THE ULTIMATE PRE-REG BNF NOTES

IMPORTANT MONITORING DRUGS

1. AMIODARONE
Treatment of arrhythmias
Loading Dose: 200mg tds for 7 days, then 200mg bd for 7 days then 200mg daily maintenance.
Important side effects: Nausea, Vomiting, Taste disturbance, Pulmonary toxicity, Reversible

corneal micro-deposits, Phototoxicity, Slate grey discolouration, Tremor, Sleep disorder,

Hypo/hyperthyroidism, Jaundice.
Monitoring: LFTs, Thyroid function tests required before treatment, then every 6 months. Measure
serum potassium concentration before treatment. Chest x-ray required before treatment. ECG
monitoring and resuscitation facilities must be available during intravenous use.

A very long half life there is potential for drug interactions to occur for several
weeks (or even months) after treatment has stopped.
The Drugs

The Interaction

Amiodarone and Warfarin

Amiodarone inhibits Warfarin metabolism enhanced anticoagulant effect

Amiodarone and Blockers

Increased risk of bradycardia, AV block and myocardial depression

Amiodarone and Lithium

Risk of ventricular arrhythmias

Amiodarone and Digoxin

Plasma conc. of Digoxin increased by Amiodarone

2. DIGOXIN
A cardiac glycoside used in AF, tachycardias and heart failure.
A positive inotrope increases the force of myocardial contraction and reduces
conductivity within the AV node.
Desired serum concentration: 1-2mcg/L (1.5mcg-3mcg/L indicates toxicity)
Monitoring: Serum electrolytes (especially potassium) and Renal function.
A narrow therapeutic index, Possibility of Digitalis toxicity, made worse by
hypokalaemia. Managed by giving potassium sparing diuretic or potassium
supplements. Note: Elderly more susceptible to digitalis toxicity.
Important side effects: Nausea, Vomiting, Diarrhoea, Dizziness, Blurred vision.
The Drugs

The Interaction

Digoxin and Amiodarone

Plasma conc. of Digoxin increased by Amiodarone

Digoxin and Erythromycin

Plasma conc. of Digoxin increased by Erythromycin (enzyme inhibitor)

Digoxin and Rifampicin

Plasma conc. of Digoxin reduced by Rifampicin (enzyme inducer)

Digoxin and St. Johns Wort

Plasma conc. of Digoxin reduced by St. Johns Wort (enzyme inducer)

Digoxin and Diuretics

Increased toxicity of Digoxin if hypokalaemia occurs with Loop & Thiazides

Digoxin and Calcium channel

blockers

Plasma conc. of Digoxin increased by Calcium channel Blockers

3. LITHIUM
Treatment and prophylaxis of mania, bipolar disorder and recurrent depression
A narrow therapeutic index and requires monitoring.
Desired serum concentration 0.4-1mmol/litre. (of or above 1.5mmol/L may be fatal and toxic)
Toxic effects: Tremor, ataxia (shaky movements), Dysarthria (speech disorder), Nystagmus

(rapid involuntary movements of the eyes), Renal impairment and convulsions, Blurred vision.
Monitoring: Measure Lithium serum concentration every 3 months, measure Renal and Thyroid
function every 6 to 12 months, Maintain Sodium levels.
Counselling: Maintain adequate fluid intake and avoid dietary changes which reduce or increase
sodium intake.

The Drugs

The Interaction

Lithium and ACE inhibitors

Excretion of lithium reduced by ACE inhibitors Risk of lithium toxicity

Lithium and NSAIDs

Excretion of lithium probably reduced by NSAIDs Risk of lithium toxicity

Lithium and Diuretics

Excretion of lithium reduced by Loop and Thiazide Sodium depletion

Lithium and Amiodarone

Risk of ventricular arrhythmias

4. METHOTREXATE
Treatment of moderate to severe active rheumatoid arthritis, Crohns disease,
malignant disease, Psoriasis.
Blood dyscrasias: full blood count needed before starting treatment and patient needs to be
advised to report any sore throat, signs of infection, bruising or mouth ulcers.

Liver toxicity/cirrhosis: LFTs (and renal) needed before starting treatment and patient needs to be

advised to report any nausea, vomiting, abdominal discomfort or dark urine)

Pulmonary toxicity: Patients need to be advised to report any shortness of breath, cough or fever.
Aspirin and other NSAIDs: If aspirin or NSAIDs taken at the same time, the dose of
Methotrexate needs to be carefully monitored, as leads to rise in Methotrexate levels. Care with OTC.

Oral Dose: 7.5mg once weekly and a maximum weekly dose of 20mg.
A folate antagonist - treatment with folic acid (5mg) helps to prevent Methotrexate-induced mucositis

or myelosuppression. Dont give folic acid at the same time.

Side effects: GI ulceration and bleeding, hepatoxicity.

5. PHENYTOIN
Treatment of epilepsy (all except absence) and neuropathic pain.
A narrow therapeutic index. Relationship between dose and plasma concentration is non
linear. Small dosage increase may produce large plasma concentrations and hence toxic effects.
Therefore monitoring is required.

Desired serum concentration: 10-20mg/L

Monitoring: Full blood counts, liver function.
Side effects: Nausea, Vomiting, Constipation, Gingival hypertrophy, Rash, Acne, Hirsutism

(coarse pigmented hair on face) Coarse faeces, blood or skin disorders.

Counselling: Look out for signs of blood or skin disorders (Fever, sore throat, rash, mouth ulcers,
bruising, bleeding, Leucopoenia) + Take with or after food.

The Drugs

The Interaction

Phenytoin and NSAIDs

Effects of Phenytoin enhanced by NSAIDs

Phenytoin and Amiodarone

Amiodarone inhibits metabolism of Phenytoin

Phenytoin and Warfarin

Phenytoin accelerates metabolism of Warfarin

Phenytoin and Cimetidine

Cimetidine inhibits the metabolism of Phenytoin

Phenytoin and Fluoxetine

Plasma concentration of Phenytoin increased by Fluoxetine

Phenytoin and St. Johns Wort

St. Johns Wort (an enzyme inducer) reduces plasma conc. of phenytoin

6. THEOPHYLLINE
A bronchodilator for asthma or COPD
A narrow therapeutic index. Theophyllines toxic dose is close to its therapeutic
dose.
Note: Potentially serious hypokalaemia may result from concomitant use of theophylline.
Desired plasma concentration of 10-20mg/L (above 20mg/L can lead to severe side effects)
Side effects: Tachycardia, Palpitation, nausea, GI, Headache, convulsions
Monitoring: Plasma theophylline concentration, Lung function tests
The Drugs

The Interaction

Theophylline and Quinolones

Increased risk of convulsions

Theophylline and St. Johns Wort

Plasma conc. of theophylline reduced by St. Johns Wort

Theophylline and Rifampicin

Plasma conc. of theophylline reduced by Rifampicin

Theophylline and Cimetidine

Plasma conc. of theophylline increased by Cimetidine

Theophylline and Fluconazole

Plasma conc. of theophylline increased by Fluconazole

7. WARFARIN
Anticoagulant (takes at least 48 to 72 hours for anticoagulant effect to develop fully).
Highly protein bound to albumin 99%
If INR is too high, there is a risk of bleeding, therefore Warfarin needs to be stopped.
If INR is too low, there is a risk of blood clotting, therefore Warfarin dose needs to be
increased.
Dose: For rapid anticoagulation: an initial dose of 10mg of the first day, Daily
maintenance dose: 3-9mg.
Side effects: Haemorrhage, Rash, Hypersensitivity, Alopecia, Diarrhoea, Unexplained drop in
haematocrit (packed cell volume), Purple toes, Skin necrosis, Jaundice, Hepatic dysfunction.

Monitoring: INR, Renal function

Counselling: Take at the same time each day, avoid major dietary changes (especially involving
salads and vegetables) as it can affect the anticoagulant effect, report any signs of bleeding or
spontaneous bruising.
The Drugs

The Interaction

Warfarin and NSAIDs

Anticoagulant effect enhanced by NSAIDs (can cause bleeding)

Warfarin and Fluconazole

Anticoagulant effect enhanced by Fluconazole (can cause bleeding)

Warfarin and Statins

Anticoagulant effect enhanced by Statins (can cause bleeding)

Warfarin and Ciprofloxacin

Anticoagulant effect enhanced by ciprofloxacin/erythromycin/metronidazole

Warfarin and Griseofulvin

Anticoagulant effect reduced by Griseofulvin

Warfarin & St. Johns Wort

Anticoagulant effect reduced by St. Johns Wort

Warfarin and Antiepileptics

Anticoagulant effect reduced by Antiepileptics

Warfarin and Alcohol

Anticoagulant control affected with alcohol consumption

Warfarin & Cranberry Juice

Anticoagulant effect enhanced by cranberry juice

Warfarin and Vitamin K

Anticoagulant effect antagonised by vitamin K

IMPORTANT INTERACTIONS
Enzyme Inducers and Inhibitors:
Enzyme Inhibitors Inhibit cytochrome P450 enzyme, resulting in decreased
metabolism of other drugs. This increases the concentration of the other drug which can
cause toxic high levels of it.
Enzyme Inducers Induces cytochrome P450 enzyme to work. This results in increased
metabolism of other drugs. This decreases the concentration of the other drug as it is
broken down by the enzymes. This then leads to a decrease in the effect of this other
drug.
ENZYME INDUCERS

ENZYME INHIBITORS

Carbamazepine

Ciprofloxacin

Barbiturates

Erythromycin

Phenytoin

Cimetidine

Griseofulvin

Sodium Valproate

St Johns Wort

Fluoxetine

Rifampicin

Ketoconazole

Smoking

Fluconazole

Alcohol

Grapefruit juice

Alcohol and Interactions:

Alcohol + Metronidazole = Disulfiram-like interaction where intensive support therapy
may be required. (See counselling section on Disulfiram)
Alcohol + Warfarin = Major changes in consumption of alcohol may affect
anticoagulant control of coumarins.
Alcohol + MAOI = Beverages containing tyramine can cause hypertensive crisis
when taken with MAOI.
Alcohol and Mirtazapine or Tricyclic antidepressants Increased sedative effect.
Combined oral contraceptives and Interactions
The effectiveness of combined oral contraceptives is considerably reduced by
interaction with enzyme inducing drugs because they increase metabolism of the
contraceptives. (Enzyme inducers: Carbamazepine, Phenobarbital, Primidone,
Phenytoin, Topiramate, Ritonavir, Griseofulvin, Rifampicin, Rifabutin, St
Johns Wort). Additional contraceptive precautions should be taken for at least 4 to
8 weeks after stopping treatment. A tricycling method whereby daily intake of
50mcg ethinylestradiol (unlicensed) 3 or 4 packs in a row without a break and then
having a 4 day pill free interval can be used by women treated with these drugs but
effectiveness is uncertain. Rifampicin and Rifabutin are such potent enzyme
inducers that IUD is always recommended.
Some antibacterials that do not induce liver enzymes (Ampicillin, Amoxicillin,
Doxycycline) may reduce the efficacy of combined oral contraceptives by impairing
the bacterial flora responsible for recycling ethinylestradiol from the large bowel (risk
is small). For these, additional precautions are required for duration of treatment and
for 7 days after stopping treatment (if this is in the last 7 days of the packet, omit the pill free period).
However NO need for extra precautions if a woman is taking the pill and has been
4

on the SAME antibacterial course exceeding 3 weeks. This is because the bacterial
flora develops resistance. If the antibiotic is changed, then YES additional
precautions are necessary. Also NO precautions are necessary if a woman is
STARTING the COC and has been on antibiotic therapy for 3 weeks or more.
For contraceptive patches, additional contraception is required for 7 days after
stopping treatment with non-enzyme inducing antibacterial drugs (except
tetracycline). However no need for extra precautions if a woman is using the patches
and has been on the SAME antibacterial course exceeding 3 weeks. If the antibiotic
is changed, then YES additional precautions are necessary. Also NO precautions
are necessary if a woman is STARTING the COC and has been on antibiotic therapy
for 3 weeks or more. IBNF page 434

