Section 1: Drugs- doses, timing, routes, interactions, side effects

Drug name Dosage Timing ( per day) Route Interactions Side Effects

Respiratory
Salbutamol 2-5mg PRN 4-6hrly with max dose 20mg NEB can stimulate cardiovascular beta- 1 and beta- 2 receptors
tachycardia, palpitation, peripheral vasodilation, blood pressure changes,
and ECG changes (e.g., flattening of the T wave; prolongation of the QT
interval; ST segment depression).

may cause CNS stimulation. Therapy with adrenergic bronchodilators

should be administered cautiously in patients with seizure disorders

Adrenergic bronchodilators may cause decreases in serum potassium

concentrations, primarily when given by nebulization or intravenous
administration.

Ipratropium bromide 250-500 PRN 4-6hrly with max dose 2mg NEB worsening of urinary retention or angle-closure glaucoma has been
reported. Increased intraocular pressure and precipitation or exacerbation
micrograms of angle-closure glaucoma may also occur due to inadvertent contact of the
eye with aerosolized or nebulized drug.
Combivent 2.5/0.5mg QDS Neb
(Salbut/Ipratrop)

Sedatives
Zopiclone 3.75-7.5mg Nocte PO
Zolpidem** (Stilnoct) 5-10mg Nocte PO

Antihistamines
Chlorpheniramine 4mg 4-6hrly PO
Certrizine (Zirtek) (Itch) 10mg OD PO
Pantoprazole (Protium) 20mg OD PO/IV
(Indigestion/heartburn)

Analgesia minor
Paracetamol 500mg-1g QDS PO/PR/IV
Ibuprofen 200-400mg TDS PO
Solpadiene 2 tabs TDS/ QDS PO
(paracetamol 500mg
codeine 8mg)
Solpadol (paracetamol 2 TABS TDS QDS PO
500mg codein 30mg)
Buscopan 10-20mg TDS QDS PO IV IM
Analgesia moderate
Diclofenac 75mg BD PO
Diclofenac suppository 100mg 18hrs apart PR
Naproxen 250-500mg Bd PO
Etoricoxib 30-90mg Od PO
Mefenamic acid 250-500mg Tds PO
(Ponstan)
Tramadol (400mg/ 50-100mg qds PO IM
24hrs)
300mg= 30mg
morphine sc= 60mg
ANALGESIA SEVERE
Oramorph (short- 2.5mg- 5mg; 4hr PO
acting) otherwise 5-
10mg
MST (sustained release) 5mg BD PO
otherwise
10mg
Morphine sulphate 2.5-5mg PRN SC
otherwise 5-
10mg
Oyxcontin 5mg Bd PO
otherwise
10mg
Oxynorm (immediate 2.5mg max 6 4-6 hr PO
relase) hrly in mild
mod renal
impairment
otherwise 5-
10mg
Pregabalin 25mg BD/ titr PO
otherwise
50mg
Palexia SR 50mg BD PO
Palexia 50mg 4-6 hr PO
otherwise
50mg
Targin 5/2.5mg bd PO
otherwise
10/5mg
Anti-emetics
Metoclopramide (body 10mg TDS PO IM IV SC
weight 60 kg>>)
Domperidone body 10mg TDS PO
weight >> 35 kg,
caution in >60yo and
those with cardiac hx.
Cyclizine (avoid in MI 50mg TDS PO IV SC
and decreased GI
motility
Prochlorperazine 12.5mg Acute attack then oral dose 6 rs IM
(stemetil) after
Prevention 5-10mg BD or TDS
Ondansetron (Zofran) 4mg TDS PO IM IV
Emergency

Anapylaxis
Adrenaline Hydrocortisone Chlorphenamine

< 6 months 150 micrograms (0.15ml 1 in 25 mg 250

1,000) micrograms/kg

6 months - 6 years 150 micrograms (0.15ml 1 in 50 mg 2.5 mg

1,000)

6-12 years 300 micrograms (0.3ml 1 in 100 mg 5 mg

1,000)

Adult and child > 12 500 micrograms (0.5ml 1 in 200 mg 10 mg

years 1,000)
Neurological
Status epilepticus lorazepam 0.1mg/ kg IV  IV bolus—to stop seizures: 
(4mg) eg lorazepam 4mg
Midazolam >10 yo: Buccal  Give 2nd dose of
10mg lorazepam if no response
5-10 yrs: after 10–20min
5mg  Thiamine 250mg IV over
phenytoin 15- IV 30min if alcoholism or
18mg/kg  malnourishment
If 60kg suspected. Glucose 50mL
max is 1g 50% IV, unless glucose
 If 80kg known to be normal. Treat
max is 2g acidosis if severe (contact
ICU) IV infusion: If seizures
continue, start phenytoin,
 15–18mg/kg IVI, at a rate
of 50mg/min. Monitor
ECG and BP.
100mg/6–8h is a maintenance dose
(check levels)

Endocrine
DKA Insulin 50 units to IV  Aim for fall in ketones by 
50ml 0.95 0.5mmol/L/h or rise in
saline @ venous bicarb by
0.1 unit/ 3mmol/L/h with fall in
kg/h glucose by same (
3mmol/L/h
 If k 3.5-5mmol/l then
40mmol KCl in 1L Iv vluid.
0.9% saline fluid of choice.
HONK LMWH Rehydrate with .9% saline over 48  
(enoxaparin) hr typical deficits are 110-220ml/
kg.
Thyroid storm Give T3 5– IV
(liothyronine) 20mcg/12h
slowly
hydrocortisone 100mg/8h IV

co-amoxiclav 1.2g/8h IV

Propranolol 60mg/ 4- IV
6hrs PO
Max IV
dose 1mg
over 1min
carbimazole 15–
25mg/6h
PO
Addisonian crisis Hydrocortisone 100mg IV
STAT
IV fluid bolus 500 ml
0.9% saline
Blood glucose
 phaeochromocytoma Short acting a 10mg/ PO
blocker 24h,
phenoxybenzamine increase
10mg/ d as
needed up
to 30mg/
12h PO
B2 blocker to be
given also.

