What are the symptoms of asthma?
SOB
Chronic cough (may be worse at night)
Wheeze
Frequent �chest infections�
Persistent cough
Children: Recurrent �wheezy bronchitis�
Chest tightness or shortness of breath
! regular scripts (or purchase) of antibiotics, cough mixtures
Asthma: Aims of treatment
Control symptoms, incl nocturnal & exercise-induced
Prevent exacerbations
No need for rescue medication
Achieve best possible lung function (FEV1 &/or PEF > 80% predicted or best)
Minimise side effects
Asthma: Non pharmacological management
Allergen avoidance e.g. pollen, house dust mite, pets
Stop smoking
Lose weight if obese
Avoid exercise in cold air
Minimise occupational stimuli
Avoid NSAIDs & b-blockers
Immunotherapy, Buteyko breathing technique
Breastfeeding
Which b2-agonists are used in asthma and how do they have their effect?
short-acting: salbutamol, terbutaline
Onset 1-5 mins, duration 4-6 h
Bronchial smooth muscle relaxation
Enhance mucociliary clearance
First-line, symptomatic relief
long-acting (LABA):
salmeterol: Onset 10-20mins, duration 12 h
formoterol: Onset 1-3 mins, duration 12 h
Which corticosteroids are used in asthma and when to use them?
inhaled: e.g. beclomethasone, budesonide
Ciclesonide (new inhaled steroid)
oral: prednisolone
IV: hydrocortisone
Suppress inflammatory process
Use if:
�Exacerbation of asthma in last 2 yrs
�Using inh �2-agonist >3 times per wk
�Symptomatic >3 times per wk
�Waking 1 night per wk
Corticosteroids: ADR's
Inhaled
�hoarseness or dysphonia
�oral candidiasis
�adrenal suppression
>1500mcg beclomethasone daily
Oral
�hypertension
�adrenal suppression
�osteoporosis
�skin thinning
�hyperglycaemia
�moon face
�acne
Which leukotriene antagonists are used in asthma and how do they work?
Oral montelukast, zafirlukast
Antagonise bronchoconstriction, oedema and mucous production by LTC4, D4, E4
Which methylxanthines are used in asthma and how do they work?
oral: theophylline
iv/oral: aminophylline (salt of theophylline)
Causes
�bronchodilatation
�anti-inflammatory effects
SR preparations used to give more predictable effect
brand must remain constant
Methylxanthines: ADRs/od
Therapeutic range: 10-20mg/l
<20mg/l: nausea, diarrhoea, nervousness, headache
>20mg/l: vomiting, insomnia, arrhythmias
>35mg/l: hyperglycaemia, arrhythmias, convulsions, death
Methylxanthines: Factors affecting clearance
Reduce clearance (Increased plasma levels)
�CCF
�liver disease
�obesity
�enzyme inhibition e.g. cimetidine, erythromycin, allopurinol, ciprofloxacin
Increased clearance (Reduced plasma levels)
�smoking
�alcohol
�enzyme induction e.g. carbamazepine, rifampicin, phenytoin
Which cromones are used in asthma and how do they work?
What ADR's are associated with them?
Nedocromil: Preventer in 5-12y olds
Inhibits mediator release from mast cells
ADRs
�N&V
�bitter taste
�dyspepsia
Which immunosuppressants are used in asthma?
methotrexate, ciclosporin, gold
steroid-sparing agents
specialist use, rarely
Which anti Ig-E monoclonal antibodies are used in asthma and how is it used?
Omalizumab
Licensed as add-on therapy in adults and children > 12 for severe persistent allergic asthma
S/C injection every 2 to 4 wks
Only initiated by specialist centres
Patients must fulfil specific criteria (NICE)
Discontinue after 16 wks if inadequate response
Adult asthma management (BTS/SIGN guideline) : Step 1
Step 1: Mild, intermittent asthma
Inhaled short acting b2 agonist as req�d
What sort of information is included in an Asthma Action Plan?
When is an action plan issued?
Inhaler/PEF training
Knowledge of drug types
Recognition of worsening asthma
Action points e.g.
�� inhaled steroids
�start oral steroid
�seek medical attention
Consider for every asthmatic on an individual basis
Written, personalised
Describes PEF at which to:
�Double dose of inhaled steroid
�Start oral steroids
�Telephone GP or call ambulance
Evidence of improved health outcomes
Mod � severe disease, i.e. BTS Step 3 or above &/or previous admission
What is a PEF?
How is one done?
How do we use the information?
Peak Expiratory Flow rate
effort dependent
best of 3
available on FP10
dependent on sex, age, ht
% predicted normal or best
�e.g. <50% acute severe asthma
Acute severe asthma treatment: What do we immediately give to treat?
Severe or life-threatening?
Immediate Rx:
�oxygen: highest possible conc. 40-60%
�b-agonist: neb or multiple doses via spacer
�Cxsteroid: prednisolone 40-50mg po or 100mg iv hydrocortisone
Consider
�Ipratropium nebs
�Single dose IV magnesium sulphate
�iv aminophylline/iv salbutamol
Monitoring of acute severe asthma
PEF
O2 saturation
arterial blood gases
HR/RR
theophylline levels (if cont >24h)
serum K+/glucose
hydration
U&E's
Monitoring of Asthma
Are aims achieved?
�PEF
�b-agonist use
�symptoms
�ADRs
Inhaler technique
Review 3 monthly: step down if possible
Self-management plan/Action plan?
Treatment of acute severe asthma - non immediate
When to transfer to ITU?
How to treat during hospitalisation after acute attack?
When to discharge patient?
Transfer to ITU if
-Deteriorating PEF
�persistent hypoxia
�hypercapnia
�exhaustion, drowsiness
�coma, resp. arrest
During hospitalisation
�iv � neb � inhaler
�oral steroid 1-3 wks
�re-start steroid inhaler
�discharge criteria
�action plan
�check inhaler technique
Steroid inhaler probably started at higher dose than previously
Discharge only with PEF >75% predicted/best
diurnal variation <25%
Been on discharge medication for at least 24 hours
COPD
How to diagnose?
What are the stages of COPD and how are they characterised?
Airflow obstruction � usually progressive, not fully reversible and does not change markedly over several months
Diagnosis: symptoms + spirometry (FEV1 < 80% predicted and post bronchodilator FEV1/FVC < 0.7
Emphysema, chronic bronchitis, COAD
FEV1 ? 80% predicted = stage 1/mild
FEV1 50-79% predicted = stage 2/moderate (mild 2004)
FEV1 30-49% predicted = stage 3/severe (moderate 2004)
FEV1 < 30% predicted = stage 4/very severe (severe 2004)
COPD risk factors
Smoking
Age
Male
Alpha-1 antitrypsin deficiency
Occupation
Existing impaired lung function
Aims of COPD treatment
Stop smoking (only intervention shown to reduce lung function decline)
Improve symptoms
Prevent acute infective exacerbations
Reduce rate of disease progression
Maintain nutritional intake
Inc QoL
Which bronchodilators are used in COPD?
Continuous bronchodilation important
Short-acting �2 agonists e.g. salbutamol
�Onset 15mins, duration 4-6h
�Most commonly used b�dilator in COPD
LABAs e.g. salmeterol
� Duration 12h
- Modest inc in FEV1, but symptoms, exercise capacity, health status improved
Anticholinergics
�� vagal airway tone & reflex bronchoconstriction
�Short-acting: Ipratropium, oxitropium
�Long-acting: Tiotropium
�Use alone or add to �2 agonists if inadequate relief
�ADRs: dry mouth, occ urinary retention
Which methylxanthines are used in COPD?
What is their mode of action?
When are they used?
Which route are they given by?
Methylxanthines (see Asthma)
Mode of action
-strengthen diaphragm
-mucociliary clearance
-improve CNS response to hypoxaemia
Place in therapy
-Inadequate control with short- and long-acting bronchodilators
-Inhalers unsuitable
Caution: elderly
Oral
�Theophylline or aminophylline
IV
�Aminophylline: Loading dose (if no previous use) then continuous infusion
�Monitor levels
Interactions important
Which corticosteroids are used in COPD?
When are they used?
Inhaled beclomethasone, fluticasone, budesonide
Use for pts with
�FEV1 <50% predicted + 2 or more exacerbations requiring antibiotics or po steroids a year
�Higher doses required
�None licensed for use alone in COPD
Oral: only when oral steroids cannot be withdrawn after exacerbation
Oxygen in COPD: How does it work?