Progestogen only contraceptives and Interactions

Progestogen only contraceptives are not affected by antibacterials that are not
enzyme inducers. However their efficacy is reduced by enzyme inducer drugs. In this
case additional protection is needed for duration of treatment and for 4 weeks
afterwards.
Sympathomimetics and Interactions
Pseudoephedrine + MAOI = hypertensive crisis
Pseudoephedrine + Beta Blockers = increased risk of hypertension
Orlistat and Alli
Orlistat + Amiodarone = Orlistat possibly reduces plasma conc of amiodarone
Orlistat + Anticoagulants = Need to monitor anticoagulant effect of coumarins
Orlistat + Diabetes = Avoid concomitant use of Acarbose as its effects work on GI
Orlistat + Ciclosporin = Orlistat possibly reduces absorption of cicloporin (black dot)

Pharmacokinetic Interactions
These occur when one drug alters the absorption, distribution, metabolism, or
excretion of another drug, thus increasing or reducing the amount of drug available
to produce its pharmacological effects.
Affects absorption reduced amount of absorption can result in ineffective therapy.
Changes in protein binding and distribution One drug can displace another drug
from a protein binding site increasing its proportion free to diffuse from plasma to its
site of action.
Affects metabolism Effects on liver cytochrome P450 enzymes.
Affects renal excretion NSAIDs delay the excretion of Methotrexate possibly
causing serious toxicity.

Pharmacodynamic Interactions
This is where effects of one drug are changed by the presence of another drug at its
pharmacological site of action.
Synergistic effect causing combined toxicity sedative + sedative, antihypertensive
drug + drugs causing hypotension, potassium sparing diuretics + K+ supplements.
Antagonistic effect causing opposite effects Warfarin + Vitamin K
Affects drug transport mechanisms - nortriptyline inhibiting the uptake of adrenaline
into adrenergic neurones.
Disturbances in fluid and electrolyte balance - cardiac glycoside + potassium
depleting diuretics, Lithium + thiazide diuretics causing sodium depletion.
5

POPULAR DRUG INDICATIONS and FACTS TO KNOW GI, CVS, CNS see separate notes
Gastro Intestinal System
Helicobacter pylori Infection
o Eradication of H. pylori reduces recurrence of gastric and duodenal ulcers and
the risk of re-bleeding.
o The presence of H. pylori should be confirmed before starting treatment.
o First Line Therapy is a seven day treatment of:
1. Proton Pump Inhibitor (twice daily dose)
2. Plus 2 Antibiotics given twice daily
- Clarithromycin
- Amoxicillin or Metronidazole
o The above regimen eradicates H. pylori in about 85% of cases. BNF page 50

Cardiovascular System
For Hypertension People younger than 55 years and Caucasians respond better to
an ACE inhibitor or angiotensin II receptor antagonists. People aged over 55 years &
afro-Caribbean (any age) first line treatment is thiazide diuretics or calcium channel
blockers. BNF page 105
For Heart Failure An ACE inhibitor titrated to a target dose combined with a
licensed beta blocker plus a diuretic to reduce fluid overload. Low doses of
spironolactone reduce symptoms and mortality. Digoxin improves symptoms and
exercise tolerance. BNF page 114
Colestyramine for hyperlipidaemia is a bile acid sequestrant which binds to bile
acids and promotes hepatic conversion of cholesterol into bile acids. Counselling:
Other drugs should be taken at least 1 hour before or 4 6 hours after bile acid
sequestrants to reduce possible interference with absorption. Colesevelam and a
statin can be taken at the same time. BNF page 166

Respiratory System
BTS Guidelines (Table Page 174 BNF) see separate Respiratory notes
Tiotropium (Antimuscarinic bronchodilator) only indicated for COPD and not
asthma.

Central Nervous System

Orlistat (and Alli) See separate OTC RPSGB guidance.
Metoclopramide under 20 years old Use restricted to severe intractable vomiting
of a known cause, vomiting of radiotherapy and cytotoxics, aid to GI intubation, premedication; also dose should be determined on the basis of body-weight. BNF page
256

Migraine 5HT1 agonists such as naratriptan and sumatriptan are used for
treatment of acute migraines. Beta blockers, pizotifen, clonidine, methysergide,
sodium valproate, topiramate, TCAs and cyproheptadine are prophylactic
treatments. Prophylaxis is required if a patient suffers more than 2 attacks per
month, suffers an increasing frequency of headaches, suffers significant disability
despite treatment for migraine attacks, cannot take suitable treatments for migraine
attacks. BNF page 277

Infections
Meningitis (Blind Therapy) - following urgent transfer to hospital; Use
Benzylpenicillin or Cefotaxime (if penicillin allergy)
For Lower Urinary Tract Infection - Trimethoprim or Nitrofurantoin or Amoxicillin or
oral Cephalosporin - for 3 to 7 days.
Tuberculosis Treat with 4 drugs (Isoniazid, Rifampicin, Pyrazinamide,
Ethambutol) in the initial phase for 2 months or possibly longer. Treat with 2 drugs
(Isoniazid and Rifampicin) for a further 4 months. Note: Ethambutol can cause colour blindness.
High Anaerobic activity Metronidazole.

Endocrine System
Insulin is given by subcutaneous injection but soluble insulin is given
intravenously and is reserved for urgent treatment. Insulin may be required for both
type 1 and 2 diabetes. It is needed for all patients with ketoacidosis and for those
whose symptoms include: rapid onset of symptoms, substantial weight loss,
weakness, ketonuria (ketone bodies in urine), and first degree relative who has
diabetes. BNF page 427
Short acting sulphonylureas (Gliclazide and Tolbutamide) Work by increasing
insulin secretion by B cells. Considered for patients who are not overweight or for
those where Metformin is CI. BNF page 435
Long acting sulphonlyureas (chlorpropamide and glibenclamide) - associated with
greater risk of hypoglycaemia; hence should be avoided in the elderly and the short
acting ones are preferred. BNF page 435
Biguanide - Metformin Works by decreasing gluconeogenesis and increasing
peripheral utilisation of glucose. It is first line therapy for diabetics. It does not cause
weight gain hence good for overweight or obese patients. Produces normoglycaemia
rather than hypoglycaemia. BNF page 437
Pioglitazone and Rosiglitazone - Work by decreasing peripheral insulin resistance
Acarbose Works by delaying digestion and absorption of starch and sucrose from
the gut by inhibiting intestinal alpha glucosidases. Usually add on therapy. BNF page
440

Diabetic Ketoacidosis (a hyperglycaemic emergency) - Symptoms include nausea,

vomiting, abdominal pain, extreme thirst, blurred vision and can be life threatening.
Treatment: a. Soluble Insulin by intravenous infusion (because subcutaneous insulin
may be slow and erratic); b. Sodium chloride intravenous infusion fluid replacement;
c. Potassium chloride is included in the infusion to prevent hypokalaemia induced by
insulin. BNF page 443
Hypoglycaemia (caused by low blood glucose levels) - Causes: Too much insulin,
little carbohydrate, delayed meals, too much exercise, hot weather, stress, alcohol.
Symptoms include tremor, sweating, anxiety, paleness, irritability, feeling faint,
stomach ache, headache, tingling sensation and blurred vision. Treatment for
conscious patient: oral sugar following a carbohydrate snack. Treatment for
unconscious patient: IV glucose infusion or Glucagon injection, followed by complex
carbohydrates once conscious. Note: Hypoglycaemia can be masked by beta
blockers and this can be dangerous. BNF page 444
ACE inhibitor - may have a specific role in the management of diabetic nephropathy
in type 2 diabetes and may minimise decline of renal function. BNF page 115
Levothyroxine - For hypothyroidism Initial dosing: If metabolism increases too
rapidly this causes diarrhoea, nervousness, rapid pulse, insomnia, tremors and
sometimes angina pain where there is latent myocardial ischemia. The dose needs
to be reduced or withheld for one to two days then restarted again. BNF page 448
Read Pages 451 to 387 455 on Steroids
7

 Corticosteroids - Important Indications: Replacement therapy for Addisons

disease, Acute adrenal insufficiency, hypopituitarism, anti-inflammatory treatment,
immunosupression.
Important Points: a. Prolonged use increases susceptibility to infections and severity
of infections. b. Unless they have already had chickenpox, patients using oral or
parenteral therapy are at risk of severe chickenpox. c. Special care is required to
avoid exposure to measles. d. Long term dosing can lead to adrenal suppression,
psychiatric reactions and growth restriction in children. e. Until one year after
stopping steroids, patients must mention that they had taken steroids.
Withdrawal: This must be gradual if a patient has received repeated courses of
systemic corticosteroids particularly if taken for longer than 3 months, if the patient
has taken a short course within one year of stopping long-term therapy, if there are
other possible causes of adrenal suppression, if the patient received more than
40mg daily prednisolone (or equivalent), if the patient has been given repeated
doses in the evening (e.g. mimicking the normal diurnal rhythm), if the patient has
received more than 3 weeks treatment.
HRT for treatment of menopausal symptoms such as vaginal atrophy, vasomotor
instability (heat, sweating) and menopausal osteoporosis. HRT can be used in
women with early natural or surgical menopause before the age of 45. For early
menopause, HRT can be given until the approximate age of natural menopause (i.e.
until the age of 50). Experience in treating women over 65 with HRT is limited.
RISKS: Increased risk of breast cancer within 1 to 2 years of initiating treatment.
Increased risk of endometrial cancer (depends on dose and duration of oestrogen
only HRT) hence progestogen can be added cyclically for 10 days in a 28 day cycle.
Increased risk of ovarian cancer (although small) with long term combined use of
HRT or oestrogen-only HRT. Increased risk of DVT and pulmonary embolism with
combined or oestrogen only HRT. Risk of stroke and CHD also found. Note: HRT
does not provide contraception and a woman is considered potentially fertile for 2
years after her last menstrual period if she is under 50 and for 1 year if she is over
50 years old. BNF page 458 and see BNF page 505 for reasons to stop HRT
Bisphosphonates (Alendronic acid, Disodium etidronate, Risedronate sodium)
Work by reducing bone turnover. They are used for the treatment of osteoporosis
and for corticosteroid induced osteoporosis. Alendronic acid dose for
postmenopausal osteoporosis is 70mg once weekly. BNF page 480

