---
# System prepended metadata

title: "Major OS-\U0001F511 alert"

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# Major OS-🔑 alert 

Sources: oscestop.com
				BNF
				NHS.uk/medicines
				NMIC
				


# GENERAL NOTES (SECTION 1)

The first section of this document to beat all documents is just general advice and things to remember. It also discusses various common consultations such as EHC and Sumatriptan, aswell as some of the common interactions/drugs that require counselling.

The second section then goes through the different therapeutic areas, with backlinks to some of the topics mentioned in section 1


## Consultation structure

**5 gathering questions**
Introduce yourself - always
Confirm address (if relevant)
Who is it for
What are the symptoms
Have they tried any thing else?
Are they taking any other prescription medications or supplements or over the counter medicines?
How long have they been taking them for?

**5 Counselling points to hit**

Drug - What is it for? Why have you been prescribed it? 
Dose - How much should they take?
Duration - How long should they take it for?
Side effects - What are the main side-effects you need to take into consideration? - always headache, nausea, vomiting
Non-drug info - What other things do they need to be aware of?
Understanding- Check understanding
Follow-up- Arrange a follow-up and monitor them

## Complaint management consultation 

ASSIST mechanism

- Apologise, Apologise and apologise

- Tell them you will mention it in our daily staff meetings that this happened so that the entire team is aware

- Tell them you will make a note on the patient file to ensure that if there is any locums or different staff in they will be aware

- Tell them you will make an amendment to our documentation to make sure that 

- Find out the risk of harm if possible and addresse it

## Calculation/doctor request station
- Introduce yourself

- Gather information while you are doing the search

- Be persistent and confident with the doctor

## Non drug info 
What is the general health advice for people with 

- Determine where they are before you start giving advice

Diabetes - sick day management
Exercise 150 minutes of moderate exercise in one week, that includes walking or 75 minutes of more vigorous exercise
Diet - healthy balanced diets consisting of health portions of carbohydates, protein and good fats that you might find in a glass of milk
If you are smoking make efforts to stop



## EHC Station

^2e4556
- Info to gather
- When was the incident
- What happened
- What part of your cycle are you in/ when was last period
- Any OTC medicines or supplements

**Contraindications**
- Omeprazole
- St. Johns wort
- Epilepsy, HIV, TB
- Dose may need to be increased in 

**- Within 3 days: Levonogestrel**
Less effective
- WIth contraception
If you have taken Levonelle, you should:

-   take your next contraceptive pill, apply a new patch or insert a new ring within 12 hours of taking the emergency pill
-   continue taking your regular contraceptive pill as normal



Vomit within 2 hours
Only discard breastfeeding after 8 hours

**- 5 days: EllaOne**
Contraindications: Tablets containing progesterone - i.e all pills
Vomit within 3 hours
If you are the pill, you stop for 5 days and then go back, and then precaution for further seven
Phenytoin
CYP inducers  - CRAPS drugs
Breastmilk needs to be discarded 1 week after
If taking CHC, wait 5 days


- Greater than 5 days or an interaction
Get the copper coil
Refer to the womans clinic
The IUD can be fitted up to 5 days after unprotected sex, **or up to 5 days after the earliest time you could have ovulated, for it to be effective**



Other info
- Mention side-effects that are to be expected : Mood swings, breast tenderness, 
- Copper-IUD is the most effective form of contraceptive
- Does not protect against STD's
- If period is more than 7 days late, get in contact with doctor
- changes to your next period – it can be earlier, later or more painful than usual





## Viagra Consultation

- Info to gather
- 
Age, Preexisting conditions, advised not to exercise, taking any other medications
Do you have any heart conditions?
Any blood pressue problems?
Any recreational drugs
Any other health conditions


What to expect:
- Dizziness, headache, blurred vision
- Take 30-60 minutes
- Absorption can be impaired by fatty meal


Side effects:
- Dizziness, headache, blurred vision
- Red flags; Erection longer than 4 hours, chest pains, difficulty breathing, any cardiac arrest symptoms


Causes:
- Anxiety/dpression
- Blood pressure/CV
- Diabetes
- Prescribed medicines - SSRI's

Contradindications:
- Nitrates/poppers
- Risk with other vasodilators like alpha blockers [[#^2af851]]
- Adverse effects increased by CYPinhibitors


Interaction with PDE5 inhibtors
- 
## PKU



## Dovonex consultation
-Must be over 18, must have been diagnosed with psiorasis before
- Can only be used on trunk and limbs
- Maximum use 100g 
- Can cause hypercalcaemia ( Excessive thirst, frequent urination, stomach upset, nausea, vomiting, constipation)
- Dovonex® Psoriasis ointment should not be used concurrently with calcium or vitamin D supplements, or drugs which enhance the systemic availability of calcium
- Not in pregnancy or PSA/ nail involvement
- To see a doctor if the condition does not start to improve within 4 weeks of treatment
- To avoid excessive exposure to either natural or artificial sunlight and avoid the use of UV lamps during treatment

## Nexium OTC (esomeprazole)
- 2 weeks use only
- Take in morning 1 hour before food

## Sumatriptan consultation

^3b66c3
- Age (Must be 18-65)
- GP
- Has migraine previously been diagnosed by doctor?
Confirm that the migraine is migraine with/without aura, not another type of headache

- Have they already used any painkillers?
- Have you previously taken sumatriptan - if yes any adverse reaction?
- Taking any regular medications, OTC, Supplments?
- Any other medical conditions?
- Any contraindications to supply?
Could be a medication overuse headache - despite regular use of medicines
Cardiovascular risk factors - any signs of ischaemic heart disease
Not to be used prophylaaticlly
Hypertension
Now within 2 weeks of MAOI's
Lowers the seizure threshold
Can cause serotonin syndrome - don't use with lithium or ergotamine, caution with SSRI's and SNRI's

- Reason for supply?
- Take one at onset (as early as possible) and should begin to work after 30 minutes , swallow whole with a glass of water
- Maximum daily dose of 2 tablets and maximum 6 in a month
- Drowsiness, n + v, fatugue, weakness, 
- 4 or more migraines per month - seek referall

Non drug info
- Avoid potential migraine triggers - light, certain foods
- Keep a migraine diary that you can show to your doctor or pharmacist
- Provide support materials
- Call back in or number in bag if any questions


## Loceryl consultation
- Two nails or less
- 18 years
- Can take up to 9 months for a big nail to grow back
- Avoid tight footwear or prolonged boots and runners
- Antifungal creams or powders for concomitant foot infections
- Once weekly
- Improvement in symptoms within 3 months, but can take much longer to fully clear
- Doctors advice with diabetes


## Legislation stuff
- Covid rules, CD2 doesn't need hand written script
- Emergency supply can be up to 10 days


## Stock orders
- Special stock order forms
- Fill out the form 
- Four copies for different people
- Doctor form: doctor submits to community HSE for approval, Community HSE sends to pharmacy
- Termination of pregnancy services: Initial pharmacy authorisation, followed by sending blue order form to HSE 
- Emergency medicines: can be given under a stock order also. allows trained non-medical people to administer specified medicines in an emergency.An organisation that is entered on the listed organisations register can obtain these medicines from a pharmacy to hold as stock on their premises for administration in an emergency situation. The register for listed organisations is available on the Health Products Regulatory Authority’s (HPRA) [website](http://www.hpra.ie/).

## CD2 Requisition
Controlled drugs may also be obtained and supplied through the use of a requisition
(or order), for administration by the medical practitioner in the course of their
professional practice. Such a requisition must contain the following information:
Name, address and profession
Signature of the medical practitioner
Date of requisition
Name of the controlled drug
Registration number 7
**Purpose of supply**
Total quantity of the medicine(s) to be supplied
The medical practitioner obtaining drugs through the use of a requisition should be asked by
the pharmacist to produce identification.
14 days

## Supply to a nursing home
- pharmacists should make themselves available to participate in the interdisciplinary review of each patient on long-term medication, at least on a threemonthly basis
- the registered pharmacist must ensure that the patient has sufficient information and advice for the proper use and storage of their prescribed medicines
- 


## Veterinary scripts
- Needs to be logged in veterienary register
- This record must contain:
	-   The date the transaction occurred
	-   The precise identity of the animal remedy (i.e. name, form, strength) or medicinal product
	-   The quantity received or supplied
	-   The name and address of the supplier or purchaser
	-   The manufacturer’s batch number of the product received/supplied, and
	-   Where the transaction relates to the supply of a prescription only medicine (POM), the serial number of the veterinary prescription.

**Prescription requirements**
-   Be in ink
-   Be issued and signed by a registered veterinary practitioner
-   Bear the name and address of the vet in block capital letters
-   Contain a declaration that the prescription is granted in respect of an animal under the prescribing vet’s care
-   Be assigned a serial number
-   Specify a date of issue and period of validity
-   Specify the name and address of the person to whom the prescription is granted
-   Contain a description of the animal or animals to which the prescription relates
-   Contain details of the animal remedy prescribed, including the remedy’s name and veterinary product authorisation (VPA) number
-   Specify the quantity of the animal remedy prescribed
-   Specify the dose rate
-   Specify the manner and site of administration
-   Specify the withdrawal period to be observed and any special instructions, precautions or risks, where applicable


## Motillium (domperidone) consultation

- What are the symptoms (needs to be N + V, not bloating)
- How long have they been going on for
- Are they on other medicines



Contraindications
- Not available OTC if it is not for N + V
- If heart failure
- With any other medicines that prolong QT interval


Non drug info
- Orodisperisble, don't swallow


## Codeine consultation
What type of pain?
No more than three days
If pain persists, see a doctor

## Emergency Supply (Request of patient) station

- Depends on COVID law or normal law
- 5 days or one pack if required (pre-covid)
- Can ring pharmacy and ask for a healthmail


## Emergency Supply (Request of doctor) station
- Depends on COVID law or normal law

- Doctors might be challenging, be persistent
[[#^8e4cdf]] 
- 

## Interaction station
- Continue to speak with the doctor while checking

- Find out if there are any other medicines they are taking

- Find an alternative => Go to the condition preamble section, see the first-line. 

- When providing the alternative, remind them of important counselling points

## Common Interaction
### CYP450 interactions

#### Inducers
**C**arbamezapine
**R**ifampicin    (very strong, interacts with COCP)
b**A**rbituates
**P**henytoin
**S**t John's wort

Smoking, alcohol, griseofulvin




#### Inhibitors
**S**odium valproate 
**C**iprofloxacin
**S**ulphonamide
**C**imetidine/omprazole
**A**ntifungals, amiodarone [[#^fdd858]] , 
**I**soniazid
**E**rthromycin/clarithromycin [[#^42a4e0]]
**G**rapefruit juice ^ad2e73

Antifungals include ketoconazole and fluconazole

Some Certain SIlly Compounds Annoyingly Inhibit Enzymes , Grrrr ^2c4963

This means that there will be more of the interacting compound as the enzyme is inhibited from acting. These are therefore **SERIOUSLY DANGEROUS**


### Drugs that interact with enzyme inhibitors/inducers

**W**arfarin
**C**OCP
**T**heophylline
**C**orticiosteroids
**T**ricyclics
**P**ethidine
**S**tatins

What cooks the corn? The perfect stove


### Other common interactions to know
Gentamicin and loop diuretics (renal failure risk)
Metformin and cimetidine (Inhibits renal elimination)
ACE inhibitors and potassium sparing diruetics (hyperkalaemia)
ACE inhibitors and Metformin (Enhanced hypoglycemic effect)
Statin & macrolides 
Statins & amiodarone (increased statin concentration and therefore risk of rhabdo)
Thiazide & PPI (Hyponatremia)
Thiazide & Lithium (increase toxicity)




## Narrow TI drugs

These drugs need close monitoring, if they stray outside of range you are in trouble

**G**entamycin (and vancomycin)
**W**arfarin [[#^a245be]]
**L**ithium
**D**igoxin 
**T**heophylline[[#^6e351d]]
**M**ethotrexate [[#^524702]]
**P**henytoin 
**I**nsulin
**C**iclosporin ^551581

Guys With Large Dongles Totally Make Perfect Internet Connections

(If you are reading this, please note I did not invent this crude acronym)


