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Common medications requiring counselling

Expand the boxes below to gain the knowledge required to counsel patients about starting medications. Use the information in conjunction with our notes on how to counsel patients.

Warfarin

Check for contraindications
– Pregnancy
– Significant risk of major bleeding
– Active bleeding

How the treatment works
– Thins the blood to treat or prevent blood clots
– It does this by blocking vitamin K โ€“ the vitamin used by the body to make proteins that cause the blood to clot

Treatment course and how it’s taken
– Once daily tablet (usually in the evening)
– Usually prescribed for 3 months for a DVT, 6 months for a PE, and lifelong for AF
– Dose changes take 2-3 days to take effect

Monitoring required
– Started at 5mg each evening
– INR on days 3,4 and 5 โ€“ warfarin dosing charts tell you how to adjust the dose
– Then regular INR checks by anticoagulation clinic โ€“ regularity determined by INR stability (patient will be given anticoagulation book)

Side effects
– Bleeding โ€“ seek medical advice if you have a significant head injury, prolonged nose bleeds, unusual headaches, blood in urine/stool/vomit, black stool, unexplained or severe bruising
– Also diarrhoea, rash, hair loss, nausea
– Many interactions (mostly with P450 cytochrome inducers/inhibitors) โ€“ patients should avoid liver, spinach, cranberry juice, alcohol binges, NSAIDs/aspirin

Direct oral anticoagulant (DOAC)

Check for contraindications
– Significant renal impairment
– Significant risk of major bleeding
– Active bleeding

How the treatment works
– Thins the blood to treat or prevent blood clots
– Many proteins are involved in blood clot formation โ€“ this medication blocks one of these proteins from working

Treatment course and how it’s taken
– Once or twice daily tablet/capsule
– Take with full glass of water whilst sitting upright
– Usually prescribed for 3 months for a DVT, 6 months for a PE, and lifelong for AF

Monitoring required
– None regularly
– Check renal function before and annually

Side effects
– Bleeding โ€“ seek medical advice if you have a significant head injury, prolonged nose bleeds, unusual headaches, blood in urine/stool/vomit, black stool, unexplained or severe bruising
– GI disturbance
– Irreversible if serious bleed occurs (except dabigatran)

Levothyroxine

Check for contraindications
– None

How the treatment works
– A synthetic version of thyroxine, the hormone produced by your thyroid gland
– It is given to bring your thyroid activity back up to normal

Treatment course and how it’s taken
– Once daily tablet before breakfast
– Taken long term
– Dose changes take 4-6 weeks to take effect

Monitoring required
– TSH test every 2-3 months until stable
– When TSH level stable, check annually

Side effects
– Rare when thyroxine level stable as itโ€™s replacing a normal hormone
– Hyperthyroid symptoms (vomiting, diarrhoea, headache, palpitations, heat intolerance) may be experienced if dosage is too high
– Hypothyroid symptoms (cold intolerance, constipation) if dosage is too low

Statin

Check for contraindications
– Pregnancy

How the treatment works
– Statins stop the liver making cholesterol
– High cholesterol causes problems with your arteries, which increases your risk of heart disease, stroke, and kidney disease
– It is important to also address other cardiovascular risk factorsโ€ฆ

Treatment course and how it’s taken
– Once daily tablet in the evening
– Taken long term
– Decreases risk over many years

Monitoring required
– Review in 4 weeks, then every 6-12 months (with lipid profile as required) โ†’ dose may be titrated up if target not met
– LFTs before starting, at 3 months and at 12 months (statins cause altered LFTs)

Side effects
– Muscle pains
– Headache
– Itching
– Also nausea, sickness, diarrhoea, abdominal pain
– Rhabdomyolysis โ€“ tell doctor if you experience unexpected muscle pain
– Some statins interact with grapefruit juice

Metformin

Check for contraindications
– Significant renal impairment
– Ketoacidosis
– Low BMI

How the treatment works
– Increases your response to insulin so your cells take up more glucose from your blood
– Also reduces the amount of glucose produced by the liver

Treatment course and how it’s taken
– Once, twice or three-times daily tablet with meals
– Taken long term
– Monitoring required
– U&Es before starting, then annually
– HbA1C every 3-6 months until stable, then 6 monthly at diabetic check ups

