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ESSENTIAL FOR THE EXAM
BNF CSM WARNINGS

ESSENTIAL CSM WARNINGS YOU NEED TO KNOW FOR THE EXAM

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Low Na+
The words low Na+ added after some preparations indicate a sodium content of less than 1 mmol per tablet or 10ml dose.

Infliximab for Crohn’s disease
Infliximab is recommended for Crohn’s disease (with or without fistulae) when treatment with immunomodulating drugs and corticosteroids has failed or is not tolerated and when surgery is inappropriate. Treatment may be repeated if the condition responded to the initial course but relapsed subsequently. Inflixamab should be prescribed only by a gastroenterologist.

Aminosalicylates (Sulfasalazine)
Blood disorders
Patients receiving aminosalicylates should report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise that occurs during treatment. A blood count should be performed and the drug stopped immediately if there is suspicion of a blood dyscrasia.

Laxative
For children with chronic constipation, it may be necessary to exceed the licensed doses of some laxatives. Parents and careers of children should be advised to adjust the dose of laxative given in order to establish a regular pattern of bowel movements in which stools are soft, well-formed, and passed without discomfort.

Clopidogrel
Clopidogrel with aspirin appropriate for management of non-ST-segment elevation acute coronary syndrome in those at moderate to high risk of myocardial infarction or of death.

Lipid-regulating drugs MUSCLE EFFECTS
The CSM has advised that rhabdomyolsis associated with lipid-regulating drugs such as the fibrates and statins appears to be rare(apporx. 1 case every 100 000 treatment years) but may be increased in those with renal impairement and possibly in those with hypothyroidism. Concomitant treatment with drugs that increase plasma-statin concentration increase muscle-toxicity; concomitant treatment with a fibrate and a statin may also be associated with an increased risk of serious muscle toxicity.

Formoterol and salmeterol
To ensure safe use, the CHM has advised that for the management of chronic asthma, long-acting beta2 agonists (formoterol and salmeterol) should:

bulletBe added only if regular use of standard-dose inhaled steroids has failed to control asthma adequately;
bulletNot be initiated in patients with rapidly deteriorating asthma;
bulletBe introduced at a low dose and the effect properly monitored before considering dose increase;
bulletBe discontinued in the absence of benefit;
bulletBe reviewed as clinically appropriate;stepping down thereapy should be considered when good long-term asthma control has been achieved

Aminophylline, Fentanyl, Remifentanil
To avoid excessive dosage in obese patients, dose should be calculated on the basis of ideal weight for height.

 

Antipychotics
IM injection of antipychotics can differ from oral dose, im has increased absorbtion especially if the patient is very active. The dose for antipsychotic for emergency use should be reviewed at least daily. Injections for depot must be titrated according to the patients response.

Lithium
Patients on lithium require a lithium card

Hyponatreamia and antidepressant therapy
Hyponatreamia (usually in the elderly and possibly due to inappropriate secretion of antidiuretic hormones) 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 hyponatreamia should be considered in all patients who develop drowsiness, confusion, or convulsion while taking an antidepressant.

SSRI’s for children
Not recommended in children as it may provoke suicidal thoughts.
Products unfavourable for under 18’s: citalopram, escitalopram, paroxetine, sertraline.
Product that is favourable: FLUOXETINE.

Drugs used in status epilepticus
If seizures recur or fail to respond with 30 minutes:
PHENYTOIN, PHENOBARBITAL, FOSPHENYTOIN should be used
If these measures fail to control seizure with 60 minutes, anaesthesia with thiopental, midazolam, or in adults, a non-barbiturate anaesthetic such as propofol should be instituted with full intensive care.

Fosphenytoin sodium
Precriptions for fosphenytoin sodium should state the dose in terms of phenytoin sodium equivalent(PE); fosphenytoin sodium 1.5mg = phenytoin sodium 1mg

Fibrotic reactions
The CSM has advised that ergot-derived dopamine receptor agonists, bromocriptine, cabergoline, lisuride[discontinued], 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 creatine and to obtain a chest x-ray. Patients should be monitored for dyspnoea, persistent cough, chest pain, cardiac failure, and abdominal pain or tenderness. If long-term tests may also be helpful.

Sudden onset of sleep
Excessive daytime sleepiness and sudden onset of sleep can occur with co-careldopa, co-beneldopa, and dopamine receptor agonists. Driving warning, drowsiness warning.

Nicotine and bupropion
Only give 2 weeks supply after the stop date, or 3-4 weeks supply of bupropion. Patients are only allowed to claim NHS supplied smoking cessation thereapy within 6 months of an unsuccessful cessation attempt.