### Specific monitoring advcie

#### Warfarin [[#^a245be]]
Start concomitant with LMWH if immediate effect needed
Start 5mg each evening
Monitor INR on days 3,4 and 5
*Target INR for most conditions is 2-3*

#### Lithium
Check level after 5 days 
Check weekly until level has been stable for 4 weeks
Then check levels every 3 months
Reference range for post dose is 0.4-0.8mmol/l

#### Digoxin
Loading dose given with ECG monitoring
Similar dose given 8 hours later
Maintenance dose given 24 hours after first loading dose
Do levels at 7 days, >6 hours post dose ^e83476

#### Methotrexate
Monitor before starting, then 1-2 weeks until stabilised
Monitor every 2-3 months

#### Phenytoin
loading dose 20mg/kg in high dependency area
check levels 2 hours after
start normal 100mg dose 6-8 hours after
Do levels at 10 days

#### Ciclosporin
Monitor until stable
PO: start at 5.5mg/kg in 2 divided dose 
Monitor creatine and GFR




## Ethical dilemma consultation
Apologise
Apologise
Apologise
- Go to consultation room


## Negotiation/disagreement

^8e4cdf
- 'I appreciate your viewpoint'
- 'I can understand why that would make sense'
- 'I would be much more comfortable if'
- 'Work together to meet the patients goals'


## Clinical trials consultation
- Accurately describe type of trial
- Accurately describe different arms
- Accurately describe endpoint used
- Determine absolute difference 
- Determine medicine risks
- Make judgement based on evidence base and level of use as well as power of clinical trial
- Odds ratio An odds ratio (OR) is **a measure of association between an exposure and an outcome**
- Where does it fit into the clinical algorithm
- A hazard ratio of one means **that there is no difference in survival between the two groups**. A hazard ratio of greater than one or less than one means that survival was better in one of the groups

## Data protection consultation
Go to consultation room
Explain that GDPR was brought in 2017
Have a responsibility to customers to protect their data
Privacy breaches are serious and potentially harmful
What measures can we put in place in SOP's to make privacy breaches less likely


## HPV Vaccine
- Can protect against HPV, which is a cause of cervical cancer
- Recommended for young girls and now young boys aswell


## Childrens vaccine
- Often inhaled
- Generally safe
**6 in 1**

**BCG**
at birth
6 months if mother has taken immunosuppressive 


## How to use NG tube
- Tablets can be crushed
- Given with a certain amount of water
- Then flushed with 5-10 mls depending on the patients fluid requirements
- Enteric coated must not be crushed
- 

## Brexit
- Delays 

## Prescription check
- Check date
- Check dose
- Check patient
- Check timing
- Check interactions


## Cannabis product
- Not recommended unless prescription only medicine
- Not controlled, quantity of actives can vary significantly

## Fall risk
- Medications like benzos [[#^df8a89]]
- Antihistamines 


## ICER's
- Incremenatal cost-effectiveness ratio
- Assessed by NCPE to determine if the medicine is cost effective


## Breastfeeding
Common medicines that are not recommended when you're breastfeeding include:

-   [codeine phosphate](https://www.nhs.uk/medicines/codeine/)
-   [decongestants](https://www.nhs.uk/conditions/decongestants/) that come as tablets, liquids or powders that you swallow
-   some [nasal decongestants](https://www.nhs.uk/conditions/decongestants/) that come as nose sprays or drops – check with a GP or pharmacist before using them
-   [aspirin for pain relief](https://www.nhs.uk/medicines/aspirin-for-pain-relief/)
-   herbal remedies – not enough is known about herbal remedies to guarantee they're safe to use when breastfeeding

Talk to a GP or pharmacist before taking antihistamines for allergies or allergy-related conditions, such as [hay fever](https://www.nhs.uk/conditions/hay-fever/).

never share a bed or sofa with your baby if you have drunk any alcohol
try avoiding breastfeeding for 2 to 3 hours for every drink you have to avoid exposing your baby to any alcohol in your milk

Storing breast milk:
in the fridge for up to 8 days at 4C or lower

## Travel health
**- Malarone**
- Malaria treatment 
- Start 2 days before travel
- Take for the duration and for seven days after
- Symptoms of malaria can be up to 1 year after, quite in first three months
- Can cause stomach upset/diarrhea

**General advice**
- Wear DEET 30%
- Use long sleeved clothing
- Wear mosquito nets
- Avoid swampy areas


**Travel vaccines**
- Yellow fever, typhoid and Hep A
- 

**Quinine**
For leg cramps, take at night
Careful with drugs that prolong QT interval
Teratogenic
Careful with hearing or vision loss



## Kardex station
- Drug allergies
- Age and weight
- Write out times: 6,8,10,12,14,16,18,20,22
- If BD circle twice daily to indicate twice daily use
- Section for as required and another section for regular prescriptions
- If need to discontinue: Do not administer this drug, please see patients medical records
- Often pharmacists write in green pen
- 

## NNT calculation
Number Needed to Treat (NNT) represents the number of patients over a given time period that one would need to treat to achieve one additional study endpoint of harm. 

First need to get the absolute risk reduction

Control event rate - Experimental event rate
.20 - .10

ARR = 0.1
1/0.1 = 10

10 patients of 

Absolute difference = difference between two sums

**Relative risk**
Relative risk is calculated by **dividing the death or disease risk in a specific population group (Group A) by the risk of people from all other groups**



## Blister packing
- Determine which medicines can or cannot be blister packed


## Doctor self-prescribing 
- Empathy
- Prefer to have it under the supervision of another doctor


## Vaccine hesitancy
- Empathy
- 'I understand your point of view'
- Respect choice, but is for your health
- How open are you to changing your mind
- Is there any information that might help

2 types mRNA and Viral Vector


**mRNA vaccine**s teach your body how to make a protein that will trigger an immune response, without using a live virus

It is much safer for your immune system to learn how to protect you from COVID-19 through vaccination than by catching the virus.

Your cells then break down the instructions (mRNA) for making the spike protein and gets rid of them from your body

mRNA: Pfizer, Moderna

**Viral vector** vaccines are like messengers. They use a weakened version of a different virus (the vector) to deliver instructions to cells in your body. **The weakened version cannot give you covid**

When you get a viral vector vaccine, the vector (adenovirus) enters a cell in your body. It then teaches the cell how to produce the COVID-19 spike protein.

After you get your vaccine, your immune system recognises that the protein doesn't belong there. Your body then begins building an immune response to fight off what it thinks is an infection. This immune response makes antibodies

Viral: AZ, Janssen


**Use of Ivermectin**
- Antiparasitic


**Use of hydroxychlorquine**
Treatment of rheumatoid arthritis, discoid and systemic lupus erythematosus, and dermatological conditions caused or aggravated by sunlight

- Not safe for Covid use
- No evidence of clinical benefit


## Flu vaccine - pregnancy
- It is allowed
- Protect immunocompromised people
- Children aged 2 to 12 can now get the nasal flu vaccine for free
- Beginning of october, last to April
- Complications of flu : pneumonia , bronchitis, brain inflammation
- Higher risk - 65+, pregnant, underlying health conditions, children 2-17, COPD, Obese, nursing homes, healthcare workers
- For children who have not previously been vaccinated against seasonal influenza, a second dose should be given after an interval of at least 4 weeks
- Soreness, redness, swelling, 
- You cannot get the flu from it
- 

## Phenylketouria (PKU)
- Increases level of phenylalanine in blood
- Special diet that avoids phenylalanine
- Basically repurposed ensures

## Extemporaneous preparation
- Expiry dates - 4 months
- Shake well before use if suspension
- Out of reach of children
- Name 
- Quantity
- Active ingredients
- Intructions
- Warnings 
- BN


## Unlicensced medicine explanation
- Unlicensed medicines must be under the supervision of a doctor
- Ordered in specifically for the patient
- These products were previously known as ‘unauthorised’ or ‘unlicensed’ medicinal products.
- , to meet the requirements of the legislation, the invoice for the product could be kept, which specifies the source from which the product is obtained and the batch number of the product


## Generic substitution case
- Communicate effectively that it is the same medicine
- There can be cases where the patient is allergic to one of the ingredients
- Reagrdless, apologise, apologise
- Call meeting with staff
- Update SOP's
- Emphasise patient centred, no-blame culture
- 

## Extemp dispening requirments
- Keep out of reach of children
- Preparation date
- Expiry date (28 days for eye drops)
- Batch number
- If suspension - shake before use
- For creams, external use only, do not swallow

### BMX
- Draw up with lidocaine with a syring filter
- Remove filter and transfer to bottle
- Measure the other stuff and add
- Close, shake and label appropriately

# SECTION 2


# INFECTIONS

## Patient counselling on antibiotics
- Check if any drug allergies
- Can be cross-allergy between penicillin and macrolides

### Penicillins (-acillin)
Penicillins reduce renal excretion of methotrexate, increaisng risk of toxicity
Monitor with warfarin



Phenoxymethylpenicillin
- Calvepen
- Take on empty stomach
- 

Flucloxacillin
- Rarely can get cholestatic jaundice
- Be careful with liver failure, in general just quite hard on the liver
- QDS for seven days
- They smell bad


**Cellulitis**
- Fluclox and calvepen
- If not responding, consult microbiologist

**First time penicillin**
- Watch out for rash
- Watch out for breathing difficulties, sweeling lips


### Metronidazole
- Anerobic
- Avoid alcohol
- GI upset, 
- Inhibits CYP enzymes


### Macrolides (-mycin)
####  Macrolides must not be used in the following situations:

-   Patients with known QT prolongation or a history of ventricular dysrhythmia.

This includes clarithromycin, erythromycin
These are very likely to interact with CYP enzymes so keep an eye out for interactions[[#^ad2e73]] . They are enzyme inhibitors
- interacts with digoxin
- Ensure no allergies to macrolides

**Clarithromycin**
- Gi side effects , colitis
- Inhibits CYP enzymes


**Clindamycin**
- Used in duac
- Can be systemically absorbed
- Dalacin 

**Azithromycin**
- Take it with food
- GI side effects
- CYP



### Tetracyclines (- )
CONTRAINDICATED IN PREGNANCY
**Doxycycline**
- RTI

**Lymecycline**
- Acne
- Don't take with milk
- Protect skin
- Empty stomach - 2hrs before food


### Cephalosporins (cefalexin, cephlaclor, cefaclor)
- Kefflex
- Increased risk of C. Difficile
- There can be a cross tolerance of penicillin with cephalosporins
- Dose reduction in renal impairment


### Fluoroquinolones(Oxacin) ^344df2

**ciprofloxacin**
- Skin can be sensitive to sunlight
- Nauseous
- UTI
- Also often in eye and ear drops
- Is an enzyme inhibitor, be careful 


Watch out for/red flags:
**- Tendonitis or history of tendon inflammation or other muscle weakness**
- Tinnutis
- Diarrhea with blood or mucus
-

**IF YOU HAVE HISTORY OF TENDON INJURY, QUINOLONES CAN MAKE THEM SNAP. IF YOU'RE PREGANT, BABIES TENDONS CAN SNAP**

### Aminoglycosides (Gentamycin, Vancomycin)
- Can cause AKI
- Pretty serious antibiotics with poetntial side effects, usually only given in hospital
- There is a risk of renal failure with gentamycin and loop diuretics



## Cystitis/UTI
- Generally need a urine sample to test

Cystopurin: 
2 day course, dissolve in 200mls of water 3 times daily
Not for children under 8
Paracetamol rather than ibuprofen
Can it be used in pregnancy??