Gynaecology
Combined oral contraceptive BNF page 502. Mechanisms: The oestrogen works
by inhibiting ovulation, and changes the endometrial environment. The progestogen
works by also inhibiting ovulation but to a lesser extent. Progestogen inhibits
fallopian tube motility, changes the endometrial environment and thickens the
cervical mucus which is hostile to sperm. Risk of DVT: Increased risk particularly
during the first year. Risk increases with age and obesity. This risk is increased by
travelling for long periods with immobility. Advice wearing graduated compression
hosiery or exercising during the journey. Missed pill: If a pill is missed it should be
taken as soon as remembered and the next one at the normal time. (A missed pill is
one that is more than 24 hours late). If ONE pill is missed, it should be taken as soon
as remembered and no further precautions are necessary. If 2 or more pills missed
(especially in the first 7 days of the packet), protection is compromised. Take an
active pill when remembered and then resume normal pill taking but barrier
contraception for 7 days after. If these 7 days run beyond the end of the packet, the
pill free interval should be omitted. EHC may be needed. Vomiting and diarrhoea: If
vomiting occurs within 2 hours of taking COC, another pill should be taken. If
8

vomiting and diarrhoea is severe and lasts more than 24 hours, additional
precautions should be used for 7 days. Risks: Small risk of breast cancer and
cervical cancer but risk of ovarian and endometrial cancer reduced). First time users:
Start on day 1 of menstruation. If started on day 4 or later then additional
precautions necessary for 7 days. Changing to COC containing a different
progestogen: Complete the whole packet then for the new pack start the very next
day without the 7 day break. If the pill free break is taken then barrier methods
should be used for 7 days after taking the new brand. Changing from POP to COC:
Start on first day of menstruation for full protection. If taken for amenorrhoea then
start at any time but barrier protection needed for first 7 days. After childbirth: Start 3
weeks after birth (risk of thrombosis if started earlier) If started later than 3 weeks,
then barrier methods needed for first 7 days. After abortion or miscarriage: Start on
the same day. For patches See BNF page 503
COC or HRT should be stopped immediately if:
a. Sudden severe chest pain
b. Sudden breathlessness
c. Unexplained swelling or severe pain in calf of one leg
d. Severe stomach pain.
e. Serious neurological effects e.g. vision loss, seizure, bad fainting, numbness.
f. Hepatitis, jaundice, liver enlargement
g. Blood pressure above systolic 160mmHg and diastolic 95mmHg
h. Prolonged immobility after surgery or leg injury
i. Detection of a risk factor e.g. DVT in the family, arterial disease, migraine
Progesterone Only Contraceptive: These may be suitable where COC is
contraindicated but do have a higher failure rate. They are suitable for older women,
heavy smokers, hypertension and heart disease, diabetics and migraine sufferers
but still need to be cautioned. Staring routine: One tablet daily, starting on day one of
cycle. Changing from COC: Start on the day following completion of COC course
without a break. After childbirth: Start at any time after 3 weeks of birth (increased
risk of breakthrough bleeding if started earlier). Breastfeeding: Lactation is not
affected; in fact POP is preferred contraceptive for breast feeding. Missed Pill: If a
pill is forgotten, it should be taken as soon as remembered and carry on with the
next one at the right time. If the pill was more than 3 hours overdue (12 hours for
Cerazette) then a woman is not protected. Continue normal pill taking but other
forms of contraception (barrier methods) should be used for the next 2 days.
Diarrhoea and vomiting: If vomiting occurs within 2 hours of taking POP, another one
should be taken as soon as possible. If a replacement pill is not taken within 3 hours
of the normal time or if severe diarrhoea and vomiting occur for a longer duration of
time then extra precautions should be taken for 2 days after recover. Risks: Small
risk of breast cancer. BNF page 509

Musculoskeletal and Joint diseases

Acute attacks of Gout Treated with high doses of NSAIDs such as diclofenac,
etoricoxib, indometacin, ketoprofen, naproxen or sulindac. Colchicine is an
alternative (e.g. for patients with heart failure who cannot take NSAIDs or for patients on anticoagulants). Aspirin is
not indicated in gout. Allopurinol and Uricosurics are not effective in treating an
acute attack but used for prophylaxis of gout. Never start a prophylactic drug during
an acute attack as it can make it worse; start them 1 to 2 weeks after the acute
attack has settled. BNF page 641
Read Pages 642 to 644 BNF on NSAIDs
9

 NSAIDs Note about GI: etoricoxib and celecoxib are COX-2 selective and hence
have fewer GI side effects. Azapropazone (non-selective) is associated with the
highest risk of GI effects and Ibuprofen (non selective) with the lowest. Other nonselective (COX-1 and 2) NSAIDs include piroxicam, ketoprofen, indometacin,
naproxen and diclofenac have intermediate risk for GI effects. Note about asthma:
NSAIDs can worsen asthma due to bronchospasm being a side effect. Note about
Cardio: COX-2 selective inhibitors are associated with an increased risk of
thrombotic events and should not be used in preference to non-selective NSAIDs
unless specifically indicated. Note about renal: NSAIDs can impair renal function and
therefore need to be used in caution. Note about Heart failure: All NSAIDs are
contraindicated in severe heart failure. Note about Peptic Ulcers: NSAIDs are
contraindicated in peptic ulcers but those patients in need of NSAIDs i.e. for severe
rheumatism can be given a PPI for prophylaxis of GI ulceration and bleeding. BNF
page 644

Read Page 658-659 BNF on Methotrexate

POPULAR DRUGS AND THEIR SIDE EFFECTS

Gastro Intestinal System
Magnesium containing antacids - Laxative effect and can cause belching due to carbon
dioxide liberation.

Aluminium containing antacids - Constipating effect.

Hyoscine (antimuscarinic) - Constipation, Transient Bradycardia, Reduced bronchial

secretions, Urinary urgency and retention, Dilatation of pupils (problematic for patients with angle
closure glaucoma), Photophobia, Dry mouth, Flushing, Dryness of the skin.
H2 Receptor Antagonists - Diarrhoea, GI disturbance, Altered Liver Function Tests,
Headache, Dizziness, Rash, Tiredness.
Proton Pump Inhibitors - GI disturbances, Headache.
Liquid paraffin - anal seepage, granulomatous reactions (especially from the emulsion), lipoid
pneumonia and interference with the absorption of fat-soluble vitamins.

Cardiovascular System
Thiazide Diuretics - Mild GI disturbance, Postural hypotension, Altered plasma lipid

concentrations, Hypokalaemia, Hyponatraemia (low sodium in the blood), Hypomagnesaemia,

Hypercalcaemia, Hyperglycaemia, Hyperuricaemia and Gout (uric acid). Less common impotence.
Loop Diuretics - Mild GI disturbance (nausea), Hypotension, Hypokalaemia, Hyponatraemia (low
sodium in the blood), Hypomagnesaemia, Hypocalcaemia, Hyperglycaemia (less common than with
thiazides), Hyperuricaemia, Gout (uric acid).
Potassium Sparing Diuretics - Hyperkalaemia
Beta Blockers - GI disturbance, Bradycardia, Heart Failure, Hypotension, Peripheral
vasoconstriction (cold hands and feet), Bronchospasm, Dyspnoea, Headache, Fatigue, Sleep
disturbance (Nightmares), Sexual dysfunction, Pins and needles , Dizziness, Interference with glucose
tolerance.
ACE Inhibitors - Can cause profound hypotension and renal impairment, Persistent dry cough,
Angioedema, Rash, Pancreatitis, Upper Respiratory symptoms, GI disturbances, Altererd LFTs
(jaundice), Hyperkalaemia, Hypoglycaemia, Blood disorders, Taste disturbance.
Angiotensin II Receptor Blockers - Dizziness (if taking high dose diuretics as well),
Hyperkalaemia (occasional), Angioedema (occasional).
Nitrates - Postural Hypotension, Tachycardia, Throbbing Headache, Dizziness, Flushing.
Calcium channel Blockers Oedema (Notably of the ankles).
Aspirin - Bronchospasm, Gastro-intestinal bleeding (PPI can be added).
Statins - Myositis, Myalgia and Myopathy (Muscle Effects) - Serious, Liver toxicity, GI disturbance
(flatulence, abdominal pain).

10

Respiratory System
Beta2 Agonists - Fine tremor, Nervous tension, Headache, Muscle cramps, Palpitations,
hypokalaemia.

Antimuscarinic Bronchodilators (Ipratropium, Tiotropium) - Dry mouth.

Inhaled corticosteroids - Oral candidiasis, Hoarseness, Adrenal suppression.
Antihistamines - Antimuscarinic side effects urinary retention, dry mouth, blurred vision,
constipation and sedation with the older generation.

Central Nervous System

Benzodiazepines - Drowsiness, Light-headedness the next day, Amnesia, In elderly: Confusion
and ataxia, Dependence.

Antipsychotic (chlorpromazine) Marked Sedative effects, Moderate antimuscarinic effects,

Moderate extrapyramidal effects see CNS Notes.

Antipsychotic (prochorperazine) Marked Extrapyramidal effects, fewer sedative effects,

fewer antimuscarinic effects.

Atypical Antipsychotics (e.g. Amisulpride, Olanzapine) - Weight gain, Dizziness,

Postural hypotension, Extra-pyramidal effects (usually mild), Hyper-glycaemia and diabetes.
Tricyclic antidepressants - Dry mouth, Sedation, Blurred vision, Constipation, Nausea,
Difficulty with urination, Cardiovascular side effects, Sweating, Tremor, Rashes, Hypersensitivity
reactions, Confusion, Suicidal behaviour.
SSRIs - Gastro-intestinal effects, Anorexia/weight loss or opposite, Hypersensitivity reactions,
Urticaria, Angioedema, Anaphylaxis, Arthralgia, Myalgia, Photosensitivity.
Mirtazapine Increased appetite and weight gain, oedema, sedation, nausea, vomiting, dizziness,
headache which commonly lead to the need for withdrawal but this should be done over several
weeks.
Venlafaxine GI disturbance, headache, anxiety, dizziness, sleep disturbance which commonly
lead to the need for withdrawal but this, should be done over several weeks.
Orlistat oily leakage from rectum, flatulence, faecal urgency, liquid or oily stools, faecal
incontinence, abdominal distension and pain (minimised by reduced fat intake), tooth and gingival
disorders, respiratory infections, fatigue, anxiety, headache, menstrual disturbance, UTI,
hypoglycaemia.
Metoclopramide Extrapyramidal side effects.
5HT1 agonists (Naratriptan, Sumitriptan) Tingling, heat, heaviness, pressure, or
tightness of any part of the body, flushing, dizziness, weakness.
Opioids Nausea, vomiting, constipation, dry mouth, biliary spasm, respiratory depression in
larger doses.