Bupropion
The CSM has issues a reminder that bupropion is contra-indicated in patients with a history of seizures or of eating disorders, CNS tumour, alcohol and benzodiazepine withdrawal. Increases the risk of seizures with ANTIDEPRESSANTS, ANTIMALARIALS(MEFLOQUINE AND CHLOROQUINE), ANTIPSYCHOTICS, QUINOLONES, SEDATING ANTIHISTAMINES, SYSTEMIC CORTICOSTEROIDS, THEOPHYLLINE, TRAMADOL. And conditions including diabetes, alcohol abuse, head trauma, and use of stimulated and anorectics.

Methadone and buprenorphine
For opiod dependence, should be administered under supervision for 3 months, until compliance is assured,

Flucloxacillin
Cholestatic jaundice and hepatitis may occur up to several weeks after treatment with flucloxacillin has been stoppened.Administration for more than 2 weeks and increasing age and risk factors. CSM has reminded that:

bulletFlucloxacillin should not be used in patients with a history of hepatic dysfunction associated with flucloxacillin
bulletFlucloxacillin should be used with caution in patients with hepatic impairment;
bulletCareful enquiry should be made about hypersensitivity reactions to beta-lactam antibacterials

Linezolid
Refer symptoms of visual impairment, and blood disorders

Co-trimoxaole
Drug of choice for:???? Pneumocystis jiroveci (Pneumocystis carinil)
Toxoplasmosis and nocardiasis
If no other alternative consider for:
Acute exacerbations of chronic bronchitis
Urinary tract infections
Acute otitis media in children

Quinonlones (e.g ciprofloxacin)
Tendon damage (including rupture) has been reported in patients receiving quinolones. Tendon rupture may occur within 48 hours of starting treatment.

bulletQuinolones are contra-indicated in patients with a history of tendon disorders related to quinolone use
bulletElderly patients are more prone to tendonitis
bulletThe risk of tendonitis rupture is increased by the concomitant use of corticosteroids
bulletIf tendonitis is suspected, the quinolone should be discontinued immediately

Urineary tract infections
Whenever possible specimen of urine should be collected for culture and sensitivity testing before starting antibacterial therapy. The antibacterial chosen should reflect current local bacterial sensitivity to antibacterials.

Itraconazole
Following rare reports of heart failure, the CSM has advised caution when prescribing itraconazole to patients at high risk of heart failure. Those at risk include:

bulletPatients receiving high doses and longer treatment courses
bulletOlder patients and those with cardiac disease
bulletPatients receiving treatment with negative inotropic drugs, e.g calcium channel blockers

Inhaled insulin
Not to be used for the routine treatment of type 1 or 3 diabetes. May be used:

bulletWith evidence of poor glycaemic control despite other interventions and
bulletWho require insulin but are unable to use subcutaneous insulin because of either a diagnosed phobia of injections, or severe or persistent problems with injection sites.

Treatment should continue beyond 6 months only if there is evidence of improvement og HBA12.

Insulin glargine
Insulin glargine should be available as an option for patients with type 1 diabetes.
Insuline glargine is not recommended for routine use in patients with type 2 diabetes who require insulin but it may be considered in type 2 diabetes for those:

bulletWho require assistance with injecting their insulin or
bulletWhose lifestyle is significantly restricted by recurrent symptomatic hypoglycaemia or
bulletWho would otherwise need twice-daily, basal insulin injections in combination with oral antidiabetic drugs

Thiazolidinediones
Pioglitazone or rosiglitazone as second-line therapy added to either metformin or a sulphonylurea is not recommened except for:

bulletPatients who are unable to tolerate metformin and sulphonylurea in combination therapy, or
bulletPatients in whom either metformin or a sulphonylurea is contra-indicated.

In such case thiazolidinedione should replace whichever drug in the combination is poorly tolerated or contra-indicated.

Carbimazole
Doctors are reminded of the importance of recognising bone marrow suppression induced by carbimazzole and the need to stop treatment promptly.

  1. Patient should be asked to report symptoms and signs suggestive of infection, especially sore throat.
  2. A white blood cell count should be performed if there is any clinical evidence of infection
  3. carbimazole should be stopped promptly if there is clinical or laboratory evidence of neutropenia

Steroid SEs – risk of sever chickenpox/measles, immunosuppression, adrenal suppression, mood changes, gi affects.

ESSENTIAL CSM WARNINGS YOU NEED TO KNOW FOR THE EXAM

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