PSA: Prescription Review section

 One of my weaker sections in the PSA

 Consists of 8 questions with 4 marks each- total of 32 marks (1
mark per choice/ tick, each question has 2 parts – part a and part b)
– some are worth 1 mark, some are worth 2 marks – not
evenly distributed!
 2021: 21/ 32 (-11), 2022: 24/32 (-8), 2025: 23/32 (-9) – have to
aim for -6

What commonly comes up:

 Most likely to be causing / exacerbating a clinical symptom
(eg: exacerbating asthma, cause of ankle oedema, cause of dry
cough)
 Most likely to be causing an electrolyte derangement (eg:
hyponatraemia, hyperkalaemia, hypokalaemia, even
hypomagnesaemia!)
 Serious dosing error
 One prescription that is contra-indicated in a specific
circumstance
 Drug that is most appropriate to be withheld in a specific
circumstance
 Drug-drug interaction

Techniques:
 Read the question!!
 Read the question as it might give hints – eg: if AKI develops, it can
result in reduced clearance of medicines and an increase in
its adverse effects  clinical symptom type questions
 Note how many drug(s) you are meant to choose!  allocation
of points
 Use appendix 1 for help but it might not give the full entire
drugs, so do not fully rely on it
 Use the BNF- side effects, caution, renal/ hepatic impairment,
contraindication, interaction sections
 If there are two/ multiple possible ones that might be the
answer – how to tackle?
Drugs that cause electrolyte derangements:
Hyponatraemia
Common classes of drugs that cause hyponatremia:
 Diuretics– Thiazide diuretics (indapamide,
bendroflumethiazide), Loop diuretics (furosemide), Osmotic
diuretics (mannitol – dilutional hyponatraemia and volume
expansion)
 SSRIs– SIADH
 Antipsychotics– typical and atypical: typical antipsychotics may
cause hyponatraemia by stimulating the thirst centre, which can
lead to severe polydipsia, atypical antipsychotics can cause
hyponatraemia by affecting serotonin receptors in the brain,
which can lead to the release of ADH, aripiprazole
 Desmopressin (ADH)
 PPI – omeprazole

 ACE inhibitors – Ramipril

 ARBs – Losartan: ARBs reduce the activity of the hormone
angiotensin II, which constricts blood vessels and increases blood
pressure. Angiotensin II also causes the body to retain salt and
water, which increases blood pressure even more
 NSAIDs – by reducing the production of prostaglandins in the kidney, by
increasing the effect of ADH, by reducing the excretion of free water, by
leading to water retention

 Anti-epileptics- carbamazepine, sodium valproate, ari

 Anti-cancer drugs- cyclophosphamide, cisplatin, vincristine
 Opioids: tramadol, codeine – can directly enhance ADH release,
indirectly stimulate ADH secretion through nausea or hypotension,
direct antidiuretic effect
 Some anti-diabetics – sulfonylureas, SGLT-2 inhibitors,
chlorpropamide, tolbutamide
 Antihistamines – occurs when antihistamines cause urinary retention
 Iatrogenic causes of hyponatraemia  fluids +++

Symptoms of hyponatraemia

How does hyponatraemia look on ECG?

How to manage hyponatraemia? What fluids to give?

Hypokalaemia
Common drugs that cause hypokalaemia:
 Thiazide diuretics– Indapamide, Bendroflumethiazide,
Chlorothiazide
 Loop diuretics – furosemide, torasemide
 Salbutamol – more likely with high dose nebulised
form rather than inhaled form
 LABAs – vilanterol, indacaterol, olodaterol, formoterol
 Steroids – due to mineralocorticoid and
glucocorticoid properties (overstimulation of
mineralocorticoid receptors, and glucocorticoids can cause
the body to excrete too much potassium):
beclomethasone, betamethasone, budesonide,
hydrocortisone, methylprednisolone, prednisolone,
triamcinolone, torasemide
 Theophylline- theophylline and aminophylline – can
cause potentially serious hypokalaemia from
aminophylline therapy. Caution is required in severe
asthma because this effect may be potentiated by
concomitant treatment with systemic
corticosteroids (like prednisolone) and by hypoxia. It is
recommended that the serum potassium
concentration is monitored closely during treatment
with IV aminophylline in patients with severe asthma.
 Antifungal – amphotericin B

Symptoms of hyponatraemia

How does hyponatraemia look on ECG?

