Pharmacy Revision

• Metformin decreases gluconeogenesis and increases the peripheral utilisation of glucose. The dose is gradually increased on initiation. The side effects are gastrointestinal e.g. nausea and vomiting, diarrhoea, and taste disturbances. It can also cause vitamin B12 deficiency. Slowly increasing the dose or using a modified-release preparation may increase tolerability.

  Treatment should be stopped if eGFR is below 30 mL/min, as metformin can cause lactic acidosis in renal impairment.
• Sulfonylureas include gliclazide, glimepiride, glipizide and tolbutamide. They augment insulin secretion from the pancreatic beta cells.

  They can have gastrointestinal side effects e.g. nausea and vomiting, diarrhoea, abdominal pain. They can also cause skin reactions in the first 6-8 weeks. They can also cause weight gain. They can cause dangerous hypoglycaemia, especially in the elderly. For this reason they should not be taken when a patient is not eating. The hypoglycaemia risk is increased in hepatic and renal impairment.
• Pioglitazone reduces peripheral insulin resistance. Avoid in heart failure as it is cardiotoxic. Also there is a risk of bladder cancer so avoid in patients with this, and report blood in urine. Avoid in hepatic impairment and report jaundice, nausea, vomiting and fatigue as it can cause liver dysfunction.

  Pioglitazone can cause an increased risk of bone fractures, infections and weight gain. It can also cause numbness, insomnia and visual impairment.
• DPP-4 inhibitors include alogliptin, linagliptin, sitagliptin and saxagliptin. They inhibit dipeptidyl-peptidase-4 to increase insulin secretion and lower glucagon secretion.

  Gastrointestinal side effects include nausea, vomiting, diarrhoea, gastric reflux.

  DPP-4 inhibitors should be avoided in heart failure, hepatic impairment, ketoacidosis and pancreatitis (report jaundice and severe abdominal pain).
• SGLT-2 inhibitors include canagliflozin, dapagliflozin and empagliflozin. They inhibit sodium-glucose co-transporter 2 in the renal proximal convoluted tubule, which leads to lowering of blood glucose via diuresis.

  Can cause euglycaemic diabetic ketoacidosis- monitor ketones if treatment interrupted.

  Can cause Fournier's gangrene (necrotising fasciitis of the genitalia or perineum)- stop drug.

  Canagliflozin has a lower limb amputation risk.

  Can cause volume depletion- constipation, thirst, hypotension.

  Can cause renal impairment- monitor.
• SGLT-2 inhibitors can cause euglycaemic DKA. Inform patients of DKA signs and symptoms (rapid weight loss, nausea and vomiting, abdominal pain, fast and deep breathing, sleepiness, a sweet pear-drop smell in the breath, sweet or metallic taste in the mouth, different odour to urine or sweat).

  SGLT-2i should be held in periods of acute illness, surgery and alcohol abuse. Blood ketone levels should be monitored during treatment interruption in those who have been hospitalised for major surgery or acute serious illnesses.

  Do not restart any SGLT2i in a patient who has experienced DKA.
• GLP-1 receptor agonists include dulaglutide, exenatide, liraglutide and semaglutide. They increase insulin secretion, suppress glucagon secretion, and slow gastric emptying.

  They can cause diabetic ketoacidosis when concomitant insulin is rapidly reduced (MHRA alert). Avoid in existing ketoacidosis!

  Can cause pancreatitis- report jaundice and severe abdominal pain.

  Gastrointestinal side effects can lead to dehydration- avoid fluid depletion.

  They are very good at causing weight loss, and there's actually a national shortage because so many people are using it for this reason.
• Tamsulosin 400 microgram capsules can be sold to the public for the treatment of functional symptoms of benign prostatic hyperplasia in men aged 45-75 years. Maximum duration is 6 weeks before clinical assessment by a doctor.

