Summary Clinical Pharmacy - Guideline and Therapeutics
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Pharmacy
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University Of East Anglia
This is a master piece that I have created since studying Pharmacy in UEA since 2018. I have been updating this document since then. I found this useful even until today, practicising as a specialist pharmacist in one of the UK hospitals.
This document contained most of the common medical conditi...
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Table of content
A) Endocrine system
1) Diabetes
2) Thyroid disease
3) Osteoporosis
4) Other endocrine-responsive conditions
5) Electrolyte imbalances
B) Cardiovascular system
1) Hypertension & hypercholesterolaemia
2) Stroke (CVA)
3) CHD – ischemic heart disease
4) Venous thrombosis
5) Heart failure
6) Atrial fibrillation
7) Renal failure
8) Peripheral vascular disease
9) Pericarditis (ECS guideline)
C) Nervous system
1) Dementia (Alzheimer’s disease)
2) Epilepsy
3) Unipolar depression
4) Anxiety
5) Bipolar disorders
6) ADHD
7) Schizophrenia
8) Parkinson’s disease, Dystonia & other involuntary movement disorders
9) Nausea and labyrinth disorders
10) Pain
11) Insomnia & narcolepsy
12) Substance dependence
D) Infections
1) Bacterial infections
2) Fungal infections
3) Viral infections
E) Respiratory disease
1) Asthma
2) COPD
3) Allergic conditions (anaphylaxis)
4) Cystic fibrosis
F) Gastrointestinal diseases
G) Genito-urinary system
H) Blood & nutrition
I) Musculoskeletal diseases
1) Gout
2) Low back pain
3) Osteoarthritis
4) Rheumatoid arthritis
5) Neuromuscular disorders
J) Fluids
K) Skin conditions
L) Eye conditions (glaucoma)
M) Immune system and malignant disease
N) General anaesthesia
O) Vaccination
P) Palliative care
Q) Wound dressings
Author: Billy Leung 1
,Endocrine system
Diabetes
Diabetes Diagnosis Normal blood glucose level: 4.0-5.4 mmol/L (HbA1c: 4-6%)
with symptoms (e.g. polyuria, polydipsia, infection, thrust, fatigue, weight loss, blurred vision, abdominal pain, nausea) –
random OR fasting glucose
without symptoms – random AND fasting glucose
Normal Prediabetic Diabetic
Random <11.1 NA ≥11.1
Fasting (at <5.5 5.6-6.9 ≥7.0
least 8 hrs)
2 hrs post- <7.8 7.8-11.0 ≥11.1
prandial
HbA1c <6.0% (42mmol/mol) 6.0-6.4% (42-47mmol/mol) ≥6.5% (48mmol/mol)
borderline case oral glucose tolerance test (OTT) DM if 2 hr post-prandial ≥11.1
Gestational DM: fasting ≥ 6.5 mmol/L OR OTT ≥ 7.8mmol/L (target HbA1c: 6.1%)
BG Target Non-diabetic Type 1 DM Type 2 DM Children w/ type 1 DM
(mmol/L) Before meals 4-5.9 4-7 4-7 4-7
(pre-prandial)
At least 90mins <7.8 <8.5 5-9 5-9
after meal
(post-prandial)
Upon waking NA 5-7 NA 4-7
HbA1c 6.5% (48mmol/mol) for type 1 DM and type 2 DM (monotherapy)
target* 7% (53mmol/mol) if patient suffer from hypo/ type 2 DM (dual or triple therapy)
Treatment Treatment for hyperglycaemia
plan & Monitoring parameters for diabetic therapy: blood glucose, HbA1c, LFT [only for pioglitazone], RF [only for
Monitoring metformin], S/E (signs of hypoglycaemia), complications
Parameters
A) Type II DM
After diagnosis of diabetes offer advice on diet (5 portions of vegetables/fruit), exercise (at least 30 mins 3-5 times
a week), avoid alcohol & smoking
After 3 months still DM start medications:
o 1st line: metformin 500mg OD 7/28, 500mg BD 7/28, 500mg TDS 7/28 (#stop if eGFR < 30ml/min/ 1.73m 2)
-alternative for 1st line: DPP4 inhibitors (sitagliptin, linagliptin) OR sulphonyl urea (gliclazide; SU become 1st
line if patients have RF) OR thiazolidinediones (pioglitazone) OR SGLT-2 inhibitor (dapagliflozin)
o 2nd line (if HbA1c rises to 7.5%) dual therapy: sulphonyl urea, DPP4-I, thiazolidinediones, SGLT-2
inhibitors, GLP-1 agonist; if metformin is CCI:
DPP4-I + pioglitazone
DPP4-I + SU
Pioglitazone + SU
o 3rd line (if HbA1c rises to 7.5%) triple therapy:
metformin + DPP4-I + SU OR
metformin + pioglitazone + SU OR
metformin + pioglitazone/SU + SGLT-2 inhibitors
other options for 2nd/3rd add-on therapy:
acarbose Reserved for when other PO treatment not tolerated/ CCI
Meglitinide e.g. nateglinide, rapaglinide (rapid onset + short DOA; usually taken shortly after each
main meal
Nateglinide only licensed when used in combination with metformin
Rapaglinide can be given as monotherapy for patient who is not overweight and
CCI to metformin
Pioglitazon Can be added to: SU (if metformin is CCI); metformin (if SU is CCI/ high risk of
e hypo); metformin & SU (if insulin is unacceptable due to lifestyle/ personal
issues/ obese)
Only continued when HbA1c reduced by > 0.5% point within 6/12
DPP4-I Sitagliptin/ vildagliptin/linagliptin/ sexagliptin can be mono or added to:
metformin if SU CCI/ high risk of hypo; SU (if metformin is CCI)
Sitagliptin/alogliptin can be added to metformin + SU (triple therapy) if insulin
is CCI
Only continued when HbA1c reduced by > 0.5% point within 6/12
GLP-1 Exetanide/ liraglutide/ lixisenatide licensed for double/ triple therapy with
agonist metformin/SU/pioglitazone
Exetanide triple therapy (with metformin + SU) when: BMI ≥ 35 (and of European
descent) or BMI < 35 (when insulin is CCI)
Only continued when HbA1c reduced by > 1.0% point and weight loss > 3%
within 6/12
SGLT-2 Canagliflozin/ dapagliflozin/ empagliflozin licensed for mono/ combi therapy
inhibitors with other antidiabetics
Avoid combination with pioglitazone due to increase risk of hypo (particularly
dapagliflozin)
insulin treatment:
o 1st line: isophane insulin OD/BD (+/- short acting insulin)
o 2nd line: insulin detemir/ glargine
Author: Billy Leung 2
, B) Type I DM
same as type II DM for non-pharmaceutical treatment start insulin if not improved within 3 months
1st line insulin treatment: multiple injection regimen (for long acting basal: detemir BD; glargine OD if not
tolerated); 2nd line: TWICE daily injection regimen
Insulin (formulation: reusable pen + cartilage, disposable pen, needles + syringe, insulin pump)
-1 unit = 100mL
o Once daily regimen: long-acting + oral hyperglycaemics – uncontrolled type 2 DM
o Twice daily regimen: pre-mixed (short + intermediate) - suitable for busy worker/shift
o Multiple daily regimen: long acting + multiple short acting before meals
o Continuous subcutaneous insulin infusion (i.e. insulin pump) – only offered in adults suffering disabling
hypo/ high HbA1c (≥8.5% or 69mmol/mol) with multiple daily injection therapy
Types of insulin:
Insulin types Onset Duration of action
Immediate Human soluble insulin (IV) Immediate 30 mins
C) Gestational DM:
Treatment begins from 11 weeks of gestation and stop after giving birth
Drug used: glibenclamide (can be given with metformin/ insulin)
Preventions of complications associated with type I & II DM
Complications: microvascular complications (e.g. retinopathy, neuropathy, nephropathy, foot ulcer) & macrovascular
complications (e.g. CVD)
Hypertension (if BP persistently over 130/80 offer antihypertensives)
No beta-blockers given for HT in DM due to its S/E can mask hypoglycaemia & avoid diuretics that may exacerbate
hyperglycaemia
Target BP for patient with DM: <140/80 (<130/80 with DM complications e.g. retinopathy, nephropathy)
1st line: ACE-I (can also prevent diabetic nephropathy) (1st line for Black Africans with DM: ACE-I + CCB/ diuretics)
o E.g. Ramipril: starting dose 1.25-2.5mg OD, increased up to 10mg at an interval of 2-4 weeks
o Monitoring parameters: BP, RF, U&E (K+, hyperkalaemia), S/E: dry cough
2nd line(dual): CCB
o E.g amlodipine: starting dose 5mg OD, increased up to 10mg OD max.