Antibiotics:

System Drug Dose Timing Route Duration Interactions

Upper respiratory
Pharyngitis / Sore Throat / Phenoxymethylpenicillin 666mg QDS PO 10 days
Tonsillitis
Clarithromycin, if allergic to
penicillin500 mg BD 10 days

Lower respiratory
COPD
Amoxicillin 500mg TDS PO 5 days
Clarithromycin 500mg BD PO 5 days
Doxycycline 200mg STAT, 100mg OD PO 5 days
co-amoxiclav 625mg TDS PO 5 days
pneumonia Amoxicillin 500-1000mg TDS PO Up to 10
days
Clarithromycin 500mg BD PO 5 days
Doxycycline 200mg STAT, 100mg OD PO 5 days
Start antibiotics immediately.B-
Assess using the CRB-65 score (Confusion, Respiratory rate ≥ 30/min, BP ≤90/60, Age ≥ 65)
Score 0: suitable for home treatment;
Score 1-2: consider hospital referral;
Score 3-4: urgent hospital admission.
Add macrolide if CRB-65=1 and suitable for home treatment (HPA guidance).

 If no response in 48 hours consider admission or add a macrolide first line or a tetracycline C to cover Mycoplasma infection (rare in over 65s).

 In severely ill patients, give parenteral benzylpenicillin before admission C and seek risk factors for Legionella and Staph. aureusinfection. D

Menigitis

 Transfer all patients to hospital immediately.

 Administer benzylpenicillin prior to admission, unless history of anaphylaxis, B- NOT allergy. Ideally IV but IM if a vein cannot be found .

Benzylpenicillin Adults and children IM or IV

10 yr and over:
1200 mg
cefotaxime
ceftriaxone
ampicillin
dexamethasone
Urinary
Acute pyelonephritis Ciprofloxacin 500mg BD PO 7 days
Co amoxiclav 625mg TDS PO 14 days
Trimethoprim 200mg BD PO 14 days
Uncomplicated UTI adults Trimethoprim 200mg BD PO 7 day men, 3 d
women
Nitrofurantoin 50mg QDS PO 7 days
Recurrent UTI women
Nitrofurantoin 50mg STAT post coital po
Trimethoprim 100mg OD nocte PO
UTI in long term care residents Trimethoprim 200mg BD PO 7 days
Nitrofurantoin 50mg QDS PO 7 days
With urinary catheter Trimethoprim 200mg BD PO
Nitrofurantoin 50mg-100mg QDS PO
 Skin
Acne vulgaris

gentamicin

VTE prophylaxis

NICE recommend the following options for pharmacological VTE prophylaxis:

 low molecular weight heparin (LMWH)

 dabigatran
 rivaroxaban
 apixaban
 fondaparinux
 unfractionated heparin (UFH) (for patients with renal failure)

Before admission

 advise women to consider stopping oestrogen-containing oral contraception or HRT 4 weeks before surgery.
 assess the risks and benefits of stopping antiplatelet therapy 1 week before surgery

The following patients are deemed at risk of VTE

Medical patients

 if mobility significantly reduced for >= 3 days or

 if expected to have ongoing reduced mobility relative to normal state plus any VTE risk factor (see below)

Surgical patients and patients with trauma

 if total anaesthetic + surgical time > 90 minutes or

 if surgery involves pelvis or lower limb and total anaesthetic + surgical time > 60 minutes or
 if acute surgical admission with inflammatory or intra-abdominal condition or
 if expected to have significant reduction in mobility or
 if any VTE risk factor present (see below)

RIVAROXABAN 10 MG OD worth 4 pts; DALTEPARIN 2500-5000 UNITS S/C OD 4pts;

Pharmacological VTE prophylaxis options:

 fondaparinux sodium

 low molecular weight heparin (LMWH)

 unfractionated heparin (UFH) (for patients with renal failure)

Mechanical VTE prophylaxis options:

 anti-embolism stockings (thigh or knee length)

 foot impulse devices

 intermittent pneumatic compression devices (thigh or knee length)

Post-procedure VTE prophylaxis

For certain procedures pharmacological VTE prophylaxis is recommended for all patients, using one of the following:

 dabigatran, started 14 hours after surgery

 fondaparinux, started 6 hours after surgery

 LMWH, started 6-12 hours after surgery

 rivaroxaban, started 6-10 hours after surgery.

 apixaban

Procedure Length of prophylaxis

Elective hip 28-35 days

Elective knee 10-14 days

Hip fracture 28-35 days

System Drug Doses Timing Route Interactions Side-effects
Anticoagulants
Warfarin As per drug
interaction section 3
Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)

enoxaparin Prophylactic 20-40mg OD SC

Therapeutic 1mg/kg BD SC
NSTEMI
Therapeutic Or
DVT/PE 1.5mg/kg OD
 Surgery -mod risk VTE: prophylaxis Enoxaparin 20mg OD Initial dose approx 2 hours pre op.
 Surgery-high risk VTE: Enoxaparin 40mg OD prophylaxis (e.g.ortho).Initial dose approx 12 hours pre-op.
 Duration average 7-10 days, until ambulatory +/or VTE risk reduced.
 Medical Patients with restricted mobility: Enoxaparin 40mg OD
 ENSURE PATIENTS ARE NOT ALREADY ON NOACS OR BLEEDING PRIOR TO ADMINISTRATION

LMWH:
Activates antithrombin III. Forms a complex that inhibits factor Xa

Standard heparin SE:

- Bleeding
- Heparin-induced thrombocytopaenia (HIT)
- Osteoporosis
Monitoring for standard heparin-
- Activated partial thromboplastin time (APTT) For LMWH: Anti-Factor Xa (although routine