Trimethoprim:
- 200mg BD for three days, further if necassary
- Be aware of renal impairment
- Don't take ibuprofen
- Be aware of ACE drugs/diuretics
- Contraindicated in pregnancy


**Macrodantin (nitrofurantoin):**
- Nitrofurantoin can be taken by adults including pregnant and breastfeeding women
- Macrobid is long acting brand
- treat a urinary tract infection is either 100mg taken twice a day or 50mg taken 4 times a day, generally for five days. Severe infections may need a higher dose of 100mg taken 4 times a day
**Change the colour of your urines**
- Renal impairment, dosage adjustment may be necassary
**- Dose should be taken with food or milk**
- Some people experience Hypersensitivity, check for allergy 
- GI Upset
- Don't take with cystopurin
- Pins and needles and breathlessness



Ciprofloxacin [[#^344df2]] ^290d4e
- 

Nitrofurantoin




Non drug info
Urinate after intercourse
Wipe the right way
Wear cotten underwear
Use an emolient wash instead of soap or ph changing gels
Don't douche

## URTI
cough
- Amoxicillin
- Cough can get worse after stop smoking

**Difflam**
Every 3 hours 
Not for use in pregnancy or if allergic to NSAIDS


## LRTI
pneumonia
- Often pinamox 500mg tds
- Doxycycline 200mg for five days


## STI
**- Azithromycin**
- Has a long half life





## Isoniazid
- For TB 
- Interacts with loads of stuff
-

## H.Pylori Infection
- Prescence should be confirmed
- Seven day triple therapy
- PPI + clarithromycin and amoxicillin and metronidazole
- PPI would be omeprazole

## Stomach ulcer
- Stress
- Alcohol
- Caffeine 


## Doctor query on antibiotics
- Check if allergies
- What type of infection do they have?
- What age are they?
- Are they taking any other medications?

## Vermox consultation
For aged over 2 years, if not over 2, go see a doctor!!

1 tablet now, one in two - 4 weeks
Everyone in the family


Contraindications:
Pregnancy!! **PRETTY SERIOUS ALWAYS ASK THIS**
Breastfeeding

Read the PIL
If symptoms don't go away after 3 days go to the doctor

Non-drug info:
Cut the nails of the child



## Thrush consultation
**Emphasise nothing to be ashamed about**
- Cottage cheese
- Diabetes, HIV, Immunocomprised,** RED FLAG**
- Canesten cream and pessary
-  If you are using the pessary to treat vaginal thrush during pregnancy it is recommended that you insert it with your fingers rather than with the applicator provided. (only in pregnancy under medical supervision)
- Diabetes, it is okay to give it  


Prevention
- Pee after intercourse
- wash yourself after
- Don't use a douche
- Use emolient like e45 
- wipe the right way
- cotton underwear
- dry after shower

**GynoPevaryl**
- Once at night
- 
- 

### Thrush and pregnancy
- Need to go the doctor
- Is common


## Oral Thrush
**- Daktarin Oral Gel**
- Clotrmazole gel
- Interacts with Warfarin [[#^0aa30d]]
- Interacts with statins
- 


**Nystatin**
- 1 ml four times daily, for 7 days or for 48 hours after lesions have improved
- Swirl around in mouth and contact with lesions
- Can swallow or spit it out
- Possible better to swallow in case 

Counselling to try prevent oral thrush in patients who get it from inhalers

### Gyno pevaryl

## Fluconazole
**- Oral**
- Take one
- Can be repeated if necessary 
- Can't be taken in pregnancy
- Used in caution with liver disease
- CYP's be careful
- 

**Topical**


**Vaginal**


## Headlice


## Impetigo
- Infection of the skin common in kids
-  **It often gets better in 7 to 10 days if you get treatment. Anyone can get it, but it's very common in young children.**
-  Generally an antibiotic cream such as fucidin
-  Then bactroban
-  The flucloxacillin if required
-  

## Cradle cap
- Sebborehic dermatitis
- wash your baby's hair regularly with mild, unperfumed baby shampoo and gently loosen flakes with a soft brush
-  do not use olive oil – recent research has found it may not be suitable for use on skin
-   do not use peanut oil (because of the allergy risk)  
-   do not use soap
-   do not use adult shampoos
-   do not pick crusts – this can cause an infection

Petroleum jelly at night and then wash off with shampoo in morning, loosen flakes with soft brush, don't pick them. Hair may come away but will come back. 

## Dandruff
- Zinc pyrthionne
- Salicylic acid
- colar tar
- Usually twice weekly then down to once a week

## Ringworm
- Treat with topical miconazole
- Low risk of systemic absorption
- Apply twice daily for seven days and for the sevn days after it has cleared to prevent it coming back
- If it doesn't work, go to the doctor
- It can be passed through close contact
- Do not scratch, it can spread



**Can be on scalp, called tinea capititis**
- 


**Jock itch**
- Ring worm in the groin area
- 


## Moles
- Asymmetry
- Border - 
- Colour - no more than 2 colours
- Diameter - less than 6

Wear factor 50
Wide brimmed cap
Long sleeved clothing
Regularly check for moles and mole evolution, including soles and plams every 3 months
Get a referall for mole mapping from GP or visit a dermatologist




## Warts and verruca
- Warm water, pummus stone, then apply salicylic acid
- Wash hands 
- Salicylic acid- once daily
- Put vaseline around the skin to prevent
- Get them frozen off from the doctor


**Genital warts**
-  warticon (Can't use in pregnancy)
-  Aldara
- 
- 

## Athletes foot
- wear breathable footwear
- Wash and dry feet with a towel
- Use seperate towels to others
- 

## Scabies
- Lyclear once weekly all over body and then next week as well
- 



## BV consultation

- Go to the doctor - it needs an antibiotic
- Relecta gel
- Inform your partner regardless
- Get checked for STD's regularly anyways

**How to use relactagel**
  
Relactagel should be used **at bedtime when lying down**, to minimise potential leakage. In the event of leakage, a panty liner may be useful. Once opened, use immediately

One tube every day for 7 days at bedtime. 
Do not use if you are allergic to shellfish


Increased risk:
- Multiple partners/new partners
- Avoid douching
- Don't use deodorants or fragranted soaps
- Smoking

**Is it an STI or a BV?**
Could be a protozoal infection or chlamydia either




## Fungal infection of skin

^fdd858

**Canesten**
- Clotrimazole
- Canesten cream, twice daily


**Nizoral shampoo**
- Twice weekly


**Daktarin**
- 

- Antifungal often combined with steroid either

**Griseofulvin**
- enzyme inducer 


## Headlice
- Fine combing
- Do it every 2 days for 2 weeks 
- Rigorously

- If that fails, go the pharmacy
- Some can't be used in pregnancy
- Some need to be careful with
- If Alcohol can't use a hairdryer
- 

  
## Cold sore
- Apply aciclovir cream seven times daily
- L-lysine helps the skin to proliferate faster 


Acic cream five times daily




## Viral infection

^8d8a07

**Aciclovir**
200mg orodispersible tablets



**Valciclovir**


### Hand foot and mouth disease

**Hand, foot and mouth disease is a common childhood illness that can also affect adults. It usually gets better on its own in 7 to 10 days**

- Viral infection
- Hydrated
- Pain killer - Paracetamol and ibuprofen
- Mouth ulcers and rash


### HIV
**HIV (human immunodeficiency virus) is a virus that damages the cells in your immune system and weakens your ability to fight everyday infections and disease**
Most people taking daily HIV treatment reach an undetectable viral load within 6 months of starting treatment.
Have yearly flu jabs
undetectable=untransmittable

**Prep**
PEP must be started within 72 hours of coming into contact with the virus for it to be effective.
It's only recommended following higher risk exposure


**Antiretroviral drusg**
Usually, people who have just been diagnosed with HIV take between 1 and 4 pills a day


# PAIN 

## Opiate prescription

Constipation 
Sleepy



## Opiate conversion case


BNF page

Morphine sulfate - breakthrough pain

Make sure to include breakthrough pain





## NSAID's
- Watch for bleeding risks
- Watch for asthma
- Renal
- Liver failure

### Naproxen
- Better on stomach


### Etorcoxib
- COX-2 selective
- Fairly big cardiovascular risks
- 



## Baby Dioralyte consultation
- Under 2 years: prescription only
- 1-1.5x normal feed if breastfeed 
- bottle fed: hold all milk
- If it doesn't improve got to the doctor


# PREGNANY

## Vaccination
- Can get whooping cough vaccine
- Can get flu vaccine
- Can get 

## Diet in pregnancy consultation

- Vitamin D Supplement
- Folic Acid supplement
- Multivitamine, not regular one, no Vitamin A


- No shellfish
- No raw meat/sushi
- Reduce Tuna
- 

## Resources to direct patients towards
- HSE Sickday 
- 



# Paediatrics

## Colic
- Gripe water
- Sit the baby up when feeding them
- Burp the baby
- Make sure teat isn't too small
- Lactase
- 
## Nappy rash
Air
Barrier
Cleanse
DIaper
Education - don't leave sitting in it 

## Baby nutrition
- Breastfeed only up to 6 months , 1 year plus is milk
- Low vit D supplement (unless they are bottle fed, where there is already vitD)

There are 3 clear signs which, when they appear together from around 6 months of age, show your baby is ready for their first solid foods alongside breast milk or first infant formula.

They'll be able to:

-   stay in a sitting position and hold their head steady
-   co-ordinate their eyes, hands and mouth so they can look at the food, pick it up and put it in their mouth by themselves
-   swallow food (rather than spit it back out)

Some babies like to start with mashed, lumpy or finger foods.

Other babies need a little longer to get used to new textures, so may prefer smooth or blended foods on a spoon at first

**Hygiene is important when preparing foods for babies**
All children aged 6 months to 5 years should be given vitamin supplements containing vitamins A, C and D every day. EXCEPT Babies who are having more than 500ml (about a pint) of infant formula a day should not be given vitamin supplements

From about 7 months, your baby will gradually move towards eating 3 meals a day (breakfast, lunch and tea). Around this age, your baby may have about 3 milk feeds a day (for instance, after breakfast, after lunch and before bed)

You can keep breastfeeding for as long as it suits you both, but your child will need less breast milk to make room for more foods. The World Health Organization recommends that all babies are breastfed for up to 2 years or longer



## Gestational age
- Premature babies have different ages for the sake of calculation
- **your premature baby's chronological age minus the number of weeks or months he was born early**.

## Teething
- Starts at 6 months 
- Slightly raised temperature but not a fever
- Should have full set of milk teeth by 3
- Teething, drroling, bad appetite, irritation on side of lips
- Can give calpol 
- Can give choline sacilyate (Bonjela) after 5 months (every 3 hours)
- Don't push back to far to avoid choking
- 
- Raw vegetables
- Teething gels 

**Teedex**
Paracetamol and diphenhydramine
Between 2 and 12 years




## Dose calculation in paediatrics
Usually age and weight, sometimes BSA, estimated from weight. Referenced in BNF for children

## Insulin patient counselling

Normal values: 3.5-7.8 mmol
Type 1: 4-9
Type 2: 4-8.5
Hyperglycaemia: >11
Hypo : <3.5
HBA1C: 4-6 is good, 6-8 is prediabetic, 9+ is diabetic

**Fast acting**
Novorapid (Aspart)
Humalog (Lispro)

**Short acting**
Actrapid
Humulin S

**Long acting**
Lantus
Levemir

**Medium acting**
Humulin
Insultard

### Regimens

**Basal-bolus**
Basal given at night (long acting)
Bolus given before meals (short acting)

**Twice daily pre-mixed regimen**
Mixed intermediate and short insulin given BD, before breakfast and before dinner

**Once-daily morning/evening regimen**
Intermediate acting insulin in morning or evening to supplement oral hypoglycamic

### Insulin pumps
Continuously infuse basal rate of short acting insulin
Rate can be changed depending on requirements e.g exercise or diet


# CARDIOVASCULAR
- Risk factors: Weight/BMI
- Waist
- Cholesterol 
- Blood glucose
- Renal impairment


## Atrial Fibrillation and flutter

**Atrial fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate**
The cause is not fully understood, but it tends to affect certain groups of people, such as older people and people living with long-term (chronic) conditions such as heart disease, high blood pressure or obesity.

It may be triggered by certain situations, such as drinking too much alcohol or smoking.

Atrial flutter is similar to atrial fibrillation, but the rhythm in the atria is more organised and less chaotic than the abnormal patterns caused by atrial fibrillation.

Treatment for atrial flutter is also slightly different. Catheter ablation is considered to be the best treatment for atrial flutter, whereas medicine is often the first treatment used for atrial fibrillation.

