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GP gauntlet #1 (anti-infectives, HRT, cardiovascular, diabetes, COPD-asthma, vaccinations, psychiatry, psoriasis)

elliptic's version from 2018-05-20 01:39

Some common antibiotics

Question Answer
Cephalexin500mg (12.5mg/kg) 6hrly. Can use 1g (25mg/kg) 12hrly instead. Decreases renal clearance of metformin.
Augmentin875+125mg (22.5+3.2mg/kg) 12hrly.
Amoxycillin 500mg (12.5mg/kg) tds - double that for pneumonia.
Trimethoprim 300mg daily for 3 days (UTI)
Di/Flucloxacillin 500mg (12.5mg/kg) 6hrly.
Doxycycline 100mg (2mg/kg >8yo) bd. IECOPD: 200mg, then 100mg daily for 5 days total. Acne/rosacea: 50mg/d.
Bactrim 160+800mg (4+20mg/kg) 12hrly.
Phenoxymethylpenicillin 500mg (12.5mg/kg) 6hrly.
Clindamycin 450mg (10mg/kg) 8hrly.

Some other drugs

Question Answer
Fexofenadine Urticaria: 180mg/d. Rhinitis: 120mg/d (single or divided dose).
Valaciclovir VZV: 1g, 8hrly for 7 days. HSV: 500mg bd for 5-10 days (primary) or 3 days (recurrence).
Alendronate alendronate 70 mg orally, once weekly on an empty stomach.
Denusomab denosumab 60 mg SC, once every 6 months
Which women get cyclical combined HRT? LMP <2 years ago. Oestrogen orally or transdermally + progestin orally. Oral- Femoston 2/10. Transdermal- Estalis Sequi.
Which women get continuous combined HRT? LMP > 2y, or withdrawal bleeding becoming lighter on cyclical combined HRT. Oral- Angeliq 1/2 (not on PBS). Transdermal- Estalis continuous.

And some more

Question Answer
Dabigatran (for non-valvular AF) 150mg bd (or 110mg bd if >75 or higher risk for bleeding). Use warfarin if eGFR<30.
Rivaroxaban (for non-valvular AF) 20 mg daily, or 15 mg daily if eGFR 30-49.
BPH medications alpha-blockers, eg. prazosin 0.5mg nocte for 3 nights, then bd for 14 days, then 1mg bd. tamsulosin 0.4mg daily. 5alpha-reductase inhibitors: dutasteride 0.5mg daily. Or combination.
3 medication options for OAB. 1. Antimuscarinic: Oxybutynin 5mg 2-3 times daily; max qid -- OR 3.9 mg/24 hours patch. 2. Vaginal oestrogen, 0.5 g cream, nightly for 2 weeks then twice per week. 3. Duloxetine 30mg bd increasing to 60mg bd after 4 weeks.
Scabies treatments Permethrin 5% cream (suitable for pregnant/breastfeeding; take special precautions if <6months) or benzyl benzoate 25% emulsion (dilute in children). Instructions for either: apply to dry skin from neck down. Under nails with nailbrush. Leave 8 hours and reapply to hands if washed. Repeat in 7 days.

Some common antihypertensives

Question Answer
Atorvastatin 10-80mg daily.
Metoprolol Arrhythmia: tartrate 25-100mg bd. CCF: succinate CR 23.75mg daily, doubling q2-4w to max tolerated dose, max 190mg daily
Amlodipine 2.5-10mg daily. Peripheral vasodilation (peripheral oedema, flushing, headache, dizziness), postural drop, tachycardia, palpitations, chest pain, gingival hyperplasia.
Candesartan 4-32mg daily. ADR: high K, renal impairment.
Perindopril arginine 5-10mg daily. (May initiate at 2.5mg/d). ADR: cough, high K, renal impairment, angioedema
Indapamide 1.5mg CR daily.
methyldopa (first line in pregnancy) 125 mg orally, twice daily, increasing as required up to 500 mg 3 times daily

Some diabetes drugs

Question Answer
Sulphonylurea Gliclazide 40mg od-bd titrating to max 320mg/day in divided doses (divide doses >=160mg); or MR 30mg titrating to max 120mg/d
DPP4 inhibitor Sitagliptin (Januvia), 100mg/d. ADR: rash, pancreatitis, nasopharyngitis.
SGLT2 inhibitor Empagliflozin (Jardiance). 10mg/d, may inc to 25mg/d. ADR: dehydration, dizziness, DKA. Avoid use with loop diuretics.
GLP-1 mimetics / incretins Exanatide. Byetta 5mcg BD, can inc to 10mg BD after a month. Bydureon 2mg weekly. ADR: nausea, vomiting.
Metformin Metformin immediate release 500mg bd with food; increase slowly to max 1g tds; or extended-release 1g with evening meal, increasing to max 2g/d.