Heparin-induced thrombocytopaenia (HIT)

immune mediated - antibodies form against complexes of platelet factor 4 (PF4) and heparin
these antibodies bind to the PF4-heparin complexes on the platelet surface and induce platelet activation by cross-linking FcγIIA receptors
usually does not develop until after 5-10 days of treatment
despite being associated with low platelets HIT is actually a prothrombotic condition
features include a greater than 50% reduction in platelets, thrombosis and skin allergy
treatment options include alternative anticoagulants such as lepirudin and danaparoid
Tinzaparin (inohep) Prophylactic 3500 units
 Therapeutic 175iu/kg

System Drug Doses Timing Route Interactions Side-effects

Cardiovascular
Cholesterol lowering drugs

statin Simvastatin 80mg As per section 3 drug

interactions
10mg ; 20mg;
Rousvastatin
40mg
Atorvastatin 20mg; 40mg;
80mg

Fluvastatin
Pravastatin
Ezetimibe Adjunct to dietary measures Common or very
and statin treatment in common Fatigue.
Primary gastro-intestinal
hypercholesterolaemia disturbances. headache.
myalgia
Adjunct to dietary
measures and statin in
homozygous familial
hypercholesterolaemia
Fibrates DRUG ACTION Fibrates act Bezafibrate Common or very
by decreasing serum BY MOUTH USING IMMEDIATE-RELEASE common Abdominal
triglycerides; they have MEDICINES distension. anorexia.
variable effect on LDL- ▶ Adult: 200 mg 3 times a day diarrhoea. nausea
cholestrol
Extras for Primary prevention:
cholesterol lowering Offer a statin as first-line drug treatment if lifestyle modifications are inappropriate or ineffective
drugs Secondary prevention:
Secondary prevention:
 Statins should be offered to all patients, including the elderly, with cardiovascular disease such as those with coronary heart disease (including
history of angina or acute myocardial infarction), occlusive arterial disease (including peripheral vascular disease, non-haemorrhagic stroke, or
transient ischaemic attacks)
Total cholesterol, HDL-cholesterol, and non-HDL cholesterol concentrations should be checked 3 months after starting treatment with a high intensity
statin.
Aim for non HDL reduction by 40%, need to manage lifestyle if not there and at <80mg atorvastatin.

Diabetes- hypoglycaemic agents

Metformin Adult: Initially 500 mg once daily for at least 1 week, Common or very
dose to be taken with breakfast, then 500 mg twice daily for at least 1 week, dose to be taken with breakfast common Abdominal
and evening meal, then 500 mg 3 times a day, dose to pain. anorexia.
be taken with breakfast, lunch and evening meal; diarrhoea (usually
maximum 2 g per day transient). nausea. taste
disturbance.
vomiting
insulin Separate section
Dipeptidylpeptidase- Linagliptin ▶ BY MOUTH Uncommon
4 inhibitors (gliptins) ▶ Adult: 5 mg once daily Cough.nasopharyngitis
to increase Alogliptin ▶ BY MOUTH
insulin secretion and ▶ Adult: 25 mg once daily
lower glucagon
secretion.

Glucagon-like Exenatide BY SUBCUTANEOUS INJECTION USING IMMEDIATE-RELEASE CONTRA-INDICATIONS

peptide-1 receptor MEDICINES Ketoacidosis. severe
agonists ▶ Adult: Initially 5 micrograms twice daily for at least gastrointestinal disease
1 month, then increased if necessary up to
10 micrograms twice daily, dose to be taken within SE
1 hour before 2 main meals (at least 6 hours apart) Common or very
common Abdominal
pain and distension.
agitation. antibody
formation

Sodium Canagliflozin BY MOUTH Common or very

glucose co-
transporter 2
inhibitors
Reversibly inhibits sodium-
glucose cotransporter 2
(SGLT2) in the renal
proximal convoluted
tubule to reduce glucose
Sulfonylureas
Thiazolidinediones
▶ Adult: 100 mg once daily; increased if tolerated to common Constipation.
300 mg once daily if required, dose to be taken dyslipidaemia.
preferably before breakfast genital infection.
hypoglycaemia
GLicazide BY MOUTH USING IMMEDIATE-RELEASE MEDICINES HYPOs.
▶ Adult: Initially 40–80 mg daily, adjusted according to
response, increased if necessary up to 160 mg once Stop until reviewed.
daily, dose to be taken with breakfast
Pioglitazone BY MOUTH Contrad: History of
▶ Adult: Initially 15–30 mg once daily, adjusted heart failure. previous
according to response to 45 mg once daily, or
reduces peripheral active bladder cancer.
insulin resistance, uninvestigated
leading to a macroscopic
reduction of blood- haematuria
glucose
concentration SIDE-EFFECTS
▶ Common or very
common Anaemia.
arthralgia. dizziness.
gastro-intestinal
disturbances.
haematuria. headache
Anti-Hypertensives
ACEi captopril Hypertension CONTRA- SIDE-EFFECTS
▶ BY MOUTH INDICATIONS ▶ Common or very
▶ Adult: Initially 12.5–25 mg twice daily, then increased The combination common Alopecia . dry
if necessary up to 150 mg daily in 2 divided doses, of an ACE mouth . dyspnoea .
inhibitor with sleep disorder
Rampipril Hypertension aliskiren is SIDE-EFFECTS
▶ BY MOUTH contra-indicated ▶ Common or very
▶ Adult: Initially 1.25–2.5 mg once daily, increased if in patients with common Bronchitis .
necessary up to 10 mg once daily, dose to be increased an eGFR less than dyspnoea . muscle
at intervals of 2–4 weeks 60 cramps . stomatitis .
mL/minute/1.73 syncope
m2 .the
combination
of an ACE
inhibitor with
aliskiren is
contra-indicated
in
patients with
diabetes mellitus
CAUTIONS Afro-
Caribbean
patients (may
respond less well
to ACE
inhibitors).
concomitant
diuretics . first
dose
hypotension
(especially in
 patients taking
high doses of
diuretics, on a
low-sodium diet,
on dialysis,
dehydrated, or
with heart
failure)
ARBs Candesartan Hyperkalaemia .
Hypertension angioedema (may be
▶ BY MOUTH delayed onset).
▶ Adult 18–74 years: Initially 40 mg once daily, increased symptomatic
if necessary to 80 mg once daily hypotension including
▶ Adult 75 years and over: Initially 20–40 mg on dizziness

