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Diclofena Pain/in ammation in RA, acute gout, post-op
, fever/pain in children, dysmenorrhoea, migraine. 1. 2-1 ,8g daily in
SEs. GI discomfort/bleeding (should take with meals), hypersensitivity, renal failure
From the BNF. Do not rely on this information for prescribing.
CI. Hypersensitivity to any NSAID, severe heart failure. COX2s are CI in some CVS dis-
eases now. NSAIDs may interfere with renal function, uid retention
1 . Non-opioid (aspirin, paracetamol, NSAID) adjuvant
Mechanism. COX inhibitor, an NSAID. Aniplatelet: stops aggregation.
2. Opioid for mild/mod (eg. co-codamol 30/500
Opioid for mod/ sev ( morphine, diamorphine, fentanyl, oxycodone, hydromor-
300-900mg every 4-6 h, max 4g daily. Alternative : clopidogrel
phone) Non-opioid Adjuvant. Oral morphine is drug of choice.
CVS disease as an antiplatelet 75mg daily. Alternative: paracetamol
Paracetamol 1g every 4-6 hours PO/IV. Max 4g daily
SEs. GI bleeding/irritation (so take after food), bronchospasm
Co-codamol 1-2 tablets every 4 hours. Max 8 tablets daily
CI.Reyes's syndrome Children < 16y, breat feeding
Hypersensitivity Previous reaction to an NSAID e.g. asthma/angiodema
Acute pain Morphine sulphate 10mg every 4 hrly subcut/IM. Slow IV : Divide dose
Give w cyclizine 50mg PO/IV/IM 3 times daily (TDS). Maximum 150mg in 24h.
Oxycodone At higher doses morphine has poor solubility & oxycodone is preferred.
Morphine available in liquid, tablet, normal and control ed release preparations. Oral mor-
Mechanism. Na/Cl co-transporter inhibitor
phine should be given every 4h. Breakthrough pain: Pain which occurs btw regular doses:
give a dose equivalent to the 4hrly dose.
Titrating morphine : Starting dose is 5-10mg 4 hrly (reduce in elderly or impaired renal
Relieve oedema in heart failure Bendro umethiazide 5-10mg daily in morning
function). Normal regime continued even if breakthrough dose taken. After 24h the new
Hypertension 2.5mg daily in morning.
dose of morphine is the net morphine in that time divided by 6, and the rescue doses
SEs. Postural hypotension, K, Ca, Mg, Urate ( gout), impotence
Maintenance of pain control: once dose titrated, pt may prefer convenience of con-
CI. Hypokalaemia, hyponatraemia, hypercalcaemia, hyperuricaemia, Addisons
trol ed release perparation of morphine. The 12hrly control ed release (MST , tradename
zomorph) is the 24h oral divided by 2.
Mechanism. Na/2Cl/K co-transporter inhibitor (ascending loop)
Pulmonary oedema IV Furosemide 250mg over 1h
Chronic stable heart failure Oral furosemide 40mg in morning
Oliguria due to renal failure Correct hypovolaemia rst.
Benzylpenicil in Most streps, menigococcus, gonococcus, syphilis, gas gangrene,
SEs. Dehydration, Na, K, Ca, ototoxic, urinary retention if enlarged prostate
anthrax, actinomycosis, many anaerobes. 300-600mg/6h IV
CI. Renal failure with anuria, precomatose states assoc w liver cirrhosis
Ampicil in Broader spectrum than penicil in, more active against G-ve rods, but -
Amoxicil in Similar to ampicilin but better absorbed
Co-amoxiclav (Amoxicil in+clavulinic acid) Confers -lactamase resistance so
Inhibit sodium reabsorption in the distal convoluted tubules and collecting
Uses. Oedema, potassium conservation w thiazide/loop diuretics
Spectrum Most active against staphs, streps, pneumococci, E coli, proteus, Klebsiel s,
Haemophilus, Salmonel a, Shigel a. 2Gs (cefuroxime, cefamadole) active against Neis-
seria & Haemophilus. 3Gs (cefotaxime, ceftazidine, ceftriaxone) better activity against
Uses Cephalosporins (ce acor) rx UTI, pneumonia, otitis media but aren't rst line
(unless penicil in al ergic). Major use is parenteral e. g. surgical prophylaxis/post-op
( Ceph & Met ). 3G drugs (e.g. ceftriaxone) may be used in septicaemia.
Mechanism. COX inhibition. It is not an NSAID: does not irritate the lining of the
SEs Hypersensitivity, warfarin potentiation
stomach, a ect blood coagulation as much as NSAIDs, or a ect function of the kid-
Examples Cefalexim, cefotaxime, ceftazidime, ceftriaxone, cefuroxime
Oral 0.5-1g every 4-6h to a max 4g daily.
Azithromycin Similar to clarithromycin gonorrhoea
Other Can also be given IV infusion, rectum
Chloramphenicol Rarely 1st line (3rd line for meningitis after penicil ins,
Co-codamol x/y where x is mg of codeine phosphate, and y is mg of paracetamol
Cipro oxacin Cystic brosis, typoid, Salmonel a, Campylobacter
SEs. Liver damage in overdose. Rashes, blood didorders (e.g. thrombocytopenia).