Some cutoffs

Question Answer
Diagnostic cutoffs for COPD FEV1/FVC < 0.7, with <200mL bronchodilator response. Moderate COPD is FEV1 40-59% predicted.
Diagnostic cutoffs for asthma FEV1/FVC < LLN for age. Moderate obstruction is FEV1 60-80% pred. FEV1 improves by 12% from baseline (and >200mL in adul
Triggers for stepping up to preventers in asthma Symptoms > 2x/month. Waking from symptoms > 1x/month. Any steroids in 12 months (adults only).
Diagnostic cutoffs for T2DM FBG > 7 (on two occasions if asymptomatic; 5.5-6.9 is indeterminate). HbA1c > 48 or 6.5% on 2 occasions. 2 hr OGTT: >7ᶠᵃˢᵗᶦⁿᵍ / >11.1² ʰʳ

Some asthma/COPD drugs

Question Answer
ICS Flixotide, inhaler comes in 50, 125, and 250 mcg; accuhaler comes in double those doses (100, 250, 500). Dose is generally 1 inhalation BD. Consider quadrupling doses during asthma flares.
ICS/LABA combo Seretide (fluticasone + salmeterol) 100/50, 250/50, 500/50 - one puff bd. Or Breo 100/25 or 200/25, 1 puff daily. [Other options: Symbicort, Flutiform, Breo]
LAMA Spiriva respimat (tiotropium) 2.5mg, 2 puffs daily. [Other options: Seebri, Bretaris, Incrus]
LABA Onbrez (indacaterol) 1 puff daily. [Other options: Onbrez, Oxis, Serevent]
LABA/LAMA Spiolto Respimat (tiotropium, olodaterol), 2.5/2.5mg 2 puffs daily. [Other options: Ultibro, Brimica, Anoro]

Standard vaccinations: childhood schedule.

Question Answer
Birth Hepatitis B (H-B-Vax II paediatric)
6 weeks, 4 months, 6 months DTPa+Hep B+IPV+Hib (Infanrix Hexa), Pneumococcal (Prevenar 13), and Rotavirus (Rotarix) at 6 weeks and 4 months only.
12 months MMR (Priorix) and Hib+Men C (Menitorix). ATSI also get Hep A (Vaqta paediatric). Children born <32wk or <200g get Hep B booster. Children at risk inc. born <28wk get pneumococcal booster.
18 months MMRV (Priorix Tetra) and DTPa (Infanrix). ATSI also get Hep A (Vaqta paediatric) and Pneumococcal (Prevenar 13).
4 years DTPa-IPV (Infanrix IPV). Children at risk inc. born <28wk get pneumococcal booster.
Live (routine) vaccines MMR/V, Varicella, Zoster, Rotavirus, (BCG)

Standard vaccinations: adult schedule

Question Answer
Year 7 students HPV (Gardasil 9, with booster at 6+ months; additional dose at 2 months if immunocompromised) and DTPa (Boostrix)
Year 10 students and 15-19 year olds Meningococcal ACWY (Menactra)
Pregnant women DTPa between 28-32 weeks gestation each pregnancy.
Pneumococcal Pneumovax 23. Non-ATSI: aged 65. ATSI: aged 50 and a booster 5 years later. If moderately higher risk (chronic cardiac/lung/liver disease, prematurity, diabetes, downs, smoking), then additional dose at time of diagnosis (or 18, whichever is later) and then a booster at least 5 years later. Then a booster after age 50 / 65. (So only 2 doses if diagnosed after routine 50/65 vaccination, 3 doses if diagnosed before.) People at the highest risk (asplenia, immunocompromise, CSF compromise) also get a 13vPVC (Prevenar 13) first.
Zoster vaccine Zostavax at age 70 (or a catchup dose for those aged 71-79).
Live (routine) vaccines MMR/V, Varicella, Zoster, Rotavirus