### Beta-blockers
- Can be used an anti-arrythmic too
- Bisoprolol

Side effects; Constipation

Watch out for : Bradychardia, dizziness

Sotalol
- Regular ECG's needed

No cough medicines like pseudoephedirine allowed



### Amiodarone
- Really, really long half-life- watch out starting new meds
- Watch out for skin, protect from sunlight
- Loading dose
- Regular liver, blood, thyroid, ecg tests. Chest x-ray required
- Monitor eyesight, corneal deposits that are reversible, 

Red flags on toxicity
- Shortness of breath
- Tiredness or restlessness

Side effcts:



### Digoxin [[#^e83476]]
- Nausua, Vom, Blurred visioin, dizziness, yellow or orange tinge to the vision
- Loading dose us given 
- Metallic taste in mouth
- Same time every day, ideally after breakfast
- DONT DOUBLE DOSE
- Interctions: St Johns Wort, Verapamil, Diltiziem
- Toxicity can be made worse by hypokalaemia, ensure potassium sparing diuretic or potassium supplements


Red flags on toxicity; fast heartbeat, dizziness, sweating

If you are having a sick day, don't take it for one to two days because it has a long half life



AFib puts you at a higher risk of stroke
- therefore also use DOAC's or warfarin
- CCB's also used


### Heart block
**Heart block is a condition where the heart beats more slowly or with an abnormal rhythm**
- Can be congenital or acquired
- Heart block normally only needs to be treated if it's causing symptoms
- All types of heart block can increase your risk of developing other heart rhythm problems, such as [atrial fibrillation](https://www.nhs.uk/conditions/atrial-fibrillation/) (an irregular and abnormally fast heart rate).


### Atropine
- AMusc to raise HR in bradycardia


## Blood pressure medication i.e Hyper tension
- Someone over 55 - CCB
- Under 55 - ACE/ARB, then CCB

### Beta-blockers
- Reduce force of contratcion and spped of conduction
- Can be used an anti-arrythmic too
- No cough medicines like pseudoephedirine allowed
- Be careful with beta agonists such as asthma, often not used in asthama
- Low dose and titrate up in HF, as they may initially worsen it
- CI with Non-HYdrypyridien CCB's such as verapimil and diltizaem
- Be careful in those with liver failure, lower doses needed
- Impotence in some patients

**- Bisoprolol**
Side effects; Constipation

Watch out for : Bradychardia, dizziness

**Metoprolol**
- Shorter half life

**Sotalol**
- Regular ECG's needed

**Propanolol**
- Dry mouth (ULM)
- Also for anxiety

### Calcium channel blockers
Can be dihydropyridine or nondhypyridine

**- Amlodopine** - 
- Plapitations
- Swollen ankles

CYP3A4 inhibitors can interact
Avoid grapefruit juice 

Severe problems; Yellowness of skin or eyes, sever stomach pain (pancreatitis), chest pain that is new or worse

- Nifidepine
- Can be given in pregnancy
- 
**nondhypyridine**
- These ones are contraindicated wity B blockers

**Diltizaem**
- Non dihydrop

**Verapimil**


### ACE Inhibitors
- Cough as a side effect
- Anti-tussive not usually effective
- Glycerine honey and lemon
- Can take 3-4 weeks for the cough to go away after switching
- Examples; Ramipril, lisinopril, perindopril
- Not recommended in pregnancy


### ARB (-Sartans)
- Possible side effects include dizziness, headaches, and cold or flu-like symptoms.
- Not recommended in pregnancy

## Angina

### Isosorbide nitrate
- Prophylaxis
- 8 am and 3 pmm
- Stops tolerance

### Glytrin spray
under the toungue
- one or two sprays within 2-3 minutes of onset - hold breath
- 
- sitting down
- after three doses , get help
- Shake for 10 seconds
- 

### Glytrin patches
- usually you put on 1 patch in the morning and take it off before you go to bed at night
- Each morning you put on a new patch. It's best to have 8 to 12 hours without a patch
- Usually 1 patch a day is enough. If this does not work, your doctor might increase your dose, or tell you to keep the patch on for longer
- Open the GTN packet with your fingers – do not use scissors because you might cut the patch
- If you use too much GTN spray, sit down and put your feet up if you feel faint. 
- 


## Diuretics
- Don't take after 6pm ideally
- Be careful to watch your salt balance and stay hydrated
- Can make you fall over
- Pulmonary oedema and ischameic heart disease

### Loop
- Contraindicated in hypovolemia or dehydration
- Can worsen gout  [[#^86d20c]]
- Effects drugs that are excreted by the kidney, for example. lithium, digoxin

**Furosemide**
**Bumetanide**

 
### Thiazide
- Impotence
- Hypokalaemia and subsequent arrythmia (opposite of ace and ARB, where HYPERkalaemia)
- Try not to combine with other drugs that lower potassium
- NSAID's may effect levels
**Bendroflumethiazide**
**Indapamide (Thiazide like)**


### MRA diuretics (aldosterone antag)
- Hyperkalaemia, They are potassium sparing
- Can cause gynomastia, swelling around nipples in men and impotence
- Try not to combine with other hyperkalemic drugs such as ACE and ARB's 

- **Spironolactone**
**Eplerenone**


### Amiloride
- Also potassium sparing
- Therefore same stuff goes



## Oedema
- **Swelling in the ankles, feet or legs often goes away on its own**
- Lie down and use pillows to raise the elevation of area
- To prevent 

**Pulmonary oedema**
- Excess fluid in the lungs

# Cholesterol lowering drugs
- Cholesterol is a risk factor for CV disease
- HDL (good) 1.5
- LDL (bad) > 5.4 is bad
- Trigylcerides > 2.5
- Total cholesterol less than 5.5


## Statins
1st line
These are most effective at LDL, but less at triglycerides
- Hepatotoxicity and increased liver enzymes are side effects
- Myalgia and rhabdomylosis are side effcts
- Be careful with 
- Can take it at night if you want to avoid that

### Ezetimibe
- 2nd line
- Decreases cholesterol absorption
- Can be used with statins
- Headache, diarrhea


## Fibrates
- 3rd line
- Reduce cholesterol synthises
- Not to be used with statins
- Better for triglycerides

# ANTIPLATELETS

## Aspirin
- Let HCP's know
- Increased risk of bleeding
- Highly effective anti-platelet used in primary and secondary prevention
- GI Irritation
- Hypersensitivy reactions. Reyes syndome under 16
- Avoid in third trimester of pregnancy
- Some caution required with other antiplatelets or antcoagulants
- Gastroprotection
- Take after food

## Ticagrelor (brillique) - ADP receptor antag
- Not a pro drug, but interacts with CYP inhibitors and inducers

## Clopidogrel
- Is a pro-drug, requires CYP activation
- Efficacy reduced by CYP inhibitors - Some certain silly compounds [[#^2c4963]]
- Acts irreversibly, takes 7-10 days to wear off
- Requires loading dose for rapid bring up to scratch


## Anti-coagulants

### Patient counselling on Warfarin (coumarin)
- Patients who need IMMEDIATE anticoagulation will take heparin and warfarin
- Can be 6 month treatment if one VTE
- Or lifelong if multiple or AF, but risk/benefit to be confirmed
- Tradiotinally warfarin is taken at 6pm in the evening. Comedian Paul O'grady, its time for our warfarin
- Patients with Liver disease are at higher risk of over warfarinazation, because there livers can't metabolise it
- 
^0aa30d
^a245be
1mg = brown
3mg = blue
5mg = pink
- Bleeding risk
- Takes 48-72hr to develop fully
- Highly protein bound
- HIGH INR -> HIGH CHANCE OF BUILDING
- Blood tests: Weekly -> 1 every 8 weeks

**Advice**
- Take at the same time every day
- Avoid any major dietary changes
- Watch our for spontaneuous bruising/bleeding
- Rapid anticoagulation 10mg, maintenance dose 3-9mg
- Don't swap brands
- Watch out for haemorrhage, rash, skin necrosis
- Bleeding card 
- **Black tarry stools is sign of INR too high**

## DOAC's
- In general, bleeding is mian risk
- Finding antidotes is hard
- Adherence is very important
- FDA has approved two DOAC reversal agents: **idarucizumab** (Praxbind—Boehringer Ingelheim) for reversal of dabigatran, and andexanet alfa (Andexxa—Portola Pharmaceuticals) for reversal of apixaban and rivaroxaban
- CI in pregnancy and breastfeeding
- Alternative agent in renal or liver disease

Apixaban (eliquis), Edoxaban (lixiana), Rivaroxaban (xarelto)

Anticoagulant effect can be increased by CYP inhibitors or inducers

 


## Heparin injection
- IU per kg
- Innohep subcut, clexane IM
- During pregnancy, prevention of clot
- Labour, stop taking for 12 hours
- Discard the rest after using, do not reuse needles

**Innohep**
Tinoparin
Same way, wash area with alcohol wipe
Pinch and inch
Similaryly throw out the rest

**Clexane**
- Pinch an inch
- Clean area, wash hands
- 90 degree angle for all sub cut
- Same time every day
- Can't take it with epidural
- If stomach gets really tight, move to thigh
- 


# Respiratory

## COPD

Get pneumococcal vaccine at 65

Start with SABA or SAMA

then 

LABA and LAMA (tioptropium, glycorprriunim)

then add ICS 

## Patient counselling on inhalers
General advice:
Take lid off
Chin up and stand up straight
https://www.asthma.ie/sites/default/files/files/document_bank/2021/Jan/Asthma%20Inhaler%20and%20Devices%20Poster%202021.pdf

**Turbohaler**
- Spin until click
- Breathe in sharp

**Evohaler/MDI**
- Shake before use
- deep, long slow breath
- 10 seconds
- Check in front of mirro, if mist escaping, not doing it correctly
- Wash in warm water

**Spacer device**
- fit together one way only
- form tight seal
- one puff at a time
- replace every 6-12 months
- Wash with detergent and don't dry with a towel, let drip dry

**Handihaler**
- capsule to be pierced
- DO NOT SWALLOW CAPSULE
- Sharp breath


**Respimat : Turn , Open , Press**
- Press safety catch and insert 
- Will need to be primed on first use
- Click
- Turn towards ground
- Daily use : two puffs once daily
- Once it gets to the red section, there are 14 puffs left
![The Respimat ® Development Story: Patient-Centered Innovation | SpringerLink](https://media.springernature.com/lw685/springer-static/image/art%3A10.1007%2Fs41030-017-0040-8/MediaObjects/41030_2017_40_Fig4_HTML.gif)

Steroid inhaler tips ^dee77b
- Rinse mouth after use
- Ensure compliance with brown and blue
- Dry mouth is a possible side-effect, saliva substitute if so
- No relief after taking it, but that does not mean its not working 
- With DPI, make sure you don't spill it 


**General inhaler advice**
Discard after three months
Damp cloth, do not use detergents, once weekly


## COPD medicines
**Theophylline** ^6e351d
- Narrow TI drug
- Bronchodilator used in COPD
- TAKE IT ONE EVERY 12 HOURS ; Can be given IV if symptoms are severe
- TAKE ON EMPTY STOMACH EITHER Generally take one hour before or two hours after food
- Avoid fattfy foids that can impair its absorption 
- lung function also needs to be monitored
- Smoking inhibits effect, so be aware of that


General side effects:
- Heart racing/palpitation
- Diarrhea
- Low potassium levels
- High blood sugar

- Caution with : -   an overactive thyroid
	-   cardiovascular disease
	-   liver problems, such as [liver disease](https://www.nhs.uk/conditions/liver-disease/)
	-   high blood pressure
	-   open sores that develop on the stomach lining [(stomach ulcers)](https://www.nhs.uk/conditions/stomach-ulcer/)
	-   a condition that affects the brain and causes repeated fits (seizures) [(epilepsy)](https://www.nhs.uk/conditions/epilepsy/)
- With liver problems, can get a toxic build up in the body