When is it used?
Criteria for LTOT
Mechanism
�Improves hypoxia & � work of breathing
Uses
�Used for acute exacerbations
�Long Term O2Therapy (>15h daily) prolongs life
24 - 28% O2 to prevent decrease in respiratory drive (O2 is stimulus for breathing due to chronic retention of CO2 - danger! High O2 concentrations)
LTOT
�criteria for use (NICE)
�hazard = smoking
�cylinders or concentrator
Assess people who have: very severe airflow obstruction FEV1 ? 30% predicted
cyanosis
polycythaemia
peripheral oedema
? JVP
O2 sat ? 92% on air
Vaccinations in COPD
Annual influenza vaccine
Pneumococcal vaccine
Antibiotics in COPD: When are they used and which ones?
Exacerbations only
Choice dependent on
�local policy
�lab sensitivity patterns
�previous Rx
Common brands are adequate, newer ones rarely appropriate
Which mucolytics are used in COPD?
How do they work?
Who should they be used for?
e.g. Carbocisteine, Mecysteine
Facilitate expectoration by reducing sputum viscosity
Consider in pts with chronic productive cough
Continue if improvement (stop after 4 wk trial if no benefit)
Shouldn't be used routinely to prevent exacerbations in people with stable COPD
Treatment of stable COPD
1. Short-acting bronchodilator as needed (�2-agonist or anticholinergic)
2. Still symptomatic: Combined short-acting �2-agonist with a short-acting anticholinergic
3. Still symptomatic: Long-acting bronchodilator (�2-agonist or anticholinergic)
4. In mod - severe COPD, consider combination of long-acting bronchodilator & inhaled Cxsteroid (Discontinue if no benefit after 4/52)
5. If still symptomatic, consider adding theophylline
Use inhaled Cxsteroids if criteria apply
Assess need for oxygen
Stop smoking, encourage exercise, nutrition, flu vaccine
Treatment of acute COPD exacerbations
Which pathogens are usually involved and which antibiotics to treat?
When to give antibiotics?
Other medication?
Pathogens:
�Haemophilus influenzae
�Streptococcus pneumoniae
�Moraxella catarrhalis
1st choice - Amoxycillin/tetracycline
2nd choice - broad spectrum cephalosporin/macrolide
Home 7d Hospital 7-14d
Antibiotics if 2 or more of
�Inc breathlessness
�Inc sputum volume
�Inc sputum purulence
Prednisolone 30mg for 7-14 days
Add or inc bronchodilator
Complications of COPD, symptoms of the complications and how to treat them?
Cor pulmonale
�Right heart failure - 90% due to COPD
�Symptoms: peripheral oedema, hepatomegaly
�Rx: diuretics reduce oedema
�O2 reduces hypoxia
Polycythemia
�? O2 ? ? RBC ? ? haematocrit ? ? Blood viscosity
�Prescribe O2 to ? hypoxia
�Venesection
Acute respiratory failure
Type 1 (emphysema)
�? O2 ? CO2 ? or N pH
�i.e. ventilation ? to compensate for ? O2
�DO NOT use doxapram (resp stimulant)
Type 2 (chronic bronchitis)
�? O2 ? CO2 ? pH
-i.e. ventilation insufficient to prevent ? CO2
�Assess need for NIV, consider respiratory stimulant: doxapram
COPD monitoring in community and hospital
Symptoms
Inhaler technique
Adverse effects
Blood gases
Sputum
Annual flu vaccine
Hospital:
-Theophylline levels
-blood gases
-U & E's
-HR/RR
-o2 sats
�Temperature
COPD symptoms
Current or ex-smoker with:
�Persistent cough
�Recurrent �bronchitis� in winter
�Breathlessness on exertion
�Wheezing
Smoking cessation
Ask about smoking status
Advise all smokers to stop
?Referral to smoking cessation service
Assist:
�Set a stop date
�Get family support
�Recommend NRT (pharmacist role)/Zyban (Rx only) - doubles chance of successfully stopping
�Arrange follow-up
Pharmacists responsibilities towards newly diagnosed pts
Ensure understanding of disease, education
Assess prescriptions:
�appropriate doses
�interactions
�sensitivities
�C/I
�Check pts have been shown how to use inhalers/take medicines
Spacer devices: Advantages and how to use
E.g. aerochamber, nebuhaler, volumatic
Avoid need for coordination with MDI
Inc lung deposition
Reduce deposition in mouth/throat
Caution! Dry in air after washing
Replace every 6-12 months
Factors affecting choice of inhaler
Depends on
�pt preference
�assessment of correct use
Consider:
�manual dexterity
�age
�portability
No evidence for correct order of use
Choice of drug may determine inhaler
Cost, e.g. Seretide 500 Accuhaler �40.92
How to obtain a nebuliser?
How to use?
Determine local policy:
�borrow from surgery/hospital?
�Purchase from pharmacy?
Advice
�Caution - over reliance (asthma)
�Mixing drugs
�Increased s/e compared with inhalers
�Servicing once/yr
Non specific monitoring for respiratory illness
General:
�Changes in Rx
�Symptoms, incl exercise limitation
�Inhaler technique
�Compliance
�Drug/disease interactions e.g. b-blockers
�Adverse effects, e.g.
- b-agonists - tremor
- inh steroids - thrush, hoarse voice
Oxygen therapy for respiratory disease: Who is it supplied by and how to order?
Supplied by commercial company for different parts of England, e.g. Air Products for NW
GP/hospital uses HOOF form to order
Provision of advice for pt &/or carer
Help monitor pts using O2
Reasons for treatment failures in respiratory illness
Consider:
�Failure to take medicines as Rx�d
- peer pressure, ADRs
�Failure to use devices correctly
�Failure to use peak flow meter regularly
�No Action Plan
�Drug causes e.g. sedative use in COPD
�Worsening of underlying disease or acute exacerbation
�Others
Asthma - counselling points
Smoking
Pets
Avoid NSAIDs, b-blockers
PEF + diary
COPD counselling points
Smoking
Nutrition
Avoid NSAIDs, b-blockers + sedatives
b-agonists in respiratory illness - counselling
Time to effect
ADRs � tremor
Short-acting
��Reliever�
�Use prn or regularly
�Blue
LABA
��Controller�
�Green
Inhaled C-steroids in respiratory illness - counselling points
�Preventers�
For inflammation
Use regularly, even if well
Rinse mouth
ADRs
Brown
Oral steroids in respiratory illness - counselling points
Usually short course
Carry steroid card if maintenance Rx
Continue with inh steroids
Take all tablets in morning
With/after food
ADRs - inc appetite, acne
Long-term ADRs � osteoporosis (consider prophylaxis) etc
Theophylline in respiratory illness - counselling points
Same brand
Take regularly but don�t inc dose if breathing worsens
Avoid OTC preps incl theophylline
ADRs � headache, irritability, nausea
Antibiotics in COPD - counselling points
Complete course
Take regularly
Drink plenty of fluids
Leukotriene antagonists in respiratory illness - counselling points
Take regularly
Combined hormonal contraception (CHC):
How effective?
What does it contain?
Mode of action?