Side effects
– Nausea, diarrhoea, abdominal pain, weight loss
– Lactic acidosis โ€“ metformin must not be taken on the day of or for 2 days after having general anaesthetic or X-ray contrast media

Iron tablets

Check for contraindications
– None

How the treatment works
– Replace your bodyโ€™s store of iron, a mineral required to make red blood cells

Treatment course and how it’s taken
– 1-3 times daily tablet or syrup (depending on brand)
– Works best if taken without food, but most take with meals as iron can irritate the stomach
– Takes 3-4 weeks for Hb to normalise, then further 3 months to replenish iron stores

Monitoring required
– Haemoglobin in 3-4 weeks to assess response

Side effects
– GI irritation (nausea, sickness, diarrhoea/constipation, abdominal pain)
– Black/green stools
– Metallic taste

SSRI

Check for contraindications
– Suicidal risk
– Mania

How the treatment works
– Antidepressants alter the balance of some of the chemicals in the brain (neurotransmitters)
– SSRI antidepressants affect a neurotransmitter called serotonin
– Imbalance of this and other neurotransmitters is thought to play a part in causing depression and other conditions

Treatment course and how it’s taken
– Once daily tablet
– May be gradually stopped 6 months after feeling better
– Effects in 4-8 weeks

Monitoring required
– None

Side effects
– GI (diarrhoea, nausea, vomiting)
– Appetite and weight change
– Headaches
– Drowsiness (can take at night)
– Anxiety for 2 weeks
– Withdrawal
– May increase risk of suicide in younger patients

Methotrexate

Check for contraindications
– Pregnancy (including male partner)
– Breast-feeding
– Hepatic impairment
– Active infection
– Immunodeficiency

How the treatment works
– It is a โ€˜disease-modifying agentโ€™ which both reduces inflammation and suppresses the immune system
– Early use improves outcome and symptoms

Treatment course and how it’s taken
– Once weekly tablet with a folic acid tablet on another day
– Same day each week
– Dose built up slowly
– Taken long-term if effective
– Takes 3-12 weeks to work

Monitoring required
– FBC, LFTs, U&EsBefore starting
– Then, every 2 weeks until therapy stabilised
– Then, every 2-3 months
– Patient should be given monitoring book

Side effects
– Alopecia
– Headaches
– GI disturbance โ€“ advise not to take with NSAIDs/aspirin
– Myelosuppression (infections, unexpected bruising/bleeding, anaemia) โ€“ seek medical advice if you have unexplained bruising/bleeding or have infective symptoms, and get annual flu jab
– Liver and lung toxicity

Lithium

Check for contraindications
– 1st trimester pregnancy
– Breast-feeding
– Cardiac insufficiency/rhythm disorder
– Significant renal impairment
– Addison’s disease
– Low sodium diets
– Untreated hypothyroidism

How the treatment works
– Mood stabiliser
– Exact mechanism unknown
– Thought to interfere with neurotransmitter release and receptors
– Treatment course and how it’s taken
– Once or twice daily tablet/liquid
– Taken long-term if effective
– Takes 1-2 weeks to work

Monitoring required
– Before starting โ€“ FBC, U&Es, TFTs, ฮฒHCG, ECG
– Check lithium level after 5 days, then every week until stable for 4 weeks, then every 3 months
– Check TFTs, U&Es, Ca2+ every 6 months

Side effects
– GI (abdominal pain, nausea)
– Metallic taste
– Fine tremor
– Water symptoms (thirst, polyuria, impaired urinary concentration, weight gain and oedema)
– Renal toxicity
– Nephrogenic diabetes insipidus
– Hypothyroidism
– Lithium toxicity symptomsGI (anorexia, diarrhoea, vomiting)
– Neuromuscular (dysarthria, dizziness, ataxia, impaired coordination, muscle twitching, tremor)
– Others (drowsiness, apathy, restlessness)

Atypical antipsychotics

Check for contraindications
– Hepatic impairment
– Phaeochromocytoma

How the treatment works
– Schizophrenia thought to be caused by problems with dopamine receptors in your brain
– Atypical antipsychotics work by blocking these receptors