Some of the medicines that can interact with bronchodilators (particularly theophylline) include:
-   some diuretics, a type of medication that helps remove fluid from the body
-   some [antidepressants](https://www.nhs.uk/conditions/antidepressants/), including monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs)
-   digoxin, a medication used to treat [arrhythmias](https://www.nhs.uk/conditions/arrhythmia/)
-   benzodiazepines, a type of sedative that may sometimes be used as a short-term treatment for [anxiety](https://www.nhs.uk/conditions/generalised-anxiety-disorder/) or sleeping problems [(insomnia)](https://www.nhs.uk/conditions/insomnia/) ^df8a89
-   lithium, a medication used to treat severe [depression](https://www.nhs.uk/conditions/clinical-depression/) and [bipolar disorder](https://www.nhs.uk/conditions/bipolar-disorder/)
-   quinolones, a type of [antibiotic medication](https://www.nhs.uk/conditions/antibiotics/)

## COPD infections
- Azithromycin often used
- One three times per week

Since liver is the principal route of elimination for azithromycin, the use of azithromycin should be undertaken with caution in patients with significant hepatic disease

Cross-resistance exists between azithromycin and other macrolides (erythromycin, clarithromycin, roxithromycin)


### Other bronchdilators
- cause smooth muscle relaxation
### SABA
- Salbutamol (beta agonists)
- Terbutaline

### LABA
- Should only be used if already on steroid
- Salmeterol, formoterol

### LAMA
- Muscarinic receptors are mucus producing 
- Antcholinergics such as, tiotropium, aclidinium and glycopyrronium

Mainly used for COPD
Caution with - 
those with BPH
Prostate cancer or bladder issues
Glaucoma
Dry mouth
Arrythmias

**ipratropium is a SAMA**

**Steroid inhalers**[[#^dee77b]]
- Rinse mouth after use
- Ensure compliance with brown and blue
- Dry mouth is a possible side-effect, saliva substitute if so
- No relief after taking it, but that does not mean its not working

### Leukotriene receptor antagonist (Montelukast):
Used in allergic asthma
Helps stop airways narrowing
Side effects: headaches or being sick
Mood disorder
Once a day
Red flags: liver problems, yellow eyes etc


## Asthma Management (General)
- Try to avoid pollutants and triggers
- Good inhaler technique and compliance
- Diagnosed using spirometer and peak flow test
- Can give patients a management book where they can track peak flow measurements and how they are feeling and their flow
- This can help manage their medicines and ensure compliance as well as identify triggers

ICS + SABA

Then 

ICS + LABA (formeterol), fast acting and long acting

Then

Add LTRA (montelukast)



## CA Pneumonia

#### Treatment Table - Community Acquired Pneumonia

Assess using the CRB-65 score (each symptom or sign scores one point)

(Confusion, Respiratory rate ≥ 30/min, BP ≤ 90/60, Age ≥ 65)



## HA Pneumonia

Treatment: Antibiotics



# Diabetes

## Sick days
- SADDMANS
- Contact nurse
- Can need more insulin then normal
- Dioralyte not recommended in diabetes
- NEVER STOP INSULIN
- Hyperglycaemic in reaction to infection
- NSAIDS - don't take them
- 


Eat small amounts
Get in water 


## Patient counselling on Insulin
- How has your use of insulin been?
- Use bolus before a meal, usually tds
- Use basal at night

## Patient counselling on metformin (biguanide)
- Have you taken this before?
- This is a medicine for diabetes, it helps to reduce your blood sugar
- GI side effects, bloating, diarrhea
- Metallic taste
**- Lactic acidosis if they have renal impairment**
- Lactic acidosis signs are abdominal or stomach discomfort, decreased appetite, diarrhea, fast, shallow breathing


General diabetes management
- Which is long, which is short
- sick day

## Diabetic kidney disease
- A simple urine test called the albumin: creatinine ratio (ACR) looks for signs that protein is leaking into the urine. This is often an early sign of kidney disease
- Both ACE inhibitors and ARBs help to protect the kidneys from further damage

## Diabetic retinopathy
- To minimise the risk of this happening, people with diabetes should:

- ensure they control their blood sugar levels, blood pressure and cholesterol attend diabetic eye screening appointments


## Diabetic Ketoacidosis 
Diabetic ketoacidosis (DKA) is a serious problem that can happen in people with diabetes if their body starts to run out of insulin. When this happens, harmful substances called ketones build up in the body, which can be life-threatening if it's not found and treated quickly

Sign would be: Breath that smells fruity (like pear drop sweets, or nail varnish


Treatments:
insulin
fluids given into a vein to rehydrate your body


## Gestational Diabetes

If you have gestational diabetes, it's best to give birth before 41 weeks. Induction of labour or a caesarean section may be recommended if labour does not start naturally by this time.

## Proteinuria
Tested with Albumin:creatinine ratio

Patients with protein in their urine in their urine get more heart
disease. This makes it even more important to keep a check on:
 Blood pressure
 Cholesterol (this is higher in patients with proteinuria)
 Other things causing heart disease such as smoking, obesity


## Patient counselling on sulfonylureas (gliclazide)
- Take in morning
- Gliclazide can sometimes make your blood sugar level too low (hypoglycaemia). Carry some sweets or fruit juice with you to help when this happens
- Can cause weight gain
- stomach ache, constipation
- Early warning signs of low blood sugar include:

feeling hungry
trembling or shaking
sweating

## Pioglitazone (thializidiones)
- Pioglitazone is indicated as second or third line treatment of type 2 diabetes mellitus as described below:
- Fluid retention
- Hepatic toxicity
- Bone fractures
- Weight gain 
- Increase your risk of bladder cancer
- 
- 


## Patient counselling on GLP-1 inhibitors (semaglutide, Dulaglutide)
**Semaglutide** i.e Ozempic
Escalating dose 0.25, 0.5, 1
Administer subcutaneously, link to a video on diabetes ireland
Common to experience nausea, vomiting and diarrhea when your first begin. This may get better over time
Can help with weight loss

Rarely can worsen eye conditions

**Liraglutide**
- Similarly The most frequently reported side effect with liraglutide was nausea
- 


## Patient counselling on SGLT2 inhibitors (-flozins)
SGLT2 inhibitor class include canagliflozin, dapagliflozin, and empagliflozin.

Invokana is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise:

- as monotherapy when metformin is considered inappropriate due to intolerance or contraindications

- in addition to other medicinal products for the treatment of diabetes

Invokana should be taken orally once a day, preferably before the first meal of the day

Renal function and risk of volume depletion should be taken into account

Canagliflozin may add to the effect of diuretics and may increase the risk of dehydration and hypotension

Canagliflozin should not be used during pregnancy. When pregnancy is detected, treatment with canagliflozin should be discontinued

Urrinary tract infections more common

**Dapigflozin**
- Increased risk of diabetic ketoacidosis
- Increased risk of thrush (if recureent, needs referall to doctor)
- Increased risk of UTI



## DPP-4 inhibitors (-gliptins)
Sitagliptin is prescribed for people who still have high blood sugar, even though they have a sensible diet and exercise regularly
You take sitagliptin once a day.
The most common side effect of sitagliptin is **headaches**.
This medicine does not usually make you put on weight. 
Sitagliptin is also called by the brand name Januvia. When combined with metformin it's called Janumet
some people may have serious side effects after taking sitagliptin.

Call your doctor straight away if you have:

severe stomach pains
yellowing of your skin, or the whites of your eyes turn yellow

Also wtach out for **acute pancreatitis**
- Do not give to people who already have pancreatitis

Signs include persistent severe abdominal pain

## Diabetes insipidus
Diabetes insipidus is a rare condition where you pee a lot and often feel thirsty
The 2 main symptoms of diabetes insipidus are:

extreme thirst (polydipsia)
peeing a lot, even at night (polyuria)
In very severe cases of diabetes insipidus, a person can pee up to 20 litres of urine in a day

Nephrogenic diabetes insipidus occurs when there's enough AVP in the body but the kidneys fail to respond to it

**Desmopresin**
It works just like natural AVP, stopping your kidneys producing urine when the level of water in your body is low



## Pregnancy and diabetes
- Gestational diabetes can happen
- Some medicines are not safe
- The best way to reduce the risks to you and your baby is to ensure your diabetes is well controlled before you become pregnant
- If you have diabetes and are trying to get pregnant, you should take 5 milligrams (mg) of folic acid each day (and until you are 12 weeks pregnant).
- If you usually take tablets to control your diabetes, you'll normally be advised to switch to insulin injections, either with or without a medicine called metformin
- You will need to monitor your blood glucose levels more frequently during pregnancy, especially since nausea and vomiting in pregnancy (known as “morning sickness”, although it can happen at any time of the day) can affect them




## Patient counselling on blood pressure medication
- Have you taken this before?
- When to take it
- What to take it with


## Glytrin spray
under the toungue
- one or two sprays within 2-3 minutes of onset
- sitting down
- after three doses , get help
- Shake for 10 seconds to prime
- 

## hepatic encelopathy
- Lactulose
- Lactulose is not good in IBS because it ferments

## Opioid Patches
- Clean area of skin, hairless, trim if required
- If breakthrough pain, give morphine oral dose as well
- upper arm, chest, or back
- Don't put it on after hot shower , pores open
- Don't use a hot water bottle on the area
- Can wear in shower, keep temperature modertae
- Once weekly, 72 hour. Try make a note of time was put on so can be taken off after X time period in 72 hours
- If converting, convert to morphine first
- Takes a lot of time to start working, use breakthrough 
- Morphine cannot be used in renal impairment, need to use oxycodone instead
- Morphine has no ceiling effect

**Patch to tablet**
- Wait about 12 hours


**Breakthrough pain**
- 1/6 of total dose is breakthrough pain



**What if it comes off??**
- Repply a new one
- Fold old one together 




# Immunosuppressants


## Patient counselling on Methotrexate

^524702

- Cancer or autoimmune disorder treatment
- Any other medication
- WEEKLY NOT DAILY - tell them what day
- Methotrexate monday Folic acid Friday
- Don't take folic acid on same day
- avoid taking NSAIDS or aspirin without doctor supervision
- Not suitable in pregnancy
- Liver and renal impairment
- **Penicillins inhibit excretion**
- 


Things to watch out for
- Sore throat (dyscrasias)
- Fatigue 
- Brusing/bleeding
- Shortness of breath (pulmonary toxicity)
- Gi bleeds
- Hepatotoxicity (LFT and renal needed before starting, report,nausea, abdominal issues, dark urine)
- Store your weekly methotrexate separately, away from any other medicines that you take daily 

## Topical steroid OTC

^6ce296

- Not for babies  OVER 12 only
- Apply thinly twice daily
- Not for face or anywhere above neck
- Need to talk to the doctor for that
- Apply emolient 15 minutes beforehand
- Not suitable if pregnant or breastfeeding


- Can use zirtek or piriton if the itch gets bad
- DO NOT APPLY TO BROKEN SKIN
- If it is oozing, keep an eye on it if it begins to feel hot/infected 
- Can use emolient as liberally as you want, at least twice daily
- Can shower with it aswell if you use an emolient soap subsititute

## Patient counselling on immunosuppressant

- sore throat
- fever
could be a sign you've picked up an infection
Azathioprine - [[#^365818]]
Mesalazine - [[#^65eab2]]



## Steroid nasal spray
- ![how to use nasal spray Cheaper Than Retail Price&gt; Buy Clothing, Accessories  and lifestyle products for women &amp; men -](https://www.dymista.com/-/media/dymistacom/assets/img/how-to-use-lg.png)


Blow nose beforehand
Can use saline nasal rinse beforehand

# ALLERGIES

## EpiPen (autoinjector)
- Blue to the sky (safety pen)
- Orange to the thigh
- Swing and push until click
- Hold for three seconds
- Massage for 10 seconds





## Hayfever counselling
Cetrein, telfast, piriton
Drowsiness
Use 

Wrap around sunglasses
Vaseline on the nose


## Montelukast

^e590dd

Also used for asthma
See asthma section [[#^e590dd]]


## Steroid injection









# MALE ENDOCRINOLOGY


## Glucocorticoids
- Antiinflammatory treatment
- Immunosuppression

**Dexamethasone**
- Cancer oedma

## Mineralocorticoid



















- 


# FEMALE ENDOCRINOLOGY


## Breast cancer lifestyle counselling
- Regular mammogram
- Regular self-checks
- Family history

## Cervical cancer lifestyle
- Regular smear tests
- Sample taken from cervix
-  If abnormal cells are not treated, they may turn into cervical cancer.
-  You may have some light bleeding or spotting after cervical screening. This should stop within a few hours

**under 25**

up to 6 months before you turn 25

**25 to 49**

every 3 years

**50 to 64**

every 5 years

**65 or older**

only if 1 of your last 3 tests was abnormal

  
Avoid using any vaginal medicines, lubricants or creams in the 2 days before you have your test as they can affect the results.