Over 99% effective
Combined synthetic hormones
Ethinylestradiol and progestogenic agent
No corpora lutea development
Endometrium doesn�t develop
Cervical mucus �increase viscosity
CHC formulations
Oral tablets (COC)
Transdermal patch (Evra�) - see FFPRHC site
Vaginal delivery system (NuvaRing�)
CHC classifications and strengths
Monophasic - fixed amounts of oestrogen and progesterone
Phasic - varying amounts over cycleBiphasicTriphasic
Low strength: ethinylestradiol 20mcg
Standard strength: ethinylestradiol 30 or 35 mcg or 30/40 mcg in phased preparations
CHC types of hormone
Oestrogen- Ethinylestradiol
- Mestranol
Progestogen
- Norethisterone
- Ethynodiol
- Levonorgestrel
- Gestodene
- Desogestrel
Advantages of CHC
Reliable (nearly 100% effective) and reversible
Often reduces period pain and pre menstrual symptoms
Protects against some pelvic infections
Protects against cancer of the womb and ovary
Reduces risk of benign breast disease
Decreases the risk of iron deficiency anaemia
CHC disadvantages/when to stop treatment
Painful swelling in the calf of one leg
Sudden, severe pain in the chest or abdomen
Sudden breathlessness or coughing blood
thromboembolism
Unusual headaches, difficulty with speech/sight
More severe migraines than usual
Numbness or weakness of a limb
Risk of thromboembolism with CHC
Healthy, no COC, not pregnant
l5 cases per 100,000 women
COC 2nd Generation
l15 per 100,000
COC 3rd Generation
125 per 100,000
Pregnancy
l60 per 100,000
Contraindications with CHC
Cardio vascular + / or thrombosis risk or history
Certain migraines
migraine with focal aura
severe migraine lasting more than 72 hours despite treatment
migraine treated with ergot derivatives
Liver disease
Pregnancy
Carcinoma of breast or genital tract
Undiagnosed vaginal bleeding
Breast feeding
CHC - missed pills
"missed pill� is one that is ?24 hours late
If a woman misses only one pill:take an active pill as soon as she remembers & next one at the normal time
No additional precautions necessary
If she misses two or more pills
take an active pill as soon as she remembers & next one at the normal time
Also additional method of contraception (e.g. condom) or abstain from sex, for next 7 days
If these 7 days run beyond end of packet
Start next packet at once (omit pill-free interval)
Or for everyday (ED) pills, omit inactive tablets
Seek advice about EHC if
2 or more CHC tablets missed from first seven tablets in the packet and unprotected sex has occurred since finishing the last packet
CHC patch - delayed or detached patch
See BNF
Nuvaring - deviation from normal regimen
If outside vagina for less than 3 hours, may rinse and reinsert
If over 3 hours then see advice in SPC www.medicines.org
CHC link with cancer
contraceptive pill use is associated with a 12% decrease in the risk of developing cancer overall
statistically significant reduction in the rates of large bowel or rectal cancer and cancer of the uterine body or ovaries
no differences between ever and never users in their risk of breast cancer
no increase in the risk of cancers of the lung, cervix, central nervous system overall
there was a very small increased risk in cervical cancer in women using OC for 8 or more years (rate 38 per 100 000 woman years)
What reduces the effectiveness of CHC?
Broad spectrum antibiotics
- If short course additional precautions during and for 7 days after stopping
- If in pill free period start next pack straight away
- If longer than 3 week course additional precautions not needed
Diarrhoea and vomiting
- Up to 3 hours after taking pill
- Additional precautions for 7 days after recovery
- If in pill free period start next pack straight away
Liver enzyme inducers
- Carbamazepine, griseofulvin, phenytoin, phenobarbitone, rifampicin, rifabutin
- Reduce effectiveness of COC
- Short term course
- Additional precautions during course and for 7 days after stopping
- If in pill free period start next pack straight away
- Long or short term course of rifampicin & rifabutin
- Additional precautions during course and for at least four weeks after stopping
Oral progesterone only contraception (POP):
Effectivity?
Mode of action?
99% effective
Contains a type of progestogen only
Cervical mucus inc� viscosity
Changes in the endometrium
Prevents ovulation in 40% of cycles
POP advantages
Useful for women who cannot take oestrogens (with caution)
Including those at risk/with history of DVT
Heavy smokers
Older women
Hypertension
Diabetes
Migraine
POP disadvantages/when to stop treatment
Few serious side effects with POP
Main problem � irregular bleeding (tends to resolve on long term treatment)
POP contraindications
Pregnancy
Undiagnosed vaginal bleeding
Severe arterial disease
Active liver disease or carcinoma
Breast carcinoma (evidence uncertain)
POP - missed pills
If a woman misses a pill
- Take as soon as she remembers and carry on with next one at the right time
Protection may be lost if it is > 3 hours late (> 12 hours for Cerazette�)
- Continue normal pill-taking
- Also use additional method e.g. condom for the next two days
Faculty of Sexual and Reproductive Health Carewww.ffprhc.org.uk recommends emergency contraception if
- one or more POP tablets missed or taken > 3 hours late (> 12 hours for Cerazette�) and
- there has been unprotected sex before a further two tablets have taken
What reduces the effectiveness of POP?
Broad spectrum antibiotics
- POP not affected by broad spectrum antibiotics
Diarrhoea and vomiting
- Up to 3 hours after taking pill
- Additional precautions for 2 days after recovery
Liver inducing enzymes
- As for COC
EHC
Levonorgestrel
Ulipristal acetate
Intra-uterine device (IUD)
- NON HORMONAL emergency contraception
Levonorgestrel: Strengths available and how to take?
EHC
Levonorgestrel 1.5 mg
- Levonelle 1500 � [POM],
Levonorgestrel 1.5mg
- Levonelle One Step� [P]
Dose 1.5mg as single dose
Within 72 hours (3 days)
Vomit within 3 hours, extra dose
If taking enzyme inducer give one single 3mg dose (unlicensed dose)
Levonelle One Step� [P]
- Can be sold to women over 16 years
What does a pharmacist need to know before supplying EHC?
Unprotected sex within the last 72 hours?
Is EHC needed?
Client present in the pharmacy?
Client over 16 years?
Is client likely to be pregnant already?
Is client taking any medicines that may interact with Levonelle�?
Does client have any medical condition?
Does the client have liver problems?
Has the client had any previous allergic reactions to levonorgestrol?
Advice about how to take and side effects
ellaOne (EHC)
Ulipristal acetate 30mg tablet (POM)
Synthetic progesterone receptor modulator
May use up to 120 hours (5 days) of unprotected sexual intercourse or contraceptive failure
If vomiting occurs within 3 hours, repeat dose
EHC counselling
Next period early or late
Barrier method for 7 days or until next period
Lower abdominal pain see GP
- Possible ectopic pregnancy
Period could be different than usual
Types of parenteral progesterone only contraceptives, how to use and contraindications?
Medroxyprogesterone acetate (Depo Provera�)
- Intramuscular injection
- Every 3 months
- Long and short term use
- Delayed fertility and irregular cycles
- Reduction in bone mineral density, rare cases of osteoporosis and osteoporotic fractures
- CSM advice
- Adolescents - only if other methods inappropriate
- In all women review risks/benefits beyond 2 years
- Consider alternatives in women with risk factors for osteoporosis
Injections
- Norethisterone Enantate (Noristerat�)
- Intramuscular injection
- Every 8 weeks
- Short term
- Same cautions and contraindications as oral POP
Implants
- Etonogestrel (Implanon�)
- Flexible, single rod, subdermal
- 3 years
- Same cautions and contraindications as oral POP
Intra-uterine progesterone only contraceptive
Mode of action?
Levonorgestrol
- Mirena� system
- Releases hormone directly into the uterine cavity
- Good if heavy periods
- Fertility returns rapidly
Non hormonal contraception - intra-uterine device
Effectivity?
Mode of action?
Side effects?
Plastic frame wound with copper wire
98 - 99% effective
IUD stimulates foreign body reaction
Reduces chance successful implantation
Not an abortion
Side effects
- Bleeding
- Dysmenorrhoea
- Pelvic Inflammation
- Expulsion
- Perforation
- Pregnancy (greater risk of ectopic)
Non hormonal contraceptive devices
Diaphragms and Caps
- Barrier method
- Effectiveness influenced by experience, age, length of use
- Up to 96% effective
- Fit by trained family planning professional
- Always used with spermicide
- Left in-situ for 6-30 hours after intercourse
What is cystitis?
Types?
Inflammation of the (urinary) bladder and urethra
Either non bacterial cystitis or bacterial cystitis
Most common lower urinary tract problem experienced by women
Rare in men
Usually acute onset
Most attacks short, however can be severe and may suffer frequent episodes
Causes of cystitis
Bacterial cystitis
- Mainly E Coli
- Possibly Klebsiella, Proteus, Enterococci
Non bacterial cystitis
- Dehydration
- Perfumed toiletries
- Sexual intercourse (minor trauma)
- Synthetic underwear
- Oestrogen deficiency in postmenopausal women
Cystitis symptoms
The same for both bacterial and non bacterial
Lower urinary tract symptoms
- Frequency
- Urgency
- Dysuria (often reported as burning sensation when passing urine)
- Haematuria
- Suprapubic discomfort (possibly spreading to back)
Specific to bacterial cystitis more general symptoms such as nausea, vomiting and malaise
OTC treatment for cystitis and how to use them?
When to refer?