Treatment course and how it’s taken
– Tablet daily or depot injection every 2-4 weeks
– Dose built up over a week or two
– Dose adjusted depending on response

Taken long-term if effective (keeps symptoms from returning)
– Takes several days or weeks to work

Monitoring required
– Before treatment, at 3 months, 12 months, then annually: pulse, BP, weight, waist circumference, ECG, HbA1C, fasting glucose, lipid profile, prolactin
– Weight checks weekly for 6 weeks

Side effects
– Anti-dopaminergic (tardive dyskinesia, tremor, movement disorders)
– Anti-cholinergic (constipation, dry mouth)
– Anti-histaminergic (weight gain, dizziness, drowsiness)
– Anti-adrenergic (hypotension)
– Neuroleptic malignant syndrome (high fever and muscle rigidity)
– Agranulocytosis (clozapine)
– Withdrawal
– Hyperglycaemia and diabetes
– Hyperprolactinaemia (sexual dysfunction, menstrual disturbance, galactorrhoea etc.)
– Prolonged QT

Levodopa

Check for contraindications
– Glaucoma

How the treatment works
– Levodopa is a replacement for some of the dopamine which your brain in no longer able to produce
– This will help to reduce your symptoms, particularly your rigidity and slow movements
– Given with carbidopa (inhibits peripheral levodopa degeneration)

Treatment course and how it’s taken
– 3-4 times daily tablet with food (reduces nausea)
– Taken as long as it works effectively โ€“ after 5 years most suffer โ€˜on-offโ€™/โ€˜wearing offโ€™ phenomena (switch between mobility and immobility that occurs before the next dose is due after prolonged levodopa use) and dyskinesias
– Fast-acting

Monitoring required
– None

Side effects
– Psychosis
– Nausea and vomiting
– Dyskinesias
– Postural hypotension
– โ€˜On-offโ€™/โ€˜wearing offโ€™ phenomena
– Impulsive behaviour
– Dizziness

Insulin

Check for contraindications
– N/A

How the treatment works
– Insulin allows the cells of your body to take up glucose from the blood and use it for energy
– This means insulin reduces the blood glucose level
– In people with diabetes, insulin may be needed because the body cannot produce it or use it effectively

Treatment course and how it’s taken
– Depends on the type of insulin regimens (see insulin)
– Injected using injection pen at a 90หš angle
– Usually injected to different sites around the lower abdomen and upper outer thighs/buttocks

Monitoring required
– Capillary glucose monitoring is done before each meal and before bed
– It should also be checked if there are any symptoms of a high/low blood sugar (explain)

Side effects
– Weight gain
– Sharp injuries (pens should be disposed of in sharps bin)
– Hypoglycaemia (educate patient about management)
– Lipodystrophy at injection sites

Bisphosphonate

Check for contraindications
– Pregnancy
– Dysphagia/abnormalities of oesophagus
– Recent peptic ulcer
– Significant renal impairment
– Unable to sit upright for 30 minutes

How the treatment works
– Prevents bone from being broken down and helps to rebuild new bone
– Remember lifestyle factors can also help with this, such as exercise, not smoking (we can help), and eating a well-balanced diet

Treatment course and how it’s taken
– Once daily or once weekly tablet
– Swallow tablet with full glass of water
– Take at least 30 minutes before food or anything other than water
– Be upright for 30 minutes after swallowing
– Taken long term
– Monitoring required
– Regular dental check-ups (risk of osteonecrosis of jaw)

Side effects
– Headache
– Heartburn, bloating, indigestion
– GI (diarrhoea/constipation, abdominal pain)
– Seek urgent medical advice if symptoms of = Osteonecrosis of the jaw, Dysphagia/odynophagia, Upper GI bleeding/black stools

4 Comments

  1. Tdawg says:

    Can you do one on Amiodarone pls?

    1. Samuel Owen says:

      Sure, i’ll add this to our reviewers list to review! ๐Ÿ˜ƒ

  2. MAGIMOL says:

    check airway breathing and circulation
    monitor vitals
    make comfortable position-head elevated45 degree
    hook up to the monitor
    provide oxygen
    administor aspirin

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