CCB Verapamil Heart failure,

SEs reduces constipation,
nausea, vomiting, cardiac output, slows the hypotension,
dizziness, agitation, heart rate, and may impair bradycardia, flushing
confusion, and atrioventricular conduction
coma in severe
poisoning. Metabolic Amlodipine Hypertension Common or very
acidosis and Most commonly for HTN first ▶ BY MOUTH common Abdominal
hyperglycaemia may line > 55 yo pain . dizziness . fatigue
▶ Adult: Initially 5 mg once daily; maximum 10 mg per
occur. . flushing . headache .
day
nausea . oedema .
palpitation . sleep
disturbances
Nifedipine Hypertension Contrad
Nifedipine relaxes vascular smooth ▶ BY MOUTH Acute porphyrias,
muscle and dilates
▶ Adult: 20–30 mg once daily, increased if necessary up aortic
coronary and peripheral arteries. It
has more influence on to 90 mg once daily stenosis .
vessels and less on the myocardium uncontrolled
than does verapamil heart failure .
hydrochloride, and unlike verapamil
unstable angina .
hydrochloride has no
anti-arrhythmic activity within 1 month
of myocardial
infarction
Lercanidipine l INDICATIONS AND DOSE
Mild to moderate hypertension
▶ BY MOUTH
▶ Adult: Initially 10 mg once daily; increased if necessary
 to 20 mg daily, dose can be adjusted after 2 weeks
Verapamil hydrochloride and diltiazem hydrochloride should usually be avoided in heart failure
because they may further depress cardiac function and cause clinically significant deterioration
Thiazides Bendroflumethiazide Hypertension ▶ Common or very
▶ BY MOUTH common
▶ Adult: 2.5 mg daily, dose Altered plasma-lipid
to be taken in the morning, concentrations . gout.
higher doses are rarely hypercalcaemia .
necessary hyperglycaemia .
hyperuricaemia .
hypochloraemic
alkalosis . hypokalaemia
. hypomagnesaemia .
hyponatraemia .
metabolic and
electrolyte disturbances
. mild gastrointestinal
disturbances . postural
hypotension
Potassium sparing spironolactone Oedema in congestive heart Acute renal failure .
diuretics failure agranulocytosis .
▶ BY MOUTH alopecia . benign breast
▶ Adult: Initially 100 mg daily, tumour. breast pain .
alternatively initially changes in libido .
25–200 mg daily, dose may be confusion . dizziness .
taken as a single dose or drowsiness . electrolyte
divided doses, maintenance dose disturbances . gastro-
adjusted according to intestinal disturbances .
response gynaecomastia

Beta blockers Labetalol Adult: Initially 100 mg twice daily, dose to be increased Difficulty in micturition
(hypertension) at intervals of 14 days; usual dose 200 mg twice daily, . epigastric
increased pain . liver damage .
nausea postural
Elderly: Initially 50 mg twice daily, dose to be increased hypotension . vomiting
at intervals of 14 days; usual dose 200 mg twice daily, . weakness
increased if necessary up to 800 mg daily in 2 divided
doses, to be taken with food
Timolol BY MOUTH
 ▶ Adult: Initially 10 mg daily in 1–2 divided doses, then
increased if necessary up to 60 mg daily, doses to be
increased gradually
Bisoprolol ▶ BY MOUTH Uncommon Cramp .
▶ Adult: 5–10 mg once daily; maximum 20 mg per day depression . muscle
weakness
▶ Rare Hearing
impairment.
hypertriglyceridaemia .
syncope
Patients< 55 yrs:
Step 1
ACEi or ARB if not tolerated. If both not tolerated, consider beta blocker.
Step 2
ACEi or CCB. If CCB not tolerated, then give thiazide diuretic.
Step 3
ACEi or ARB and CCB and thiazide
Step 4:
Spironolactone or thiazide high dose if potassium > 4.5

Antidepressants
Anti psychotics:

Extra pyramidal side effects

- Parkinsonism
- acute dystonia (e.g. torticollis, oculogyric crisis)
- akathisia (severe restlessness)
- tardive dyskinesia

other side effects:

- antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
- sedation, weight gain
- raised prolactin: galactorrhoea, impaired glucose tolerance
- neuroleptic malignant syndrome: pyrexia, muscle stiffness
- reduced seizure threshold (greater with atypicals)
- prolonged QT interval (particularly haloperidol)
TCAs

Common side-effects
- drowsiness
- dry mouth
- blurred vision
- constipation
 - urinary retention

More sedative Less sedative

Amitriptyline Imipramine
Clomipramine Lofepramine
Dosulepin Nortriptyline
Trazodone*

low-dose amitriptyline is commonly used in the management of neuropathic pain and the
prophylaxis of headache (both tension and migraine)
Osteoporosis

bisphosphonates
Alendronic acid ▶ BY MOUTH Contrad
▶ Adult (female): 10 mg daily, alternatively 70 mg once Abnormalities of
weekly oesophagus.
hypocalcaemia.
SIDE-EFFECTS
▶ Common or very
common Abdominal
distension.
abdominal pain.
constipation. diarrhoea.
Dyspepsia

Severe oesophageal
reactions (oesophagitis,
oesophageal
ulcers, oesophageal
stricture and
oesophageal erosions)
 Risedronate Prevention of osteoporosis (including corticosteroidinduced CAUTIONS Atypical
osteoporosis) in postmenopausal women femoral fractures.
▶ BY MOUTH oesophageal
▶ Adult (female): 5 mg daily abnormalities. other
factors which delay
transit or
emptying