Alkalising agents;
- Sodium citrate - Canestan Oasis�, Cymalon�, Cystemme�
- One sachet three times daily for 48 hours
- Potassium citrate mixture
- 10mls, diluted with water three times daily
- Potassium citrate sachets Cystopurin�
- One sachet three times daily for 48 hours
Only for mild symptoms
Refer if no improvement after 2 days
Potassium citrate cautions - cystitis treatment
Renal impairment
Cardiac disease
Those predisposed to high potassium levels
- Potassium sparing diuretics
- ACE inhibitors
- Aldosterone antagonists
(see BNF for further information)
Sodium citrate cautions - cystitis treatment
Hypertension
Renal impairment
Cardiac disease
Pregnancy
Cystitis treatment options
Alkalising agents (sodium and potassium citrate)
Herbal products � (alkalinizing effect)
- Uva ursi tea
- Equisetum herb
- Lovage
Cranberry juice or capsules� (thought to inhibit microbial adherence to urinary epithelium if taken regularly)
Antibiotics � GP referral & investigation
(see BNF section on antibiotics)
Cystitis - non pharmacological advice
Drink plenty of fluids & empty bladder regularly (flushing effect)
Avoid alcohol and coffee (possible bladder irritants)
Pay attention to toilet hygiene!
Wear cotton underwear & avoid tight fitting clothes
Always empty bladder (fully) when need to
Analgesics � paracetamol / aspirin / ibuprofen
Cystitis: Who to refer?
Girls under 16 years
- To exclude UTI and kidney damage
Pregnancy
- Bacteruria in pregnancy can lead to kidney infection
Males presenting with symptoms
- Possibility of kidney/bladder stones or prostrate problems
Diabetics with recurrent cystitis
Haematuria (blood in urine)
- Excessive inflammation of the bladder lining, kidney stones, tumour (if haematuria and no pain)
Moderate to severe symptoms including fever and malaise
Duration longer than 2 days and failed OTC treatment
Thrush - causative organism?
Most common cause of vaginal infection in women of child bearing age
Caused by yeast - Candida albicans
Opportunistic organism
- Low levels in mouth, gut, skin
- Becomes pathogenic when natural balance of flora is upset
Thrush symptoms
Itching
Soreness
Discharge
- Usually creamy-coloured and thick
- No odour
Dysuria (pain on urination) may occur
Partner�s symptoms?
Thrush risk factors
Pregnancy
- Occurs in 15-20% of pregnant women
- Linked to hormonal changes
Diabetes
- Higher levels of glucose in tissue and blood may favour occurrence of Candida
Broad spectrum antibiotics
- Disrupt normal flora
- Steroid / immunosuppressant therapy
Oral contraceptives
Vitamin B and zinc deficiencies
Tight clothing, hot weather, strong scented bath foams
Thrush OTC products
Antifungals � Imidazoles
Clotrimazole (Canesten� - range of products)
Pessaries, internal and external creams for topical application
Antifungals � Triazoles
- Fluconazole - 150mg oral as single dose
- Peak plasma levels achieved after a few hours
- Long half life
- Liver enzyme inhibitors
- Anticoagulants
- Oral sulphonylureas
- Ciclosporin
- Phenytoin
- Theophylline
- C/I in pregnancy and breast feeding
- 16 � 60 years
Thrush - non pharmacology interventions
Decrease sugar in diet
Avoid using bubble bath / vaginal deodorants
Use K Y Jelly or Replens
Avoid tights, nylon underwear and tight fitting jeans
Use of live yogurt
Contains Lactobacilli that create and environment in which it is difficult for Candida to grow
Treatment of partner
Thrush - when to refer?
First occurrence of symptoms
More than 2 attacks in 6 months?
Under 16 or over 60
Pregnancy or suspected pregnancy
Abnormal bleeding
Dysuria / lower abdominal pain
Previous history of sexually transmitted disease
Any previous treatment failure
Dysmenorrhoea: Types and when they typically present?
2 types
Primary
- No underlying pathology - First occurs 6-12 months from onset of menarche - More common in women late teens to early twenties - Pain starts shortly before or during menstruation or both - Lasts for up to 72 hours
Secondary
- Presents in women in 30�s / 40�s- Presents after several years of painless periods- Most often due to underlying pelvic pathology- Pelvic inflammatory disease (PID)- Endometriosis- Fibroids
Dysmenorrhoea symptoms
Primary;
- Lower abdominal pain � congestive or spasmodic
- Bloating
- Nausea, vomiting, constipation and/or diarrhoea
- Headache
Secondary
- Pain persisting after period ends
- Intermenstrual bleeding
Dysmenorrhoea treatment
NSAIDs - decrease prostaglandin synthesis
Paracetamol
Hot water bottle
Bed rest
Moderate exercise
Secondary dysmenorrhoea;
- NSAIDs may help
PMS
A combination of distressing physical, psychological, and behavioural changes
Can start up to14 days before menstruation
Reports suggest that up to 95% of women will experience symptoms at some time!
PMS symptoms
Psychological
- Depression, mood swings or anxiety
Physical
- Abdominal bloating
- Breast tenderness
- Abdominal pain
-Water retention
- Headaches
Behavioural
- Reduced spatial awareness
PMS treatment
OTC treatments
- Vitamin B6 supplements
- 50-100mg daily
- Magnesium and Zinc supplements
- Menopace�
- Evening primrose oil supplements
- NSAIDs for pain relief
Consider referral if no response after 3 months
- Hormonal treatment � for moderate symptoms
- Combined oral contraception
- Antidepressant � for severe symptoms
- SSRI
- CBT
PMS - general advice
Talking with friends, family
Increased education can decrease anxiety
Maintain a menstrual diary
Exercise
Alter diet � regular, small, balanced meals rich in complex carbohydrates
Stop smoking
Restrict alcohol
Reduce stress
Osteoporosis: causes and characterisation
Low bone mass
Disruption of bone microarchitecture
Increased skeletal fragility and fracture risk
OP caused by: reduced osteoblast activity
increased osteoclast activity
low peak bone mass
Osteoporosis: signs and symptoms
Fracture
Reduced bone density
Pain
Reduced mobility
Kyphosis
Reduction in height
Osteoporosis risk factors
Hx of fracture
Hx of fracture in 1st degree relative
Smoking
Low body weight
Female
Oestrogen deficiency
Corticosteroid use
White race
Increase age
Low calcium intake
XS alcohol
Lack of exercise
Recurrent falls
Dementia
Impaired eyesight
Poor health/ frailty
Osteoporosis: Primary prevention
Adequate Ca and Vit D
Weight bearing exercise
Reduced alcohol intake
Stop smoking
Reduce risk of falls esp in elderly
Osteoporosis: Secondary prevention
Pharmacological management:
Calcium
Vit D
Calcitriol
HRT
SERMS
Bisphosphonates
Calcitonin
Strontium
PTH
Denosumab
In addition to lifestyle changes
Calcium in osteoporosis
Adequate dietary calcium(400mg-700mg/d)can prevent bone loss and risk of OP
Need extra if risk factors (500mg-1g)
Should only be used as adjunct to other Tx in at risk ps
Choice of preparation
Vitamin D in osteoporosis
Vit D helps control serum Ca levels
Obtained from diet (10%) or action of sunlight on skin (90%)
Metabolised to active form by liver and kidneys
800 units/day recommended supplement
Combined with Ca can increase bone mass and reduce fracture rate
Regular plasma Ca checks needed
Calcitriol
Vitamin D analogue
Licensed for use in PM women
May reduce vertebral fracture risk
250ng bd
Regular plasma Ca checks needed
Oral bisphosphonates: when and how to use?
Reduce bone resoprtion
To treat PM OP
To prevent and treat steroid-induced OP
Should be used as 1st line Tx
Alongside Ca+/- Vit D
Take 30-60mins away from food/ meds
Take while sitting/standing with full glass of water
Stay upright for 30-60mins after
Alendronate (Fosamax)- once weekly
Risedronate (Actonel)- once weekly
Ibandronate ( Bonviva)- once monthly
Parenteral bisphosphonates: When and how to use?
Zolendronate- first choice iv bisphosphonate
- Tx of postmenopausal osteoporosis
- Pts unresponsive / intolerant to oral
- Short iv infusion every 12 months
Ibandronate
- Tx of postmenopausal OP
- Pts unresponsive / intolerant to oral
- iv. bolus every 3 months
Pamidronate
- For men with established osteoporosis resistant to oral treatment
- Iv infusion every 3 months for 12 months
Denosumab in osteoporosis: when and how to use?
Monoclonal antibody
Just licensed / approved by NICE
For treatment / prevention of postmenopausal OP in women resistant / intolerant to oral bisphosphonates
Given by sc injection 2 / year
HRT in osteoporosis: When and how to use?
