1

Clinical Enquiry
Simvastatin +
Amiodarone/
Amlodipine/Verapa
mil/ Diltiazem
(simvastatin
should be max
20mg)

Told that
hypercholesterola
emia has been
stabilised for past
3 months. (not
relevant?)

Comment/Case
-patient has been just diagnosed with
rhabdomyolysis due to enhanced effect
of simvastatin. CK levels raised. Urine is
darkly coloured.

Management
Withdraw Simvastatin and reintroduce at capped dose of max
20mg, once myopathy subsides.
OR

Q. Reason for dark urine?

Dark urine and muscle weakness and
muscle pain are symptoms of
rhabdomyolysis. When muscle is
damaged, a protein called myoglobin is
released into the
bloodstream. Myoglobin effects kidney.

You can suggest changing

simvastatin to pravastatin
because its not significantly
metabolised by CYP 450 so it will
not be affected by the diltiazem
and hence reduce the risk of
myopathy. (lectures: Where there is a
potential for drug interactions, pravastatin can be
recommended over simvastatin, as it is not significantly
metabolised by the CYP450 enzymes in the liver).

Verapamil and diltizem act as enzyme

inhibitor!
Simvastatin +
fibrate = max
simvastatin 10mg

Pravastatin and fluvastatin have

lower number of reported cases
of myopathy and
rhabdomyolysis.
OR
change simvastatin to
atorvastatin
also
If transaminases (ALT, AST) are
raised to three times the upper
limit of normal consider
stopping statin.

2
Lithium and
NSAIDs =
TOXICITY

Patient is on regular Lithium tablets he

started suffering nervousness, tremor,
vomiting.
He also says he was prescribed two
antibiotics (Penicillin, Flucloxacillin) and
Ibuprofen 400mg TDS two days ago in
walk in clinic.
NSAIDs can deteriorate renal function;
and lithium is renally excreted so less is
eliminated from body therefore toxicity
occurs as its a narrow therapeutic drug.
Lithium levels should be 0.4-1mmol/L.
Early signs of toxicity (Li+ ~
1.5mmol/L): tremor, agitation, twitching
Intermediate: lethagy
Late (Li+ ~ >2mmol/L) spasms, coma,
fits, renal failure

Stop ibuprofen and monitor

lithium.
Lithium levels should be taken
12 hours after the last dose and
if the level is toxic then
management is essentially to try
and increase urine flow (without
diuretics as they can also affect
renal function).
Li+ above 1.5mmol/l can be
fatal and toxic-this patient is
exhibiting signs of Li+ toxicity!

ACEI + NSAIDs =
both cause renal
deterioration

Paracetamol, Diclofenac, Aspirin,

Simvastatin, Ramipril and Atenolol.

Change NSAID to weak opioid

e.g. codeine.

Patient has had previous cardiovascular

event and osteoarthritis. Renal function
is dropping. What should you do?

Withhold ACEI until renal

function improves.

-Interaction between diclofenac and

ramipril = increased risk of renal
impairment

Recheck U&Es and reintroduce

at lower dose perhaps and retitrate up or if renal function
adequate can reintroduce same
dose!

-Diclofenac reduces blood flow to

kidneys so replace to weak opioid.
4

Iron-deficiency
anaemia

Low MCV, Low haematocrit, low Hb, Low

RBC.

Must mention
Microcytic
Anaemia

What are the signs and symptoms, how

would you treat it? Signs = pallor
symptoms=fatigue, dyspnoea (SOB),
palpitations, headaches
Causes of the iron-deficiency anaemia
are blood loss, particularly menorrhagia
or GI bleeding e.g. from oesophagitis,
peptic ulcer, carcinoma, colitis,
diverticulitis or haemorrhoids.

The cause will need to be

investigated and treated = STOP
NSAID change painkiller to weak
opioid, or stronger as this
patient is already getting a weak
opioid.
PPI for treatment and prevention
for NSAID associated GI
bleed/ulceration.
If Hb<8g/dl patient should be
considered for blood transfusion.

Patient on diclofenac, paracetamol and

codeine for pain relief = potentially
NSAID-induced GI bleed so remove
Diclofenac.