Travel vaccinations

Question Answer
Consider for most travellers, esp to developing world Hep A, Hep B.
Developing world Typhoid, Rabies.
Developing world minus Eastern Europe TB
South America and sub-Saharan Africa Yellow Fever
Sub-Saharan Africa (meningitis belt) Meningococcal
Asia, PNG Japanese Encephalitis
Live (travel) vaccines Oral typhoid vaccine, Japanese encephalitis, yellow fever, (BCG)

Viral exanthems

Question Answer
Pruritic papules, vesicles, pustules, and crusted lesions. Predominantly face and trunk. Fever, headache, urti, nvd Chickenpox
Widespread morbilliform erythema; starts on cheeks, spreads 1 day later to trunk and limb. Prodrome of malaise/anorexia; then conjunctivitis, cough, and coryza. Measles
Pale pink erythema; starts on face, spreads to neck, trunk, extremities. Asymptomatic, or slight fever, sore throat, rhinitis, malaise. Rubella
Mild toxic eryhema on face and trunk. High fever for 3-5 days, rhinitis, cough, irritability, tiredness. Febrile seizures in 5-15%. Roseola
Slapped cheeks, evanescent lacy erythema on limbs and trunk 1-4 days later. May have slight fever and headache. Fifth disease / erythema infectiosum
Flat, small blisters on the hands and feet + painful ulcers in the mouth. HFMD.

Adverse effects & monitoring of immunomodulators

Question Answer
History, examination, and investigations before starting immunomodulators History of infections (inc HSV, HZV, TB); vaccination history; environmental risks (eg travel). Examine for signs of infection (pyoderma, scabies, lung, dental, sinusitis). Investigate: TV screening, Hep B + VZB, strongyloides serology, pap smear.
Vaccinations before starting immunomodulators UTD with routine vaccinations. Hep B if seronegative. VZV if seronegative and no reliable history of chickenpox.
Advice for someone starting immunomodulators avoid walking barefoot; avoid raw eggs/meat, unpasteurised dairy; go to travel medicine specialists for travel advice
Monitoring for TNF-alpha inhibitors Clinical review every 3-6 months
Monitoring for azathioprine / mercaptopurine Baseline FBC/LFT. FBC weekly then at increasing intervals (macrocytosis and lymphopenia common; don't always require cessation). 3 monthly LFT. Annual skin check.
Monitoring for methotrexate FBC, ELFT monthly (then every 1-3 months depending on risk of altered LFTs). Those with abnormal transaminases that don't normalise after stopping MTX may need fibroscan +/- liver biopsy.
Monitoring for cyclosporin FBC, ELFT, lipids and BP (CV check) at baseline. Annual skin check. Monitor as advised by specialist (usually not required).

AF / TIA / stoke / MI / CCF : long-term rx

Question Answer
AF Send to hospital for rhythm control new/recent onset, reversible cause, heart failure, or bad symptoms. Rate control: metoprolol 25-100mg bd. Anticoagulation: CHA₂DS₂Vasc and HASBLED to decide between nothing, aspirin, warfarin, or dabigatran (110-150mg bd).
Stable angina PRN GTN. Start a beta-blocker (eg atenolol 25-100mg daily), or if that's contraindicated, a calcium channel blocker (diltiazem CR 180-360mg/d). Can also start a GTN patch if required. Refer promptly to a cardiologist.
Secondary prevention after MI aspirin+clopidogrel, beta blockers, ACEi/ARBs, and statins
Secondary prevention after thrombotic TIA/CVA Antiplatelet (clopidogrel 75mg, or asasantin), Statins regardless of cholesterol level (NICE says atorvastatin 80mg/d), control hypertension aiming for SBP 120-130 (but not in the first 48 hours). Stroke foundation says to give everyone ACEI.
Secondary prevention after haemorrhagic CVA ACEI +/- diuretics and BP control.
Heart failure (LVSD) ACE inibitors and beta-blockers. Spironolactone. If not controlled, replace ACEI with Entresto (36 hours washout). Loop diuretics for symptom control. Specialists may add ARB+ACEI, hydralazine, nitrate

Some risk assessment algorithms

Question Answer
CHA₂DS₂Vasc score CCF/LV dysfunction, Hypertension, Age>75 (2 points), Diabetes, Stroke/TIA/thromboembolism hx (2), Vascular disease, Age 65-74, Sex female. Stroke risk in non-valvular AF. 2+: anticoagulate. 1: aspirin or anticoagulation (prefer latter). 0: aspirin or nothing (prefer latter).
HASBLED Hypertension (SBP>160), Abnormal renal or liver function, Stroke, Bleeding, Labile INRs, Elderly (>65), Drugs (aspirin or alcoholism). Score >3 indicates high risk of bleeding.
ABCD₂ score Identify those at high risk of CVA in the 7 days post-TIA: high risk if score >3. Age>60; BP>140/9; Clinical features of unilateral weakness (2 points) or speech impairment without weakness (1 point); Duration >60 min (2 points), 10-59 min (1 point); Diabetes.