Oestrogens reduce bone resorption and increase Ca absorption
Prevention of PM OP in women intolerant/unresponsive to other treatments
Should be started early in menopause
Can continue for up to 5 yrs
Bone loss increases soon after stopping
Should not be used as 1st line treatment due to increased risk of breast Ca
Should not be used as long term prevention at >50yrs
HRT risks
Oestrogen only
- Increases risk of breast and endometrial Ca
- Increased risk of DVT,PE & stroke
Oestrogen and progestogen combined
- Increased risk of breast Ca compared to oestrogen only
- Reduced risk of endometrial Ca
- Increased risk of DVT, PE and stroke
SERM's in osteoporosis: When to use?
Mode of action?
Selective agonist and antagonist activity on oestrogen receptors
Reduce bone resorption
Treatment and prevention of OP
Used in women intolerant/unresponsive to bisphosphonates
Reduced risk of breast and endometrial Ca compared with traditional HRT
Does not redcue vasomotor menopausal symptoms
Still risk of DVT, PE , stroke
Calcitonin in osteoporosis: Mode of action and when to use?
Reduces bone resorption
Option if failed other treatments
Nasal spray
Injection
Strontium in osteoporosis: Mode of action
Increases bone production and reduces resorption
Licensed for treatment of PM OP
Awaiting NICE review
Parathyroid hormone in osteoporosis: Mode of action?
When and how to use?
Side effects?
Increases bone formation and reduces fracture rate
Restrictions as per NICE:
Women > 65yrs unresponsive/intolerant to bisphosphonate with either:
- vv low bone density
- v low bone density with more than 2 fractures and other risk factors
Daily s.c. injection
Max 18 mth course
Approx. �5,000/ course
Side effects
- Dizziness
- Leg cramps
- Antibody production
Types of influenza treatment
Vaccination
Zanamivir (Relenza) & Oseltamir (Tamiflu)
Amantadine
�antiviral
Who should have the influenza vaccine?
Over 65
Chronic respiratory disease
Chronic heart disease
Chronic renal disease
Chronic liver disease
Diabetes mellitus
Immunosuppressed
HIV
Influenza symptoms
Rapid onset
7 - 10 day duration
High fever
Aches and pains
Severe malaise
Severe sweating
Severe headache
Slight nasal symptoms
Sore throat infrequent
Cough infrequent
Bacterial infection common and severe
Cold symptoms
Slow onset
4 - 7 days duration
Slight fever
No aches and pains
Slight malaise
Slight sweating
Slight headache
Pronounced nasal symptoms
Frequent sore throat
Frequent cough
Bacterial infection uncommon and mild
Cold treatment
Self-limiting (1 to 2 weeks)
Rest
Maintaining an adequate fluid intake
Decongestant
Analgesics and antipyretics
Antihistamines
Steam inhalation
Decongestants: types and examples of each
Systemic V.s Topical
Sympathomimetics (alpha adrenergic agonists)
Systemic
�Ephedrine
�Pseudophedrine
�Phenylephrine
�Phenylpropanolamine
Topical
�Ephedrine
�Naphazoline
�Xylometazoline
�Oxymetazoline
Decongestant side effects
Topical
�Little systemic effect
�Local irritation
�Rebound congestion (rhinitis medicamentosa)
Systemic
Use caution
�Diabetes
�Hyperthyroidism
�Raised interocular pressure
�Prostatic hypertrophy
�MAOI
Antihistamines - use in colds: examples?
Mode of action?
Side effects?
Triprolidine
Chlorpheniramine
Brompheniramine
Pheniramine
diphenylpyraline
Intrinsic anticholinergic properties
Decrease mucus production
Side effects
Antihistamines - 1st generation - reduce rhinorrhoea, sneezing and weight of nasal secretions
Mainly due to anticholinergic effect
Drowsiness - side effect - benefit in sleep disturbance?
Anticholinergic cold preparations: mode of action
Ipratropium bromide intranasal spray
significantly reduced nasal drainage and sneezing
Echinacea for colds
Not enough evidence to recommend
Zinc for colds
No clear evidence
Vitamin C for colds
Reduces symptoms of URTI's but benefit is small
Sore throat: Symptoms and causes
Hoarseness � children �croup
Dysphagia
More than 1 week
Medication- steroid inhalers, carbimazole (agranulocytosis)
Bacterial sore throat symptoms
Rapid onset
Marked soreness
URTI and LRTI symptoms not always present
Large tender lymph nodes
Viral sore throat symptoms
Slower onset
Less marked soreness
URTI and LRTI symptoms usually present
Slight enlargement of lymph nodes, not usually tender
Sore throat treatments
Analgesics
Mouth washes and sprays
-Antiseptics
-Anti-inflammatory
-Local anaesthetics
Lozenges and pastilles
-Antiseptics
-Antifungal
-Local anaesthetics
Types of mouthwashes and sprays for sore throats
Antiseptics
�Chlorhexidine, hexedine, providone-iodine, cetylpyridinium
�Effective antimicrobial action
Anti-inflammatory-benzydamine
�Numbness and stinging
�Spray from 6 years, mouthwash from 12 years
Lozenges and pastilles for sore throat
Antifungal & antibacterial � dequalinium, tyrothricin
Local anaesthetics- benzocaine
�Insoluble in water
�action for 5-10 minutes
External ear conditions: types
Boil (furuncles)
Otomycosis
Dermatitis
Impacted cerumen
Foreign Objects
External otitis
Swimmer�s ear
Allergic/dermatitis
Middle ear conditions: types
Otitis media (infection � many virus)
Otitis Media With effusion (OME) � Glue ear
Tympanic membrane perforation
Otosclerosis
Vertigo (meniere�s disease)
Barotrauma
Ear condition treatments
Boil � antibiotics
External otitis
�Antibiotics and hydrocortisone drops
�5% aluminium acetate
Impacted wax
�Cerumen-softening agents � olive, aracis oil, urea, DDSS, hydrogen peroxide, sodium bicarbonate
Foreign objects
Otitis media � antibiotics?
�80% clear in 3 to 4 days
Barotrauma � sympathomimetics, amtihistamines, Valsalva�s maneuver
Factors in choosing an antibiotic
Sensitivity: active and no resistance (hospital microbiology departments will advise)
Get to site of infection?
Will patient tolerate drug: allergies, renal or liver function
Most appropriate route of administration?
Dose: affected by age, renal, hepatic function
Length of treatment
Side effects
Cost
Pneumonia: signs and symptoms
Purulent sputum
deterioration in blood gases
radiological changes
shortness of breath
Inc WBC count
pyrexia and fever
Lowered blood pressure
myalgia, arthralgia
Pneumonia diagnosis
sputum gram stain
x-ray
sputum & blood culture
Community Acquired Pneumonia: causative organisms
Influenza virus
Strep. pneumoniae (60-75%): lobar and broncho-pneumonia
Haemophilus influenzae (commonest cause in COPD): broncho-pneumonia
Mycoplasma pneumoniae (not so common in older patients)
Pneumococcus pneumoniae
Also less commonly Staph. aureus (in COPD or as super-infection), Legionella pneumophila
Community acquired pneumonia: treatment
Which drugs to use, when and for how long?
If patient is in high risk group, sputum sample should be collected
Viral: Relenza� (zanamivir), Tamiflu� (oseltamivir) Influenza A and B vaccines
Bacterial: Need to treat empirically (i.e. without knowing what the causative organism is)
amoxicillin 500mg tds po & clarithromycin 500mg bd po
COPD patients: Gram-ve & Staph infections:
? add quinolone if organism sensitive
�-lactamase-producing Haemophilus: ? co-amoxiclav
If seriously ill ? iv antibiotics (amoxicillin or co-amoxiclav plus clarithromycin)
Use CURB65 score to determine severity (3-5 = severe)
If allergic to penicillins ? clarithromycin
Treatment should be continued for 10 � 14 days
Alternative drugs: clindamycin: for gram+ve cocci, eg penicillin resistant staph, or metronidazole: for anaerobes
Tetracyclines can also be used for H inf and Mycoplasma
Community acquired pneumonia: When to admit infants?
