Prescribing Course SESSION 2 Max Roberts max.roberts@nhs

Prescribing Course SESSION 2 Max Roberts [email protected]

The basics Objectives PSA overview – with a focus on Section 1 Insulin Practise writing FP10s Practise using the BNF/Medicines Complete

The Common Common things Drugs patients are commonly on Drugs you may initiate Anti-hypertensives Antibiotics VTE prophylaxis Anti-hypertensives Statins Diuretics Inhalers Analgesia Laxatives Beta blockers Type 2 diabetes Insulin Antiemetics Blood products Other Fluids Things ACEi: Ramipril, Enalapril ARB: Losartan, Candesartan CCB: Amlodipine Simvastatin, Atorvastatin Furosemide, Bumetanide Bendroflumethiazide Salbutamol, ipratropium Fostair (beclometasone ICS & formoterol LABA) Seretide (fluticasone ICS & salmetarol LABA) Bisoprolol, atenolol Metformin, sitagliptin, gliclazide Slow: Glargine (Lantus), Detemir (Levemir), Tresiba (Degludec) Intermediate: Humilin Rapid: Aspart (Novorapid), Lispro (Humalog) Mixed insulins Anti-epileptics, anti-coagulants, anti-depressants, finasteride/tamsulosin, laxatives

Consider the systems System Renalcomplications Cytochrome P450 ACE and ARBs Metformin NSAIDs Aminoglycosides (e.g. Gentamicin) Lithium Allopurinol Digoxin Methotrexate Morphine Warfarin inhibitors Increased [warfarin] - raised INR Warfarin inducers Considerations: Nephrotoxic drugs Renally excreted drugs - poor renal function increased/toxic concentrations Decreased [warfarin] - lower INR Considerations: Warfarin and P450 inhibitors/inducers? Altering drug doses depending on patient pre-existing inhibiting/inducing medications

PSA Format

Prescribing (10) Max marks Drug Choice – 4 marks Dose and Route – 4 marks Date and time – 1 mark Signature – 1 mark 8 questions – 10 marks each 80 marks

Case 2 - PSA 1 – Prescribing (10) For the following patients, prescribe the appropriate insulin management. Mr Ram Ipril – serum [K ]: 7. Appropriate medications have been held. Tented T-waves on ECG. Already started on calcium gluconate. 60kg. Date Infusion Solution Drugs and Dose to be added Total Volume Route Rate Today 50% dextrose Actrapid 10 units 50mL IV 5-15 Doctor minutes 123 Mrs Pam Creas – known T1DM. DH: Lantus 20 units at 6am and 16 units at 6pm. Her BMs have been am: 3.1-4.1; pm: 8-11. Adjust her regular medication. 60 kg Signature, GMC, Bleep Lantus Hyperkalaemia: 10mL of 10% calcium gluconate then 10 units Actrapid/50ml 50% dextrose What else can you give? Lantus 20 units SC 14 units SC Doctor Today Doctor Today Ms Sue Gar – BM 25, urine ketones 3 VBG: pH 7.19, HCO3-: 13, lactate 3. 80kg Date Today Infusion Solution 0.9% Sodium chloride Drugs and Dose Total to be added Volume Actrapid 50 units 50mL Route Rate IV 8 ml/ hour Signature, GMC, Bleep Doctor 123 DKA: NaCl - fixed rate insulin infusion (0.1 units/kg/hour) - Prescribe insulin as brand names - Adjust by no more than 2 units at a time - NEVER stop a long-acting insulin - Involve diabetes nurses early Review BMs/trend, diet, drugs, etc

FP10s Pharmacy Stamp Age Title, forename, surname and address 50 DOB 1/1/1969 Number of days treated Fake Patient House 1 12 Street Road England Po57 C0DE Endorsements Drug name, strength, formulation (e.g. Bisoprolol 2.5mg tablet) Patient friendly directions dose (e.g. Take one tablet once a day) Quantity (e.g. Supply 28 tablets) Name and initials of prescriber Signature of prescriber For Dispenser FAKE FP10 Doc tor Doctor S.Safe S.S Date Xx/xx/xx Dr Good Doctor The Good Doctor Practise Healthy Lane Healthy County DRD DRD 0800 – Saving Lives Patient details Full name, address, age and DOB Drug name, strength, formulation Patient friendly directions dose Quantity Prescriber initials, name and signature Date Practise/hospital address and stamp (usually pre-written)