# Contraception 
Weight gain, acne, mood changes, headaches
COCP: Blood clots, breats CA, Cervical CA
Progesterone: 
	POP- irregular, stopped or light perioids, time for fertility to return
			Osteoporosis with depot
			

## Contraception counselling

General Risk Factors:
Over 35
Family history of breast cancer
Smoking
Need to be careful with enzyme inducers (link to enzyme inducers here)
Some antibacterials may reduce efficacy by imparing bacterial flora (source needed) Extra precaution needed for seven days after

### Contraception after pregnancy
- Don't need anything until 21 days generally


## Combined Pills
- Celeste
- Ovreena
- 

## Progesterone only Pills
- Dianette
- Noriday - 3 hours
- Qlaira


### EHC
[[#^2e4556]]


### Patch 
Day 1, 8, 15, new pathces
Write it in the calander or set reminder in phone
- Swimming is okay
- Keep a diary
- Don't put on after a hot shower or

**If you miss a day**
- If you are within 48 hours, usually 


### Missed Pill
If week one  - Panic at the disco, use a barrier method for 7 days
Week two - Probably fine
Week three - Barrier for 7 days

### Vaginal ring
- Unlike the pill, the ring still works if you have sickness (vomiting) or diarrhoea
- The ring can sometimes come out on its own, but you can rinse it in cold or warm water and put it back in as soon as possible
- The standard way to use the ring is you leave it in for 21 days, then remove it and have a 7-day ring-free break. You're protected against pregnancy during the ring-free break. After the 7-day break you then put a new ring in for another 21 days
- You'll be protected against pregnancy straight away if you insert it in the first 5 days of your period (the first 5 days of your menstrual cycle)

If the ring is out for more than 48 hours in the **first week of using a ring:**

-   insert a new ring as soon as possible and keep it in until the scheduled removal day
-   use additional contraception for 7 days

If the ring is out for more than 48 hours in the **second or third week of using a ring**:

-   insert a new ring as soon as possible and keep it in until the scheduled removal day
-   use additional contraception for 7 days
-   if the ring came out in the third week and you are using the ring the standard way, skip the ring-free break



## Using contraception post-pregnancy
- You can start using the vaginal ring **42 days** after giving birth if you are breastfeeding
- You may be able to start using the ring earlier than this – on day 21 after giving birth – if you're not breastfeeding, but your doctor will advise you





## HRT
For the treatment of postmenopausal symptoms, HRT should only be initiated for symptoms that adversely affect quality of life. In all cases, a careful appraisal of the risks and benefits should be undertaken at least annually and HRT should only be continued as long as the benefit outweighs the risk
- Prevent bone loss
- Potentially increased risk of cancers
- Potentially increased risk of DVT or Thrombotic event

Before initiating or reinstituting HRT, a complete personal and family medical history should be taken. Physical (including pelvic and breast) examination should be guided by this and by the contraindications and warnings for use. During treatment, periodic check-ups are recommended of a frequency and nature adapted to the individual women.

Regular exercise -> reduce hot flushes and improve sleep
- Cooling down at night
- Cut down on caffeine, alcohol and spicy foods
- Quitting smoking

**Premarin**
Estrogen only HRT


## IVF
- Generally, start on pill
- Injections to stimlate ultra ovulation

## Duphaston
- Progesterone 
- If a dose has been forgotten, it should be taken as soon as possible. When more than 12 hours have elapsed, it is recommended to continue with the next dose without taking the forgotten tablet. The likelihood of breakthrough bleeding or spotting may be increased.
- Dysfunctional uterine bleeding, ammerohea, 



## Letrozole
- It is mainly prescribed for women who have been through the menopause and have a type of cancer called "hormone-dependent" breast cancer
- You usually take letrozole once a day – try to take it at the same time each day.
- Most people are given letrozole for 5 years, but some will take it for up to 10 years

Hot flushes/sweating

## Anastrazole
- Aromatse inhibitor
- 


## Tamoxifen
- Increases likelihood of endometrial cancer
- Not safe in pregnancy
- Suppression of lactation
- Prodrug that requires CYP to convert it to active form, therefore can cyp interact
- 
## Dostinex (cabergoline)
- Stops lactation
- 


# EMERGENCY SITUATION

For the administration of emergency prescription-only medicines the pharmacist must have completed a training course and have the certificate. This can be done at IIOP. Regularly review the training materials. 

## Documentation after administration of emergency medicine
- Write it in the register
- 

## Emergency Seizure
- Midazolam


## Stephen Johnsons syndrome
- suphur based drugs such as sulphonamides
- Antiepileptics, gold, penicillin, allopurinol

## Agranulocytosis
- 4 C's 
- Carbamezapine  , clozapine, Colchicine, Carbimazole [[#^a5fb22]]


## Allergy (Anaphylaxis) management counselling
Have patients carry two epipens with them.

Swing and Jab
Always call the ambulance
Can give it to anyone as long as you can reach them and are on duty

## Naloxone

Available as a nasal spray or as an injection


## Salbutamol
Use as normal

## Glyceryl trinitrate
- Under the tongue
- Sitting down
- If doesn't work after three sprays 

## Emergency glucagon
Hypoglycaemia (If they are conscious, just give glucose tablets)
1mg IM 
- If you have a hypo- take sugar, if you go unconscious - use the glucagon
- Entire contents into the muscle
- will not work if you have been fasting or drinking alcohol
- use immediately after reconstiution
- You push the water into the vial from the needle and then Turn it upside down and pull into needle
- Call an ambulance anyways
- Check expiry dates

## Emergency aspirin
- Any anticoagulants
- Knees to chest position


## Defribillator
- Make staff aware of one nearby
- Check that it is in date
-  wipe sweat off their skin 
-  Shave skin on chest


## CPR
- Press on chest
- no mouth to mouth in covid
- CPR machine will coach


## Supply to a listed organisation

Label them for an audit trail



## Wound management counselling


# DIGESTION

## Patient counselling on acid reflux

Short term use only, if using more than that need to go see the doctor. 

Take in the morning on an empty stomach, about 1 hour before food

eating smaller meals more often and avoiding fatty and spicy foods


**Warning signs/RED FLAGS:**
Blood in stool
Weight loss
dark stools
Severe pain

**gaviscon**
After meals and before bed up to four times a day

## Creon


## Diverticulitis 
straining, constipation, blood, mucus
When flare-up , go on a low residual diet, i.e liquid food
It is linked to age, diet and lifestyle and genetics
can get infections
flagyl - cant use greather than 3 months
liquid diet 


## Orlistat
- for weight loss
- interacts with amiodarone, anticoagulants, acarbose, ciclosporin


## Infant acid reflux

Losec Mups

Infant Gaviscon


## Diarrhea

- ORT
- Loperamide if necassary

Loperamide is an opioid that does not cross BBB


Contraindications
- More than 8 in one day
- Long lasting diarrhea more than a few days
- Antibiotic 
ed diarrhea
- If they have IBD

## Motion sickness counselling
- Sturgeon
- Phenergan for children


Sit at the front 
Focus on a fixed object

# IBS counselling

Symptoms:
Cramps


Counselling:
Psychosomatic, brought about by stress etc.
Manage stress with exercise, rest and meditation
Set sleep times, get up at same time every morning

For avoiding indigestion: eating smaller meals more often and avoiding fatty and spicy foods

## Hyoscine (buscopan)
- Antimuscarinic, therefore can cause amusc efffect. Antispasmodic
- Be careful with Amuscs used for urinary
- be careful with glaucoma
- 2 four times daily
- 

**Hydropbromide**
- Quells

## Colpermin
- 1 or 2 up to three times daily
- Need to be diagnosed with IBS
- Peanut allergy

## Loperamide
- Antidiarrhea
- 2 tablest to start
- Up to max 5 a day
- 

## General constipation management
First line is water, movement and fibre
These should be practiced regardless
Then can try a firbrous drink such as fybogel
WIth fybogel, it is important to drink it immediately rather than waiting for it to settle

Laxatives can disturb mineral balance
Be careful if on diruetics or lithium or things like that

### Microlax
- Enema
- 15 minutes and youre gone

### Constipation in child
- Glyceryol suppository. The suppository should be dipped in water before insertion
- Diet is not first line
- They will get anxious about going to the toilet because it is painful
- Senakot is 12+
- Lactulose 14+

## Senna
- Take 1 or 2 before bed
- Not for people under 18
- Stimulant laxitive
- If there is no bowel movement after 3 days, or if symptoms persist, in particular if you have persistent abdominal pain or are passing blood, consult your doctor.
- Laxative dependency occurs from overuse
- Not to be used for more than 1 week. Usually it is sufficient to take this medicinal product up to two to three times during that week.



## Opioid induced constipation
General regimen involves both a stimulant laxative and a stool softener

Stimulant laxative being senna or bisacodyl
Stool softener include osmotics such as lactulose (dulphalac) 

## Antacids
More immediate relief
Gaviscon
- Safe for pregnancy

aluminium hydroxide

**magnesium carbonate
magnesium trisilicate
magnesium hydroxide**
- Laxative effect from magnesium antacids


calcium carbonate
- 

sodium bicarbonate
Some antacids also contain other medicines, such as an alginate (which coats your gullet with a protective layer) and simeticone (which reduces flatulence)

It's best to take antacids with food or soon after eating because this is when you're most likely to get indigestion or heartburn

Antacids can affect how well other medicines work, so do not take other medicines within 2 to 4 hours of taking an antacid

**When are antacids unsafe?**
- Sodium content and blood pressure
- Sometimes liver and kidney diseas

**Rennie**
1-2 as required up to 12 times 

**Gaviscon**
3 times daily and at night


## Proton Pump Inhibitors

**Cimetidine**
-Interacts with stuff

**Omeprazole (losec)**
-  **It's usual to take omeprazole once a day in the morning**
-   For severe illness, you can take it twice a day – in the morning and in the evening.
-   Common side effects include headaches, diarrhoea and stomach pain. These tend to be mild and go away when you stop taking the medicine.
-   If you're self-treating with omeprazole, do not take it for longer than 2 weeks without checking with a doctor

Omeprazole can be taken by adults, including pregnant and breastfeeding women.

Omeprazole can be taken by children and babies if it's been prescribed by a doctor (losec mups)

Swallow tablets whole with a glass of water or juice

Interacts with a good few things, including 
- St john's wort
- Warfarin
- Phenytoin
- Digoxin
- Clopidogrel

If dispersed in water: 
Patients should be advised that the dispersion should be taken immediately (or within 30 minutes) and always be stirred just before drinking and rinsed down with half a glass of water.
The capsules must not be chewed or crushed.