  Referral criteria:

  • outside of age range
  • receiving anti-hypertensive medications
  • experiencing postural hypotension
  • scheduled eye surgery
  • symptoms present for less than 3 months
  • cloudy urine (or signs of UTI)
  • sudden inability to pass urine (medical emergency!)
• MHRA warnings for bisphosphonates:

  • osteonecrosis of the jaw
  • report dental pain, swelling, non-healing sores or discharge
  • risk is higher for IV bisphosphonates e.g. zoledronic acid
  • atypical femoral fractures
  • report thigh, hip or groin pain
  • osteonecrosis of the external auditory canal
  • report any ear pain, discharge or infections

  Evaluate the need for bisphosphonate treatment periodically, consider a drug holiday after 5 years.
• Bisphosphonates may cause oesophageal irritation. Take this tablet whole, 30 minutes before food or other medicines, with a whole glass of water and remain upright (sitting or standing) for 30 minutes after.
• Warfarin Overdose?

  If there is major bleeding after warfarin overdose: stop warfarin, give IV phytomenadione and dried prothrombin complex.

  If INR is over 8 with no bleeding, stop bleeding and give oral phytomenadione.

  If INR is over 5 with minor bleeding, stop warfarin and give IV phytomenadione.

  If INR is between 5 and 8 and there is no bleeding, withhold 1 or 2 doses of warfarin; reduce subsequent maintenance dose.

  Repeat doses of phytomenadione after 24 hours if INR is still too high, and restart warfarin when INR is less than 5
• Record keeping?

  CD book (with destructions) - 7 years

  CD book (no destructions) - 2 years

  PMR - 6 years

  Responsible Pharmacist register - 5 years

  Vet script - 5 years

  Private Script - 2 years

  Signed Order - 2 years
• Benzodiazepines with legal driving limits?

  Acronym COLDF(ee)T

  Clonazepam

  Oxazepam

  Lorazepam

  Diazepam

  Flumitrazepam

  Temazepam
• Status epilepticus?

  For seizures longer than 5 minutes: use IV lorazepam and IV diazepam, but runs a risk of thrombophlebitis.

  Repeat after 10 minutes- if treatment fails after 25 minutes: phenytoin, fosphenytoin, or phenobarbital should be used.

  If these measures fail to control seizures in 45 minutes of onset: anaesthesia with thiopental, midazolam or propofol.

  When resus isn't available, use rectal diazepam or buccal midazolam.
• Paracetamol max doses?

  2-3 months: 60mg can be used for immunisation pyrexia- to be repeated once only after 4-6 hours if needed

  3-5 months: 60 mg

  6-23 months: 120 mg

  2-3 years: 180 mg

  4-5 years: 240 mg

  6-7 years: 250 mg

  8-9 years: 375 mg

  10-11 years: 500 mg

  12-15 years: 750 mg

  16+ years : 1000 mg
• Clostridioides Difficile (C.diff)?

  Normal gut microbiota are suppressed, so toxin-producing C.diff strains can flourish.

  Causes include the Cs and PPI- clindamycin, co-amoxiclav (broad-spectrum penicillins), cephalosporins, ciprofloxacin (quinolones), proton pump inhibitors (suppressing acid).

  Other risk factors include age over 65, prolonged hospitalisation, underlying comorbidity, exposure to other people with the infection, previous history of C.diff.

  C.diff can be treated using oral vancomycin, oral fidaxomycin, or for life threatening C.diff, IV vancomycin and IV metronidazole
• Acute diverticulitis?

  A condition where diverticula (small pouches protruding from the walls of the large intestine) suddenly become inflamed or infected. Complicated acute diverticulitis refers to diverticulitis associated with complications such as abscess, bowel perforation and peritonitis, fistula, intestinal obstruction, haemorrhage, or sepsis.

  For asymptomatic patients, use a watchful waiting strategy. For patients who are systemically unwell, immunocompromised or have significant comorbidities, prescribe antibiotics.
• Typhoid fever from Middle East, South Asia and Southeast Asia should be sensitivity tested as it may be multiple drug resistant. Treat with cefotaxime, azithromycin or ciprofloxacin.

  For severe shigellosis, prescribe ciprofloxacin or azithromycin.

  For non-typhoid salmonella, treat if invasive or severe with ciprofloxacin or cefotaxime.

  Biliary tract infection should be treated with ciprofloxacin or gentamicin or a cephalosporin.
• Impetigo, a superficial bacterial skin infection, can be non-bullous (thin-walled vesicles that rupture quickly and form a golden-brown crust) or bullous (fluid-filled vesicles that rupture quickly and form a yellow-brown crust). Transmission occurs directly through close contact with an infected individual or indirectly via contaminated objects.