Infections
Penicillin, Flucloxacillin, Amoxicillin, Ampicillin, Co-amoxiclav, Co-fluampicil

Hypersensitivity reactions can be fatal (uticaria, fever, joint pains, rashes, angioedema, anaphylaxis.)
Cephalosporins (Cefaclor, Cefalexin) - Hypersensitivity reactions (0.5-6.5% of penicillin
allergic patients will also be allergic to cephalosporins), diarrhoea and antibiotic associated colitis
(more likely with higher doses), nausea, vomiting, abdominal discomfort, headache, liver problems.

Tetracyclines (Tetracyline, Doxycycline, Lymecycline, Minocycline,

Oxytetracycline) - nausea, vomiting, diarrhoea, Dysphagia, oesophageal irritation.
Aminoglycosides (Gentamicin, Neomycin) Ototoxicity (inner ear or balance of hearing
toxicity) and nephrotoxicity.

Macrolides (Erythromycin) Nausea, vomiting, abdominal discomfort and diarrhoea

(Clarithromycin - also dyspepsia and tongue/tooth discolouration. Smell and taste disturbances).

Clindamycin Diarrhoea (discontinue treatment as associated with fatal antibiotic associated

colitis), abdominal discomfort, oesophageal ulcers.

Trimethoprim - GI effects, pruritus, rashes, hyperkalaemia.
Rifampicin - GI effects (diarrhoea antibiotic associated colitis reported, anorexia, nausea,
vomiting), hepatic disorders, coloured bodily fluids (urine red).

11

 Metronidazole - GI effects, taste disturbance, furred tongue, oral mucositis, and anorexia.
Quinolones (Ciprofloxacin) - Nausea, vomiting, dyspepsia, abdominal pain, diarrhoea,
headache, dizziness, rash, sleep disturbances.

Nitrofurantoin - Anorexia, nausea, vomiting, diarrhoea, acute and chronic pulmonary reactions.
Terbinafine Abdominal discomfort, anorexia, nausea, diarrhoea, headache, rash and urticaria.

Endocrine System
Insulin - fat hypertrophy at injection site, hypoglycaemia (heavy sweating, shakiness, dizziness,

visual disturbance, tingling of hands and lips, speech disturbance)

Sulphonylureas - Weight gain, GI effects (nausea, vomiting, diarrhoea, constipation),
hypoglycaemia.
Biguanides (Metformin) - Anorexia, nausea, vomiting, diarrhoea, abdominal pain, metallic
taste, vitamin B12 deficiency.
Levothyroxine Diarrhoea, vomiting, angina pain, arrhythmias, palpitation, tachycardia, tremor,
restlessness, excitability, insomnia, headache, flushing, sweating, fever, heat intolerance, weight loss,
muscle cramps, transient hair loss in children.
Carbimazole nausea, mild GI disturbance, headache, rash, bone marrow suppression
(neutropenia, agranulocytosis)
Oral corticosteroids: Euphoria, nightmares, insomnia, irritability, mood lability, suicidal
thoughts, psychotic reactions, immunosupression, adrenal suppression.
Mineralocorticoids - Hypertension, sodium and water retention, potassium and calcium loss.
Glucocorticoids - Diabetes, osteoporosis, muscle wasting and weakness, peptic ulceration and
perforation, Cushings syndrome (moon face, striae, acne occurs with higher doses and is reversal on
withdrawal), growth suppression in children, GI effects, menstrual irregularities, hirsutism, weight
gain, increased susceptibility to infection, insomnia, glaucoma, uticaria, skin atrophy, myocardial
rupture following MI or congestive heart failure, hypersensitivity, thromboembolism, nausea, malaise,
hiccups, headache, vertigo.

Gynaecology
Combined Oral Contraceptives: Nausea, vomiting, abdominal cramps, changes in body

weight, liver impairment, hepatic impairment, fluid retention, and hypertension.

Progestogen-only Contraceptives: Menstrual irregularities, nausea, vomiting, headache,
dizziness, breast discomfort, depression, skin disorders, disturbance of appetite, weight changes,
changes in libido.

Musculoskeletal and Joint Diseases

NSAIDs - GI discomfort, nausea, diarrhoea, bleeding and ulceration, hypersensitivity

(bronchospasms), headache, dizziness, nervousness, depression, drowsiness, insomnia, vertigo,

hearing disturbance, photosensitivity, blood disorders, fluid retention, renal failure.
Methotrexate anorexia, abdominal discomfort, dyspepsia, GI ulceration and bleeding, diarrhoea
plus many more.

DRUGS THAT COLOUR BODILY FLUIDS

Dantron (Co-danthramer) Urine Red

Sulfasalazine Urine Orange
Triamterene (potassium sparing) Urine may look slightly blue in some lights
Rifampicin Urine Orange/Red
Nitrofurantoin Urine Orange/Brown
Levodopa Urine and other bodily fluids coloured Dark Red

12

DRUGS THAT CAUSE CONTACT SENSITISATION or PHOTOTOXICITY

Chlorpromazine - Healthcare professionals should avoid direct contact with this
medication and tablets should not be crushed and solutions should be handled with
care. This is due to the risk of contact sensitisation. Avoid direct sunlight due to
photo sensitisation. BNF page 221
Amiodarone Causes phototoxicity and slate-grey skin discolouration. Due to the
phototoxic reactions, patients should shield the skin from light during treatment and
for several months after discontinuing treatment. A wide-spectrum sunscreen to
protect against wide spectrum UV and visible light should be used. BNF page 94
Doxycycline - photosensitivity
Azapropazone (NSAID) photosensitivity.

CSM WARNINGS and ADVICE

Gastro-Intestinal System
Sucralfate - Bezoar formation (a mass of swallowed foreign material within the stomach) has been

reported and should therefore be used in caution for seriously ill patients. Extra care with those
receiving concomitant enteral feeds or those with predisposing conditions such as delayed gastric
emptying. BNF page 54
Pancreatin high strength preparations data recommendations. See BNF page 79-80

Cardiovascular system
Beta-blockers (including cardioselective) should not be given to patients with history of asthma or
bronchospasm. However, in rare situations where there is no alternative a cardioselective betablocker is given with extreme caution under specialist care. BNF page 98 This is also true for the
case of Beta-blocker eye drops. BNF page 687
Sotalol - The use of sotalol should be limited to the treatment of ventricular arrythmias or
prophylaxis of supraventricular arrhythmias. It should no longer be used for angina, hypertension,
thyrotoxicosis or for secondary prevention after myocardial infaction; when stopping sotalol for these
indications, the dose should be reduced gradually. BNF page 99/104
Heparin - Hyperkalaemia: Inhibition of aldosterone secretion by heparin (including low molecular
weight heparins) can result in hyperkalaemia; patients with diabetes mellitus, chronic renal failure,
acidosis, raised plasma potassium or those taking potassium-sparing drugs seem to be more
susceptible. The risk appears to increase with duration of therapy and the CSM has recommended
that plasma-potassium concentration should be measured in patients at risk of hyperkalaemia before
starting heparin and monitored regularly thereafter, particularly if heparin is to be continued for longer
than 7 days. BNF page 140
Lipid-lowering drugs - Rhabdomyolysis associated with lipid-lowering drugs such as fibrates
and statins is rare (1 case in every 100000 treatment years) but can be increased in those with renal
impairment and possibly in those with hypothyroidism. Concomitant treatments with drugs that
increase plasma-statin concentration increase the risk of muscle toxicity; concomitant treatment with
a fibrate and a statin may also be associated with an increased risk of serious muscle toxicity. BNF
page 162-164

Respiratory System
Salbutamol - The CSM has advised that potentially serious hypokalaemia may result from beta2
agonist therapy. Particular caution is required in severe asthma because this effect may be
potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, and
diuretics, and by hypoxia. Plasma-potassium concentration should therefore be monitored in severe
asthma. BNF page 177-178

13

Inhaled corticosteroids - The height of children receiving prolonged treatment of

corticosteroids should be monitored. Large volume spacer devices should be used for administering
inhaled corticosteroids under 5 year old children. BNF page 186-188
Leukotriene receptor antagonists - Churg-Strauss syndrome (severe asthma with increased
eosinophil count) has occurred very rarely in association with the use of leukotriene receptor
antagonists; in many of the reported cases the reaction followed the reduction or withdrawal of oral
corticosteroid therapy. The CSM has advised that prescribers should be alert to the development of
eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, or peripheral
neuropathy. BNF page 192
Bee and Wasp Allergen extracts/Grass and tree pollen extracts - The CSM has
advised that facilities for cardiopulmonary resuscitation must be immediately available and patients
monitored closely for one hour after each injection. BNF page 197-198

Central Nervous System

Benzodiazepines a. Are indicated for short term relief (two to four weeks only) of anxiety that is

severe, disabling, or subjecting the individual to unacceptable distress, occurring alone or in

association with insomnia or short-term psychosomatic, organic, or psychotic illness. b. The use of
benzodiazepines to treat short-term mild anxiety is inappropriate and unsuitable. c. They should be
used to treat insomnia only when it is severe, disabling, or subjecting the individual to extreme
distress. BNF page 210
Atypical Antipsychotics and Stroke Olanzapine and Risperidone are associated with an
increased risk of stroke in elderly patients with dementia. BNF page 219

Clozapine - a. Withdrawal b. Agranulocytosis c. Myocarditis and Cardiomyopathy d.