o Monitoring parameters: BP, apex pulse
3rd line(triple): thiazide-like diuretics
o E.g. indapamide
o Monitoring parameters: BP, U&E (K+, hypokalaemia), RF, glucose
o Not given at first line as worsen DM
Hypercholesterolaemia
Pt > 40 (18-39 with at least one risk factor of CVD) with DM start statins immediately
-risk factors of CVD in DM pt.: retinopathy, nephropathy, poor hyperglycaemic control (HbA1c>9%), high BP (>130/80)
Target: >40% reduction in non-HDL cholesterol (i.e. LDL+VLDL)
Assess pt QRISK2 score (estimate 10-year CVD risk)
1st line: atorvastatin starting dose: 20mg OD
o Monitoring parameters: lipid profile, LFT, creatinine kinase (CK), S/E: myalgia
2nd line: simvastatin starting dose: 20-40mg noct*, adjust at intervals of at least 4 weeks; max 80mg noct
o Monitoring parameters: same as atorvastatin (*simvastatin taken at night as cholesterol is synthesized at night)
Management of diabetic complications
Short term complications (medical emergency)
Source: JBDS-IP (Joint British Diabetes Societies for inpatient care) – Management of diabetic ketoacidosis in adults
A) Diabetic ketoacidosis (DKA)
Diagnostic criteria (all criteria must be present): capillary BG > 11 mmol/L, capillary ketone > 3 mmol/L (or urine
ketone ++ or more), venous pH < 7.3 (± bicarbonate < 15 mmol/L)
Immediate management (refer to JBS-IP guideline for continuous treatment):
1) 500 ml normal saline over 10-15 mins (repeat if sBP remains < 90 mmHg)
2) Once sBP > 90 mmHg, give 1 L normal saline over the next 60 mins
Author: Billy Leung 3
, o Add potassium replacement in this second litre of fluid:
Potassium Potassium replacement (mmol/L)
level (mmol/L)
>5.5 Nil
3.5-5.5 40 mmol/L
< 3.5 Senior review – additional potassium
required
3) Commence fixed rate insulin infusion – 50 units soluble human insulin (Actrapid/ Humulin S) made up to 50 ml
of NS
4) Continue long acting insulin analogue at usual administration time
Aim of treatment:
1) Rate of fall of ketone at least 0.5 mmol/L/hr or
2) HCO3- rises 3 mmol/L/hr and blood glucose fall 3 mmol/L/hr
3) Maintain serum potassium in normal range
4) Avoid hypoglycaemia
B) Hyperosmolar hyperglycaemic state (HHS) – ITU review
Source: JBS-IP (Joint British Diabetes Societies for inpatient Care) - Management of HSS in adults
Diagnostic criteria: hypovolaemia, blood glucose (≥ 30 mmol/L) without significant hyperketonaemia (< 3 mmol/L) or
acidosis (pH > 7.3, HCO3- > 15 mmol/L), osmolality (≥ 320 mosmol/kg)
o Initial hyponatraemia – caused by dilutional effect from hyperglycaemia which draws water out from cells
o Subsequent hypernatraemia – caused by profound fluid loss
Key principles of HSS treatment:
1) Replace fluid loss
2) Normalize osmolality, blood glucose
Diabetic nephropathy
Urinary protein should be tested annually (using Albustix) and at least THREE positive tests to confirm microalbuminuria
(earliest sign of nephropathy)