SIDE-EFFECTS
▶ Common or very
common Abdominal
pain. constipation.
diarrhoea. dyspepsia.
headache.
musculoskeletal pain.
nausea
Strontium ranelate CAUTIONS
Predisposition to
DRUG ACTION Stimulates bone formation and cardiovascular
reduces disease—
bone resorption. assess risk before and
every 6–12 months
during treatmen

SIDE-EFFECTS
▶ Common or very
common Dermatitis.
diarrhoea. eczema.
headache. myocardial
infarction. nausea.
venous
thromboembolism

Teriparatide BY SUBCUTANEOUS INJECTION SIDE-EFFECTS

▶ Adult: 20 micrograms daily for maximum duration of ▶ Common or very
treatment 24 months (course not to be repeated) common Anaemia.
arthralgia. asthenia.
depression. dizziness.
dyspnoea
Denosumab ▶ BY SUBCUTANEOUS INJECTION Denosumab is
▶ Adult: 60 mg every 6 months, supplement with calcium associated with a risk
and vitamin D of osteonecrosis of the
DRUG ACTION Denosumab is a human monoclonal ® jaw (ONJ) and with a
antibody that inhibits osteoclast formation, function, risk of hypocalcaemia.
and survival, thereby decreasing bone resorption Osteonecrosis of the
jaw
Osteonecrosis of the
jaw is a well-known
and common
side-effect in patients
receiving denosumab
120 mg for
cancer.
Musculoskeletal
Gout Colchicine
Allopurinol
Febuxostat
Joint pain:
see analgesia
Opthalmology
glaucoma
Dry eyes
Skin
psoriasis - trauma
- alcohol
- drugs: beta blockers, lithium, antimalarials (chloroquine and
hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
- withdrawal of systemic steroids
eczema
Acne Isotretinoin - teratogenicity: females should ideally be using two forms of
contraception (e.g. Combined oral contraceptive pill and
condoms)
- dry skin, eyes and lips: the most common side-effect of
isotretinoin
- low mood*
- raised triglycerides
Insulin

Premixed preparations

 combine intermediate acting insulin with either a rapid-acting insulin analogue or soluble insulin

 Novomix 30: 30% insulin aspart (rapid-acting), 70% insulin aspart protamine (intermediate-acting)

 Humalog Mix25: 25% insulin lispro (rapid-acting), 75% insulin lispro protamine (intermediate-acting); Humalog Mix50: 50% insulin lispro, 50% insulin lispro protamine

 Humulin M3: biphasic isophane insulin (human, prb) - 30% soluble (short-acting), 70% isophane (intermediate-acting)

 Insuman Comb 15: biphasic isophane insulin 9human, prb) - 30% soluble (short-acting), 70% isophane (intermediate-acting)

Rapid-acting insulin analogues

 the rapid-acting human insulin analogues act faster and have a shorter duration of action than soluble insulin (see below)
 may be used as the bolus dose in 'basal-bolus' regimes (rapid/short-acting 'bolus' insulin before meals with intermediate/long-acting 'basal' insulin once or twice daily)

insulin aspart: NovoRapid

insulin lispro: Humalog

Short-acting insulins

 soluble insulin examples: Actrapid (human, pyr), Humulin S (human, prb)

 may be used as the bolus dose in 'basal-bolus' regimes

Intermidate-acting insulins

 isophane insulin
 many patients use isophane insulin in a premixed formulation with

Long-acting insulins

 insulin determir (Levemir): given once or twice daily

 insulin glargine (Lantus): given once daily
Section 2: Disease-specific treatments
Section 3: Common drug interactions

DRUG INTERACTIONS

ANTIBIOTIC CLASS INTERACTING DRUG COMMENTS

PENICILLINS methotrexate

MACROLIDES Statins Risk of myopathy. Avoid concomitant use (hold statin for duration of antibiotic course and
 ERYTHROMYCIN for 7 days after last antibiotic dose).
 CLARITHROMYCIN Warfarin Monitor INR
 AZITHROMYCIN NOACs* - Dabigatran, Rivaroxaban, Increased risk of bleeding, monitor
 TELITHROMYCIN Drugs that prolong QT interval**
Colchicine Clarithromycin, erythromycin and azithromycin possibly increase risk of colchicine
toxicity—hold or reduce dose of colchicine (avoid concomitant use in hepatic or renal
impairment) (BNF)
Antiepileptic drugs Increased plasma concentrations of carbamazepine with clarithromycin and
erythromycin, phenytoin with clarithromycin and possibly valproate with erythromycin

TRIMETHOPRIM & CO- Warfarin May increase anticoagulant effect of warfarin with increased risk of bleeding -
TRIMOXAZOLE monitor INR closely
methotrexate Risk of severe bone marrow depression and other haematological toxicities - avoid
if possible
 Amiodarone

TETRACYCLINES Antacids Risk of reduced bioavailability and efficacy. Separate the doses by 2 to 3 hours or
more to avoid interaction.
Iron zinc calcium Risk of reduced bioavailability and efficacy. Separate the doses by 2 to 3 hours or
more to avoid interaction.
Warfarin Risk of bleeding - monitor INR closely.
methotrexate Doxycycline, tetracycline increase risk of methotrexate toxicity

ANTI FUNGALS: Statins Increased risk of myopathy. Hold for 7 days

FLUCONAZOLE ITRACONAZOLE NOACs Increased concentration, no prescription
Warfarin Increased risk of bleeding, monitor INR
Drugs that prolong the qt As per patient

RIFAMPICIN Warfarin Decreased availability so monitor the INR

OCP Non hormonal contraception
NOACs Decreased availability, not to be prescribed

DRUGS THAT PROLONG THE QT:

