be stained

Hopefully these colours will help you remember them in exam. if only there are more combination of colours,would make my blog post more colourful, if you know any other drugs that causes Green Urine/saliva, that’ll be great ;D

Stable Angina Tx

• Acute – Sublingual GTN
• Regular therapy
• 1. Beta-Blocker
• 2. Long-acting nitrate i.e. ISMN
• 3. Rate-limiting CCB i.e Verapamil or Diltiazem (If BB is contra-indicated)
• 4. Dihydropyridine CCB i.e. felodipine, amlodipine
• 5. Nicorandil

* Avoid BB+Verapamil (hazardous)

Unstable Angina Tx

• 1. Oxygen
• 2. Nitrates – Subl GTN, or IV/buccal GTN
• 3. Diamorphine/morphine (metoclopramide for nausea)
• 4. Aspirin 300mg, Clopidogrel 300mg
• 5. LMWH
• 6. BB -indefinately

Nitrates

• flushing, headaches, postural hypotension
• subl GTN – efect last 20-30min
• tolerance – reduce blood-nitrate levels for 4-8hrs daily (8am,4pm dosing) – for tabs & patches
• Subl dose – 0.3-1mg, repeated as required
• GTN tabs supplied in glass bottle, containing no > 100 , close with foil-lined cap, no cotton wool wadding, discard after 8 weeks in use

Prvention of CVD events (NSTEMI)

• Aspirin+clopidogrel used for 12 months, then continue aspirin 75mg indefinately
• ACEi
• Statin
• BB

I was reading chapter 12 (blood disorders) of Adverse Drug Reactions 2^nd edition by Anne Lee, and I thought I’d summarize what I found important. Blood disorders aka dyscrasias, are relatively rare, but when it occurs, it is always very serious. In practice, they will often be presented with sore throat, fever, mouth ulcers, bruising, bleeding, rash. Early recognition is therefore crucial.

CSM warning

Methotrexate – blood dyscrasias & liver cirrhosis

Linezolid – blood disorders & optic neuropathy

Sulfasalazine, mesalazine (aminosalicylates)- blood disorders

Carbimazole, propylthiouracil - neutropenia and agranulocytosis

Clozapine – agranulocytosis, myocarditis, cardiomyopathy & GI obstructions

Blood disorders as side effect (not a CSM warning)

• Phenytoin
• Mianserin
• Co-trimoxazole
• Azathioprine
• Mycophenolate
• Chloramphenicol
• GOLD
• Leflunomide
• Penicillamine 
• Tacrolimus
• Heparin
• Mefenamic acid