Case 1 - PSA 1 – Prescribing (10) Pharmacy Stamp Age Title, forename, surname and address Age DOB DOB Patient details Patient full name and address Number of days treated 57 1/1/1962 Jane Notreal Big Mansion 1 Rich Avenue London Po57 C0DE Endorsements Drug name, strength, formulation Patient friendly directions dose Quantity Name and initials of prescriber Prescriber name and initials Signature of prescriber Signature For Dispenser FAKE FP10 Date Date Dr Good Doctor The Good Doctor Practise Healthy Lane Healthy County DRD DRD 0800 - SavingLives Practise/hospital address and stamp (usually pre-written) Metformin 500mg tablets Take 2 tablets, twice a day Please supply 112 tablets -----------------------------------Sitagliptin 100mg tablets Take 1 tablet, once a day Please supply 28 tablets Jane Notreal DOB: 1/1/1962 Big Mansion 1 Rich Avenue London, Po57 C0DE You are an FY2 on your GP placement. Jane has come to see you for her medication review. Despite lifestyle measures and taking metformin 1g BD, Jane’s HbA1c is 65mmol/mol and your GP supervisor advises you to add an appropriate oral medication. Please prescribe Jane a 28-day supply of: - metformin 1g BD - an appropriate additional medication

Case 1 - PSA 1 – Prescribing (10) Pharmacy Stamp Age Title, forename, surname and address Age DOB DOB Patient details Patient full name and address Number of days treated 57 1/1/1962 Jane Notreal Big Mansion 1 Rich Avenue London Po57 C0DE Endorsements Drug name, strength, formulation Patient friendly directions dose Quantity Name and initials of prescriber Prescriber name and initials Signature of prescriber Signature For Dispenser FAKE FP10 Date Date Dr Good Doctor The Good Doctor Practise Healthy Lane Healthy County DRD DRD 0800 - SavingLives Practise/hospital address and stamp (usually pre-written) Metformin 500mg tablets Take 2 tablets, twice a day Please supply 112 tablets -----------------------------------Sitagliptin 100mg tablets Take 1 tablet, once a day Please supply 28 tablets First intensification: Consider dual therapy with: - metformin and a gliptin - metformin and a pioglitazone - metformin and a sulphonylurea - metformin and an SGLT-2i You are an FY2 on your GP placement. Jane has come to see you for her medication review. Despite lifestyle measures and taking metformin 1g BD, Jane’s HbA1c is 65mmol/mol and your GP supervisor advises you to add an appropriate oral medication. Please prescribe Jane a 28-day supply of: - metformin 1g BD - an appropriate additional medication

Case 1 - PSA 1 – Prescribing (10) Pharmacy Stamp Age Title, forename, surname and address Age DOB DOB Patient details Patient full name and address Number of days treated 8 1/1/2011 Rich Notreal III Big Mansion 1 Rich Avenue London, Po57 C0DE Endorsements Drug name, strength, formulation Patient friendly directions dose Jane has also brought in her son, Rich, due to concerns of a new itchy isolated rash on his arm (see photo). Prescriber name and initials Signature of prescriber Signature For Dispenser Big Mansion 1 Rich Avenue London, Po57 C0DE Please prescribe an appropriate medication to treat the rash. Quantity Name and initials of prescriber Terbinafine 1% cream Topical, one application, twice a day, to affected area for 2 weeks Please supply 30 grams Rich Notreal III DOB: 1/1/2011 Date Date Dr Good Doctor The Good Doctor Practise Healthy Lane Healthy County DRD DRD 0800 - SavingLives Practise/hospital address and stamp (usually pre-written) FAKE FP10 https://www.nidirect.gov.uk/conditions/ringworm