Start ACE-I or ARB (even if patient has no HT); HT can worsen diabetic nephropathy
Pt with nephropathy increase risk of hyperkalaemia (avoid concomitant use of ACE-I & ARB)
Diabetic neuropathy
A) Neuropathic pain
Choice: Duloxetine amitriptyline (if duloxetine not effective) pregabalin (combinational therapy prn)
Tramadol if none of the above work; gabapentin/ carbamazepine sometimes used
Topical capsaicin cream (0.075%, Axsain) licensed for painful diabetic nephropathy (warn pt may have burning
sensation initially)
B) Autonomic diabetic neuropathy diarrhoea
Treated with tetracycline (unlicensed) or codeine
Erythromycin (especially for IV) for gastroparesis
C) Neuropathic postural hypotension
Increase Na salt, fludrocortisone acetate (unlicensed), (unlicensed) combined therapy of fludrocortisone + ephedrine
+ flurbiprofen, midazolam (α agonist)
D) Gustatory sweating: propantheline bromide (antimuscarinic) for hyperhidrosis (excessive sweating)
E) Neuropathic oedema: ephedrine (unlicensed)
Diabetic foot infection (local guideline):
Severity measured via PEDIS (perfusion, extent, depth, infection, sensation) score (max 12 points; higher point = higher
risk of amputation/ non-healing ulcer/ death)
Common pathogen: staphylococcus/ streptococcus
Antibiotics treatment:
Mild 1st line (PO): flucloxacillin 1g QDS or doxycycline 200mg stat. then 100mg OD or clindamycin 300mg QDS
Duration: 1-2/52
moderat 1st line (PO): flucloxacillin 1g QDS or co-amoxiclav 625mg TDS (no previous MRSA); otherwise: linezolid
e 600mg BD
1st line (IV): co-amoxiclav 1.2 TDS (if <60) (no previous MRSA); otherwise: vancomycin
Duration: 2-3/52
Severe 1st line (IV): tazocin 4.5g TDS (+ vancomycin if previous MRSA)
2nd line (IV) ertapenem 1g OD
Duration: 2-4/52
Counselling Lifestyle advice:
Avoid smoking (recommend NRT when required) and alcohol (alcohol may mask hypoglycaemia and augment insulin
secretion due to redistribution of blood from exocrine to endocrine system)
o take some starch food before drink alcohol
Exercise at least 30 minutes 3-5 times weekly
Eat 5 portions vegetables or fruit daily
No point having diabetic food as contain high fat content
Blood glucose monitoring:
Medications that can cause hypo: all insulins (including insulin pump), SU, exenatide, nateglinide
Type 1 DM: at least four times daily (before each meal and bed)
Type 2 DM: depend on medication used
HbA1c should be measured every 3-6 months (if HbA1c is unstable, every 6 months if stable) for type 2 DM
Hypoglycaemia (blood glucose < 4mmol/L):
Degree of Signs Treatment
hypoglycaemia
Mild Tremor, hunger & sweating, fatigue, choose one of the following: 2 teaspoon of sugar/3 sugar
headache, blurred vision lumps/Glucogel 1.5-2 tubes/100ml Coco-Cola/110ml Lucozade/
19ml Ribena Blackcurrent (to be diluted)
Author: Billy Leung 4
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