She would be offered oral iron

eg ferrous sulphate 200mg TDS
(side effects include constipation
and black stools) Hb should
rise 1g/dL/week continue until
Hb is normal and for atleast 3
months to replenish stores

Iron-deficiency
anaemia

Pt on Codeine, warfarin, digoxin,

paracetamol.

Withhold warfarin, as patient

may be suffering from
haemorrhage. (Check INR) If
bleed confirmed and Vit K for
reversal! (BNF)
Treatment of anaemia ferrous
sulphate 200mg TDS and 3
months after!

Vit b12 deficiency

(macrocytic
anaemia)

High MCV, but Low Hb/Hct/RBCs

Further tests = low B12

Treated by replenishing stores

with hydroxocobalamin (B12)
1mg IM alternate days for 2
weeks. Maintenance 1mg IM

A raised MCV indicates vitamin B12 or

folate deficiency, these should therefore

be tested.
Low B12 then further Schillings test to
determine whether there is
malabsorption or whether there is a lack
of intrinsic factor.
A reduced vitamin B12 and Hb and
raised MCV suggests pernicious
anaemia. This disease affects all the
cells of the body and is due to
malabsorption of B12 resulting from
atrophic gastritis and lack of intrinsic
factor secretion.

every 2 months FOR LIFE

-any counselling related to

condition and treatment?

(oxford handbook)

Symptoms - tiredness and weakness,

dyspnoea, sore red tongue, diarrhoea
and mild jaundice
7

Morphine to
fentanyl patch

Currently = MST 30mg BD and Oramorph

10mg/5mL, 15mL daily. So currently
taking 30mg for breakthrough pain.

What would she take and how much for

breakthrough pain?

Total daily dose of morphine = 90mg

So fentanyl 25 patch (25mcg/hour for
72 hours) can be given.
New dose for breakthrough pain = 90/6
= 15mg (so 7.5mL of Oramorph
10mg/5mL)

1/6 total daily dose every four hours

when required

What should be done when switching

patient from oral morphine to fentanyl
patches?
Make sure patients chronic pain is
generally controlled. Patch is not suitable
for acute pain.

Should we gradually reduce

morphine? No.

Counselling on patient: How the

fentanyl patch can be
administered?
Apply the patch to dry, nonirritated, non-irradiated, and
non-hairy skin on upper arm or
torso. Remover after 72 hours
and apply a new patch to a
different area. (BNF under
Fentanyl, p.272)

How to initiate fentanyl?

Fentanyl patch should be
applied at the same time as last
m/r morphine tablet so allow
time for fentanyl to reach steady
state.

Patch will take 12-24hrs to reach

steady state can advise to
apply first patch at the same
time as taking their last
morphine tablet this gives 12
hrs pain relieve while plasma
levels of fentanyl rise

Switch MAOI to
SSRI
Phenelzine to
fluoxetine

A patient was on MAOI (Phenelzine). He

asks his GP to switch him to Fluoxetine
because he heard theres more evidence
for it.

Phenelzine is an MAOI, fluoxetine

is an SSRI
If an antidepressant is taken for
longer than 8 weeks must
gradually decrease over a period
of 4 weeks.
So gradual withdrawal of MAOI
(slowly reduce the dose) due to
risk of withdrawal syndrome.
Symptoms on withdrawal can be
agitation, irritability, movement
disorders, insomnia, etc.
Then allow a 2 week washout
period (MAOI stopped
completely) before starting SSRI,
to prevent risk of serotonin
syndrome.
Continue to avoid tyramine rich
foods (e.g mature cheese) for 2
weeks after stopping MAOI.

Switch SSRI to
MAOI

Fluoxetine to MAOI

SSRI withdrawal symptoms = GI

disturbances, headaches,
anxiety sweating. Tapper the
dose off over a few weeks;
gradual withdrawal.
Then stop SSRI. Washout period
is generally 1 week before
starting MAOI (or RIMA). BUT
wait 2 weeks after stopping
sertraline.
Fluoxetine have longer half-life
so washout period is 5 weeks.