GI obstruction. See Guidance BNF page 226
Hyponatraemia and Antidepressants - Hyponatraemia which is a low blood sodium
concentration (usually in the elderly and possibly due to inappropriate secretion of antidiuretic
hormone) has been associated with all types of antidepressants; however, it has been reported more
frequently with SSRIs than with other antidepressants. The CSM has advised that hyponatraemia
should be considered in all patients who develop drowsiness, confusion, or convulsions while taking
an antidepressant. BNF page 235
Depressive illness in Children - SSRIs citalopram, escitalopram, paroxetine, and sertraline,
and for mirtazipine and venlafaxine are unfavourable for under 18 years olds as clinical trials have
failed to show efficacy and an increase in harmful outcomes. Only fluoxetine was found to be effective
in clinical trials. Children and adolescence should be monitored carefully for suicidal behaviours. BNF
page 242
Fluvoxamine - The CSM has advised that concomitant use of fluvoxamine and theophylline or
aminophylline should usually be avoided. BNF page 242
Paroxetine - Extrapyramidal effects (including orofacial dystonias) and withdrawal syndrome are
reported to the CSM more commonly with paroxetine than with other SSRIs. Also, the recommended
dose for the treatment of depression, social anxiety disorder, generalised anxiety disorder, and post
traumatic stress disorder is 20mg daily. For OCD and panic disorder it is 40mg daily. There is no
evidence that higher doses are more effective. BNF page 245
Sumatriptan - Following reports of chest pain and tightness (coronary vasoconstriction) CSM has
emphasised that sumatriptan should not be used in ischaemic heart disease or Prinzmentals angina,
and that use with ergotamine should be avoided. BNF page 277
Lamotrigine - Serious skin reactions including Steven-Johnson syndrome and toxic epidermal
necrolysis have developed especially in children. Most rashes occur in the first 8 weeks. Rash is
sometimes associated with hypersensitivity syndrome. Consider withdrawal if rash or signs of
hypersensitivity syndrome develop. Factors associated with increased risk include concomitant use of
valproate, initial lamotrigine dosing higher than recommended, and more rapid dose escalation than
recommended. BNF page 290
Topiramate has been associated with acute myopia with secondary angle-closure glaucoma,
typically occurring within one month of starting treatment. Choroidal effusions resulting in anterior
displacement of the lens and iris have also been reported. The CSM advises that if raised intra-ocular
pressure occurs then seek medical ophthalmic advice, use appropriate measures to reduce IOP and
stop topiramate as rapidly as feasible. BNF page 294
Vigabatrin is associated with visual field defects. The CSM has advised that onset of symptoms
varies from 1 month to several years after starting treatment. In most cases, visual field defects have
persisted despite discontinuation. Product literature advises visual field testing before treatment and

14

at 6 month intervals; a procedure for testing visual fields in those with a developmental age of less
than 9 years is available from the manufacturers. Patients should be warned to report any new visual
symptoms that develop and those with symptoms should be referred for urgent ophthalmic opinion.
Gradual withdrawal of vigabatrin should be considered. BNF page 297
Dopamine Receptor Agonists The CSM has advised that ergot-derived dopamine receptor
agonists, bromocriptine, cabergoline, lisuride and pergolide have been associated with pulmonary,
retroperitoneal, and pericardial fibrotic reactions. Before starting treatment with these ergot
derivatives it may be appropriate to measure the erythrocyte sedimentation rate and serum creatinine
and to obtain a chest X-ray. Patients should be monitored for dyspnoea, persistent cough, chest pain,
cardiac failure, and abdominal pain or tenderness. BNF page 302
Buproprion (Zyban) - The CSM has issued a reminder that bupropion is contra-indicated in
patients with a history of seizures or of eating disorders, a CNS tumour, or who are experiencing
acute symptoms of alcohol or benzodiazepine withdrawal. Bupropion should not be prescribed to
patients with other risk factors for seizures unless the potential benefit of smoking cessation clearly
outweighs the risk. Factors that increase the risk of seizures include concomitant administration of
drugs that can lower the seizure threshold (e.g. antidepressants, antimalarials [such as mefloquine
and chloroquine], antipsychotics, quinolones, sedating antihistamines, systemic corticosteroids,
theophylline, tramadol), alcohol abuse, history of head trauma, diabetes, and use of stimulants and
anorectics. BNF page 316

Infections
Flucloxacillin - Very rarely, cholestatic jaundice and hepatitis may occur up to several weeks after
treatment with Flucloxacillin has been stopped. Administration for more than 2 weeks and increasing
age are risk factors. CSM remind that flucloxacillin should not be used in patients with a history of
hepatic dysfunction associated with flucloxacillin, it should be used with caution in patients with
hepatic impairment and careful enquiry should be made about hypersensitivity reactions to betalactam antibacterials. BNF page 342
Co-Amoxiclav - 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 with co-amoxiclav than with amoxicillin. Cholestatic jaundice is more common in
patients above the age of 65 years and in men; these reactions have only rarely been reported in
children. Jaundice is usually self-limiting and very rarely fatal. The duration of treatment should be
appropriate to the indication and should not usually exceed 14 days. BNF page 344
Linezolid - Haematopoietic disorders (thrombocytopenia, anaemia, leucopenia, and pancytopenia
simultaneous decrease in the blood cells) have been reported in patients receiving linezolid. It is
recommended that full blood counts are monitored weekly. Close monitoring is recommended in
patients who a. Receive treatment for more that 10 to 14 days. b. Have pre-existing myelosupression.
(may need to stop treatment unless considered essential) c. Are receiving drugs that may have
adverse effects on haemoglobin, blood counts, or platelet function. d. Have severe renal impairment.
BNF page 366
Linezolid Severe optic neuropathy may occur rarely, particularly if used for longer than 28 days.
It is recommended that visual impairment is reported immediately, evaluated promptly and monitored
regularly (if treatment is longer than 28 days). BNF page 366
Co-trimoxazole is associated with rare but serious side effects e.g. Stevens-Johnson syndrome
(serious allergic skin reaction) and blood dyscrasias (blood problems), notably bone marrow
depression and agranulocytosis (marked decrease in number of granulocyte white blood cells). It
should only be used where there is good reason. See BNF page 367
Quinolones Tendon damage (including rupture) has been reported with patients receiving
quinolones. Tendon damage may occur within 48 hours of starting treatment. CSM reminds that a.
Quinolones are CI in patients with tendon disorders relating to quinolones use, b. Elderly patients are
more prone to tendinitis, c. The risk of tendon rupture is increased by the concomitant use of
corticosteroids. d. If tendinitis is suspected, the quinolones should be discontinued. BNF page 376
Quinolones in Children cause arthropathy (Joint disorders) in the weight bearing joints of
immature animals. Therefore generally not recommended in children and growing adolescence.
However, the significance of this effect in humans is uncertain and in some specific circumstances
short term use of quinolones in children may be justified. Nalidixic acid is used for UTIs in children
over 3 months of age. Ciprofloxacin is licensed for pseudomonal infections in cystic fibrosis (for
children above 5 years old) and for treatment and prophylaxis of inhalational anthrax. BNF page 377

15

 Quinolones and Convulsions - CSM have warned that quinolones may indice convulsions in
patients with or without a history of convulsions. Taking NSAIDs at the same time may also induce
them. Therefore should also be used with caution in epileptics BNF page 377
Amphotericin B The CSM have advised that anaphylaxis occurs rarely with any intravenous
amphotericin product and a test dose is advisable before the first infusion. The patient should be
carefully observed for at least 30 minutes after the test dose. Prophylatic antipyretics and
hydrocortisone should only be used in patients who have previously experienced acute adverse
reactions (in whom continued treatment with amphotericin is essential). BNF page 386
Itraconazole - Rare reports of heart failure have been reported. CSM advise caution when
prescribing itraconazole to patients at high risk of heart failure. Those at risk include Patients
receiving high doses and long courses, older patients and those with cardiac disease and patients
receiving treatment with negative inotropic drugs e.g.. calcium channel blockers. BNF page 383
Ketoconazole Associated with fatal hepatotoxicity. The CSM advise that prescribers should
weigh the potential benefits of ketoconazole treatment against the risk of liver damage and should
carefully monitor patients both clinically and biochemically. It should not be used by mouth for
superficial fungal infections. The risk of this greater if given for longer than 10 days. BNF page 385
Mefloquine (Lariam) CSM have advised that travellers should be informed about adverse
reactions to mefloquine (nausea, vomiting, diarrhoea, abdominal pain, dizziness, loss of balance,
headache, and sleep disorders) and if these occur, medical advice should be sought on alternative
antimalarials before the next dose is due. The PIL should always be provided when dispensing
mefloquine. BNF page 416-417

Endocrine System
Carbimazole (antithyroid drug) - Doctors are reminded of the importance of recognising bone
marrow suppression induced by Carbimazole and the need to stop treatment promptly. a. Patients
should be asked to report symptoms and signs suggestive of infection, especially sore throat. b. A
white blood cell count should be performed if there is any clinical evidence of infection. c.
Carbimazole should be stopped promptly of there is clinical or laboratory evidence of neutropenia.
BNF page 449

Steroids - CSM advice on chickenpox, withdrawal, pregnancy and breast feeding

see BNF page 453-455
HRT - BNF page 458
Desmopressin (posterior pituitary hormone for diabetes) can cause hyponatraemic convulsions
(low sodium in blood, occurs in dehydration). Patients being treated for primary nocturnal enuresis
should be warned to avoid fluid overload (including swimming) and stop taking desmopressin during
episodes of vomiting and diarrhoea. BNF page 475-476

Gynaecology
Medroxyprogesterone acetate (Depo-Provera) be used only when other methods of

contraception are inappropriate. In all women, benefits of using medroxyprogesterone acetate beyond
2 years should be evaluated against risks (as reduction in bone mineral density has been reported).
In women with risk factors for osteoporosis a method of contraception other than
medroxyprogesterone acetate should be considered. BNF page 510
Spermicidal contraceptives - Products such as petroleum jelly (Vaseline), baby oil, oil based
vaginal and rectal preparations are likely to damage condoms and contraceptive diaphragms made
from latex rubber, and may render them less effective as a barrier method of contraception and as a
protection from sexually transmitted diseases (including HIV). BNF page 512
Co-Cyprindiol (Dianette) - Venous thromboembolism occurs more frequently in women taking
co-cyprindiol than those taking a low-dose combined oral contraceptive. The CSM has reminded
prescribers that co-cyprindiol is licensed for use in women with severe acne which has not responded
to oral antibacterials and for moderately severe hirsutism; it should not be used solely for
contraception. It is contra-indicated in those with a personal or close family history of venous
thromboembolism. Women with severe acne or hirsutism may have an inherently increased risk of
cardiovascular disease. BNF page 742

16

Cytotoxic drugs
Guidelines on handling cytotoxic drugs:
1.
2.
3.
4.
5.
6.

