Commonly Prescribed Drugs in Community

Anti-hypertensives

<55y Add ACEi ACEi Add Spironolactone + Thiazide-like diuretic or >55y or Afro-Caribbean Ca channel blocker (chlortalidone, indapamide) α- or β-blocker Ca channel blocker

Oral hypoglycaemics

Add Try Sulfonylurea (if not on Metformin Triple oral therapy Diet it) or Thiazolidinedione (or sulfonylurea if thin) or add (not if LVF) or Insulin DPP-4 inhibitor

Drug class Drug name Mechanism Side effects Contraindications Biguanides Metformin ↑insulin sensitivity and supress -GI disturbance -Low BMI gluconeogenesis -Weight loss -Creatinine >150 or GFR -Lactic acidosis <30 -Metallic taste Sulfonylureas Gliclazide, Glibenclamide ↑β-cell insulin secretion -Hypos -Patients at risk of hypos (must be at mealtimes) -Weight gain -Severe hepatic/renal impairment Thiazolidinedione -glitazones e.g. Pioglitazone PPARγ agonist → increases -Fluid retention -Heart failure fat/muscle glucose uptake -Fractures (glitazones and -History of bladder broken bones) cancer -Hepatotoxic -Weight gain DPP4-inhibitors Sitagliptin Inhibits DPP4 which breaks down -Pancreatitis has been GLP-1 (a hormone released by the reported gut to ↑insulin after food) GLP-1 agonist (S/C) Exenatide Mimics GLP-1 (a hormone released -GI disturbance and -GFR <50 by the gut to ↑insulin after food) indigestion -History of pancreatitis -Pancreatitis -Severe gastrointestinal -Weight loss disease SGLT2-inhibitors -flozins e.g. Dapagliflozin, Increase urinary glucose excretion -UTIs -GFR <30 Canagliflozin, Empagliflozin -Ketoacidosis Meglitinide -glinides e.g. Repaglinide, Closes ATP-dependant K+ channel of -Hypos -Patients at risk of hypos Nateglinide β-cells → insulin release pre-meal -Weight gain

Note: only metformin and insulin are known to be safe in pregnancy; all drugs should be temporarily discontinued in ketoacidosis; metformin should be temporarily discontinued in lactic acidosis, peri-operatively and if using iodinated contrast agents. Note: aim HbA1c 48-58mmol/mol

Asthma ladder

Trials of: medium- Inhaled steroid Add dose inhaled steroid; Trials of: high-dose inhaled steroid; (beclometasone, Inhaled long- long-acting muscarinic Add budesonide, antagonist; fourth drug acting β2 agonist Daily steroid ciclesonide, leukotriene receptor (choose from: (salmeterol, antagonist tablet fluticasone, previous step plus formoterol) (montelukast); β2 agonist tablet) mometasone) SR theophylline

PULS Inhaled Short-acting β2 agonist (salbutamol)

ALL PATIENTS Inhaled Short-acting β2 agonist (salbutamol) OR Short-acting anti-muscarinic (ipratropium) PRN

Inhaled long-acting β2 Add Inhaled steroid agonist (beclometasone, (salmeterol, formoterol) budesonide, ciclesonide, fluticasone, mometasone) Inhaled long-acting β FEV1 ≥50% 2 Or agonist (mild/moderate) Inhaled long-acting + anti-muscarinic Inhaled long-acting anti- (tiotropium) muscarinic FEV1 ≤50% + Or (severe/ very severe) Inhaled steroid Inhaled long-acting β2 agonist + Inhaled steroid

Combination inhalers Seretide = salmeterol + fluticasone Symbicort = formoterol + budesonide Fostair = formoterol + beclometasone

Hormone replacement therapy  Routes of administration o Systemic: oral; transdermal (patches or gels) – available in oestrogen-only or combined preparations o Vaginal (for urogenital atrophy): tablet, cream, pessary or vaginal ring  Types of systemic therapy o No uterus → oestrogen-only HRT (oral or transdermal) o Uterus . Peri-menopausal → cyclical HRT (oestrogen every day, but oestrogen and progesterone given together for 12-14 days to cause bleed at the end of every menstrual cycle (‘monthly’) if still having regular periods or every 13 weeks (‘three-monthly’) if having irregular periods) . Post-menopausal (i.e. no periods for >1 year or been on cyclical HRT for >1year) → continuous HRT (continuous combined oestrogen and progesterone – no bleed)