Oxygen saturations < 92% air
Respiratory rate > 70 breaths/min
Difficulty breathing
Intermittent apnoea/grunting
Not feeding
Family not able to support the infant at home
Treatment of CAP in children
Treatment of children who are admitted
Oral and IV treatment are equivalent for CAP, so oral amoxicillin should be used
Oral group spend significantly less time in hospital and require less oxygen
Time to resolution of symptoms is the same in both groups
Use iv antibiotics when the child is severely ill or unable to absorb (e.g. co-amoxiclav, cefuroxime, cefotaxime)
Hospital acquired pneumonia: high risk pts
Mechanical ventilation
Recent surgery
Immunosuppressed
Recent broad spectrum antibiotics
Hospital acquired pneumonia: causative organisms
Gram negative � E coli, Klebsiella, Pseudomonas spp
Gram positive � Strep pneumoniae, Staph aureus
Occasionally fungi � Candida, Aspergillus spp
Hospital acquired pneumonia: treatment
Which drugs and when, and how long to treat
Empiric intravenous antibiotics � penicillin with beta-lactamase inhibitor:
Augmentin�
Tazocin�
Timentin�
Cephalosporins, carbapenems, aminoglycosides, quinolones in penicillin allergy
Sputum culture and sensitivity determine further treatment; antibiotic resistance
Treat for 14 days
Broad spectrum antibiotics used ***risk of Clostridium difficile high***
Aspiration pneumonia: Who's at risk?
Which organisms?
How to treat?
Hospital or community acquired
High risk patients
Impaired swallowing � e.g. stroke, Parkinson�s disease, Myasthenia gravis, other neurological conditions
Mechanical ventilation
Recent surgery
Organisms � from GI tract
Gram negative � E coli, Klebsiella spp
Anaerobes
Treatment � as for community or hospital acquired but cover anaerobes in addition
- metronidazole (IV, rectal or oral)
Non gonococcal urethritis - causative organisms
Chlamydia trachomatis 30-50%
Ureaplasma urealyticum 10-30%
Mycoplasma genitalum 20%
Not known 30%
Non gonococcal urethritis - symptoms
Pain on passing urine (dysuria), penile tip irritation
Discharge from penis: clear, creamy, yellow
Sometimes symptom-free
Non-gonococcal urethritis - treatment
Azithromycin 1g as a single dose or doxycycline 100mg bd 7 days
Alternative: treat with eythromycin 500mg qds 14 days
Contact tracing recommended
Gonorrhoea: signs and symptoms
Can get rectal or throat infection as well as genital; usually symptom-free
Men
- Urethritis, or infection of testicles and epididymides causes swelling and pain in the testicles
Women
- Infection of cervix �vaginal discharge (not always)
- Infection in uterus and Fallopian tubes� abdomen pain
Gonorrhoea - treatment
Some resistance to penicillins (?-lactamase gene), tetracyclines (plasmid-mediated), and 4-quinolones.
Uncomplicated: ciprofloxacin 500mg single dose
Oropharyngeal: ciprofloxacin (5/7) or IV ceftriaxone (5/7)
Again, contact tracing recommended
Thrush: causative organism, symptoms and treatment
Candida albicans
White itchy discharge, soreness
Topical vaginal application of an imidazole (clotrimazole, econazole, ketoconazole or miconazole) as vaginal tablets, ovules or creams
SR preparations, requiring single insertion e.g. clotrimazole 500mg
In vulvitis, creams should also be applied
Single dose oral fluconazole 150mg or itraconazole 200mg is as effective as topical treatment
Bacterial vaginosis: casuative organisms, symptoms and treatment
Many, often caused by: Gardnerella vaginalis
Signs and symptoms
- Sometimes symptom-free
- Discharge: grey-white, malodorous
- Sometimes painful or sore vagina
Treatment
Oral metronidazole 400mg bd for one week
Recurrence is common
Trichomonas vaginalis: causative organism, symptoms and treatment
Causative organism: Trichomonas vaginalis (protozoan)
Much more common in women
Transmitted during sexual intercourse
Can be spread through sharing towels
Can cause urethritis in men
Signs and symptoms
- Yellow frothy discharge, often malodorous
- Itching and sore vulva
- Pain on passing urine and during sex
Treatment
Metronidazole 2g single dose
Treatment failure is common
Genital herpes: causative organism, symptoms and treatment
Herpes simplex virus (HSV): 2 forms: HSV1 and HSV2
Sexually transmitted infections are predominantly HSV2
The virus is spread by direct contact with an infected person
Recurrence is common
Signs and symptoms
-Tingling sensation followed by small fluid-filled blisters
- Blisters burst to reveal ulcers
- Sometimes flu-like symptoms
Treatment
- Oral aciclovir 200mg 5 times a day for 5 days, started as soon as prodromal symptoms become apparent
- Topical 5% aciclovir cream applied 5 times a day for 5 days
- First bout may take 2-4 weeks to heal: highly infectious during this time
Syphilis: causative organism and symptoms
Causative organism: Treponema pallidum
Signs and symptoms
Primary syphilis presents as a painless but highly infectious, ulcer (chancre) at the site of infection
- Heal without treatment in 2-6 weeks, remain infected, with some lymphadenopathy
Secondary syphilis
- Non-irritating rash on the chest, back, palms and soles of the feet
- Hoarseness, lymph node enlargement
- Sometimes wart-like growths around the genitals
- Can resolve without treatment
Tertiary syphilis: neurological, cardiovascular disease, gummas, congenital syphilis
Syphilis treatment
Intramuscular procaine penicillin (= benzathine benzylpenicillin), single dose
Standard treatment of syphilis more than two years after infection will not prevent neurological involvement, so 1200mg procaine penicillin i.m. is given weekly for 2 weeks
In case of allergy, use doxycycline 100mg bd for 14 days in early syphilis and for 28 days for syphilis of more than two year�s duration
Genital warts: causative organism, symptoms and treatment
Causative organism: Human papilloma virus (HPV)
Signs and symptoms
- Painless but itchy
Treatment
- Podophyllotoxin 0.5% applied twice daily for three days
- Application of trichloroacetic acid
- Scissor excision
- Freezing or electrocautery, surgery (rare)
- May be associated with precancerous changes in the cervix
- High recurrence rate
HPV vaccine: Who to use it in?
Which types do they prevent against?
Which one is used in the UK, why?
Cervarix� and Gardasil� � licensed for use in girls and young women aged 9 � 26
Protection against HPV types 16, 18 / 6, 11, 16 and 18
90% of all genital warts caused by HPV types 6 and 11
70% of all cervical cancers caused by HPV types 16 and 18
Routine vaccination to be given to 12-13 year-old girls from September 2008; two-year catch up for girls up to 18
In UK concerns about effect of increasing promiscuity; only country to use Cervarix� vaccine
Safety and potential use in boys and young men?
Chlamydia: causative organism, symptoms and treatment
Chlamydia trachomatis
Signs and symptoms in women
- Some vaginal discharge, itching and sore vulva
- Pain on passing urine, abdominal pain
- Irregular menstrual bleeding
- Swollen, red eyes
Asymptomatic in 80% of women and 50% men
Treatment
- Single dose azithromycin. 7 days of doxycycline or 14 days erythromycin can also be used
- No sex (of any sort) until drugs taken
Common causative agents of UTI's
E coli
Strep faecalis
Proteus spp
Pseudomonas spp
Klebsiella spp
Antibiotics used in cystitis
Trimethoprim (70% effective)
Nitrofurantoin, cephalosporins, co-amoxiclav, 4-quinolones, gentamicin
Not amoxicillin
Duration: 3-5 days
Antibiotics used for recurrent UTI's
Prophylactic trimethoprim
3-6 months
Antibiotics used in acute pyelonephritis
2nd generation cephalosporin, 4-quinolone, gentamicin
10-14 days
2nd generation cephalosporin, 4-quinolone, gentamicin
Antibiotics used in asymptomatic bacteruia
treat in pregnancy with amoxicillin
often needlessly treated (esp in hospitalised patients with catheters)
7 days
UTI features
UTIs are common in healthy adults, particularly women
cystitis produces symptoms of frequency, dysuria, urgency
ascending infection causes pyelonephritis (loin pain, fever, malaise)
UTI less common in men due to extra urethral length
Repeated episodes need to be investigated
- possibility of kidney stones needs to be eliminated
- midstream urine test done
- local obstruction must be treated
Management of UTI in women: prevention, when to treat and in pregnancy
Prevent by
- maintaining adequate fluid intake
- ensure bladder is fully empty
- empty bladder after sexual intercourse
Treat only
- when woman is symptomatic
- and urine tests positive for signs of infection (nitrites, WBCs)
In pregnancy
- UTI is common
- may lead to acute pyelonephritis
- screen for bacteruria at first visit and treat with antibiotics even if no symptoms
Management of UTI in children
1% boys <11 develop a UTI, 3x in girls, most infections <12 months of age
risk of upper tract infection and scarring
vesicoureteric reflux present in 25-50% infections
Most infections only need 3-5 days antibiotics
Trimethoprim side effects
Blood disorders long term
Nitrofurantoin side effects
Nausea, GI disturbance
Rarely, pulmonary reactions, peripheral neuropathy
Contraindicated in renal impairment
Cephalosporin/penicillin side effects
GI disturbance (allergy, C diff)
4-quinolones side effects
GI disturbance, N&V
Rarely arthralgia, tendon damage
Gentamycin side effects
Nephro , ototoxic
Meningitis risk factors
Age; under 5s and teenagers / young adults (14-24)
In neonates, maternal infection at birth
Children with facial cellulitis, sinusitis
Head trauma
Chronic disease
Splenectomy (vaccinations, prophylactic penicillin)
How can organisms enter the CNS to cause meningitis?