Anti psychotics

- Atypical anti psychotics

Anti depressants

- Sertraline
- Paroxetine
- Venlaflaxine
- Tricyclics
Anti arrthymics

- amiodarone
Antibiotics

- Co trimoxazole
 -
NON-DRUG RISK FACTORS FOR PROLONGED QT:

- Electrolytes
o Hypokalaemia
o Hypocalcaemia
o Hypomagnesaemia
- Hypothyroidism
- hypoglycaemia
- Cardiomyopathy
-
- Family history

SIDE EFFECTS TO MEMORISE:

TB:

- R: ORGANGE TEARS/ URINE + HEPATITIS

- I: NEUROPATHY
- P:-
- E: OPTIC NEURITIS
ANTI EPILEPTICS:

- PHENYTOIN: toxicity resulting in cerebellar syndrome; acne, coarse face, gum hypertrophy, hirstutism
- CARBAMAZEPINE: rash, dizziness, hyponatremia & hair thinning
- VALPROATE: tremor, weight gain, hair thinning
- LAMOTRIGINE: rash- SJS
ANTI DEPRESSANTS

- SSRIS: nausea, low libido, withdrawal, hyponatremia

- TCA anti muscarininc effects anti histaminergic effects anti alpha adrenergic effects hyponatremia, abnormal Lfts, siadh
- MOAI: hypertension, hepatocellular jaundice, hyperthermia
ANTI HYPERTENSIVES:

- ACEI: dry cough, postural hypo, renal failure in RAS check u/e before and 2 wks after start, angioedema of tongue,
hyperkaelaemia
- CCB: ankle oedema, headache flushing dizziness
- BB: diabetes, impotence, bradycardia, low cardiac outpout, fatigue, cold hands and feet
- AB: anti alpha effect
DIURETICS:

- ALL: dehydration, hypotension, hyperuricaemia, hypokalaemia low mg

- LOOP: hypocalcaemia
- THIAZIDE: hypercalcaemia
- K SPARING: hyperkaelamia, gynaecomastia

HYPOGLYCAEMICS:

- METFORMIN: WEIGHT LOSS AND LACTIC ACIDOSIS METALLIC TASTE

- SULPHONYLUREAS: hypoglycaemia weight gain
- Thiazolidinediones- glitazones: fluid retention- Heart failure & oedema, hepatoxic, bone fractures
- INSULIN: hypoglycaemia, fat hypertrophy at injection site, hypokalaemia
STEROIDS:

- Diabetes
- Cushings
- Psychosis
- Osteoporosis
- Hypokalaemia
- Hyperglycaemia
- Infections
- Leucocytosis
- Diabetes insipidus
PPI

- Tinnitus
- Nausea, diarrhoea
- Headache
ANTI ARRTHYMICS:

- AMIODARONE: thyroiditis, pulmonary fibrosis, peripheral neuropathy, blue grey skin

- DIGOXIN: xanthopia yellow orange tinge to vision, GI sx: nausea anorexia vomiting
- ADENOSINE: flushing impending sense of doom

ORGAN TOXICITY:
Renal failure
NTERSTITIAL NEPHRITIS: nsaids, penicillin, calcineurin inhibs

- ATN: lithium, gentamicin, amphotericin

- RENAL ARTERY STENOSIS: ACEI
- GLOMERULAR DAMAGE: gold/ NSAIDS/ penicillamine
CHOLESTASIS:

- Carbamazepine
- Co amoxiclav
- Erythromycin
- Sulphonylureas
HEPATITIS:

- RIP of RIPE
- Valproate
- Methotrexate
- Methyldopa
- Amiodarone
- Statin
- Paracetamol
- Phenytoin
- Nitrofurantoin
SPAM RIP
HYPOTHYROIDISM:

- AMIODARONE
- CARBIMAZOLE
- LITHIUM
- RADIO IODINE
- PROPYLTHIOURACIL
PHOTOTOXICITY:

- TETRACYCLINES
- AMIODARONE- BLUE GREY COLOUR
- VINCRISTINE
- CIPROFLOXACIN
C DIFFICLE RISK:

- CEPHALOSPORINS
- CLINDAMYCIN
GYNAECOMASTIA:
DISCO MVT

- DIGOXIN
- ISONIAZID
- SPIRONOLACTONE
- CIMETIDINE
- OESTROGENS
- METHYLDOPA / METRONIDAZOLE
- VERAPAMIL
- TCAD
Adverse drug reactions:

Drug Side-effect

Calcium channel blockers • Headache

• Flushing
• Ankle oedema

Verapamil also commonly causes constipation

Beta-blockers • Bronchospasm (especially in asthmatics)

• Fatigue
• Cold peripheries
• Sleep disturbances

Nitrates • Headache
• Postural hypotension
• Tachycardia

Nicorandil • Headache
• Flushing
• Anal ulceration

Drug-induced impaired glucose tolerance

Drugs which are known to cause impaired glucose tolerance include:

 thiazides, furosemide (less common)

 steroids

 tacrolimus, ciclosporin

 interferon-alpha

 nicotinic acid

 atypical antipsychotics e.g. olanzapine

Drug-induced urinary retention
The following drugs may cause urinary retention:

 tricyclic antidepressants & anticholinergics

 opioids & NSAIDs & disopyramid

DRUG INTERACTIONS:
CYP450 inducers- reduce the concentration of drugs metabolised by the CYP450 SYSTEM
Carbamazepine
Rifampicin
bArbituartes
Phenytoin
St Johns Wort
CYP450 inhibitors- increase the drug concentration of those metabolised by the CYP450 system
Sodium valproate
Ciprofloxacin
Sulphonamide
Cimetidine/ omeprazole
Antifungals/ amiodarone
Isoniazid
Erythromycin/ clarithryomycin
Grapefruit juice
Drugs that interact with CYP450 INDUCERS/ INHIBITORS
WARFARIN:
Metabolised by CYP2C9
Intrxn with CIMETIDINE/ FLUCONAZOLE AS THESE ARE INHIBITORS OF CYP2C9
Intrxn with rifampin and St Johns wort as INDUCERS SO INCREASED CONCENTRATION
COCP:
THEOPHYLLINE:
Metabolised by CYP1A2
Intrxn with CIMETIDINE/ CIPROFLOXACIN/ ISONIAZID AS THESE ARE INHIBITORS SO DECREASED CONC
Intrxn with rifampin and OMEPRAZOLE, CARBAMAZEPINE wort as INDUCERS SO INCREASED CONCENTRATION