How to manage hyponatraemia? What fluids to give?

Hyperkalaemia
Common drugs that cause hyperkalaemia
 ACE-inhibitors: Ramipril, quinapril, trandolapril, quinapril,
perindopril, lisinopril, imidapril, fosinopril, enalapril
(Due to angiotensin-aldosterone inhibition)
 ARB – azilsartan, candesartan, irbesartan, valsartan,
Olmesartan, telmisartan, finerenone, losartan
 Potassium sparing diuretics– spironolactone,
eplerenone, amiloride, co-amilofruse (amiloride +
furosemide)
 NSAIDs – ibuprofen, aspirin, diclofenac, aceclofenac,
flurbiprofen, naproxen, meloxicam, etoricoxib, ketoprofen,
tolfenamic acid, indomethacin, celecoxib, bromfenac
 Beta blockers - labetalol
 Antibiotics – trimethoprim
 Immunosuppressants - Cyclosporin, tacrolimus,
voclosporin
(tacrolimus causes hyperkalaemia most probably because of
reduced potassium excretion)
 Obs/ Gynae: Mefenamic acid, tiaprofenic acid,
drospirenone (synthetic hormone used in birth control pills and
menopausal hormone therapy),
 Heparins: Tinzaparin, bemiparin, dalteparin, enoxaparin, heparin
(Dalteparin – and all heparins- can contribute to
hyperkalaemia because of inhibition of aldosterone
synthesis)
 NOT salbutamol!!

Patients at risk of the development of hyperkalaemia:

 Renal insufficiency
 Age >70 years
 Uncontrolled diabetes mellitus
 Hyperaldosteronism
 Dehydration
 Metabolic acidosis
 Acute cardiac decompensation
  Those using potassium salts, potassium
retaining diuretics, other plasma potassium
increasing active substances

Drugs that cause/ exacerbate a clinical symptom:

 Learn the classic drugs that would cause these
clinical symptoms! – usually ask about very common
side effects
 Think dose-dependent side effects!
 Learn the common class side effects (eg: PPI –
hypomagnesaemia, thiazide – hypo electrolytes)
 If the question asks “most likely to” and there are two
possible answers – the one most likely will be the one
that is systemically absorbed, not the one that is
inhaled (see paper 5 Prescription Review Question 3)

 Common culprits: NSAIDs, steroids – but do not get

booked down assuming it’s these! – might not necessarily!
 Don’t assume that if one has been chosen, the other
part will not be the correct answer – the answer might
be the same for both parts!
 What if two answers can also make sense – how to choose
more appropriate one? (eg: beta blocker and NSAIDs
causing bronchoconstriction)- Do the drugs’ form matter
for these type of questions? – not sure about the relevance
of the drug form (eg: topical treatment, PRN vs oral daily)
  Use the Appendix 1/ side effects section of the BNF
to familiarise yourself with the common symptoms/ side
effects that drugs cause!

Cardiorespiratory symptoms
Exacerbation of asthma/ bronchoconstriction
 Beta blocker
 NSAIDs

-If both are present as options, choose the one more likely!!
(as the question asks most likely)  in this case it would
be the beta blocker

Drugs that cause bradycardia

 Bisoprolol fumarate: beta adrenoceptor blocker– these
commonly or very commonly cause bradycardia
 Digoxin: negatively chronotropic, positively inotropic –
decreases the heart rate but increases the force of the
heartbeat, causes a range of rhythm disturbances, including
bradycardia, particularly if the dose is too high

Drugs that can worsen heart failure (causing exacerbation of

heart failure)
 Corticosteroids (Prednisolone) – congestive heart failure
 Diltiazem- its negative inotropic effect and may cause
hemodynamic decompensation in patients with reduced ejection
fraction; myocardial contractility may be reduced, the formation and
propagation of electrical impulses within the heart may be
depressed, and coronary or systemic vascular tone may be
diminished.