Erythromycin Macrolide used in penicil in al ergy, atypical pneumonia
Clarithromycin A macrolide like eythromycin, used for S aurues, Mycoplasma, H
Co-trimoxazole (sulfamethoxazole trimethroprim) P carini m toxoplasmosis
Doxycycline Travel er's diarrhea, Chlamydia, leptospirosis, suphilis
Fusidic acid Anti-staph used in osteomyelitis
Metronidazole First choice for anaaerobes, Gardnerel a
Rifampicin Mycobacteria, prophylaxis in meningitis contacts
Tetracyline Chronic bronchitis, chlamydia, Lyme disease
Vancomycin Pseudomembranous colitis if metronidazole is contraindicated, MRSA
Acute Rx. OH SHIT: Oxygen High- ow (100%), Salbutamol (5mg nebs), Hydrocorti-
SEs. GI distrubance, altered liver function, headache, dizziness, rash, tiredness
sone (or prednisolone 40 mg PO), Ipratropium (500 micrograms nebs), Theophyl ine.
Repeat salbutamol every 1 5 mins, monitor PEFR/SATs
Mechanism. Inhibit the conversion of angiotensin I to angiotensin II
Step 2 Low dose inh steroids: 100-400 micrograms Beclometasone inh twice daily
Uses. Heart failure, hypertension, diabetic nephropathy, prophylaxis of CVS events]
Step 3 Salmeterol inh 50 micrograms (2 pu s) twice daily
Step 4 High dose inh steroids: Beclometasone 1000 micrograms (in divided doses).
Hypertension/heart failure Captopril 25mg bd
Or oral theophyline, or leukotriene receptor antagonist
SEs. Cough, hypotension, renal impairment, anaphylaxis, rash, pancreatitis, URT sx, GI
Step 5 Regular prednisolone tablets. Initial y 10-20mg (after breakfast). Mainte-
CI. Hypersensitivity, renovascular disease
SEs.Salbutamol Tremor, tachycardia, headache
Ipratropium Antimuscarinic: dry mouth, nausea, constipation, headache
Inhaled steroids Adrenal suppression (pt's should have a steroid card, may need
corticosteroids during il ness), groth retardation, glaucoma, oral hoarseness/candidi-
SEs. Postural hypotension, HR, headache, dizziness
CI. Hypersensitivity, hypotension, hypertrophic cardiomyopathy, aortic stenosis, cardiac
Bulk forming Increasing the mass peristalsis. It's like eating more bre (so get the
pt to try this rst). E.g. Ispaghula husk (TN e. g. Fybogel)
Motility. Often cause cramp so avoid in obstruction. Excessive use can
cause diarrhoea (and hence hypokalaemia). E.g. Senna
Osmotic Increase water in the large bowel. E.g. lactulose (also useful in hepatic
Mechanism. Block beta receptors in heart, vasculature, bronchi, pancreas, liver
Uses. Hypertension, angina, MI, arrhythmias (by attenuating the SNS), heart failure,
Inhibit gastric acid secretion by blocking H-K pump.
Uses. E ective short term rx for gastric/duodenal ulcers. Also used for eradication of H
SEs. Precpitate asthma, fatigue, coldness of extremities, nightmares
Asthma, uncontrolled heart lure, bradycardia, hypotension, severe peripheral arterial
GI disturbances (nausea, vomiting, abdo pain. .), headache, dizziness
Mechanism. Decreasing the conduction of electrical impulses through the AV node
Uses. Heart failure, supraventricular arrhythmias
Uses. Depression, panic disorder, anxiety
SEs. Usual y excessive dosage: anorexia, nausea, vomiting, diarrhoea, abdo pain, visual
SEs. GI (e.g. nausea, vomiting), Antimuscarinic (fewer than TCAs), cardiotoxic in over-
CI. Heart block (cos of e ect on on AV node), WPW, VT/VF, hypertrophic cardiomy-
CI. Not if < 18y (except uoxetine).
Uses. Cholesterol, lipids, symptomatic CVS disease ( risk irrespective of initial level),
Moderate-severe depression assoc w psychomotor/physiological changes (e. g.
asymptomatic prophylaxis of risk CVS disease, consider in diabetes
sleep/apetite disturbance), nocturnal enuresis in children. E. g. Imipramine
SEs. Cardiac (arryhythmiax, heart block), antimuscarinic (dy mouth, blurred vision, con-
SEs. Reversible myositis, headache, LFTs, paraesheisa, GI
Uses. DVT/PE, AF (or other at-risk), mechanical valves. Take 48-72h.
Ultra-fast (use w meals) Humalog, novarapid
Recurrent DVT/PE, mechanical valves INR 3.5
Soluble (30m before meals) Humilin S, Actrapid
SEs. Haemorrhage, hypersensitivity, rash, alopecia
Pregnancy (teratogenic in rst trimester), peptic ulcer, severe hypertension, bacterial
Long acting analogue Lanctus/inslin glargine
Uses. Hypnotic, short term relief of severe anxiety, panic disorders. Longer acing e.g.
diazepam, shorter acting e.g. lorazepam.