  If localised non-bullous impetigo: use hydrogen peroxide 1% cream or a topical antibiotic (2nd line)

  Widespread non-bullous impetigo: topical or oral antibacterial

  Systemically unwell or bullous: oral antibacterial e.g. fluclox, clari.
• Methotrexate

  • NHS never event- patients given methotrexate for non-cancer treatment should be given it weekly
  • Only the 2.5 mg tablet should be prescribed and dispensed
  • Patient to report any blood disorders (sore throat, bruising, mouth ulcers), liver toxicity (N+V, abdominal pain, dark urine), pulmonary toxicity (shortness of breath, cough, fever)
  • keep safe in the sun as can cause photosensitivity
  • use effective contraception until 6 months after
  • folic acid reduces side effects - given on different days to methotrexate
  • FBC, U+E and LFT tests 1-2 weekly until stable then every 2-3 months
• Methotrexate (2)

  • Methotrexate is used for autoimmune diseases e.g. Crohn's disease, rheumatoid arthritis and severe psoriasis.
  • It works as a folate inhibitor.
  • It is contraindicated in active infection, immunodeficiency and pleural effusion.
  • Patient should report any signs of infection including a sore throat
  • In acute toxicity, use calcium folinate (type of folinic acid)
  • Taking NSAIDs with methotrexate can slow its clearance, allowing dangerous levels to build in the blood. Don't give OTC NSAIDs.
• Childhood vaccination schedule?

  8 weeks - [diphtheria, tetanus, pertussis, polio, HiB, hepatitis B (6 in 1)], meningococcal group B, rotavirus

  12 weeks - 6 in 1, pneumococcal, rotavirus

  16 weeks - 6 in 1, meningococcal group B

  1 year - HiB, meningococcal group C, pneumococcal, MMR, meningococcal group B

  Eligible paediatric groups - influenza (every year from September)

  3 years and 4 months - diphtheria, tetanus, pertussis, polio, MMR

  Boys and girls 12-13 years (year 8) - HPV

  14 years (year 9) - tetanus, diphtheria, polio, meningococcal groups A, C, W and Y
• Vaccinations for the elderly

  65 years old - pneumococcal, influenza, shingles

  70-79 years of age, plus severely immunosuppressed - shingles
• Vancomycin

  • a glycopeptide antibiotic
  • can be used for infections, including C.diff. The injectable preparation is licenced for oral use too.
  • contraindicated in people with previous hearing loss. test auditory function periodically
  • initial doses based on body weight and subsequent doses on serum vancomycin concentration
  • Therapeutic Drug Monitoring - trough level should normally be 10 - 15 mg/L or 15 - 20 mg/L in susceptible pathogens e.g. endocarditis
  • reduce dose in elderly and renal impairment and monitor renal function
  • avoid in pregnancy
• Vancomycin (2)

  • the most common hypersensitivity reaction associated with vancomycin is Red Man Syndrome. You get a rash on the face, neck, chest, upper arms. This is more common when vancomycin is infused too quickly. (frequency not known)
  • can cause Severe Cutaneous Adverse Reactions (SCAR) e.g. Stevens-Johnson Syndrome (frequency not known)
  • vancomycin infusion reaction is common e.g. thrombophlebitis
  • blood dyscrasias e.g. agranulocytosis, neutropenia, thrombocytopenia
  • vancomycin is nephrotoxic
• Helicobacter Pylori

  • causes most peptic ulcers
  • you must test for H.pylori before starting eradication therapy ('test and treat')
  • symptoms of a peptic ulcer include burning or gnawing pain in stomach that either increases or decreases after eating, indigestion, reflux, nausea
  • taking NSAIDs can increase the risk of ulcer
  • can test using urea 13C breath test, Stool Antigen Test, or Laboratory based Serology. Testing should not be done within 2 weeks of PPI or 4 weeks of antibiotics -> false negatives.
• Treatment of helicobacter pylori

  • Treatment involves triple therapy with a PPI and two antibiotics
  • First line treatment includes:
  • Amoxicillin 1000mg twice daily, or
  • Clarithromycin 500mg twice daily, or
  • Metronidazole 400mg twice daily
  • If diarrhoea develops, consider C.diff infection
• Hyperthyroidism is characterised by low TSH and high T3 and T4.