Trained personnel should reconstitute cytotoxics

Reconstitution should be carried out in designated areas
Protective clothing (including gloves) should be worn
The eyes should be protected and means of first aid should be specified
Pregnant staff should not handle cytotoxics
Adequate care should be taken in the disposal of waste material, including syringes,
containers, and absorbent material. BNF page 527

Tacrolimus (prophylaxis of organ rejection) - Cardiomyopathy has been reported in children given

tacrolimus after transplantation. Patients should be monitored carefully. BNF page 569
Tamoxifen is linked with a small risk of endometrial cancer but patients can be told that the
benefits far outweigh the risks. A 20mg dose daily substantially increases survival in early breast
cancer. Also note tamoxifen is linked with endometrial changes and thromboembolism (report any
sudden breathlessness or pain in the calf of one leg) BNF page 582-583

Nutrition
Thiamine IV - reports potentially serious allergic adverse reactions. BNF page 628

Musculoskeletal and Joint diseases:

NSAIDs and GI side effects - See BNF page 642-644
NSAIDs and asthma - Any degree of worsening of asthma may be related to the ingestion of

NSAIDs either prescribed or (in the case of ibuprofen and others) purchased over the counter. BNF
page 644
Azapropazone (NSAID for pain and inflammation in rheumatic disease) CSM has restricted its
use to rheumatoid arthritis, ankylosing spondylitis (inflammation of synovial joints in the backbone)
and acute gout only where other NSAIDs have been tried and failed. It is CI in patients with history of
peptic ulceration and the maximum daily dose is now reduced to 600mg for RA and ankylosing
spondylitis in patients over 60 years and those with renal impairment. Not in BNF 62
Tiaprofenic acid (NSAID for pain and inflammation in rheumatic disease) - has had reports of
severe cystitis. Tiaprofenic acid should not be given to patients with urinary-tract disorders and should
be stopped if urinary symptoms develop. Patients should be advised to stop taking tiaprofenic acid
and to report to their doctor promptly if they develop urinary-tract symptoms (such as increased
frequency, nocturia, urgency, pain and urinating, or blood in urine). BNF page 652

Methotrexate - Blood count, liver toxicity, pulmonary toxicity, with aspirin and other
NSAIDs. See BNF page 658-659
Baclofen (skeletal muscle relaxant for severe spasticity e.g. multiple sclerosis) The CSM have
advised that serious side effects can occur on abrupt withdrawal. To minimise risk, discontinue by
gradual dose reduction over at least 1 to 2 weeks (longer if symptoms occur). BNF page 672

Nutrition
Co-cyprindiol Venous thromboembolism occurs more frequently in women taking co-cyprindiol
than those taking low-dose combined oral contraceptive. Reserved for women with severe acne or
hirsutism. BNF page 742

17

KEY COUNSELLING POINTS ON DRUGS

Gastro-Intestinal System
Antacids - a. They are best taken when symptoms occur or are expected, usually
between meals or at bedtime. b. They should preferably not be taken at the same
time as other drugs since they may impair absorption. c. Antacids can damage
enteric coatings on tablets. d. The words low Na+ added after some preparations
indicates a sodium content of less than 1mmol per tablet or 10ml dose. This is
directed for people with hypertension. BNF page 44-46
Ispaghula - Preparations that swell in contact with liquid should always be carefully
swallowed with water and should not be taken immediately before going to bed. BNF
page 68

Liquid Paraffin should not be taken immediately before going to bed. BNF page 71
Cardiovascular system
Nitrate Tolerance - Patients on long acting nitrates can rapidly develop tolerance
(reduce therapeutic effect). Reducing the nitrate concentration in the blood for 4 to 8
hours each day usually maintains effectiveness e.g. by giving twice daily
preparations after 8 hours then after 16 hours. BNF page 125
Glyceryl Trinitrate Sublingual Tablets GTN tablets should be supplied in glass
containers of not more than 100 tablets, closed with a foil-lined cap, and containing
no cotton wool wadding (i.e. the original container). They should be discarded after 8
weeks. They should be placed under the tongue to dissolve. Dosing is when
required. BNF page 125
GTN spray Spray one to two doses under the tongue then close mouth. This
should relieve the pain within a minute or so. If no improvement after 5 minutes then
use it again. If no improvement, then use again after 5 more minutes. Then if no
improvement despite using the spray 3 times within 15 minutes, call an ambulance.
Respiratory System
Salbutamol inhalation - Advise patients not to exceed the stated dose. If a
previously effective dose of inhaled salbutamol fails to provide at least 3 hours relief,
a doctors advice should be obtained as soon as possible. BNF page 180
CFC-free inhalers - Patients receiving CFC-free inhalers should be reassured about
their efficacy and counselled that aerosol may feel and taste different. BNF page 187
Ipratropium - Acute angle-closure glaucoma reported with nebulised Ipratropium,
particularly when given with nebulised salbutamol (and possibly other beta2
agonists). Care is needed to protect patients eyes from nebulised drug or from drug
powder. BNF page 182
Corticosteroid Inhalers - The risk of oral candidiasis can be reduced by rinsing the
mouth with water after using the inhaler or by using a spacer device. BNF page 187
Central Nervous System
Patients taking MAOIs (including Linezolid) should avoid large amounts of Tyraminerich foods as it can cause a hypertensive crisis. An early warning symptom may be a
throbbing headache. The danger of interaction persists for up to 2 weeks after
treatment with MAOIs is discontinued. Tyramine rich foods include mature cheese,
pickled herring, broad bean pods, Bovril, Oxo, Marmite or any similar meat or yeast
extracts, undistilled alcohol beverages, and fermented soya bean products. Patients
also need to avoid stale or going off foods and stick to eating fresh foods. Alcoholic
drinks need to be avoided (including drinks with low alcohol content). Note that no
tyramine at all can cause hypotension. BNF page 240-241

18

 Epileptic Medication summarised Carbamazepine and Oxcarbazepine linked

with Blood, Hepatic and Skin disorders reported (Patients and their carers need to be able
to recognise signs of blood, liver, or skin disorders). Ethosuximide linked with Blood
disorders. Lamotrigine linked with Blood and Skin reactions. Phenytoin linked with
Blood and Skin disorders. Topiramate linked with Myopia with secondary angleclosure glaucoma. Sodium Valproate linked with Liver toxicity, Blood or Hepatic
disorders and Pancreatitis (Patients need to know how to recognise signs of pancreatitis
abdominal pain, nausea and vomiting). Vigabatrin linked with visual field defects. BNF
section 4.8.1

Parkinsons disease Excessive daytime sleepiness and sudden onset of sleep

can occur with co-careldopa, co-beneldopa, and dopamine receptor agonists.
Patients starting treatment should be warned of the possibility of these effects and
the need to exercise caution when driving or operating machinery. Patients, who
have suffered excessive sedation or sudden onset of sleep, should refrain from
driving or operating machinery until the effects have stopped. BNF page 302
Disulfiram (treatment of alcohol dependence) Patients should be aware of
unpredictable and occasionally severe nature disulfiram-alcohol interactions.
Reactions can occur within 10 minutes and last several hours which may require
oxygen therapy. Patients should not ingest alcohol at all and should be warned of
possible presence of alcohol in liquid medicines, remedies, tonics, foods and even
toiletries (alcohol should be avoided at least one week after therapy has stopped).
BNF page 315

Infection
Malaria prophylaxis - Travellers need to be warned about the importance of
avoiding mosquito bites and importance of taking prophylaxis regularly and
importance of immediate visit to doctor if ill within one year and especially within 3
months of return. BNF page 410-419
Endocrine System
Insulin:
A. Wash hands before using a blood glucose monitor.
B. Beware of problems with absorption as a hot climate or exercise can increase
the absorption of insulin and a cold climate or cool skin can reduce it.
Absorption is most rapid from the abdomen and slowest from the thigh.
C. Avoid diabetic foods as a healthy diet is more important. Diabetic foods
substitute sorbitol for glucose and are there for the occasional treat.
D. Check feet daily and wear appropriate footwear. Do not treat any foot
conditions yourself consult a chiropodist or doctor.
E. Be aware of retinopathy.
F. Sick day rules: Common illness can upset diabetic control. Consult urgent
medical help immediately if vomiting, drowsiness or deep rapid breathing
occurs. Do not stop taking insulin or oral hypoglycaemics. Test blood glucose
every 2 to 4 hours. Drink plenty of fluids to prevent dehydration. If not able to
eat then take Lucozade or sugar containing drinks.
G. Travelling with Insulin: use a cool bag for carrying the insulin. On long haul
flights, inject before eating and carry extra carbohydrates. Test more
regularly.
Acarbose - Tablets should be chewed with first mouthful of food or swallowed whole
with a little liquid immediately before food. To counteract possible hypoglycaemia,
patients receiving insulin or a sulphonylurea as well as acarbose need to carry
glucose (but not sucrose acarbose interferes with sucrose absorption). BNF page
440

19

 Alendronic acid (osteoporosis) - Tablets should be swallowed whole with plenty of

water while sitting or standing; to be taken on an empty stomach at least 30 minutes
before breakfast (or another oral medicine); patient should stand or sit upright for at
least 30 minutes after taking tablet. Also, patients should stop taking tablets and
seek medical attention if they develop symptoms of oesophageal irritation such as
Dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain.
BNF page 480-481

Didronel PMO (osteoporosis) Avoid food for at least 2 hours before and after oral
treatment, particularly calcium containing products such as milk; also avoid iron,
mineral supplements and antacids. BNF page 482
Risedronate (osteoporosis) - Tablets should be swallowed whole with plenty of
water while sitting or standing; to be taken on an empty stomach at least 30 minutes
before breakfast (or another oral medicine); patient should stand or sit upright for at
least 30 minutes after taking tablet. Granules should be stirred into a glass of water
and after dissolution complete taken immediately. BNF page 483
Gynaecology
Oral contraceptives see indications section
Prazosin (urinary retention)- First dose effect where the first dose may cause
collapse due to hypotensive effect (therefore should be taken on retiring to bed).
Patient should be warned to lie down if symptoms such as dizziness, fatigue or
sweating develop, and to remain lying down until they are abate completely. BNF
page 516

Drugs Affecting Immune Response

Ciclosporin (potent immunosuppressant e.g. for organ transplantation brand
Neoral) Total daily dose should be taken in 2 divided doses. Avoid grapefruit or
grapefruit juice for one hour before dose. For oral solution - Mix the solution with
orange juice (or squash) or apple juice (to improve taste) or with water immediately
before taking (and rinse with more to ensure total dose). Do not mix with grapefruit
juice. Keep the medicine measure away from other liquids (including water) BNF page
566-568

Skin
Isotretinoin (oral retinoid for severe acne) Warn patient to avoid wax epilation
(risk of epidermal stripping), dermabrasion, and laser skin treatment (risk of scarring)
during treatment and for at least 6 months after stopping; patient should avoid
exposure to UV light (including sunlight) and use sunscreen and emollient (including
lip balm) preparations from the start of treatment. Take tablets with or after food. BNF
page 742-743

COUNSELLING and IMPORTANT POINTS ON ANTIBIOTICS

Penicillin V, Flucloxacillin, Ampicillin - Label 9: regular Intervals and complete the course.
Label 23: an hour before food or on an empty stomach.

Amoxicillin - Unlike Ampicillin, absorption is not affected by the presence of food. Label 9: regular
Intervals and complete the course.