If overweight start with metformin (SE: slimming), if underweight start with sulfonylurea
SEs. Dependence, drowsiness, confusion, ataxia, amnesia, muscle weakness
Insulin sensitivity (also rx for PCOS).
SE: GI (anorexia, nausea. .), lactic acidosis. CI: liver/renal impairment (lactic aci-
CI. Resp depression, sleep apnoea, sev hepatic impairment
dosis), recent MI, XR contrast, general anaesthesia, pregnancy, breast feeding
Insulin secretion. SE: GI, liver function (
SEs. Corneal microdeposits (rarely interfere with vision), nausea, vomiting, slate-grey
cholestasis). CI: liver/renal impirment, breast-feeding, pregnancy, ketoacidosis
CI. Bradycardia, sino-atrial block, thyroid dysfunction.
Mechanism. Block inward travel of Ca through slow channels in myocardium & smooth
muscle: contractility, electrical impulses, vascular tone
2. Enquire: Sexual y active, partner, consenting relationship (if underaged), last period
Verapamil Angina, hypertension, arrhythmias. SE: constipation, heart failure (neg-
3. Options, failures, SEs, how to take pil reliably, what to do if miss pil , extra pro-
Nifedipine/amlodipine Angina, hypertension. SE: vasospasm, vasodilatation
tection w abx. Do u have any questions or concerns , arrange follow up
Failure : IUD (1 %), CoC (5%), Male condoms (1 4%), Diaphragm+spermicide (20%),
Diltiazem Angina, hypertension. SE: bradycardia
Cap+spermicide (20-40%), 'Natural' (35%).
Verapamil/diltiazem avoid use in heart failure, bradycardia (so consider use on when
beta-blockers), hypotension, heart block, sick-sinus syndrome, WPW
CoC If <12h late protection maintained. If >12h take as soon as possible but use
barrier for 7d (if that 7d runs in to pil -free, than continue next packet w/o break).
Vomiting within 2h of taking pil : advice for missed pil s.
PoC Take as soon as possible and resume normal schedule. If >3h late use backup.
Dose. 100-200 micrograms daily before breakfast
Progesterone only Levorgestrel 1.5mg as soon as possinle
CI. thyrotoxicosis. Cautions: Panhypopituitarism (initiate steroids rst)
CoC (E and P): prevent ovulation, thicken cervical mucus, dec receptivity.
Generalised. Sodium valproate lamotrigine. Also: sodium valproate/ethosuximide for
tive, reversible, convenient, relief of menstrual probs/less ovarian/endometrial Ca, pro-
Headaches, BP, breakthrough bleeding, wt gain, breast tender-
Partial (focal) 2 generalisation. Carbamezepine sodium valproate
ness, acne, mood swings, no protection for STDs. Risks: TED, MI/stroke, br Ca, cer-
1 . CVS: hx or FH of thrombosis, clotting disorders, IHD, valvular hrt disease, AF,
3. Hepatic: abn LFTs, jaundice of pregnancy
4. Other: hormone dependent carcinoma, pregnancy, undiagnosed vaginal bleeding
5. Relative CIs: DM, BP, smoking, age> 35, obesity
Mechanism. Beta blocker-like and calcium channel blocker-like actions on the SA and
Interactions: dose if broad spectrum abx, enzyme inducers (eg. carbamezepine,
AV nodes, increases the refractory period via sodium- and potassium-channel e ects,
and slows intra-cardiac conduction of the cardiac action potential, via sodium-channel
Preliminary: Measure BP beforehand, ask about smoking
Uses. SVT, Refractory VF, haemodynamical y stable VT, AF (acutely rhythm conver-
PoP (eg. norethisterone, levonorgestrel): same method.
nient, avoid CVS e ects of E, used if contraI to CoC, can use during br feeding.
Amenorrhoea/breakthrough bleeding, needs to be taken same time daily, inc ovarian
Dose. Oral maintenance. IV infusion (5mg/kg subsequent given)
Injectables (eg. Depo-Provera): long acting P prevents ovulation, thicken mucus, dec
Levonorgestrel IUD (Mirena): T shaped, 5y, reduces endometrial growth and pre-
E ective, convenient, reversible, reduces blood loss and dysmen-
strual irregularities common, wt gain common.
Menstrual irreg for rst m's, prestegenic SEs, ovarian cyst.
Subdermal implant (Implanon): A prog rod Similar to injectables, but long duration.
Insertion before intercouse al ows spontaneity, protect against
IUD Cu wire. Left in 5y. Induces in ammatory response in uterus.
Planning, lacks spontaneity, cooperation from
after tting), reversible, convenient.
Bleeding btw periods, menorrhagia rst few
cycles, uterine perforation ( rst 20d, ectopic pregnancy (if failure, so low absolute risk).
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