**Esomeprazole (PPI)**
- Nexium
- OTC 14 days max

**Pantoprazole(PPI)**
- Interacts with less

**Lanzoprazole **
- Interacts with less

## H2 Receptor antagonists
- Diarrhoea, GI disturbance, altered LFT, Headache
- Exaamples include:

**Cimetidine**


**Ranitidine(Zantac)**

**Pepsid AC**
- Famotidine

## Liquid parrafin
- Interference with fat-soluble vitamins
- Seepage

## Piles or haemmorhoids
- Often caused by constipation
- Piles are swollen blood vessels
**Anusol**
- Not recommended for children
-  apply to the affected area at night, in the morning and after each evacuation until the condition is controlled. Thoroughly cleanse the affected area, dry and apply cream. ANUSOL cream is prepared in a vanishing cream base and may be gently smoothed on to the affected area without the need to apply a gauze dressing.
-   For internal conditions, use rectal nozzle provided. Remove the nozzle cap. Clean the nozzle after each use
-   Can also use suppositories for internal


Lifestyle
- Drink water
- Fibre
- Warm bath
- Ice pack
- Cut down on alcohol and caffeine
- Do not take ibuprofen if bleeding

## Using suppositories
- Gently squeeze suppository to ensure it is firm enough to insert. If not hard enough,
place in fridge for a few minutes
- You may moisten the tip of the suppository using lubricating jelly (e.g. KY jelly) or
apply a small amount of water to your rectal area
-  Stand up with one foot raised on a chair or lie down on your side with your top leg
bent towards your stomach and your bottom leg straight
- Remain seated or lying down for approx 15 mins


## IBD
- smoking is worst thing

**Azathioprine** ^365818
- Full blood count - Bone marrow suppression

- 
**Mesalazine** ^65eab2


# SKIN

Topical Steroid [[#^6ce296]]
Viral infection of skin[[#^8d8a07]]
Fungal infection of skin [[#^fdd858]]

## Acne managament
Salicylic acid facewash
moisturise twice daily
benzyl peroxide, stains pillows

**Tetracyclines**
- Doxcycline

Protect skin from sunlight
Eosapgheal irritation, don't take it too close to lying down


- Lymecyclin (tetralysal)
 Binds with calcium, don't take with milk
 Take 1 hour or two before food
 Eosapgheal irritation also
 
 **Clindamycin**
 - Macrolide
 - Can be systemically absorbed
 
 **Erthromycin**
- Macrolide
- 



**Roaccutane**
Prescription must be within 7 days for females
Only 30 days can be dispensed
- What to expect: very dry skin
- dry lips
- potentially mood effects
- Regular blood tests for liver function
- POP is not considered effective for 




## Psioriasis management
Emolient-as much as you would like
Apply emolient first, let it dry before applying steroid
Only apply the steroid to affected area, but the rest as liberally as you'd like


## Eczema

- contact dermatitis
- Allergic dermatitis



## Nappy rash
- 



## Shingles
Take paracetamol to ease pain

keep the rash clean and dry to reduce the risk of infection

wear loose-fitting clothing

use a cool compress (a bag of frozen vegetables wrapped in a towel or a wet cloth) a few times a day

It can take up to 4 weeks for the rash to heal

But people who have not had chickenpox before could catch chickenpox from you. This is because shingles is caused by the chickenpox virus.

Try to avoid:

pregnant people who have not had chickenpox before
people with a weakened immune system – like someone having chemotherapy
babies less than 1 month old – unless you gave birth to them, as your baby should be protected from the virus by your immune system

A shingles vaccine is available on the NHS for people in their 70s. It helps reduce your risk of getting shingles.


## Chickenpox
- In children don't use ibuprofen
- You might get symptoms before or after the spots appear, including:

a high temperature
aches and pains, and generally feeling unwell
loss of appetite
drink plenty of fluid (try ice lollies if your child is not drinking) to avoid dehydration

<mark> take paracetamol to help with pain and discomfort, not ibuprofen </mark>

put socks on your child's hands at night to stop scratching

cut your child's nails

use cooling creams or gels from a pharmacy such as calamine lotion

speak to a pharmacist about using antihistamine medicine to help itching

bathe in cool water and pat the skin dry (do not rub)

dress in loose clothes

check with your airline if you're going on holiday – many airlines will not allow you to fly with chickenpox

**Rule out meningitis**
- Stif neck
-  a rash that does not fade when a glass is rolled over it (but a rash will not always develop)
-   a stiff neck
-   a dislike of bright lights
-   drowsiness or unresponsiveness
-   seizures (fits)


## Meningitis
**Meningitis is an infection of the protective membranes that surround the brain and spinal cord (meninges)**
There is some vaccines available
Needs to be treated straight away
Viral meningitis tends to get better on its own within 7 to 10 days and can often be treated at home.
Bacterial meningitis usually needs to be treated in hospital for at least a week
The risk of someone with meningitis spreading the infection to others is generally low

# LIFESTYLE 

## Smoking cessation counselling 
- Motivational interviewing
- On a scale of 1-10
- Use patches 
- Then for short term cravings use a gum or lozenge
- Make a plan
- Keep a diary
- Remember reasons for quitting
- exercise, even a 5-minute walk or stretch, cuts cravings and may help your brain produce anti-craving chemicals.
- With lozengers, avoid acidic beverages for 15 minutes before
- Patients can be concerned about weight gain, which is legit

DETERMINE the SITCH
MAKE a PLAN
KEEP a DIARY
HELP them implememnt (treatment + support)



**5 A's**
- Ask 
- Advice
- Assess
- Assist
- Arrange

**NRT**
- Becareful with people with blood disorders
- Leave patch on during day
- Take a gum or lovenge or spray when you get a craving
- Difficulty sleeping, dry mouth and headache


**Buprionon**



**Varenicline**
- Can get suicidal thoughts
- Start 1-2 weeks before quit date




## Alcohol
- 2 alcohol free days
- Maxmimum of 14 units per week
- Interacts with warfarin, MAOI, mirtazapine, metronidazole



# SKELETAL

## Alendronic acid

- Once a week
- Same time
- Empty stomach and full glass of water
- Don't lie down afterwards
- Should not be used for longer than five years
- Can cause femur fracture


rED FLAGS
- osteonecrosis of the jaw

## Calcium supplements

^3298f0
- Usually one twice daily
- Be careful not to over do it with calcium
- Do not take with levothyroxine, tetracyclines or quinolones


## Vitamin D
- Often combined with calcium
- 10mcg in pregnancy
- Many people are deficient
- Fat soluble, taking it with a fatty meal may help absorption

## Denosumab (Prolia)
- Once every 6 months
- Need to take calcium and vitamin D supplements
- Watch out for skin infections and osteonecrosis of jaw



## Gout

^86d20c

- Build up of uric acid
- An attack of gout usually lasts 5 to 7 days, then gets better. It may not cause lasting damage to joints if you get treatment immediately.
- Usually treated with NSAID 
- Keep pressure off of joint
- Apply an ice pack
- Eat a healthy diet and reduce alcohol
- avoid offal and sugary/fatty foods
- You can get kidney stones if your uric acid levels are very high
- The usual dose is 1 tablet (500 micrograms), taken 2 to 4 times a day

## Allopurinol
- This is a medicine for gout, which is a build up of a thing called uric acid in your joints, which is painful
- Allopurinol is a medicine used to lower levels of uric acid in your blood
- It may take several months before you feel the full benefit of allopurinol
- In the early stages of treatment with allopurinol, as with uricosuric agents, an acute attack of gouty arthritis may be precipitated. Therefore, it is advisable to give a prophylactic dose of a suitable anti-inflammatory agent or colchicine
- It's unusual to have serious side effects after taking allopurinol. Tell a doctor straight away if you:

get yellow skin or the whites of your eyes go yellow – these can be signs of a liver problem
get a high temperature, sore throat and swollen glands or feel generally unwell – this could mean there are problems with your white blood cells

## Colchicine
- Colchicine is a medicine for treating inflammation and pain.

It can be used to: treat flare-ups (attacks) of gout
prevent increased flare-ups of gout when you first start on a medicine like allopurinol – taken to manage your condition long term

***important***: 
- It's important to stick to your prescribed dose. Taking even a little bit more can be very serious.Taking too many colchicine tablets can be very dangerous. It could be fatal.

Symptoms of taking too much colchicine can include:

feeling or being sick (nausea or vomiting)
stomach ache
bloody diarrhoea
signs of low blood pressure (such as feeling dizzy or lightheaded)
- Avoid grapefruit and grapefruit juice while taking colchicine.
- Some people find it's gentler on their stomach if they take their medicine with or after food.
- Colchicine is not usually recommended in pregnancy or when breastfeeding
- **red flags**
have stomach pain
have diarrhoea
have a high temperature, swollen mouth, sore throat, bleeding that does not stop, unusual bruising or skin problems – these can be signs of a serious problem with your blood (Blood dyscrasias)


# DMARDS

## Hydroxychloroquine
- Less toxic derivative of chloroquine
- It is used to treat rheumatoid arthritis and also discoid and systemic lupus erythematosus (SLE)
- It can reduce inflammation, pain, swelling and joint stiffness. It may also improve the rash in patients with lupus. Hydroxychloroquine is also used in the treatment of malaria, but it does not prevent malaria
- Skin rashes, dizziness
- Very rarely, Hydroxychloroquine may damage the retina (part of the eye)
- Not recommended for those with eye damage
- Not recommended for those with COVID

## Sulfasalazine
- You'll need blood tests and liver and kidney tests before you start treatment with sulfasalazine
- Drink plenty of fluids when taking sulfasalazine to help prevent possible kidney problems
- 
- Rashes
- Bone marrow suppression, i.e risk of infection
- Is an aminosalicylate, therefore aspirin sensitivity, asthma, stomach ulcers etc. 
- GI upset and headache
- Can cause renal impairment, similar to salicylates
- Rare but serious blood abnormalities


## TNF alpha inhibitors
- Infusion reactions
- Risk of infection

## Gold
- Proteinuria
- Thromboctyopenia - when blood platelet count is low


## Penicillamine
- Nephrotic syndrom and proteinuria






# EYE

## Minor eye infection
- Check if contacts
- Brolene
- Warm compress
- Go to doctor for antibiotics
- Avoid touching eye with drops, spread of infection

![Altacor Eye Products on Twitter: &quot;How to correctly administer #Clinitas Eye  Drops https://t.co/iOtfAEaLeX… &quot;](https://pbs.twimg.com/media/ETjsqKNXQAEfU-C.png)


## Dry eye
- WASH YOUR HANDS BEFORE PUTTING IN DROPS
- Hylo-forte
- Up to four times daily
- Safe to use with contact

## Blepharitis
- Crusty eye 
- Wipe away

## Conjunctivitis
Eye drops for moisture
Warm compress

## Glaucoma management
- Adherence to the drops
- Go to the optometrist to get it checked


Pain behind the eye: medical emergency

## Antibiotic eye drops [[#^290d4e]]
- Often ciprofloxacin
- Can get white specks on your eye, tell your doctor if they do not go away

## Prostaglandin analogue
- Latanoprost
- Blurred vision, reddening and pain


# ENT

- do not put anything inside your ear to remove [earwax](https://www.nhs.uk/conditions/earwax-build-up/), such as cotton buds or your finger
-  do not let water or shampoo get in your ear
-   do not use decongestants or antihistamines – there's no evidence they help with ear infections



## Otitis media
- Most ear infections clear up within 3 days, although sometimes symptoms can last up to a week
- -   use painkillers such as [paracetamol](https://www.nhs.uk/medicines/paracetamol-for-children/) or [ibuprofen](https://www.nhs.uk/medicines/ibuprofen-for-children/) (children under 16 should not take aspirin)
-   place a warm or cold flannel on the ear
-   remove any discharge by wiping the ear with cotton wool


## Ear Drops
- Check allergies
- How to put them in?


## Ear wax drops
- Olive oil
 Ensure no peanut allergy


## Decongestant (Sudafed)

- Short term use, no longer than 7 days
- over 12
- No use with blood pressure allowed
- Limt sales to one pack
- Can worsen BPH
- Take one four times day

## Decongestant nasal spray
- 3 sprays daily 
- Over 12
- No longer than 7 days
- Rebound congestion can occur with long term use

## Hand Sanitizer




## Cold sore
- Aciclovir cream
- Apply seven times daily (check this)
- 

## Sore throat


# ENDOCRINE

## Thyroid

 ## Hypothyroidism 
 eltroxin - levothyroxine
 Binds to calcium and salts [[#^3298f0]] 
 Should be taken in the morning before breakfast
 Leave 30 minutes before levothyroxine and caffeine
 Kelp has Iodine, which can make hypothyroidism worse
 
 Oestroegen and amiodarone interact
 Need to be aware of starting on warfarin or diabetes meds
 
 
 ## Hyperthyroidsim
 Symptoms are basically the opposite of hypo 
 - fast heartbeat, sweating, 
 
 
Treatments:
Carbimazole ^a5fb22
Radioiodine treatment: radiotherapy used to destroy cells

It can be caused by amiodarone, graves disease , nodules on the thyroid

 
 
 
 