Cephalosporins (Cefaclor, Cefalexin) - Label 9: regular Intervals and complete the course.
Tetracycline, Oxytetracycline - Label 7: Do not take milk, indigestion remedies, or medicines
containing iron or zinc at the same time of day as this medicine (prevents absorption of the antibiotic
and should be taken 2-3 hours apart) Label 9: regular Intervals and complete the course. Label 23:
an hour before food or on an empty stomach.
Doxycycline - Label 6: Do not take indigestion remedies or medicines containing iron or zinc at
the same time of day as this medicine. Label 9: regular Intervals and complete the course. Label 11:

20

Avoid exposure of skin to direct sunlight or sun lamps. Label 27: With plenty of water. C: Capsules
should be swallowed whole with plenty of fluid during meals while sitting or standing.
Lymecycline - Label 6: Do not take indigestion remedies or medicines containing iron or zinc at
the same time of day as this medicine. Label 9: regular Intervals and complete the course.
Minocycline - Label 6: Do not take indigestion remedies or medicines containing iron or zinc at
the same time of day as this medicine. Label 9: regular Intervals and complete the course. C: Tablets
or capsules should be swallowed whole with plenty of fluid during meals while sitting or standing.
Erythromycin - Label 5: Do not take indigestion remedies at the same time of day as this
medicine.(should be taken 2-4 hours apart) Label 9: regular Intervals and complete the course. Label
25: swallowed whole, not chewed.
Clindamycin - Label 9: regular Intervals and complete the course. Label 27: with plenty of water.
C: Patients should discontinue immediately and contact the doctor if diarrhoea develops; capsules
should be swallowed with a glass of water.
Trimethoprim - Label 9: regular Intervals and complete the course. C: Watch out for signs of
blood dyscrasias i.e. sore throat.
Rifampicin - Label 8: Do not stop taking this medicine except on your doctors advice. Label 14:
This medicine may colour the urine. Label 22: Half to one hour before food. C: Watch out for signs of
liver toxicity i.e. nausea, vomiting, malaise, jaundice.
Metronidazole - Label 4: Warning. Avoid alcoholic drink. Label 9: regular Intervals and complete
the course. Label 21: with or after food. Label 25: swallowed whole, not chewed. Label 27: with
plenty of water.
Ciprofloxacin - Label 7: Do not take milk, indigestion remedies, or medicines containing iron or
zinc at the same time of day as this medicine. Label 9: regular Intervals and complete the course.
Label 25: swallowed whole, not chewed. C: Driving may impair performance of skilled tasks e.g.
driving. Effects are enhanced by alcohol.
Nitrofurantoin - Label 9: regular Intervals and complete the course. Label 14: This medicine may
colour the urine. Label 21: with or after food.

DRUGS THAT REQUIRE COUNSELLING ON REPORTING SORE THROAT RISK

OF BLOOD DYSCRASIAS
Patients or their carers need to be able to recognise signs of blood dyscrasias such as
agranulocytosis so that they know when to seek immediate medical attention. Symptoms
include sore throat, fever, malaise, rash, mouth ulcers, bruising or bleeding:
Aminosalicylates (e.g. Mesalazine, Sulfasalazine) Full blood count should be performed
and the drug stopped immediately if there is suspicion of a blood dyscrasias.

Mirtazapine
Carbamazepine
Ethosuximide
Phenytoin
Sodium valproate
Co-trimoxazole
Trimethoprim
Carbimazole
Gold (Drug for rheumatic disease)
Penicillamine (Drug for rheumatic disease)
Methotrexate
Azathioprine (transplant recipient) Bone marrow suppression patients should be warned to
report any signs or symptoms of bone marrow suppression e.g. inexplicable bruising, bleeding or
infection.

21

HEPATOTOXIC DRUGS
Labetalol Severe hepatocellular damage reported after both short-term and longterm treatment. Appropriate lab testing needed at first sign of symptom of liver
dysfunction. If lab evidence of damage present; or jaundice, labetalol should be
stopped and not restarted. BNF page 102
Sodium Valproate reported usually in the first 6 months and usually with multiple
antiepileptic therapies. Monitoring for liver function is important. BNF page 295
Rifampicin and Isoniazid patients and their carers need to know how to recognise
signs of liver disorders and should be advised to discontinue treatment and seek
immediate medical attention if symptoms such as persistent nausea, vomiting,
malaise or jaundice. BNF page 372 & 373
Itraconazole - patients should be told how to recognise signs of liver disorder and
advised to seek prompt medical attention if symptoms such as anorexia, nausea,
vomiting, fatigue, abdominal pain, jaundice or dark urine develop. BNF page 383
Pioglitazole - rare reports of liver dysfunction reported. BNF Page 442
Cyproterone (Prostate cancer treatment) - Direct hepatic toxicity; including jaundice,
hepatitis and hepatic failure have been reported. BNF Page 586
Leflunomide (rheumatoid arthritis) BNF Page 658
Methotrexate BNF Page 659
Halothane for anaesthesia has had reports of severe hepatotoxicity. BNF Page 795

RENAL FUNCTION
Reduced renal excretion of a drug or its metabolites can cause toxicity. Therefore
the dose may need to be adjusted.
Renal function is measured by GFR (Glomerular Filtration Rate) or it can be
expressed by CCL (Creatinine Clearance).
In the Open Book Exam, calculations will involve Creatinine Clearance values to be
determined using the formula. This value can then be used to decide whether the
dose needs to be adjusted or whether the patient should avoid the medication in the
question Prescribing in Renal Impairment BNF Page 17-18

DRUGS WITH WARNING CARDS

Lithium
Warfarin
MAOIs
Steroids

DRUGS WHERE THE SAME BRAND NEEDS TO BE PRESCRIBED

Different drug versions of e.g. modified release preparations may not have the same
clinical effect. To avoid confusion between different formulations, the same brand should
be specified by the prescriber.
Lithium
Theophylline and Aminophylline
Diltiazem and Nifedipine
22

DRUGS WITH DRIVING WARNINGS

Epilepsy - Patients suffering from epilepsy may drive a motor vehicle provided they
have been seizure free for one year. If subject to having attacks only while asleep,
they should have had no awake attacks within 3 years. BNF page 283
Diabetes - Drivers need to notify the DVLA of their condition. Driving is not permitted
when hypoglycaemic episodes occur. Drivers should check their blood glucose
levels before driving and at 2 hour intervals on long journeys. If hypoglycaemia
occurs stop the vehicle in a safe place, switch off the ignition, eat or drink a
suitable source of sugar and wait until recovery before continuing journey. This may
take 15 minutes or longer which should preferably be confirmed by checking bloodglucose concentration. BNF page 427

DRUGS AND SURGERY

Drugs normally NOT STOPPED before surgery: BNF page 675

Antiepileptics
Antiparkinsoniun drugs
Antipsychotics and Anxiolytics
Bronchodilators
Cardiovascular drugs - Potassium sparing diuretics may need to be stopped on
morning of surgery because hyperkalaemia may develop if renal perfusion is
impaired or if there is tissue damage. ACE inhibitors and Angiotensin II antagonists
can be associated with severe hypotension after induction of anaesthesia and
therefore may need to be discontinued 24 hours before surgery. Beta blockers
shouldnt be stopped suddenly and can be continued.
Drugs for dependence
Glaucoma drugs
Immunosuppressants
Progestogen only contraceptives - All are suitable before and after surgery even
for surgery that involves prolonged immobilisation of the lower limb.
Thyroid or antithyroid drugs

Other Surgery Points on Drugs

Antidepressants - Lithium Should be stopped 24 hours before major surgery. Normal
dose can be continued for minor surgery. MAOI should not be withdrawn suddenly
as there is risk of withdrawal symptoms. Gradual withdrawal is advised and they
should be stopped 2 weeks before the surgery. TCA do not need to be stopped
before surgery but there is a risk of arrhythmias and hypotension, therefore the
anaesthetist should be informed if they are not stopped.
Aspirin or Oral anticoagulant - Needs to stop because increased risk of bleeding.
It may need to be replaced by heparin therapy to prevent blood clotting.
Combined hormonal contraceptives Should be stopped 4 weeks before major
elective surgery and all surgery to the legs or surgery which involves prolonged
immobilisation of the lower limb. Can be recommended again 2 weeks after full
mobilisation. If the COC cannot be stopped (e.g. trauma surgery) then heparin and
graduated compression hosiery is advised. These recommendations do not apply for
minor surgery. (Stop HRT 4 to 6 weeks before surgery and restart full mobilisation) BNF page 460
Diabetes - Give an injection of the patients usual insulin on the night before
operation. Early on the day of the operation, give an infusion of glucose with
potassium and insulin on a sliding scale. Once the patient begins to eat, start SC
insulin before breakfast and stop IV insulin 30 minutes later. BNF page 429
23

Drugs to help with the surgery:

H2 receptor antagonist (1 to 2 hours before surgery) or a Proton pump inhibitor
such as Omeprazole (12 hours before surgery) may be used before surgery to
increase the pH and reduce the volume of gastric fluid to prevent acid aspiration
from general anaesthetics.
Antimuscarinic drugs like hyoscine reduce saliva secretion to prevent lung
congestion.
Benzodiazepines - Relief of anxiety, sedation and amnesia.
Antibiotics may be given for prophylaxis of infection depending of the likely
organisms which could cause infection.
Post-operatively - Pain Relief, Heparin to prevent DVT, Nausea and vomiting
management.
Driving - IV benzodiazepines and short general anaesthetics can extend risks for at
least 24 hours after administration.

PREGNANCY
Foods to Avoid:
Soft and blue veined cheeses
All types of pt (and any liver products)
Raw eggs, partially raw eggs e.g. homemade mayonnaise.
Raw meat
Fish - shark, swordfish, marlin
Social Drugs:
Alcohol - 1st and 2nd trimesters - Regular daily intake is teratogenic (foetal alcohol syndrome) and
rd
may cause growth restriction; occasional single drinks are probably safe. In the 3 trimester

withdrawal syndrome may occur in babies of alcoholic mothers.

Smoking - Can cause vasoconstriction, hypoxia, low birth weight, premature birth or perinatal birth.
Caffeine - Limit intake to 2 cups per day. A high intake can possibly increase miscarriage and
stillbirth rate.

Gastro Intestinal System

Misoprostol (for NSAID-induced ulcers) - Should not be used in women of childbearing age

unless the patient requires NSAID therapy and is at a high risk of complications from NSAID-induced
ulceration. In such patients, it is advised that misoprostol should only be used if the patient takes
effective contraceptive measures and has been advised of the risks if pregnant. Misoprostol in all
trimesters must be avoided. It is a potent uterine stimulant (has been used to induce abortion) and
may be teratogenic.
Omeprazole is the only PPI that is not known to be harmful.
H2 antagonists should be avoided unless essential.
Loperamide Should be avoided. Oral Rehydration Salt preparations can be used to replace lost
fluid.
Simple antacids are appropriate for pregnant women e.g. Gaviscon. Avoid those with high
content of sodium as a high salt content can cause a rise in blood pressure.
Bulk forming laxatives are appropriate for pregnant women e.g. Fybogel.
Osmotic laxatives Lactulose is not known to be harmful. Macrogols should be avoided unless
essential as no information is available.
Stimulant laxatives Avoid as no information available.
Haemorrhoid treatments - Local therapies are appropriate but avoid steroids.

24

Cardiovascular System
Hypertension Methyldopa is a centrally acting antihypertensive and is the treatment of choice

for hypertension in pregnancy and also pre-eclampsia. Pre-eclampsia is pregnancy induced

hypertension which can cause hypertensive crisis.
Heparin - Do not cross placenta but LMWH preferred. i.e enoxaparin not known to be harmful.
Warfarin - Teratogenic; should not be given in the first trimester. (Congenital malformations, Fetal
and neonatal haemorrhage).
Statins - should be avoided as a decreased synthesis of cholesterol possibly affects fetal
development. Congenital abnormalities have been reported.