Drugs that can cause hyperlipidaemia

 Olanzapine + other anti-psychotic medications– well
recognised cause of disturbances of lipid
metabolism  elevated cholesterol and triglycerides
– secondary to weight gain
 Lamivudine (reverse transcriptase inhibitor/ anti-
retroviral treatment) – metabolic effects: fat
redistribution, insulin resistance, dyslipidemia
 Thiazide diuretics – well recognised cause of
dyslipidaemia – thiazides inhibit lipoprotein lipase in
capillaries which leads to an increase in the circulating
VLDL concentration and lipoproteins
Drugs that can cause anaphylactic reaction:
 NSAIDs are amongst the most frequently used drugs that may
cause hypersensitivity reactions
 Beta lactam antibiotics (penicillin, cephalosporins)
 Aspirin
 Chemotherapy
 Vaccines
 Parenteral iron injections
 Herbal preparations
 X ray contrast
 Vancomycin
 Morphine

Drugs that can cause pulmonary fibrosis

Alkylating agents – Cyclophosphamide, mitomycin, bleomycin,
bisulfan, chlorambucil
Nitrofurantoin
Ergot derived dopamine R agonists – bromocriptine,
cabergoline, pergolide

Sulfasalazine
Cytotoxics - bleomycin
Amiodarone
Rheumatic drugs – methotrexate

(ANE SCAR??)

GI symptoms
Drugs that cause constipation
 Opioids – codeine, morphine, co-codamol
 Ferrous fumarate/ ferrous sulphate
 Nifedipine – relaxes smooth muscle in the GI tract which may
cause constipation

-Post-natal constipation – can develop for a number of reasons including

dehydration, lack of fibrous diet, anaesthetics used in the peri-
operative period, medicines prescribed antenatally and postnatally.
-In order to minimise the risk of constipation when these medicines
are prescribed, patients should be advised to drink plenty of fluids and
eat a fibrous diet. It is also common for osmotic, bulk-forming or
stimulant laxatives to be prescribed concomitantly.

Drugs that cause diarrhoea

 Lansoprazole (and all PPIs) – can cause loose stools and
diarrhoea – class effect!
 Alendronic acid – can also cause diarrhoea!
  Penicillin – most common with broad spectrum penicillins – can
cause antibiotic-associated colitis

Drugs that cause dyspepsia

 Alendronic acid – alendronic acid (a bisphosphonate) – direct
irritant to the upper GI tract, and symptoms are not
improved by PPI?
 Prednisolone – prednisolone commonly contributes to GI
disturbances, including dyspepsia

Drugs that can cause pancreatitis

 Sodium valproate
 Carbimazole

Drugs that cause urinary symptoms

Urinary retention
 Morphine + other opioid analgesics / opiates (esp. in
the early postoperative period)
 Anticholinergics (antipsychotic drugs, antidepressant
agents, anticholinergic respiratory agents, detrusor
relaxants, atropine)
 General anaesthetics
 TCA - amitriptyline

 Alpha-adrenoceptor agonists
 Ca-channel blockers

 NSAIDs (Ibuprofen)
 Alcohol

 Benzodiazepines (Diazepam)
 Anti-histamines
 Disopyramide (For prevention/ treatment of ventricular/
supraventricular arrhythmias, maintenance of sinus
rhythm after cardioversion)

