Common medications requiring counselling

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 – 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 – warfarin dosing charts tell you how to adjust the dose
– Then regular INR checks by anticoagulation clinic – regularity determined by INR stability (patient will be given anticoagulation book)

Side effects
– Bleeding – 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) – patients should avoid liver, spinach, cranberry juice, alcohol binges, NSAIDs/aspirin

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 – 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 at least 3-6 months for VTE, and lifelong for AF

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

Side effects
– Bleeding – 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)

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 it’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

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 factors…

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) → 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 – tell doctor if you experience unexpected muscle pain
– Some statins interact with grapefruit juice

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 – metformin must not be taken on the day of or for 2 days after having general anaesthetic or X-ray contrast media

Check for contraindications
– None

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

Treatment course and how it’s taken
– May be taken on alternate days or 1-3 times daily as a tablet or syrup
– 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

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

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

How the treatment works
– It is a ‘disease-modifying agent’ 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 – advise not to take with NSAIDs/aspirin
– Myelosuppression (infections, unexpected bruising/bleeding, anaemia) – seek medical advice if you have unexplained bruising/bleeding or have infective symptoms, and get annual flu jab
– Liver and lung toxicity

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 – FBC, U&Es, TFTs, βHCG, 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)

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

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 – after 5 years most suffer ‘on-off’/‘wearing off’ 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
– ‘On-off’/‘wearing off’ phenomena
– Impulsive behaviour
– Dizziness

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 90˚ 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

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