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Commonly prescribed drugs in community

Antihypertensives

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Oral hypoglycaemics

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NB: 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, perioperatively, and if using iodinated contrast agents.

NB: aim HbA1c 48-58mmol/mol

Asthma ladder

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COPD ladder

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Produced using NICE ‘CG101 chronic obstructive pulmonary disease in over 16s: diagnosis and management’ 2010

Combination inhalers

  • Seretide = salmeterol + fluticasone
  • Symbicort = formoterol + budesonide
  • Fostair = formoterol + beclometasone
  • Trimbow = formoterol + beclomethasone + glycopyrronium

Abbreviations 

  • LABA = long-acting β2 agonist  
  • LAMA = long-acting muscarinic antagonist
  • ICS = inhaled corticosteroid

Hormone replacement therapy

  • Routes of administration
    • Systemic (for systemic symptoms, e.g. vasomotor): usually transdermal oestorgen (e.g. gel or patch) – women with a uterus on transdermal oestrogen preparations must still take progesterone separately as discussed below 
    • Vaginal oestrogen (for local symptoms, e.g. urogenital atrophy, vaginal dryness): tablet, cream, pessary or vaginal ring
  • Types of systemic therapy
    • No uterus → oestrogen-only HRT (usually transdermal, i.e. gels or patches)
    • Uterus present (oestrogen as above but also need progesterone, usually as oral micronised progesterone, e.g. utrogestan)
      • Perimenopausal → cyclical HRT (oestrogen given every day, and progesterone given for 12 days of each 28 day cycle – to induce bleed)
      • Post-menopausal (i.e. no periods for >1 year or been on cyclical HRT for >1 year) → continuous combined HRT(continuous oestrogen and progesterone – no bleed)

NB: the Mirena coil can also suffice as the progesterone component.

Contraindications: undiagnosed PV bleeding, pregnancy/breastfeeding, oestrogen-dependent 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 VTE risk (except transdermal preparations), increased stroke risk, increased breast cancer risk with time, increased ovarian cancer risk if used >5 years, increased endometrial cancer risk (but only with unopposed oestrogen), coronary artery disease (if started >10 years after menopause)

Antidepressants 

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Lipid-lowering drugs

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Heart failure

  • Treat cause where possible 
  • Diuretic (e.g. furosemide, bumetanide) if fluid overloaded
  • Treatments with prognostic benefit for heart failure with reduced ejection function (use all)
    • ACE inhibitor or angiotensin receptor-neprilysin inhibitor (e.g. sacubitril/valsartan)
    • β-blocker (e.g. bisoprolol)
    • Aldosterone antagonist (e.g. eplerenone) 
    • SGLT2-inhibitor (e.g. dapagliflozin, empagliflozin)
  • Control specific causes/associated conditions (e.g. hypertension, AF, obesity, diabetes, myocardial ischaemia) for heart failure with preserved ejection function
  • Non-pharmacological treatments
    • Cardiac resynchronisation therapy device: considered if QRS significantly prolonged
    • Implantable cardioverter defibrillator: considered if risk of ventricular arrhythmias
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