Drugs that can cause erectile dysfunction

 Antidepressants (citalopram, clomipramine
hydrochloride, duloxetine)
 Antihypertensives (thiazide diuretics, beta blockers,
clonidine)
 Cytotoxic drugs (ponatinib)
 Recreational drugs (alcohol)
Drugs that cause haematological disorders
 Cytotoxic/ chemotherapeutic agents
 Carbimazole (Anti-thyroid)
 Chloramphenicol (aplastic anaemia, dose-related bone
marrow suppression)
 Olanzapine (agranulocytosis, neutropaenia, thrombocytopaenia and
leucopaenia)
 Clozapine (agranulocytosis, leucopaenia, neutropaenia and
thrombocytopaenia)
 Azathioprine (Immunosuppressant, bone marrow suppression –
anaemia, thrombocytopenia, leucopenia), autoimmune haemolytic anaemia,
macrocytosis, pancytopenia (more common in patients with concurrent allopurinol use
or TPMT deficiency), aplastic anaemia (complete bone marrow failure),
myelodysplastic syndrome, increased long term risk of leukaemia
 Methotrexate
 Sodium valproate– bone marrow suppression, causing
pancytopenia – thrombocytopenia, neutropenia, aplastic anaemia
 Phenytoin – folate interference, immune reactions–
megaloblastic anaemia, aplastic anaemia, haemolysis,
leucopenia
 Quinine – antibody mediated destruction, direct toxicity- immune
thrombocytopenia (ITP), haemolytic anaemia (G6PD related),
aplastic anaemia

Drugs that cause ankle swelling

 Amlodipine (classic Ca2+ channel blocker which cause ankle
swelling/ peripheral oedema)
 Naproxen – can also cause ankle oedema (in the BNF it only
states side effect as “oedema” not specifically “ankle oedema”)
 Insulin (common/ very common S/ E) – oedema associated with
insulin usually resolves and is not a reason to stop treatment

Drugs that cause confusion

 Especially in the elderly
 Opioids - Codeine/ co-codamol, fentanyl
 Benzodiazepine – Diazepam, temazepam
 Prednisolone (Glucocorticoid) – can cause confusion, particularly in
the elderly
 Trazodone (Antidepressant – SARI)
 Metoclopramide – can cause confusion and disorientation
Drugs that can cause cognitive impairment
 Chlorphenamine (Concentration impaired)
 Anti-muscarinics (Oxybutynin)
 Paroxetine (concentration impaired)

Drugs that can cause insomnia

 Cyclizine
 Dexamethasone

Drugs that can cause seizures/ lower seizure

threshold:
Several drug classes can cause seizures or lower the seizure
threshold, making patients more prone to seizures. Here are the main
categories:

1. Antibiotics & Antimicrobials

 Carbapenems (e.g., imipenem, especially in renal impairment)

 Fluoroquinolones (e.g., ciprofloxacin, levofloxacin—GABA
inhibition) – the BNF and SPC list convulsions as a rare adverse
effect of levofloxacin. CHM has warned that quinolones may
induce convulsions in patients with or without a previous
history of convulsions
 Penicillins & Cephalosporins (e.g., benzylpenicillin, cefepime
—high doses or renal impairment)
 Isoniazid (INH) (due to pyridoxine deficiency)

2. Antipsychotics & Antidepressants

 Typical antipsychotics (e.g., chlorpromazine, haloperidol)

 Atypical antipsychotics (e.g., clozapine—dose-dependent risk)
 Tricyclic antidepressants (TCAs) (e.g., amitriptyline,
imipramine—anticholinergic & sodium channel effects)
 Selective serotonin reuptake inhibitors (SSRIs) (e.g.,
fluoxetine, sertraline—rare but dose-dependent)
 Bupropion (dose-dependent, especially in smoking cessation use)

3. Opioids & Analgesics

 Tramadol (lowers seizure threshold via serotonin & noradrenaline

effects)
 Meperidine (Pethidine) (metabolite normeperidine is pro-
convulsant)
 Fentanyl, morphine (high doses or in renal failure)
 Non-steroidal anti-inflammatory drugs (NSAIDs) (e.g.,
ibuprofen, diclofenac, though rare)
4. CNS Stimulants & Recreational Drugs

 Cocaine & Amphetamines (increase CNS excitability)

 MDMA (Ecstasy) (serotonergic effects)
 Methylphenidate (Ritalin) (dose-related risk)
 Theophylline (used in asthma/COPD, narrow therapeutic index)