Respiratory System
Inhaled bronchodilators - Safe in pregnancy
Inhaled corticosteroids - Benefit of treatment in asthma, outweighs risk. Risk of intra-uterine
growth restriction on prolonged or repeated systemic treatment. Corticosteroid cover may be required
by the mother during labour. Monitor closely if fluid retention occurs.

Central Nervous System

Epilepsy - Benefit of treatment outweighs risk to foetus. Risk of teratogenicity is greater if more

than one drug is used. Adequate folate supplements are advised for women before and during
pregnancy to counteract the risk of neural tube defects. Regular monitoring of serum levels is
important. Prophylactic vitamin K can help stop bleeding complications on delivery. Routine injection
of vitamin K at birth effectively counteracts any antiepileptic associated risk of neonatal haemorrhage.
Breastfeeding is acceptable with almost all antiepileptic drugs taken in normal doses. BNF page 247
Analgesics - Paracetamol is safe in pregnancy although advise when required use only.
Ibuprofen and Aspirin are contraindicated in pregnancy.
Opioid analgesics are contraindicated in the 3rd trimester because they depress neonatal
respiration. Can lead to withdrawal effects in neonates of dependent mothers, gastric stasis and risk
of inhalation pneumonia in the mother during labour.
Morning sickness Promethazine (antihistamine) may be required for short term treatment as
first line therapy. Prochlorperazine or metoclopramide may be considered second line therapy.

Infections:
Penicillins, Cephalosporins, Erythromycin, Clindamycin are NOT known to be
harmful in pregnancy.
Tetracyclines - 1st Trimester animal studies show effects on skeletal development. In 2nd and
3rd trimester dental discolouration and maternal hepatotoxicity found with large parenteral doses.
Aminoglycosides can cause auditory or vestibular nerve damage. The risk is greatest with

streptomycin. It is probably very small with gentamycin and tobramycin, but avoid unless essential. If
nd
rd
given, serum aminoglycoside concentration monitoring is essential. Risk in the 2 and 3 trimester.
Macrolides (except erythromycin) Manufacturer advises use only if potential benefit outweighs risk.
Co-trimoxazole has teratogenic (developmental abnormalities of the foetus) risk in the 1st
rd
trimester because Trimethoprim is a folate antagonist. In the 3 trimester, there is risk of
neonatal haemolysis and methaemoglobinaemia (presence of methaemoglobin in the blood which
cannot bind to oxygen and therefore cannot transport it round the body). Trimethoprim = teratogenic.
Rifampicin - 1st trimester very high doses show to be teratogenic in animal studies. 3rd trimester
there is risk of neonatal bleeding being increased.
Metronidazole - Manufacturer advises avoidance of high-dose regimens.
Quinolones - Avoid in all trimesters due to arthropathy (joint disorders) in animal studies.
Nitrofurantoin - May produce neonatal haemolysis in the 3rd trimester.

Endocrine System
Oral antidiabetic drugs - Avoid as can cause neonatal hypoglycaemia. Insulins are substituted

during pregnancy in all diabetics. If oral drugs are used then they should be stopped at least 2 days
before delivery.
Finasteride - Avoid in all trimesters as can cause feminisation of the male foetus. Finasteride is
excreted in semen and use of a condom is recommended if sexual partner is pregnant or likely to

25

become pregnant. Women of child bearing age should avoid handling crushed or broken tablets. BNF
page 401

Gynaecology
Combined oral contraceptive can be started 3 weeks after child birth (risk of thrombosis if
started earlier)

Progestogen only contraceptive start at any time after 3 weeks of child birth (increased

risk of breakthrough bleeding if started earlier).

Cystitis A suspected UTI should be referred. Sodium bicarbonate and sodium citrate are not
advised for pregnancy due to their high sodium content. Potassium citrate can be used.

Musculoskeletal and Joint diseases

Methotrexate avoid (teratogenic; fertility may be reduced during therapy but this may be
reversible). Manufacturer advises effective contraception use during and for at least 3 months after
treatment has been stropped for both men and women.

BREASTFEEDING
Bromocriptine (dopamine receptor agonist) suppresses lactation
Combined oral contraceptive is not recommended in breast feeding because oestrogens
have adverse effects on lactation The progestogen only pill is preferred.
Metronidazole - produces a bitter metallic milk taste.
Aspirin - Avoid as can cause Reyes syndrome.
Lithium - Avoid as can cause toxicity in infant.

POPULAR CONTRAINDICATIONS
Tetracyclines are contraindicated in children under 12 years old and pregnant
because deposition of tetracyclines in growing bone and teeth (by binding to calcium)
causes staining (yellow/grey) and occasionally dental hypoplasia, which could be permanent.
Quinolones can cause joint disorders in children and should therefore not be
recommended.
Aspirin is contraindicated in children under 16 years old.- Reyes syndrome
NSAIDs are contraindicated in patients with history of sensitivity to aspirin.
Salicylate salt products (Bonjela, Bonjela cool) not suitable for under 16 years of
age due to Reyes syndrome. (New Law)

HOSPITAL PHARMACY and KEY PARAMETERS

Blood Pressure
Normal Blood Pressure Value: 120/80
High Blood Pressure (Hypertension in a non-diabetic patient): 140/90 or above
High Blood Pressure (Hypertension in diabetic patient): 130/80 or above
Normal Pulse: 60 to 80 beats per minute
INR: International Normalised Ratio is the method of expressing the time it takes for
blood to clot. Target INR values usually range between 2 and 3.5 for medical conditions
such as DVT, Atrial fibrillation etc. So an INR which is very high (possibility of bleeding)
would mean that the Warfarin dose needs to be reduced. For an INR which is lower than
the target set by the clinic, the Warfarin dose would need to be increased (possibility of
coagulation).
26

Blood Glucose:
Normal Blood Glucose Range: 4 to 9mmol/litre
Normal Range Before Meals: 4 to 7mmol/litre
Normal Range After meals: < 9mmol/litre
Considered HIGH if Fasting Blood Glucose >7mmol/litre
Cholesterol Desirable Lipid Profile (Targets):
Total Cholesterol: < 5mmol/L
LDL Cholesterol: < 3mmol/L
Serum Triglycerides: < 1.7mmol/L
HDL Cholesterol: > 1.0mmol/L
Alcohol Units:
A large Glass of wine (250ml) = 3 units
A standard Glass of wine (175ml) = 2 units
A small Glass of wine (100ml) = 1 unit
Half a pint of 3.5% beer, lager, cider = 1 unit
A single shot of 40% spirit (25ml) = 1 unit
A single measure of whiskey = 1 unit
A standard measure Port, Sherry (50ml) = 1 unit
BMI:
BMI less than 18.5 underweight
BMI between 18.5 and 24.9 normal weight
BMI between 25.0 and 29.9 overweight
BMI 30.0 or above obese
Electrolytes:
Sodium: 136 146mmol/L
Potassium: 3.5 5.1mmol/L
Calcium: 2.15 2.5mmol/L
Magnesium: 0.7 1.0mmol/L
Urea: 2.5 6.4mmol/L
Creatinine clearance (CCL) Men: 97 140ml/min, Women: 85 125ml/min
Hospital Abbreviations:

PC = Presenting Complaint
PMH = Patient Medical History
SH = Social History
DHx = Drug History
O/E = On Examination
CVS = Blood Pressure and Pulse
R/S = Respiratory system
GIT = Gut

Hospital Charts

Patient Details
Allergies section
Drugs for once only or pre-anaesthetic medication
MEDICATIONS SECTION
-

Drug and strength

Date
Route (PO, top, inh, sc, iv, im)
Time of day
Dose according to the time of day (denoted by x indicates that a dose is given)
Additional instructions (e.g. pc after food)

As required medicines e.g. paracetamol

Intravenous and subcutaneous infusions

27

KEY TABLES FOR OPEN BOOK

Palliative Care
Table on Page 20 Equivalent doses of morphine sulphate and diamorphine
hydrochloride.
Gastro-Intestinal System
Table on Page 50 - Recommended regimens for H. pylori eradication in adults.
Cardiovascular System
Page 105 Hypertension thresholds and targets for treatment
Page 147 Target INRs
Page 147 What to do if there is a haemorrhage (INR too high)
Respiratory System
Table on Page 174-175 Management of chronic and acute asthma
Table on Page 200 Dose of intramuscular injection of adrenaline
(epinephrine) for anaphylactic shock
Page 203-204 Long-term Oxygen therapy and when it should be considered
Central Nervous System
Page 210 Equivalent doses to Diazepam 5mg
Table on Page 221 - Equivalent doses of oral antipsychotics
Table on Page 230 - Equivalent doses of depot antipsychotics
Infections
Table on Page 326 - Notifiable Diseases. Doctors need to notify the Proper Office when

attending a patient suspected of suffering from any of the diseases listed in the table.
Table on Page 328 to 336 - Summary of antibacterial therapy. Gives you specific
infectious diseases and their specific antibiotic treatment.
Table on Page 337 to 338- Summary of antibacterial prophylaxis. Gives you
specific infectious diseases and their specific prophylactic treatments.

Endocrine System
Table on Page 451 Equivalent anti-inflammatory doses of corticosteroids.

Lists equivalent doses of other corticosteroids for anti-inflammatory treatment compared with
prednisolone 5mg.
Table on Page 459 - HRT Risk Table. Lists the risks of cancers and other medical conditions
when taking HRT.

Nutrition
Table on Page 589 Iron content of different iron salts
Page 603 G6PD deficiency
Table on Page 606 Electrolyte concentrations for intravenous fluids
Table on Page 615 Proprietary Infusion Fluids for Parenteral Feeding
Tables on Page 640 Drugs which are unsafe in acute porphyrias
Skin
Table on Page 722 Suitable quantities of corticosteroid preparations to be
prescribed for specific areas of the body. For an adult single daily application for 2
weeks.

Page 723 Topical corticosteroid preparation potencies.

Table on Page 755 Suitable quantities of parasiticidal preparations. For an adult
single application.

28

DRUGS LIKELY TO BE ABUSED

Codeine Linctus
Kaolin and Morphine
Gees Linctus
Do-Do Chesteze
Laxatives (Senna, Bisacodyl)
Antihistamines for temporary sleeplessness
Solvents

G6PD DEFICIENCY
Glucose 6-phosphate dehydrogenase deficiency can lead to acute haemolytic anaemia
which can occur from taking certain drugs. Ingestion of fava beans (especially raw) and
broad beans can also cause the deficiency.
Notes for prescribing drugs to patients with G6PD deficiency:
G6PD deficiency is heterogeneous; a drug found safe in one individual with the
deficiency may not be equally safe in another individual.
Manufacturers do not routinely test drugs for their effects on G6PD deficient
individuals.
The risk and severity of haemolysis is almost always dose-related.
Drugs with definite risk of haemolysis in most G6PD deficient individuals:

Dapsone
Methylene blue
Nitrofurantoin
Primaquine
Quinolones
Sulphonamides

Drugs with possible risk of haemolysis in most G6PD deficient individuals:

Aspirin
Chloroquine
Menadione
Quinine

29