Contraindications: undiagnosed PV bleeding; pregnancy/breastfeeding; oestrogen dependant cancer; active liver disease; uncontrolled hypertension; history of breast cancer; history of venous thromboembolism; recent stroke/MI/angina Side effects: vaginal bleeding; premenstrual syndrome; breast tenderness; leg cramps; nausea/bloating Long term risks: increased venous thromboembolic risk; increased stroke risk; increased breast cancer risk with time; increased ovarian cancer risk >5y; increased endometrial cancer risk (but only with unopposed oestrogen)

Antidepressants

Drug class Drug name Mechanism Side effects Notes Selective serotonin reuptake Fluoxetine, Citalopram, Increase extracellular -Sexual dysfunction -Safe in overdose inhibitors (SSRIs) Paroxetine, Sertraline serotonin by limiting its -Withdrawal -May increase suicide 1st line reabsorption -Insomnia risk -Hyponatraemia

Serotonin-noradrenaline Duloxetine, Venlafaxine Increase extracellular -Similar to SSRIs reuptake inhibitors (SNRIs) serotonin and noradrenaline -May elevate blood by limiting their reabsorption pressure

Tricyclic antidepressants Amitriptyline Block serotonin and -Anti-muscarinic effects -Dangerous in overdose (TCAs) noradrenaline transporters (dry mouth, constipation, No longer recommended resulting in elevation in their blurred vision, urinary synaptic concentrations retention) -Hyponatraemia

Monoamine oxidase inhibitors Moclobemide, Phenelzine, Inhibits monoamine oxidase -Hypertension -“Cheese effect”: if (MAOIs) Selegiline (an enzyme that oxidises -Hepatocellular jaundice tyramine containing Rarely used monoamines to inactivate -Hyperthermia foods (e.g. cheeses, them) cured meats) are ingested while on MAOIs, they may trigger a hypertensive crisis

Drug class Drug name Mechanism Indications Side effects Notes Statin Atorvastatin, Inhibit HMG-CoA -Any vascular disease -Myalgia and -Most effective at 1st line Fluvastatin, reductase (enzyme -Lipid disorder rhabdomyolysis lowering LDL- Pravastatin, involved in hepatic -QRISK2 score ≥10% -Hepatotoxicity cholesterol (but less Rosuvastatin, cholesterol synthesis) -T1 diabetic if >40y/had diabetes >10y/ and increased effective than Simvastatin nephropathy/CVS risk factors liver enzymes fibrates at reducing -Chronic kidney disease triglyceride levels) -Ratio of total cholesterol:HDL ≥6

Ezetimibe Ezetimibe Decreases cholesterol -Primary hypercholesterolaemia if statin not -Headache -Can be used with 2nd line absorption in small tolerated or contraindicated (2nd line) -Diarrhoea statins intestine -In conjunction with statin if statin fails to control (steatorrhoea) total cholesterol or LDL-cholesterol alone

Fibrates Bezafibrate, Act in liver to reduce -Isolated triglyceridaemia (>10mmol/L) -GI disturbance -Most effective at 3rd line (or 1st Ciprofibrate, cholesterol synthesis, -Hypercholesterolaemia if statin not tolerated or -Myalgia and reducing for isolated Fenofibrate, reduce vLDL secretion contraindicated (3rd line) rhabdomyolysis triglyceride levels triglyceraemia) Gemfibrozil and increase their -Not to be used removal from blood, with statins and increase plasma HDL

Heart failure  1st line: ACE-inhibitor + beta-blocker, + diuretic (e.g. furosemide, bumetanide) if peripheral/pulmonary oedema  2nd line: add aldosterone antagonist (e.g. spironolactone, eplerenone)  3rd line: add digoxin