5. Immunosuppressants & Anti-Inflammatory Drugs

 Ciclosporin & Tacrolimus (dose-related neurotoxicity)

 High-dose corticosteroids (e.g., dexamethasone,
prednisolone)

6. Antihistamines

 First-generation antihistamines (e.g., chlorpheniramine,

diphenhydramine)

7. Local Anesthetics

 Lidocaine, Bupivacaine (high doses or IV administration)

8. Withdrawal from Sedatives (Rebound Excitability)

 Benzodiazepines (e.g., diazepam, lorazepam)

 Alcohol withdrawal
 Barbiturates

9. Aminophylline

 Convulsions are an adverse effect of aminophylline,

especially if given rapidly by IV injection or in high
doses

Drugs that can cause peripheral neuropathy

 Amiodarone (can also cause myopathy)

Drugs that can cause raised CK

 Simvastatin
 Haloperidol
Drugs that can cause/ precipitate gout

 Thiazide type diuretics (indapamide)

 Aspirin
 Chemotherapy drugs
 Cyclosporin
 ACE inhibitors
 Ticagrelor
 ARB - Olmesartan

Note: If someone has a history of gout and you are

prescribing antihypertensives – do not give ACE
inhibitor or thiazide diuretics!

Drugs that can cause tremor

 Haloperidol
 Salbutamol
 Theophylline
 Tacrolimus

Drugs that can worsen fluid retention

 Pioglitazone (Thiazolidinedione)
 NSAIDs
 Steroids
1. Corticosteroids (Glucocorticoids)

 Prednisolone, Dexamethasone, Hydrocortisone

 Mechanism: Increase sodium and water retention via mineralocorticoid effects.

2. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

 Ibuprofen, Naproxen, Diclofenac, Celecoxib

 Mechanism: Inhibit prostaglandins, reducing renal perfusion and sodium excretion.
3. Calcium Channel Blockers (CCBs)

 Amlodipine, Nifedipine, Diltiazem, Verapamil

 Mechanism: Vasodilation leading to capillary leakage and dependent edema.

4. Thiazolidinediones (TZDs) - Antidiabetic Agents

 Pioglitazone, Rosiglitazone
 Mechanism: Increase sodium reabsorption and expand plasma volume.

5. Estrogens & Hormonal Therapies

 Oral contraceptives, Hormone replacement therapy (HRT)

 Mechanism: Increased renin-angiotensin-aldosterone activity, leading to water
retention.

6. Vasodilators

 Hydralazine, Minoxidil
 Mechanism: Increased capillary permeability leading to fluid accumulation.

7. Monoamine Oxidase Inhibitors (MAOIs)

 Phenelzine, Tranylcypromine
 Mechanism: Cause sodium and water retention by affecting sympathetic outflow.

8. Androgens & Anabolic Steroids

 Testosterone, Oxymetholone
 Mechanism: Induce sodium retention via androgenic activity.

9. Antipsychotics & Antidepressants

 Clozapine, Olanzapine, Risperidone, SSRIs

 Mechanism: Alter sodium handling and may increase ADH secretion.

10. Immunosuppressants

 Cyclosporine, Tacrolimus
 Mechanism: Vasoconstriction and renal sodium retention.

11. Chemotherapy & Targeted Therapies

 Cisplatin, Docetaxel, Bevacizumab

 Mechanism: Increased vascular permeability and renal dysfunction.
Drugs that can cause yeast infection
 Prednisolone (systemic)
 Clarithromycin (Uncommon side effect = candida infection) –
antibiotics- wipe out the natural flora
 Amoxicillin (Rare or very rare = Mucocutaneous candidiasis) –
antibiotics – wipe out the natural flora

Drugs that can cause dermatitis/ photosensitivity

SunTan TAN
Sulfonamides – sulfamethoxazole, sulfasalazine, co-
trimoxazole
Thiazides and diuretics – furosemide,
hydrochlorothiazide
Tetracyclines (doxycycline and lymecycline),
Quinolones (Ciprofloxacin)
Amiodarone
NSAIDs – naproxen, piroxicam

Drugs that can cause hypotension

Table 6 Drugs that cause first dose hypotension
The following is a list of some drugs that can cause first-dose hypotension
(note that this list is not exhaustive). Concurrent use of two or more drugs
from the list might increase this risk.