Psychiatric meds

Question Answer
Risperidone (oral) Schizophrenia, mania: 0.5-1 mg nocte, increasing to 2mg nocte. Max daily dose = 6mg.
Risperidone (depot) Schizophrenia, bipolar prophylaxis: 25mg IM, every 2 weeks, titrating up to 25-50mg IM. Does not secrete drug for ~3 weeks so bridging oral antipsychotic therapy required in schizophrenia.
Escitalopram 10-20mg daily. Note: PBS listed for GAD & social anxiety disorder.
Sertraline 50mg/d, increasing to 100mg/d in 5-7 days as tolerated; max dose 200mg/d. Note: Best SSRI for pregnancy & breastfeeding. Also: PBS listed for panic disorder where other treatment has failed, and OCD.
Quetiapine Bipolar depression: quetiapine 50 mg orally, twice daily on day 1, then 100 mg twice daily on day 2, then increasing to 150 to 300 mg, twice daily. Higher doses required in acute mania or schizophrenia, often no effect until 400mg bd.
Mirtazapine 15 mg orally, at night, increasing according to tolerability and patient response. Maximum dose 60 mg at night
Duloxetine 30-60mg mane, titrating to 60mg bd.
Diazepam As a short term measure in adjustment disorder with anxious features, or in GAD in acute crises with unacceptable distress: diazepam 2 to 5 mg orally, as a single dose, which may be repeated, if required, up to twice daily. Max 2 weeks. Taper before stopping.
Propranolol (Non-generalised social anxiety disorder) propranolol 10 to 40 mg orally, 30 to 60 minutes before the social event or performance

Some skin preparations

Question Answer
Daivobetcalcipotriol + betamethasone 50+500 mcg/g
Advantanmethylprednisolone aceponate 0.1%
Clobex shampooClobetasol proprionate 0.05% - massage onto dry scalp and leave on for 15 minutes before adding water and rinsing/lathering. Use for up to 4 weeks. When symptoms control, add coal-tar based shampoo.
EloconMometasone furoate 0.1%
Resolve plus 1.0Hydrocortisone 1% + miconazole nitrate 2%

Psoriasis treatment

Question Answer
Scalp psoriasisADVANTAN lotion daily for 2-6 weeks; add coal tar shampoo when it starts improving. (2nd line: CLOBEX shampoo for 6 weeks; use a 6+3 tar pomade if scale develops)
Trunk and limb plaque psoriasisCOAL TAR + SA 6+3 emulsion or cream, od-bd for 1 month. (2nd line, or for acute flares: ADVANTAN cream/ointment daily for 2-6 weeks. 3rd line, with caution DAIVOBET ointment.)
Hyperkeratotic palm/sole psoriasisCOAL TAR + SA 6+6 cream/ointment bd for 1 month. (2nd line: DAIVOBET ointment daily for up to 6 weeks.)
Flexural/genital psoriasisADVANTAN ointment daily until clear (no more than 2 weeks in a child with nappies). Use COAL TAR 2% (without SA) while withdrawing from steroids.
Facial psoriasisCentral face: ADVANTAN cream/ointment daily until clear (2-6 weeks). Around ears/hairline: ELOCON in adults, SIGMACORT in kids. While withdrawing from steroids, add COAL TAR + SA 2+2%.
Risk factors for psoriasisstrep infection; sunlight usually beneficial but may exacerbate in some; local trauma to skin; post-pregnancy; stress; etoh/smoking; HIV/AIDS; change in climate
Scalp seb derm1. Standard shampoo daily. 2. Antiyeast shampoo twice weekly. 3. Add Advantan for 7 days. 4. Add coal tar emulsion/gel 1-2 times/week. 5. Replace antiyeast shampoo with clobex (clobetasone) shampoo.
Non-scalp seb derm1. Resolve plus 1.0 cream od-bd for 2 weeks. 2. Advantan + clotrimazole 10mg/g cream 1-2 times/day for 2 weeks. 3. Tar cream