10

Reduced renal
function and
Metformin

eGFR = 30ml/min. Patient on

simvastatin, aspirin, metformin high
doses for all -- patient had declined renal
function. A list of blood results and had a
high creatinine level and patient on
metformin and the red flag was to
mention lactic acidosis.
blood lactate >5mmol/L
Signs of Lactic Acidosis = N+V,
hyperventilation. Specialist referral

Withhold metformin until renal

function improves. (eGFR must
be above 45ml/min)
Simvastatin max dose =10mg
when eGFR is <30ml/min
If patient is also on ACEI =
carefully
monitored to ensure its ongoing
suitability

11

Choosing
antibiotic for UTI

Pregnant lady with UTI, the infection was

sensitive to trimethoprim or
nitrofurantoin.
eGFR low

Reduced Renal function means

nitrofurantoin is not very
effective therefore trimethoprim
should be selected. BUT
trimethoprim is teratogenic and
should be avoided in pregnancy.
Can suggest trimethoprim if
patient isnt in 1st trimester of
pregnant = 7 days supply
200mg bd (3days may enough
for women!)
In pregnancy. Can choose
amoxicillin or Cefalexin= not
known to be harmful however
broad spectrum so can have a
higher chance of resistance
concerns!
e.g Cefalexin (2 tablets a day for
3 days but can give upto 7 days
tx)

12

NSAID associated
renal impairment

A 50 yr old man with osteoarthritis

suddenly experienced renal failure.
There was a list of drugs. He was
prescribed Diclofenac two weeks ago
and he had been taking the other drugs
for at least 2 months.
Most likely cause would be the NSAID.
-The mechanism of action of NSAIDS and
how they affected renal function?
NSAIDs M/A = inhibit COX-1 and COX-2
which inhibit inflammatory PGs.

stop NSAID immediately and

manage his pain using
alternatives weak opioid such as
codeine, continue Paracetamol.
Monitor renal function closely.

Renal perfusion is reduced by NSAIDs

and can cause renal function to
deteriorate as they are vasoconstrictors
of the afferent artertioles
13

Cholestatic
jaundice caused
by co-amoxiclav

Raised ALP and total bilirubin. Also

has nausea and abdominal discomfort.
Started taking co-amoxiclav 10 days.
Cholestatic jaundice is a complication of
drugs including co-amoxiclav,
Flucloxacillin, erythromycin and
chlorpromazine.

Stop co-amoxiclav and monitor

hepatic function!
It is self-limiting once the drug is
stopped it will correct itself so
yes with drugs that cause a chile
static reaction

Jaundice and it said it is self-limiting

(BNF) provided that co-amoxiclav isnt
taken for more than 14 days. It is very
rarely fatal.

The CSM has advised that cholestatic

jaundice can occur either during or
shortly after the use of co-amoxiclav. An
epidemiological study has shown that
the risk of acute liver toxicity was about
6 times greater than with amoxicillin.
Cholestatic jaundice is more common in
patients above the age of 65 years and
in men.
14

Hyperkalaemia (A
CEI +
Spironolactone)

Hyperkalaemia with mild renal

impairment.
Taking Digoxin, Furosemide, Lisinopril
and Spironolactone and a few more.
Digoxin excreted through kidneys, risk of
toxicity.

15

Hyperglycaemia
related to Steroid
and acute
infection

Patient on COPD and diabetes (humulin,

metformin) meds. Given amoxicillin and
prednisolone short-term [for
exacerbation of COPD].

Hyperglycaemia, confusion experienced.

Infection (most likely upper respiratory

tract) and the steroids (prednisolone)
contribute to hyperglycaemia.

stop treatment and give an

alternative antibiotic if
necessary.
Other drugs can cause
hepatitis characterised by
prominent elevation of
ALT (which is not elevated in this
case) for example isoniazid,
hydralazine,
rifampicin and paracetamol (in
overdose).

Stop spironolactone and also

withhold ACEI. Recheck K+
levels and can reintroduce while
monitoring U&Es and renal
function.

Patient is only given

prednisolone for 5 to 7 days so
theres no need to stop it.
Continue course or infection
might not be fully cleared and
could reoccur and cause another
exacerbation of asthma/ COPD.
Monitor more closely blood
glucose levels and amend
diabetic meds according to
response (i.e. increase dose to
improve glycaemic control)
Also hyperglycaemia in short
term is not usually a problem.
Chronic hyperglycaemia is
associated with complications.

Why is the patient confused?

Excessively high blood glucose. Need to
increase diabetic control. Insulin should
help but keep monitoring blood glucose.
Hyperglycaemia in type
1 DM

Need insulin
Diabetic ketoacidosis (DKA) may be cause due to
excessively high glucose levels. Symptom of DKA

includes confusion.