Spread via the blood (haematogenous) from another site in the body - most common
Direct spread from sinuses or middle ear � less common
Defects in skull or spinal column
- Congenital or acquired
Causative organisms for meningitis in neonates
E coli
other G negative; ? haemolytic Strep from mother
Causative organisms for meningitis in 6month-5year age group
Neisseria meningitidis
Strep pneumoniae
H influenzae in developing countries (no vaccination)
Causative organisms for meningitis in 5-40 year age group
Neisseria meningiditis,
Strep pneumoniae
Causative organisms for meningitis in the over 40 age group
Strep pneumoniae,
Staph aureus,
Neisseria meningitidis; Listeria in the elderly
Causative organisms for meningitis in those with a skull injury/defect
Staph aureus
Viral causes of meningitis
Viral causes include Herpes simplex, Varicella zoster, mumps virus
Meningitis: signs and symptoms in adults and older children
Headache (80%)
Neck stiffness (70%)
High temperature, confusion
Also photophobia and/or phonophobia
Petechial rash
�Usually only associated with meningococcal disease
Meningitis symptoms in small children
Often only irritable (inconsolable crying or when picked up/held)
Poor feeding, bulging fontanelle in babies
Cold extremities, abnormal skin colour (septicaemia)
Petechial rash
�Usually only associated with meningococcal disease
Tests to confirm meningitis
Analysis of cerebrospinal fluid obtained through lumbar puncture
�Protein � increased in bacterial meningitis
�WBCs � greater risk of meningitis if increased
�Glucose � less than 50% ? bacterial meningitis
�Bacterial culture (can take 48hrs for result)
Lumbar puncture must not delay treatment (30 mins max wait)
FBC (markers of infection / inflammation) e.g. CRP, ESR, WBCs
Blood culture (septicaemia)
Meningitis complications
Seizures and neurological sequalae e.g. hearing loss, visual field defects, palsies
Low blood pressure ? under-perfused organs
Disseminated intravascular coagulation (DIC) due to activation of clotting cascade
Adrenal failure caused by haemorrhage
Septicaemia
- Meningococcal
�Gangrene of limbs
Meningitis treatment
Empirical antibiotics
- Benzylpenicillin: i.v. 2.4g every 4h in adults
- Cefotaxime: i.v. 2g every 6h in adults or ceftriaxone
- Chloramphenicol in true penicillin and cephalosporin allergy
Course length: 10-14 days
Review antibiotic when culture and sensitivities return
Eradicate nasopharangeal carriage - oral rifampicin additional 2-4 day course
Supportive treatment for meningitis
In addition to antibiotics, patient may require
�Hydration therapy (to increase BP, treat septic shock)
�Paracetamol to reduce fever
�Dexamethasone to reduce cerebral inflammation (hence neurological complications)
�Oxygen or ventilation if breathing difficulties
�Anti-epileptic medication if seizures
�Dialysis if kidney failure
Consequences of meningitis treatment
Risk of C difficile overgrowth with broad-spectrum cephalosporins
Chloramphenicol � blood disorders; FBC must be monitored
Antibiotics cause paradoxical increase in cerebral oedema due to bacterial death
Blood flow decreased, harder to obtain therapeutic antibiotic concentrations
Meningitis: treatment of contacts
Close contacts given 2-4 days rifampicin in meningococcal or H influenzae disease
Single dose ciprofloxacin (unlicenced) can be used in meningococcal disease
Rifampicin prophylaxis indicated in epidemics
Meningitis vaccines
What does PEG tube stand for?
Percutaneous endoscopic gastrostomy tube
What types of drug should never be crushed to administer down an enteral feeding tube?
Enteric coated
Modified release
Cytotoxics and hormones
Which specific drugs can be a problem for administration down an enteral feeding tube and why? What can be done to improve the situation?
Penicillin: the feed may reduce absorption of penicillin - increased dose may be needed, if poss stop feed for one hour before and two hours after administration
Antacids: metal ions bind to protein in the feed and may block the tube - consider alternative drugs
Phenytoin, digoxin, carbamazepine: blood levels may be affected by feeds - check regularly, dose may need to be increased
Other antibiotics: levels of cipro, tetracyclines and rifampicin etc can be reduced by the feed - consider other drugs or increase dose
What are the consequences of malnutrition?
Poor wound healing
Weakness and loss of muscle mass
Apathy and depression
Reduced immune response
Increased morbidity and mortality
What are the benefits of enteral nutrition?
More physiological
Less risk of infection
Maintain GI tract
Gut bacterial translocation?
Costs less
Easier for home patients
How can EN be administered?
Orally - sip feed
Naso-gastric tube
Percutaneous Endoscopic Gastrostomy tube
What problems can develop with EN?
Diarrhoea
Regurgitation
Abdominal distention
Blocked feeding tube
Problems with the pump
What questions should be asked before administering medication down a feeding tube?
Can the patient take the meds orally?
Are all the drugs necessary?
Can alternative routes be used?
Can another drug from the same class be used?
Is the drug available in a more appropriate formulation?
What ADR's are associated with b-agonists?
fine tremor
nervous tension
headache
peripheral vasodilatation
tachycardia
hypokalaemia
What ADR's are associated with leukotriene antagonists?
GI upset
abdo pain
headache
Adult BTS guidelines for asthma: Step 2
Step 2: Regular preventer therapy
Add inhaled steroid, dose appropriate to severity
Adult BTS guidelines for asthma: Step 3
Step 3: Add-on therapy
Add LABA
Assess control & continue if good
If inadequate, continue LABA & inc inhaled steroid dose
No response to LABA - stop & inc inhaled steroid dose
Adult BTS guidelines for asthma: Step 4
Step 4: Persistent poor control
Consider trials of:
�Inc inhaled steroid
�add another drug, eg leukotriene antagonist, SR theophylline, b2 agonist tablet
Adult BTS guidelines for asthma: Step 5
Step 5: Continuous or frequent use of oral steroids
Use daily steroid tablet in lowest dose to give control
Maintain high dose inhaled steroid
When to use TPN?
When EN is not an option;
- cannot take anything by mouth or GI tract
- "gut failure" - unable to digest or absorb food
- the GI tract may be unavailable or unable to absorb nutrients
- may be short or long term
Indications for short term TPN?
Awaiting feeding tubes
Bowel obstruction
Following major excisional surgery
ICU pts with MOSF
Minority of pts with IBD
Severe pancreatitis
Indications for long term TPN?
Radiation enteritis
Crohn's disease following multiple resections
Motility disorders e.g. scleroderma
Bowel infarction
Cancer surgery
How can TPN be administered?
Peripheral line via venflon - short term use
Peripherally inserted central catheter (PICC) - likely to be over two weeks or more use
A central line - long term or when suitable veins cant be found - infection dangerous
Basic contents of a TPN bag
Nitrogen (protein)
Glucose (carbohydrates)
Fat (not in all)
Fluid
Electrolytes
Vitamins
Trace elements
Monitoring for a patient on TPN?