 
 # URINARY SYSTEM
 
 ## ALPHA-BLOCKERS

**Lifestyle advice**
Fizzy drinks and drinks that contain alcohol, caffeine (such as tea, coffee or cola) and artificial sweeteners can irritate the bladder and make urinary symptoms worse

Try to reduce the amount of fluids you drink in the evening and avoid drinking anything for 2 hours before you go to bed

Double voiding involves waiting a few moments after you have finished peeing before trying to go again. It can help you empty your bladder properly. But take care not to strain or push

Eating more fibre (which is found in fruit, vegetables and wholegrain cereals) can help you avoid constipation, which can put pressure on your bladder and make the symptoms of an enlarged prostate worse

Absorbent pads and pants can be worn inside your underwear, or may replace your underwear altogether. These will soak up any leaks

Bladder training is an exercise programme that aims to help you last longer without peeing and hold more pee in your bladde

Desmopressins slow down urine production so less urine is produced at night

## Combodart
Tamsulosin and Dutasteride ^2af851

## Doxaszosin
Alpha blocker


## Tamsulosin
- alpha blocker for BPH
- occasionally for kidney stones


## Anticholinergics
- Anticholinergics relax the bladder muscle if it's overactive
- CI with UTI
- Bladder training
- Voiding
- Problematic in elderly and dementia
- Chew sugar free gum
- Good dental care is important


- **Regurgin (trospium)**
Used for urinary incontinence
Dry mouth
Can't pee or poo


**Oxybutynin**
**Tolferidone**
**Solifenancin**

**Mirabegron**
 

 
 ## Diuretic counselling points 
 
Don't take past 6pm or you will have an urge to get up in the night
Be careful with medicines that require salt balance
 
 
 # NERVOUS SYSTEM 
 
 
 # Opioids
 
 ## Mild to moderate
 
 **Codeine**
 - Constipation
 - Be acreful OTC
 - Generally not recommended in pregnancy. Can pass to breastmilk
 
 **Dihyrdocodeine**
 - Standard dihydrocodeine tablets take 1.5 to 2 hours to work fully
 - DO not take with any other medicines containing codeine
 
 **Tramadol**
 - 
 
 **Solpadol**
 
 ## Moderate to severe
 
 
 ## Methadone
 
 - Miss one day: Tell the clinic
 - Never give in methadone bottle
 - Under influence of alcohol or drugs
 - Three or more doses - tolerance reduced
 - Can cause dry mouth, importance of dental hygiene
 - Can cause sweating
 - Can effect result of a pregnancy test

**Supplying to a supplier**
- May request for patients under his or her care
- Written requisition for CD drugs
- Standard methadone requisition form
 

## Naloxone
-   If you wish to provide **naloxone**, you will need to have valid training in **CPR, RESMA and naloxone**
- Can cause vomiting when used

 
 ## Oral opioids
 - 
 
 ## Tramadol
 - Can cause serotonin syndrome
 - 
 
 ## Targin
- Oxycodone + naloxone
 - 
 
 
 ## Anti - Depressants
 - Be careful with tramadol and sumatriptan
 - SSRI's can lower the seizure threshold
 - Peptic ulcer disease is at higher risk
 - Suicidal thoughts
 - Dose reduction in those with hepatic impairment
 - Be careful with drugs that prolong QT interval
 - Be careful with St. Johns wort
 - Some antidepresants and warfarin can interact, be careful
 - **In general, can take time for effects, never suddenly stop**
 - Weight gain, insomnia
 - TCA's  - anticholinergic effects also dopamine blockade
 - MAOI - hypertension + hyperthermia
 - Swithcing from MAOI to another have to wait 14 days

Withdrawal symptoms:
- Flu-like
- Sleepiness
- Tingling


**Pregnancy and breastfeeding**
Depends on the drug


 
 ### Escitalopram
 Usually takes 4-6 weeks to start working.
 Can make diabetes more difficult to manage
 - Dry mouth
 - Sweating
 - sleepiness

The usual dose of escitalopram is 10mg a day in adults. But you may start on a lower dose and increase to a maximum dose of 20mg a day.
reduce dose gradually if stopping
 
 ### MAOI
 - Avoid tyramine rich foods
 - Interacts with pseduoephidrene
 - rarely used 
 
 ### Citalopram
 It usually takes 4 to 6 weeks for citalopram to work.
Side effects such as tiredness, dry mouth and sweating are common. They're usually mild and go away after a couple of weeks.
If you and your doctor decide to take you off citalopram, your doctor may recommend reducing your dose gradually to help prevent extra side effects.
 Take in the morning if it keeps you up
 ### Venlaflaxine
 SNRI
 Meant to help with mental clarity as well as depression
 Take it in the morning as it can keep you up
 
 ### Duloxetine
 60mg , comes in 30mg tabs
 It's used to treat [depression](https://www.nhs.uk/conditions/clinical-depression/) and [anxiety](https://www.nhs.uk/conditions/generalised-anxiety-disorder/).

It's also used to treat nerve pain, such as [fibromyalgia](https://www.nhs.uk/conditions/fibromyalgia/), and can be used to treat stress [urinary incontinence](https://www.nhs.uk/conditions/urinary-incontinence/) in women.

-   **difficulty sleeping** - try taking duloxetine first thing in the morning

If your doctor or health visitor says your baby is healthy, duloxetine may be used during breastfeeding
 
 ### Paroxetine
 
 
 ### Fluoxetine
 
 
 ### Brintillex
 - Vortioxetine
 - Combining this medicine with alcohol is not advisable
 
 ### Mirtazapine
 
- Need to take this at night, makes you sleepy 
- Don't drink alcohol or will be very drowsy
 
 ### Amitryptiline
 - 25mg 
 - TCA's more dangerous than SSRi's
 -  Used at a low dose for neuropathic pain rather than depression (10mg)
 - Improvement can take a few weeks 
 - Blocks a wide array of receptors
 - **DO NOT STOP SUDDENLY**
 - Do not take with MOA inhibitors
 - Dopamine blockade can cause mania and breast changes
 - Heightened risk in CV, epileptic, 
 - Antimuscarinic effects, be careful with BPH, glaucoma, constipation
 
 
 ## Anti-psychotics
 In general:
 EPS symptoms
 Tardive dyskinesia - if moves to mouth and tongue
 Prolactin and sexual dystfunction
 Weight gain
 Cholesterol and diabetes
 
 
 
** Typical - First gen**
 
 Haloperidol

Chlorpromazine
- Phototoxicity

**Atypical - Second gen**
 Olanzapine


Quetipaine


 Clozapine
 - Agranlocytosis
 Risperidone


Apiprazole

## Anxiolytics/Sleepers
- SSRI's also often used for GAD

## Barbiturates
Often are enzyme inducers
More potent than benzos

- Phenobarbital
- anything with 'barb' in it
- 


## Benzos
- Can be addictive 
- Do pose a fall risk
- Do not take alcohol, can cause serious sedation
- 


### Diazepam
- Fall risk


### Alprazolam
- If its daily can get withdrawal symptoms

## Z-drugs and sleepers

### Zolpidem and Zopiclone 
- Fall risk


### Dalmane
- Fall risk

## Anti-Emetics
### Cyclizine
- Not for use in pregnancy
- Drowsiness

### Prochlorperazine
- 


## D2 receptor blocker

### Domperidone
- only for nausea and vomiting OTC
- Do not take for longer tha 7 days without consulting doctor
- Take 15-30 mins before meals

### Metoclopramide
- can cause problems with movement

### Ondansetron
- Generally for chemo-induced nausea
- Can prolong QT interval


## Parkinsons

### dopamine agonist

### levodopa



### Cariban (Pregnancy)


## Epilepsy
- Driving in epilepsy: generally prohibited unless seixure free for 12 months, and then for 6 months after any treatment changes
- Generally avoid brand switching
- Antieplielptic hypersensitivy, be aware of **RASH**
- Women with epilepsy planning pregnancy should take high dose folic acid
- Generally mention importance of adherence
- Generally all require titration


### Carbamezapine
- **SERIOUS CYP ENZYME INDUCER**
- CRAPS the hell outta drugs
- Stop if you get a rash
- Neuralgia and sezire prophylaxis
- Increased risk with people with cardiac, renal and liver disease

### Topiramate
- Can be used for migraines


### Levericeratam
-   The most common side effects of levetiracetam are headaches, feeling sleepy and a blocked nose or itchy throat.
-   It can take a few weeks for levetiracetam to work. You may still have seizures during this time
-   Dosage reduction in renal impairment
-   Do not stop abruptly
-   Small minority experience mood chnages

### Clobazam - frizium 
- Is a benzo

### clonazepam
- Also a benzo

### Briviractam

### Lamotrigine
- **A RASH REQUIRES URGENT REVIEW**
- Escalating dose slowly
- Interacts with a good few things , through glucoronidation
- Headache, drowsiness, GI symptoms
- DO not stop treatment suddenly
- Reasonable choice in pregnancy
- If starting COC, may need to increase dose


### Phenytoin
All epilepsy (except abscence) and neuropathic pain
Non-linear dose plasma relationship
Full blood count and liver function is important
Look out for blood and skin disorders (rash, sore throat, fever, mouth ulcers)
take with or after food
It takes around 4 weeks for phenytoin to work
small number of people have suicidal thoughts
Not for pregnancy

### Valproate


### Pregablin
Both pregablin and gabapentin are add-on therapies when traditional epileptics not working
Can also be used for neuropathic pain and anxiety
Works by reducing neuronal excitation
Main effects are drowsiness and dizziness
Sedative effects may be enhanced by other sedatives
Dose should be reduced in renal impairment

Pregabalin treatment can be started at a dose of 150 mg per day given as two or three divided doses. Based on individual patient response and tolerability, the dose may be increased to 300 mg per day after an interval of 3 to 7 days, and if needed, to a maximum dose of 600 mg per day after an additional 7-day interval

In accordance with current clinical practice, if pregabalin has to be discontinued, it is recommended this should be done gradually over a minimum of 1 week independent of the indication


### Gabapentin
Both pregablin and gabapentin are add-on therapies when traditional epileptics not working
Works by reducing neuronal excitation
Main effects are drowsiness and dizziness
Escalating dose regimen
It's usual to take gabapentin 3 times a day
Dose should be reduced in renal impairment

-   treat epilepsy in adults and older children (aged 12 years and over) is between 900mg and 3,600mg a day split into 3 doses
-   treat nerve pain in adults is between 900mg and 3,600mg a day split into 3 doses
-   prevent migraine in adults varies, but can be up to 2,400mg a day split into 3 doses [[#^ccc049]]
-![[Pasted image 20210831103821.png]]



## Lithium
- Tremor, speech disorer, blurred vision
- Monitor concentration every three months, renal and thyroid every 6-12 months
- maintain adequate fluid intake and 
- If there are salt imbalances caused by diuetics etc, can be very serious
- Can cause significant weight gain
- avoid dietary changes that reduce or increase sodium
- NO ALCOHOL
- 



## Dementia and alzeihmers
Dementia is a syndrome (a group of related symptoms) associated with an ongoing decline of brain functioning

Because memory is proliferated by acetylecholine, it inhibits acetylcholinesterase to increase the amount of it in the brain


### Donepezil and rivastigmine
- does not work for everyone, after 3 months it should be stopped if not working. Review after 2-4 weeks aswell

-   The most common side effects of donepezil are diarrhoea, headache and feeling sick (nausea).
-   You can take it with or without food.
-   Drinking alcohol stops donepezil from working as well as it should. It also increases the risk of side effects

It's best to take your donepezil at bedtime. This is because you may feel dizzy after you take it.

If donepezil gives you bad dreams or makes it hard to sleep, you can take it in the morning instead.

Cautions with:
- Asthma
- COPD

Potentially serious one:
- Peptic ulcer
- Heart block/ bradycardia

**Rivastigmine may be preferred if hallucinations are occuring**


### Memantine
- 





## Headaches


### Types of headache
Tension

Tension-type headaches are known as primary headaches, which means they're not caused by an underlying condition. Can be **Medication overuse**

Cluster
The pain is very severe and is often described as a sharp, burning or piercing sensation on one side of the head. It's often felt around the eye, temple and someti