DKA occurs because the body has insufficient

insulin to process glucose into fuel, so the body
breaks down fats to use for energy. When the body
breaks down fat, ketones are produced as byproducts. It this occurs, its a medical emergency.

16

17

Angioedema
induced by ACEI

Compliance issues
with alendronic
acid

65 years old afro carribean male on

Bendoflumethiazide, Lisinopril
Simvastatin. He had angioedema. The
causative drug is Lisinopril.

Heartburn and mouth ulcers caused by

alendronic acid of daily supply and
patient chew tablets because couldn't
swallow.
Incorrect usage of the drug. Alendronic
acid should not be chewed as it can
cause mouth ulcers. And the patient may
not have been taking it correctly hence
the oesophageal irritation (heartburn).
Swallowing difficulty oesophageal
irritation
Also not sutiable to give oral
bisphosphonates in bed ridden patients
who cant sit/stand upright.

So stop ACEI monitor renal

function, add amplodipine (CCB
first line anyways) for
hypertension control and reduce
the dose of simvastatin to max
20mg (because of the addition
of amlodipine).
Investigate further to ensure
patient is not suffering from
oesophageal ulceration. Refer to
specialist? STOP alendronic acid!

Mouth ulcers management?

Options
Oral solution: Patient cant
swallow tablets so should be
offered oral solution instead
(which is available as
70mg/100mL). Still counsel that
the oral solution should be taken
with plenty of water on an
empty stomach at least
30minutes before food, and the
patient should sit or stand to
remain upright for 30 minutes
post dose.
IV infusion annually given as day
patient
IV Ibandronic acid for tx of postmenopausal women give iv inj
over 15 to 30 seconds 3mg
every 3 months (BNF)
Denosumab inj every 6 months

Also can suggest

for the alternative

for alendronic is strontium ranelate (but
cant find why)

18

Long term risks of

prednisolone

Long term risks of prednisolone for a

COPD patient

-Bisphosphonates for
prophylaxis of osteoporosis.
-Advice on balanced diet as it
can increase appetite and it also
increases risk of induce diabetes
in long-term use. (monitoring of
blood glucose may be needed)
-Avoid abrupt withdrawal.
-Avoid infectious people!
(increased risk of susceptibility
to infections)
-Carry your steroid card with
you.
GI protection..

Take prednisolone
tablets with food. The
enteric-coated tablets may
be taken before or after
food. But there is still GI
risk!

If you have been given

enteric-coated
prednisolone, swallow
these tablets whole. Do
not chew or crush them.
You should avoid taking
indigestion remedies at the
same time as entericcoated prednisolone as
these can interfere with the
special coating on your
tablets.

19

Amiodarone skin
reaction

Amiodarone was stopped a month ago

but patients been in sun and
experienced very red skin.
Photosensitivity known ADR of
amiodarone.
Despite having discontinued, likely to be
causing the ADR as it has a long half-life
(extending to several weeks)

Stay out of the sun

Use high factor sunscreen
Has a long half life so cause for
weeks after discontinuation

20

SSRI+ tramadol

Increased risk of serotonin syndromeIncreased risk of seizures.

Other signs mental status, autonomic
hyperactivity (tachycardia, diarrhoea)
and neuromuscular abnormalities
(hyperreflexia)

Avoid both together, change

tramadol to different analgesic
see if patient has tried codeine
first

21

SSRI + NSAIDS

Increased risk of GI bleeds

Change NSAID

22

Paracetamol
overdose but
hypersensitive to
acetylcysteine

Patient also on enzyme inducing

carbamazepine so high risk

Use methionine if within 10-12

hours of overdose and make
sure patient isnt vomiting!

23

Epileptic patient
needing
ciprofloxacin

Ciprofloxacin = quinolone = lower the

threshold of seizures

Change antibiotic

24

NSTEMI

Also avoid NSAIDs with

quinolones = can also cause
convulsions
2 antiplatelet for 1 year
(clopidogrel + aspirin)
Also beta-blocker/ statin/ ACEI
GTN spray 999
-spray under tongue wait 5 mins
- can do that up to 3 times and if
pain doesnt go away = call 999
= suggests further MI

Good luck in sha Allah it will be cool Hira