Clinical history
U&E's
LFTs
FBC including folate and vitamin B12
Trace elements
Vitamins
Fluid balance
U&E monitoring frequency and rationale for a patient on TPN
Daily - 3/7
Fluid and electrolyte balance
PO4, Mg, Ca monitoring frequency and rationale for a patient on TPN
Daily - 2/7
Refeeding - adequacy of the regimen
LFTs and CRP monitoring frequency and rationale for a patient on TPN
2/7
Liver and acute phase response
FBC monitoring frequency and rationale for a patient on TPN
2/7
Infection/anaemia
Blood glucose monitoring frequency and rationale for a patient on TPN
4hrly - weekly
hypo/hyperglycaemia
Trace elements monitoring frequency and rationale for a patient on TPN
Weekly/monthly
Adequacy of regimen
Weight monitoring frequency and rationale for a patient on TPN
Daily - weekly
Nutritional status/fluid balance
Anthropometry monitoring frequency and rationale for a patient on TPN
Fortnightly
Nutritional status
Temperature monitoring frequency and rationale for a patient on TPN
Daily
Infection
Line site monitoring frequency and rationale for a patient on TPN
Daily
Infection
Fluid balance monitoring frequency and rationale for a patient on TPN
Daily
Fluid and electrolyte requirement
Complications of TPN
Air embolism
Catheter blockage
Central line infection
Metabolic problems e.g. hypoglycaemia, impaired liver function
Bone disease
Signs and symptoms of anaemia
Fatigue
Breathlessness
Dizziness
Headache
Insomnia
Pallor
Palpitations, tachycardia, systolic murmurs
Anorexia
Pins and needles
Angina
Anaemia classifications
Macrocytic - large cells
Microcytic - small cells
Normocytic - normal sized cells
Causes of anaemia
Reduced red cell production
- iron deficiency
- megaloblastic anaemia
- sideroblastic anaemia
- aplastic anaemia
Increased requirements
- pregnancy/lactation
Excessive red cell destruction
- G6PD deficiency
Blood loss
- acute trauma
- chronic e.g. GI bleed
Causes of iron deficiency anaemia
(Microcytic anaemia)
Reduced intake: poor diet
Increased requirements: pregnancy, lactation
Blood loss: trauma, GI bleed, menstruation
Treatment or iron deficiency anaemia
Find and treat underlying cause
and/or
Iron therapy
Oral Fe - 1st line
- Avoid OTC sales without investigation
- 100-200mg for deficiency
- 60-130mg for prophylaxis
- Haemoglobin should rise by 2g/100ml over 3-4 weeks
- Treat for a further 3 months after normal levels reached
Oral iron products: salts, combination products, modified release
Different salts have different amounts of elemental iron
- Ferrous sulphate 300mg = 60mg
- Ferrous gluconate 300mg = 35mg
Combo products - only one recommended - with folic acid for prophylaxis in pregnancy
Modified release
- e.g. Ferrograd
- fewer side effects as have less iron
- poor absorption due to max absorption occurring in duodenum
- BNF - no therapeutic advantage, don't use
Oral iron side effects
Nausea
Epigastric pain
Diarrhoea/constipation
Dark stools
Manage by;
- taking with food
- change salt
Parenteral iron therapy: When to use? Formulations? Problems?
Use only if oral is not possible
- not any quicker than oral in most cases
Indications
- malabsorption
- unable to tolerate oral iron
- continuing blood loss
- chronic renal failure
Iron dextran (i.v. and i.m.)
Iron sucrose (i.v.)
Problems
- painful
- stains skin
- risk of anaphylaxis
Megaloblastic anaemia: type of anaemia, causes and treatment
Macrocytic anaemia
Due to;
- folic acid deficiency - poor diet - alcoholism - malabsorption - pregnancy - drugs
- vitamin B12 deficiency - lack of intrinsic factor - GI surgery - Bacterial overgrowth - Tape worm - Strict veganism - may cause peripheral neuropathy as a symptom
Treatment
- oral folic acid 5mg daily for 4 months
- hydrocoxobalamin i.m. - 1mg alternate days - then 1 mg every 3 months - lifelong treatment
Production of red blood cells
In bone marrow
- erythroblasts
- normoblasts
In circulation
- reticulocytes
- erythrocytes
Lifespan typically 120 days
Microcytic anaemia - lab test characteristics
RBC - reduced
MCV - reduced
HB - reduced
MCHC - unchanged
Serum Fe - reduced
TIBC - Increased
Reticulocyte count - variable
Macrocytic anaemia - lab test characteristics
RBC - reduced
MCV - increased
HB - decreased
MCHC - unchanged
Serum Fe - unchanged
TIBC - unchanged
Reticulocyte count - reduced
Normocytic anaemia - lab test characteristics
RBC - reduced
MCV - unchanged
HB - reduced
MCHC - reduced
Serum Fe - reduced
TIBC - unchanged or reduced
Reticulocyte count - increased or decreased
Types of short acting insulin
Human Actarapid
Humulin S
Onset: 1/2 - 1 hr
Peak: 2-3 hr
Duration: 8-10 hr
Types of rapid acting insulin analogues
Humalog (insulin lispro)
Novorapid (insulin aspart)
Onset: 15-30 min
Peak: 30-90 min
Duration: 4-6 hr
Types of intermediate insulin
Human insulatard
Humulin I
Onset: 2-4 hr
Peak: 4-10 hr
Duration: 12-18 hr
Types of long acting insulin
Insulin zinc suspension - Hypurine Bovine Lente
Protamine zinc - Hypurin Bovine Protamine Zinc
Onset: 2-10 hr
Peak: 4-16 hr
Duration: up to 24 hr
Types of long acting insulin analogues
Insulin glargine (Lantus)
Detemir (Levemir)
Flat profile (no peak)
Onset: 2-4 hr
Duration: 20-24
Types of biphasic insulin
Human mixtard 30
Humulin M3
Humalog Mix 25, 50
Novomix 30
Onset: 1/2 hr
Peak: 1-12 hr
Duration up to 12 hr
Metformin in type 2 diabetes: When to use?
Mode of action?
Advantages?
First line choice if overweight
Reduces hepatic gluconeogenesis
Inc peripheral utilisation of glucose
Doesn't cause weight gain or hypos
Metformin side effects
Serious GI disturbances
- anorexia
- nausea
- diarrhoea
Lactic acidosis (rare)
- renal impairment major risk factor (also hepatic or cardiac failure)
How to take metformin
Start with low dose (500mg daily)
Take during or after food
Increase slowly
Take in divided doses 2-3 times daily
Sulphonylureas: examples
When to use?
Mode of action?
Gliclazide
Glibenclamide
Chlorpropamide
Use first line in non obese type 2's
Stimulates insulin production by the pancreas (needs residual pancreatic function)
Can cause hypo's if meals missed
Avoid long acting in elderly
Gliclazide dose and side effects
Starting dose 40-80 mg od
Usual dose 80-160 mg bd
Hypo
Weight gain
Mild GI disturbances
Glitazones (pioglitazone):
Mode of action?
When used?
Enhanced insulin sensitivity
Reduces hepatic glucose production
Used in combination therapy if pt unable to take metformin and sulphonylurea combo
Monitoring needed for pioglitazone
LFT's before starting and yearly
Pioglitzone: side effects and contraindications
Dose?
Weight gain
C/I in heart failure
15mg initially then up to 45 mg OD
Prandial glucose regulators: examples
Mode of action
When to use?
Dose?
Repaglinide
Nateglinide
Stimulate insulin secretion
Less likely to cause hypo
Use to control post prandial hyperglycaemia in combo
Take immediately before food - omit dose if meal missed
Acarbose: Mode of action?
Dose?
Side effects?
Intestinal alpha glucosidase inhibitor that inhibits absorption of starch and sugars
Can lower blood glucose
Start at 50 mg increase slowly to 100-200 mg tds
GI side effects problematic - flatulence
Must be chewed with first mouthful of food to be swallowed
Useful for post prandial hyperglycaemia
Incretin mimetics: examples
Mode of action
When to use?
Dose?
Exenatide
Liraglutide
Inhibits gastric emptying and reduces appetite
Licensed for pts not achieving control with metformin and sulphonyls
s/c injections
GI side effects, transient
Pancreatitis risk
Incretin enhancers: examples
Mode?
Sitagliptin
Vildaglyptin
Saxaglyptin
Blocks rapid degredation of GLP-1
Well tolerated but concerns about immune system
Treatment of painful diabetic neuropathy
1st line: Amitriptylline/nortriptylline 10-75mg unlicensed
2nd line: Gabapentin, pregabalin, duloxetine licensed
3rd line: topical capsacin cream, lidocaine patches, tramodol or accupuncture