Drugs that cause first dose hypotension

alfuzosin captopril doxazosin
enalapril fosinopril imidapril
indoramin lisinopril perindopril
prazosin quinapril ramipril
tamsulosin terazosin trandolapril

Table 7 Drugs that cause hypotension

The following is a list of some drugs that cause hypotension (note that this
list is not exhaustive). Concurrent use of two or more drugs from the list
might increase this risk.
Drugs that cause hypotension
acebutolol alcohol alfuzosin
aliskiren alprostadil amantadine
amitriptyline amlodipine apomorphine
apraclonidine aripiprazole asenapine
atenolol avanafil azilsartan
Drugs that cause hypotension
baclofen bendroflumethiazide benperidol
betaxolol bisoprolol bortezomib
brimonidine bromocriptine bumetanide
cabergoline canagliflozin candesartan
captopril cariprazine carvedilol
celiprolol chlorothiazide chlorpromazine
chlortalidone clomipramine clonidine
clozapine dapagliflozin desflurane
diazoxide diltiazem dipyridamole
dosulepin doxazosin doxepin
droperidol empagliflozin enalapril
eplerenone epoprostenol eprosartan
ertugliflozin esketamine esmolol
etomidate felodipine finerenone
flupentixol fosinopril furosemide
glyceryl trinitrate guanfacine haloperidol
hydralazine hydrochlorothiazide hydroflumethiazide
iloprost imidapril imipramine
indapamide indoramin irbesartan
isocarboxazid isoflurane isosorbide dinitrate
isosorbide mononitrate ketamine labetalol
lacidipine landiolol lercanidipine
levobunolol levodopa levomepromazine
lisinopril lofepramine lofexidine
losartan loxapine lurasidone
methoxyflurane methyldopa metolazone
metoprolol minoxidil moxonidine
nadolol nebivolol nicardipine
nicorandil nifedipine nimodipine
nitroprusside nitrous oxide nortriptyline
olanzapine olmesartan paliperidone
pericyazine perindopril phenelzine
pimozide pindolol pramipexole
prazosin prochlorperazine promazine
propofol propranolol quetiapine
quinagolide quinapril ramipril
riociguat risperidone ropinirole
rotigotine sacubitril sapropterin
selegiline sevoflurane sildenafil
sodium oxybate sotalol spironolactone
sulpiride tadalafil tamsulosin
Drugs that cause hypotension
telmisartan terazosin thiopental
timolol tizanidine torasemide
trandolapril tranylcypromine treprostinil
trifluoperazine trimipramine valsartan
vardenafil verapamil vericiguat
vernakalant xipamide zuclopenthixol

Major class of drugs:

1. Anti-psychotics
2. Anti-hypertensives
3. Anti heart failure medication
4. Beta blockers
5. Anaesthetic agents
6. MOA inhibitor

Drugs that can cause postural hypotension

Drugs that can cause nasal congestion

 Prazosin
 Selegiline hydrochloride
 Sildenafil, tadalafil, vardenafil
 Amiloride
 Methyldopa
 Travaprost
 Selexipag
 Raltegravir
 Hydralazine hydrochloride
 Mepolizumab
 Raltegravir
 Ivacaftor
 Antipsychotics (haloperidol, olanzapine, quetiapine, amisulpiride)
 Promazine hydrochloride
 Bromocriptine
 Ribavirin

Drugs that can cause gingival hyperplasia

 Cyclosporin
 Calcium-channel blocker – well recognised class effect –
verapamil, nifedipine, diltiazem, amlodipine, lacidipine, nicardipine
 Phenytoin
Drugs that can cause gingival pain/ bleeding
 Topiramate
 Orlistat
 Ethosuximide
 Trastuzumab
 Ribavirin
 Emtansine
 Varenicline