PSA 1 – Prescribing (10) Ann Emia DOB: 16/11/1998 MRN 1234001 Case presentation A 20- year-old university student presents to A&E with complaints of light headedness, dizziness, palpitations and fatigue. She is given 2L normal saline, which resulted in little improvement. PMH. Menorrhagia – LMP 1 week ago . DH. Nil . SH. She lives in student accommodation; non smoker, no alcohol intake. NKDA On examination Airway patent. Chest clear. RR 18. Sats 94% RA. HS I II O, regular. HR 100, 36.4C, 105/69 Abdo SNT. No rash. BM 5. Please prescribe the most appropriate blood product. Date Infusion Solution Today Packed red blood cells Drugs & Dose added Total Volume 1 unit Only 1 unit at a time Rate 2-4 hourly Route of infusion IV Signature, Name, Bleep Doctor 123 Typically 2-3 hours No slower than 4 hours Investigations Hb 61 (115-165) Na 141 MCV 69 (80-100) K 4.3 (3.5 – 5) Plat 300 Urea 5.1 (2.5-7) WCC 8.6 Creat 80 (50-100) (4-11) What is the difference between cross match and group & save?

Blood Transfusion Reactions Acute Delayed Urticarial reaction Delayed hemolytic reaction Acute hemolytic reaction Iron overload Allergic reaction Transfusion-associated graft-versus-host disease Anaphylactic reaction Overtransfusion or undertransfusion Coagulation problems in massive transfusion Post-transfusion purpura Febrile nonhemolytic reaction Transfusion-related immunomodulation Metabolic derangements Mistransfusion (transfusion of the incorrect product to the incorrect recipient) Septic or bacterial contamination Transfusion-associated circulatory overload Transfusion-related acute lung injury

PSA 2 – Prescription Review (4) Questions A &B Select which drugs may have cause SE/may be contraindicated/may need to be stopped etc. Same medicine can be selected multiple times 8 questions – 4 marks each 32 marks

PSA 2 – Prescription Review (4) A 70 year old man is admitted to hospital with a 4 day history of shortness of breath, purulent sputum and fevers. He complains of pleuritic chest pain and is confused (AMTS 7/10). PMH: hypertension, constipation, CCF, hypercholesterolaemia. Allergies: penicillin. SH: Retired cleaner, non-smoker. Observations: BP 100/70, HR 100, SpO2 92% on RA, RR 26, T38.5 Bloods: WCC 16; Hb 140, Na 120, K 4.3, Urea 10, Creat 130 (baseline 80), CRP 50, LFTs NAD Question A Select drugs which should be stopped/held (3) Question B Select drugs which should be altered (1) Drug Dose Route Frequency Stopped/Held Altered Co-amoxiclav 1.2g IV TDS Lactulose 10ml PO OD Bendroflumethiazide 2.5mg PO OD Lisinopril 10mg PO OD Paracetamol 1g PO Every 4 hours Simvastatin 10mg PO ON

PSA 3 – Planning management (2) Chose a combination of 2 most appropriate pharmaceutical management options for a patient (5 options given) based on signs/symptoms/results etc. Preventative/curative/symptomatic or palliative Could be non-pharmacological (e.g. physio) 8 questions – 2 marks each – 16 marks

PSA 3 – Planning management (2) A 22-year-old woman presents to the GP practice complaining of a sore throat, cough and fevers for the past 2 days. PMH: anxiety DH: Nil Allergies: nil A. Refer to on-call ENT team B. Start a course of oral antibiotics for 10 days C. Refer to A&E for IV antibiotic therapy On examination Airway patent. Bilateral enlarged tonsils with exudate on the left tonsil. Cervical lymphadenopathy. 60kg. Observations: HR 80, BP: 115/80, T 38C, RR 18, SpO2 98% on RA D.Advise the patient this is likely viral and manage conservatively E. Test for EBV What is the most appropriate management option at this stage? Fever PAIN criteria Fever (during previous 24 hours) Purulence (pus on tonsils) Attend rapidly (within 3 days after onset of symptoms) Severely Inflamed tonsils No cough or coryza A score of 4 or 5 is thought to be associated with a 62 to 65% likelihood of isolating streptococcus. Centor criteria 1. Tonsillar exudate 2. Tender anterior cervical lymphadenopathy or lymphadenitis 3. History of fever (over 38 C) 4. Absence of cough A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.

The basics Objectives PSA overview – with a focus on Section 1 Insulin Practise writing FP10s Practise using the BNF/Medicines Complete

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