  Symptoms include:

  • anxiety
  • irritability
  • insomnia
  • sensitivity to heat
  • tachycardia
  • goitre
  • trembling
  • weight loss
• Hypothyrodism is characterised by high TSH, and low T3 and T4.

  Symptoms include:

  • fatigue
  • weight gain
  • bradycardia
  • depression
  • sensitivity to cold
  • dry skin
  • constipation
  • muscle aches
  • menstrual irregularities
• Water soluble beta blockers are less likely to cross the blood brain barrier and therefore are less likely to cause nightmares.

  Remember them using Water CANS:

  Celiprolol

  Atenolol

  Nadolol

  Sotalol
• Ibuprofen max dosage?

  3-5 months = 50 mg TDS

  6-11 months = 50 mg QDS

  1-3 years = 100 mg TDS

  4-6 years = 150 mg TDS

  7-9 years = 200 mg TDS

  10-11 years = 300 mg TDS

  12-17 years = 400 mg QDS
• Clozapine

  • heart issues- can cause myocarditis and cardiomyopathy, most commonly in the first 2 months. perform physical exam when starting
  • blood issues- can cause agranulocytosis and neutropenia
  • GI issues- can cause constipation, report immediately
  • monitor blood counts every week for 18 weeks, then every 2 weeks until 1 year, then every 4 weeks thereafter, including 4 weeks after treatment cessation.
• Finasteride

  • used for benign prostatic hyperplasia and male pattern baldness
  • side effect includes male breast cancer, report nipple pain, lumps or discharge
  • MHRA safety alert for depression and suicidal thoughts- stop and inform a healthcare professional
  • contraception- men to wear condoms if partner is of child-bearing potential
  • women of childbearing potential should avoid handling crushed or broken tablets of finasteride
• Diabetes and driving

  • check blood glucose 2 hours before driving and every 2 hours on a long journey
  • travel with sugary snacks, and snacks with long-lasting carbs
  • if levels are low: stop the car when it's safe, treat hypoglycaemia and do not drive until 45 minutes after blood glucose is over 5 mmol/L
• The use of Ovex (mebendazole) for threadworms


  Treat the whole family, and repeat after 14 days if necessary.

  Mebendazole is contraindicated in children under 2 years old, and in pregnant women. You should wear close-fitting underpants at night, shower frequently and use separate towels, and discourage finger sucking and nail biting.
• Loperamide

  • MHRA warning for serious cardiac adverse reactions with high doses of loperamide used for abuse or misuse e.g. QT prolongation, torsades de pointes and cardiac arrest.
  • If overdose should occur, the antidote is naloxone
  • For acute diarrhoea, it is initially 4mg, followed by 2mg after each loose stool
  • maximum dose is 16mg per day
  • can be sold OTC for 12 years or over, or prescribed for 4 years or over.
  • contraindicated in infective diarrhoea and ulcerative colitis
• Proton Pump Inhibitors

  • can cause hypomagnasaemia, osteoporosis and C.diff
  • can rarely cause severe cutaneous adverse reactions (SCAR)
  • MHRA warning that there is a low risk of subacute cutaneous lupus erythmatosus. Protect the skin from the sun, and the symptoms resolve when PPI is stopped, however steroids may be necessary.
  • Omeprazole interacts with clopidogrel to cause reduced antiplatelet effect
  • Omeprazole interacts with methotrexate to cause toxicity
• Phenytoin Toxicity

  Therapeutic level is 10-20 mg/dL

  Symptoms include

  S: slurred speech

  N: nystagmus

  A: ataxia

  C: confusion

  H: hyperglycaemia

  D: double vision
• Dyspepsia referral critera

  Dr. Alarm!

  D: dysphagia

  R: recurrent vomiting

  A: anaemia

  L: loss of weight

  A: anorexia

  R: recent onset in age 55+

  M: malaena
• Rapid acting insulins

  L: lispro

  A: aspart

  G: glulisine