Drugs that can cause renal impairment

 ACE-inhibitor
 ARB
 NSAID
 Alendronic acid (common, very common)

Serious dosing error type questions

 *these are more difficult questions which require more thinking
and checking through the BNF – think: how to speed up on
these type of questions?
 It will be a big, serious mistake!
 It can be the route/ frequency that’s prescribed wrong? – CAN!!!
(taken weekly, not daily, or taken daily, not weekly)

Think about the following possibilities:

 Is the patient subject an elderly/ child? – these have very
different dosing requirements than normal adult patient

(eg: citalopram  required dose is 10-20 mg once daily, maximum

dose for the elderly = 20mg/ day)

 Is the patient pregnant? – use weight-based dosing, note no. of

weeks/ post-partum

 Is there a max dose per day that is exceeded?

 Do the doses match the form? (eg: tablets vs oral drops for
citalopram – different max doses and daily requirements)

 Do the doses match the indication? (ie: if the same drug has
two/ three different indications – do the doses match correct
indication?) (Eg: Dexamethasone  for suppression of
inflammatory and allergic disorders in adults = 0.5-10 mg
daily vs COVID-19 requiring supplemental oxygen in adults =
6mg OD for 10 days)

 Is there a dose calculation error? (eg: for weight based

prescriptions in children/ adults  make sure the decimal
places/ units are not wrong – eg: dexamethasone for mild/ severe
 croup would be initially 150 micrograms/ 0.15 miligrams / kg
for 1 dose (PO once only), check if dose is correct based on
patient’s weight (eg: if 10kg  1.5 mg not 15 mg!)

(Eg: Tacrolimus is weight based)

 Is it a weekly prescription as opposed to a daily prescription?

(eg: Alendronic acid, methotrexate)

 Dose reduction/ adjustments in renal/ hepatic impairment

 Contraindications/ interactions

Paracetamol
 Note paediatric dose threshold
 Adult dose threshold = 4g/ day max PO, but for IV – is
weight based!
 IV dose is different from oral dose!

By mouth

Adult
 0.5–1 g, every 4–6 hours; maximum 4 g per day.

By intravenous infusion

Adult (body-weight up to 51 kg)

 15 mg/kg, every 4–6 hours, dose to be administered over 15
minutes; maximum 60 mg/kg per day.

Adult (body-weight 51 kg and above)

 1 g, every 4–6 hours, dose to be administered over 15 minutes;
maximum 4 g per day.
Contraindications type questions
 Think about obvious contraindications – eg: are the use of
penicillins/ beta lactams/ cephalosporins all contraindicated
in penicillin allergy/ hypersensitivity to penicillins?? (ie:
question may have subtle “hints” like patient had ‘urticarial rash
following phenoxymethylpenicillin for scarlet fever’–
suggestive of hypersensitivity after receiving a penicillin-containing
drug)
 How to choose between two answers that equally make
sense (eg: paracetamol and amoxicillin contraindicated in
cholestatic obstructive jaundice)
 Check “contraindications” section in the BNF – in
some drugs are present, but not all!! (eg: present for
naproxen but not for amoxicillin) – so need to rely on
general knowledge sometimes, not just rely on the BNF!

Drugs contraindicated in heart failure

 NSAID

Drugs contraindicated in obstructive jaundice

 Antibiotics  cause hepatic impairment (eg: amoxicillin)
 Paracetamol  ???