Anti-coagulants See anti-coagulants page

Analgesic ladder

Paracetamol Paracetamol Paracetamol + + Codeine Opioid

± Ibuprofen ± Ibuprofen

© 2015 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision CONTRACEPTIVE METHODS Method Contraindications How it works Treatment course Side effects / Risks / Effect on cycle Positives vs negatives Comments Combined oral Absolute: Smoker >35 years, •Stops ovulation Pill: take daily (3 Hormonal SEs* + controls periods, bleeding •Start on day 1 of cycle contraceptive pill <6/52 postpartum, breast •↑cervical mucus (i.e. a weeks on, 1 week Blood clots (especially for higher and pain •Reduced risk of endometrial and ovarian cancer 2nd gen (Microgynon, feeding, hypertensive, mechanical barrier to pill-free) generation COCPs •MISSED PILL→ take ASAP (even with next one). If next Rigevidon), 3rd gen current or past VTE Hx, sperm) Patch: change Increased risk of breast/ cervical on time, it’s fine. If miss two, take one pill immediately (Marvelon, Yasmin, Cilest), migraine with aura, CVD, •Thins endothelium (i.e. weekly (one patch- cancer use a condom for 7 days. Further management depends 4th gen (Glaira) current breast ca, liver reduces change of free week per Periods may become lighter on week: Combined contraceptive cirrhosis implantation) month) Local irritation from the patch 1st week of packet: will need emergency contraception if patch Evra Relative: adequately Ring: leave in for 3 Pain from the ring during intercourse- had sex in pill-free interval or 1st week of pill packet Combined contraceptive controlled hypertension, weeks then one can be removed if uncomfortable but 2nd week: no action vaginal ring NuvaRing migraine >35, BMI>35, ring-free week only for a maximum 3 hours 3rd week: omit the pill-free week 99% effectiveness enzyme inducing medications -7 day (condom) rule for: D&V, enzyme inducing drugs Progesterone only pill Forgetfulness; breast cancer; •↑cervical mucus Take daily at same Hormonal SEs* - must remember to take at •Start on day 1 of cycle Cerazette undiagnosed PV bleeding; •Thins endothelium time (no breaks) Periods → an exact time •Must be taken at same time each day 99% effectiveness liver disease stop/irregular/lighter/more frequent •MISSED PILL → take ASAP (even with next one). But if >3 hours late (or >12hours late for Cerazette), use condom for 2 days, and consider emergency contraception if had sex in the 2-3 days before missed pill or had sex since the missed pill. Intra-uterine device Pelvic infection; PID Copper acts as Lasts for 5 years Coil insertion risks* + can forget about it •Check for string monthly Copper coil <3months ago; gynae cancer; spermicide and also (3years for the Periods may be heavier - heavy periods •STI check before inserting 99% effectiveness small uterine cavity; causes intra-uterine jaydess) •Put in anytime if not had sex since period, or within first undiagnosed PV bleeding; inflammation 5 days of start of period copper allergy (for IUD) •If fitted >40y (IUD)/ >45y (IUS), can stay in place until Intra-uterine system •Stops ovulation Coil insertion risks* + can forget about it menopause Mirena or Jaydess for •↑cervical mucus Spotting in first 6months then periods + reduces dysmenorrhoea/ younger women •Thins endothelium → light/stop in some women menorrhagia 99++% (best) - Some continue to have unpredictable spotting

Progesterone implant Liver/genital/breast cancer; Lasts for 3 years Hormonal SEs* + can forget about it •Placed under skin of inner upper arm (4cm long) under Implanon liver disease; undiagnosed PV Insertion risks (bruising, infection, - Some continue to have local anaesthetic 99% effectiveness bleeding; on enzyme scarring, expulsion) unpredictable spotting •Can feel it inducers Periods → stop/irregular/longer

Progesterone injection Lasts for 3 months Hormonal SEs* - must remember to come Depo-Provera Periods → stop/irregular/longer back every 3 months 99% effectiveness Weight gain - time for fertility to return Time for fertility to return - once given cannot remove, Osteoporosis (>2y consider, >5y stop) so side effects may last 3 months Vasectomy May consider children in Vas deferens cut and Single operation Failure (1 in 2000), bleeding/bruising, + long term •Can take up to 3 months for remaining sperm to be used 1 in 2000 fail future tied via forceps trough infection - consider as irreversible up skin or 2x 1cm cuts in (50%) •Sperm sample at 8 weeks, then 2-4 weeks later (both scrotum. Local Swollen scrotum for a few days - surgical risks must be -ve) anaesthetic. Takes 20 Sperm granulomas may form if leaks •Can have sex (with condom) whenever feel ready mins. Chronic testicular pain (1-3%) Tubal ligation Fallopian tubes clipped Single operation Anaesthetic risk, failure (1 in 200), 1 in 200 fail laproscopically under bleeding/bruising, infection general anaesthetic Condom Allergy to ingredients (latex- Physical barrier New condom each Small risk of allergy + stops STI transmission •Only method which stops STI transmission 98% effectiveness free are available) time have sex May slip off/break - interrupts sex •Oil based products damage latex

© 2015 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision *Hormonal SEs = Weight gain, acne, mood changes, headache *Coil insertion risks = infection in first 3 weeks, bleeding, perforation 1in1000, expulsion 5%, vasovagal 1in10