STEROIDS:
Metabolisd by CYP3A4
Inducers:
Intrxn with CARBAMAZEPINE; PHENYTOIN as INDUCERS = increased CONC
Inhibitors:
Intrx with AMIODARONE; CLARITHROMYCIN; FLUCONAZOLE; GRAPREFRUIT JUICE; KETOCONAZOLE AS INHIBITORS =
DECREASED CONC
TCAs:
Metabolism: cyp2d6
Inducers: none
Inhibitors: amiodarone cimetidine sertaline

PETHIDINE:
Metabolism: CYP2D6
Inducers: none
Inhibitors: amiodarone cimetidine sertaline
STATINS
Metabolism: cyp3a4; cyp2c9
Inducers:
Inhibitors: amiodarone cimetidine sertaline
Drug Side-effects

Methotrexate Myelosuppression
Liver cirrhosis
Pneumonitis

Sulfasalazine Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease

Leflunomide Liver impairment

Interstitial lung disease
Hypertension

Hydroxychloroquine Retinopathy
Corneal deposits

Prednisolone Cushingoid features

Osteoporosis
Impaired glucose tolerance
Hypertension
Cataracts

Gold Proteinuria

Penicillamine Proteinuria
Exacerbation of myasthenia gravis

Etanercept Demyelination
Reactivation of tuberculosis

Infliximab Reactivation of tuberculosis

Adalimumab Reactivation of tuberculosis

Rituximab Infusion reactions are common

Drugs and particular patient groups

Breastfeeding women

What drugs are ok for breast feeding women?

- antibiotics: penicillins, cephalosporins, trimethoprim

- endocrine: glucocorticoids (avoid high doses), levothyroxine*
- epilepsy: sodium valproate, carbamazepine
- asthma: salbutamol, theophyllines
- psychiatric drugs: tricyclic antidepressants, antipsychotics**
- hypertension: beta-blockers, hydralazine
- anticoagulants: warfarin, heparin
- digoxin

what drugs are NOT ok for breast feeding women ?

- antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides

- psychiatric drugs: lithium, benzodiazepines
- aspirin
- carbimazole
- methotrexate
- sulphonylureas
- cytotoxic drugs
- amiodarone

COPD and asthma

A number of drugs should be used with caution in patients with asthma:

- NSAIDs
- beta-blockers
- adenosine

Prescribing in patients with epilepsy

The following drugs may worsen seizure control in patients with epilepsy:

- alcohol, cocaine, amphetamines

- ciprofloxacin, levofloxacin
- aminophylline, theophylline
- bupropion
- methylphenidate (used in ADHD)
- mefenamic acid
Prescribing in patients with heart failure

The following medications may exacerbate heart failure:

 thiazolidinediones*: pioglitazone is contraindicated as it causes fluid retention

 verapamil: negative inotropic effect

 NSAIDs**/glucocorticoids: should be used with caution as they cause fluid retention

 class I antiarrhythmics; flecainide (negative inotropic and proarrhythmic effect)

Prescribing in patients with renal failure

Questions regarding which drugs to avoid in renal failure are common

Drugs to avoid in renal failure

- antibiotics: tetracycline, nitrofurantoin

- NSAIDs
- lithium
- metformin

Drugs likely to accumulate in chronic kidney disease - need dose adjustment

- most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin

- digoxin, atenolol
- methotrexate
- sulphonylureas
- furosemide
- opioids

Drugs relatively safe - can sometimes use normal dose depending on the degree of chronic kidney disease

- antibiotics: erythromycin, rifampicin

- diazepam
- warfarin
Section 4: drug calculations

Percentage concentrations

 % w/v = number of grams in 100mL; (A solid is dissolved in a liquid, thus 5% w/v means 5 g in 100 mL.)
 % w/w = number of grams in 100 g (A solid mixed with another solid, thus 5% w/w means 5 g in 100 g.)
 %v/v = number of mL in 100 mL (A liquid is mixed or diluted with another liquid, thus 5% v/v means 5 mL in 100 mL.)
 Most common percentage strength encountered is % w/v

There will always be the same amount of drug present in 100mL irrespective of the total volume. Thus in a 5% w/v solution, there is 5g dissolved in each

100mL of fluid and this will remain the same if it is a 500mL bag or a 1 litre bag.

Example: 0.9% saline 1 l= 0.9g in 100ml, find total vol= 9g in 1L of NaCl

Simple formula ?

amount = base/ 100 x per cent or total amount g= percentage/ 100 x total volume mL

mg/mL Concentrations

 Defined as the number of milligrams of drug per millilitre of liquid.

 Oral liquids – usually expressed as the number of mg in a standard 5 mL spoonful, e.g. erythromycin 250 mg in 5 mL.
 Injections are usually expressed as the number of mg per volume of the Converting percentage concentrations to mg/mL concentrations
Converting percentage concentrations to mg/ml concentrations
 Multiply the percentage by 10, e.g. lidocaine (lignocaine) 0.2% = 2mg/mL. ampoule (1mL, 2mL, 5mL, 10mL or 20mL), e.g. gentamicin 80mg in 2mL

Converting mg/mL concentratios to percentage concentrations

Divide the mg/mL strength by 10, e.g. lidocaine (lignocaine) 2 mg/mL = 2%.

sodium chloride 0.9% = 0.9 g per 100 mL

= 900 mg per 100 mL

= 9 mg per mL (9 mg/mL)

glucose 5% = 5 g per 100 mL

= 5,000 mg per 100 mL

= 50 mg per mL (50 mg/mL)

If you know the percentage concentration, an easy way of finding the strength in mg/mL is by simply multiplying the percentage by 10.