Drugs contraindicated in renal impairment/ renal failure

Nitrofurantoin:
 Avoid if eGFR less than 45 mL/ minute/1.73 m2; may be used
with caution if eGFR 30–44 mL/ minute/1.73 m2 as a short-
course only (3 to 7 days), to treat uncomplicated lower urinary-tract
infection -- use trimethoprim instead!
Drugs “most appropriate to be withheld” type
questions
 Similar to contraindication type questions
 Commonly asks “Select the two prescriptions that are most
appropriate to withhold until her renal function recovers”
 Approach to the above: think which drugs are renally excreted?
(these drugs can accumulate in renal injury), which drugs are
contraindicated in renal impairment?, which drugs are
nephrotoxic?
 Note drugs that are nephrotoxic is different from drugs that
are renally excreted/ hence has to be withheld until renal function
recovers!
 Think of which of the drugs may be the contributor to the
presenting symptoms, hence has to be withheld based on the
results

1. Nephrotoxic Drugs
A nephrotoxic drug is one that directly damages the kidneys, leading to acute kidney
injury (AKI), chronic kidney disease (CKD), or electrolyte imbalances.

Examples of Nephrotoxic Drugs:

 Antibiotics: Aminoglycosides (e.g., gentamicin), vancomycin, amphotericin B

 NSAIDs: Ibuprofen, naproxen, diclofenac (reduce renal perfusion)
 ACE Inhibitors & ARBs: Ramipril, losartan (can reduce kidney function in some
patients) – a small rise in creatinine (<20%) is to be expected when starting an
ACE inhibitor and does not require investigation or a change in prescription (at
what time point/ U+E levels will it require escalation?)
 Diuretics: Loop diuretics (furosemide), thiazides (cause dehydration, electrolyte
imbalance)
 Contrast Media (IV contrast for CT/MRI scans)
 Chemotherapy Drugs: Cisplatin, methotrexate (high doses)
 Immunosuppressants: Cyclosporine, tacrolimus

Management of Nephrotoxic Drugs

 Monitor kidney function (e.g., creatinine, eGFR, urea)

 Adjust dose or avoid use in patients with pre-existing kidney disease
 Hydration to reduce kidney damage risk (e.g., before contrast dye administration)
 Monitor for signs of toxicity (reduced urine output, swelling, high potassium levels)
2. Drugs That Must Be Withheld in Renal Impairment
Some drugs are not directly nephrotoxic, but they accumulate in the body when kidney
function is reduced, leading to toxicity or serious side effects. These drugs are withheld
(stopped or adjusted) in renal impairment.

Examples of Drugs That Should Be Withheld or Dose-Adjusted in Renal

Impairment:

 Metformin → Risk of lactic acidosis if GFR <30 mL/min

 Gabapentin & Pregabalin → Can cause CNS toxicity (sedation, confusion) in CKD
 Opioids (e.g., Morphine, Codeine) → Risk of accumulation & respiratory
depression
 Digoxin → Excreted by kidneys; toxic at high levels
 Antibiotics: Nitrofurantoin (ineffective in GFR <30), aminoglycosides (dose-adjust)
 Diuretics (if severe CKD) → Can cause dehydration & electrolyte imbalance
 Lithium → Narrow therapeutic index; high toxicity risk in renal impairment
 Insulin & Hypoglycemics → Reduced clearance in CKD, increased hypoglycemia
risk
 Allopurinol

Management of Drugs That Require Withholding in Renal Impairment

 Adjust the dose based on eGFR or creatinine clearance

 Monitor drug levels (e.g., digoxin, lithium)
 Consider alternative medications that are safer in renal impairment
 Temporarily withhold drugs during acute kidney injury (AKI) to prevent
worsening function

Common culprits:
 ACE inhibitors, ARBs: ramipril, candesartan, losartan –
nephrotoxic so should be suspended whenever an AKI arises,
as they can contribute to further renal injury
 Allopurinol – can accumulate in renal dysfunction – BNF
advises use with caution (risk of accumulation) – dose
adjustments required (max. daily dose of 100mg, in severe
impairment, reduce daily dose to below 100 mg, or increase dose
interval
For immunosuppressive drugs:

Tacrolimus – the brand name must be specified

Can look under Medicines “Tacrolimus—See all results” for complete list of
tacrolimus formulations, including the brand name and what dose it
contains (eg: Prograf comes in 1mg, 500 microgram and 5mg capsules)

Maintenance doses of tacrolimus may commonly be in the range 1-2

mg PO 12 hourly