You have lidocaine (lignocaine) 0.2% – this is equal to 0.2g in 100mL.

Divide by 100 to find out how much is in 1mL. Thus:

0.2/100g/mL

Multiply by 1,000 to convert grams to milligrams. Thus:

0.2/ 100 x 1000mg/mL

Simplify the above calculation to give:

0.2 × 10 = 2 mg/mL

Therefore you simply multiply the percentage by 10

‘1 in …’ Concentrations or Ratio Strengths

Defined as: one gram in however many millilitres.

For example:

1 in 1,000
means 1 g in 1,000 mL
1 in 10,000 means 1 g in 10,000 mL

Adrenaline/epinephrine 1 in 1,000 which is equal to 1mg in 1 mL

Adrenaline/epinephrine 1 in 10,000 which is equal to 1mg in 10 mL

PARTS PER MILLION (ppm)

1 ppm means 1 g in 1,000,000 mL or 1 mg in 1 litre (1,000 mL. 1 ppm equals 0.0001%

Example

1 in 200,000 means: 1 g in 200,000 mL.

However, you have a 20mL vial.

First convert 1 g to milligrams:

1,000 mg in 200,000 mL=1000/200,000 mg in 1ml

Now 1000/200,000 x 20= 0.1mg in 20ml so answer is 0.1mg in 20ml

http://file.zums.ac.ir/ebook/145-Drug%20Calculations%20for%20Nurses%20A%20Step%20by%20Step%20Approach,%203rd%20Edition-
Robert%20Lapham%20Heather%20Agar-.pdf

infusion calculation rates

Giving sets

• The standard giving set (SGS) has a drip rate of 20 drops per mL for

clear fluids (i.e. sodium chloride, glucose) and 15 drops per mL for blood.

• The micro-drop giving set or burette has a drip rate of 60 drops per mL.

Conversion of Dosages to mL/hour

• In this type of calculation, it is best to convert the dose required to a volume

in millilitres.

• Doses expressed as mcg/kg/min:

Ml/hr= volume to be infused x dose x weight x 60 ( mins)/ amount of drug x 1000

1000 conerts mcg to mg; 60 mins to hrs

If doses in mg then no need to divide by 1000.

Fluid therapy:

The prescription of intravenous fluids is one of the most common tasks that junior doctors need to do.

In the 2013 guidelines NICE recommend the following requirements for maintenance fluids:

 25-30 ml/kg/day of water and

 approximately 1 mmol/kg/day of potassium, sodium and chloride and

 approximately 50-100 g/day of glucose to limit starvation ketosis

Section 5: Prescription errors

Penicillin allergy

Types of penicillin:

- phenoxymethylpenicillin
- benzylpenicillin
- flucloxacillin
- amoxicillin
- ampicillin
- co-amoxiclav (Augmentin)
- co-fluampicil (Magnapen)
- piperacillin with tazobactam (Tazocin)
- ticarcillin with clavulanic acid (Timentin)

Many patients who report an allergy may be describing an intolerance/side-effects (e.g. diarrhoea) or a coincidental rash (e.g. amoxicillin in patients with infectious
mononucleosis).

Around 0.5-6.5% of patients who are allergic to penicillin are also allergy to cephalosporins

Note from BNF:

Patients with a history of immediate hypersensitivity to penicillin should not receive a cephalosporin. If a cephalosporin is essential in these patients because a suitable
alternative antibacterial is not available, then cefixime, cefotaxime, ceftazidime, ceftriaxone, or cefuroxime can be used with caution;

Similar sounding drugs:

Carbimazole and Carbmazepine

- carbimazole: antithyroid
- carbmazepine: antiepileptic
Chlorphenamine and Chlorpromazine
- chlorphenamine: antihistamine
- chlorpromazine: antipsychotic

Timing of drugs:

The following medications are usually taken at night:

- Statins
- amitriptyline
 Drug monitoring:

Therapeutic drug monitoring

Lithium

range = 0.4 - 1.0 mmol/l

take 12 hrs post-dose

Ciclosporin

trough levels immediately before dose

Digoxin

at least 6 hrs post-dose

Phenytoin levels do not need to be monitored routinely but trough levels, immediately before dose should be checked if: adjustment of phenytoin dose

suspected toxicity detection of non-adherence to the prescribed medication

Cardiovascular drugs

Drug Main monitoring parameters Details of monitoring

Statins LFT LFTs at baseline, 3 months and 12 months

ACE inhibitors U&E U&E prior to treatment

U&E after increasing dose
U&E at least annually

Amiodarone TFT, LFT TFT, LFT, U&E, CXR prior to treatment

TFT, LFT every 6 months
 Rheumatology drugs

Main
monitoring Neuropsychiatric drugs
Drug parameters Details of monitoring

Methotrexate FBC, LFT, U&E The Committee on Safety of Medicines recommend 'FBC Endocrine drugs
and renal and LFTs before starting treatment and repeated
weekly until therapy stabilised, thereafter patients should
be monitored every 2-3 months'

Azathioprine FBC, LFT FBC, LFT before treatment

FBC weekly for the first 4 weeks
FBC, LFT every 3 months

Drug Main monitoring parameters Details of monitoring

Glitazones LFT LFT before treatment

LFT 'regularly' during treatment

Main monitoring
Drug parameters Details of monitoring

Lithium Lithium level, TFT, U&E TFT, U&E prior to treatment

Lithium levels weekly until stabilised then every
3 months
TFT, U&E every 6 months

Sodium LFT LFT, FBC before treatment

valproate LFT 'periodically' during first 6 months