Pocket Prescriber
Editedby TimothyRJNicholsonMBBSBSC
MSC MRCPMRCPSYCH
AcademicClinicalLecturer,SectionofCognitiveNeuropsychiatry, InstituteofPsychiatry,London,UK
DonaldRJSingerBMEDBIOL MDFRCP ProfessorofClinicalPharmacologyandTherapeutics, ClinicalSciencesResearch,WarwickMedicalSchool, UniversityofWarwickand UniversityHospitalsCoventryandWarwickshire,Coventry,UK
FirstpublishedinGreatBritainin2004
Secondedition2006
Thirdedition2009
Fourtheditionpublishedin2011
Thisfiftheditionpublishedin2012by HodderArnold,animprintofHodderEducation,anHachetteUKCompany, 338EustonRoad,LondonNW13BH
http://www.hoddereducation.com
2012TimothyRJNicholsonandDonaldRJSinger
Allrightsreserved.ApartfromanyusepermittedunderUKcopyrightlaw,this publicationmayonlybereproduced,storedortransmitted,inanyform,orbyany meanswithpriorpermissioninwritingofthepublishersorinthecaseof reprographicproductioninaccordancewiththetermsoflicencesissuedbythe CopyrightLicensingAgency.IntheUnitedKingdomsuchlicencesareissuedbythe CopyrightLicensingAgency:SaffronHouse,6 10KirbyStreet,LondonEC1N8TS
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Whilsttheadviceandinformationinthisbookarebelievedtobetrueandaccurate atthedateofgoingtopress,neithertheauthor[s]northepublishercanacceptany legalresponsibilityorliabilityforanyerrorsoromissionsthatmaybemade.In particular(butwithoutlimitingthegeneralityoftheprecedingdisclaimer)every efforthasbeenmadetocheckdrugdosages;howeveritisstillpossiblethaterrors havebeenmissed.Furthermore,dosageschedulesareconstantlybeingrevisedand newside-effectsrecognized.Forthesereasonsthereaderisstronglyurgedto consulttheLicensingAuthority’sanddrugcompanies’printedinstructionsbefore administeringanyofthedrugsrecommendedinthisbook.
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CONTRIBUTORS
AdamMCArchibaldBSc(Hons)MBChB
StRObstetricsandGynaecology,NHSGreaterGlasgowandClyde
PeterJBarnesDMDScFRCPFMedSciFRS
ProfessorandConsultantinRespiratoryMedicine,NationalHeart& LungInstitute,ImperialCollegeLondon
AlisonBedlowBScMBBSFRCPDipRCPath
ConsultantDermatologist,SouthWarwickshireNHSFoundationTrust
AodhanBreathnachMDFRCPath
ConsultantMedicalMicrobiologist,DepartmentofMedicalMicrobiology StGeorge’sHospital,London
EmmaCDerrett-SmithBScMBBSMRCP
ClinicalResearchFellow,CentreforRheumatologyandConnectiveTissue Diseases,UCLMedicalSchool,London
TimothyWRDoultonBScMDMRCP
ConsultantNephrologist,KentKidneyCareCentre,EastKentHospitals UniversityNHSFoundationTrust
DavidHallBSc(Hons)MBChB(Hons) RoyalAirForceMedicalOffice
HNikkiHallMBChBBSc(Hons)
SpecialistTraineeinOphthalmology,QueenMargaretHospital, Dunfermline
BethDHarrisonMABMBChDM(Oxon)FRCPFRCPath
ConsultantHaematologist,UniversityHospitalCoventryand WarwickshireNHSTrust
StevenHarsumMBBSBScPhDFRCOphth
ConsultantOphthalmologist,Epsom&StHelierUniversityHospitals NHSTrust
RobinDCKumarBScMBBSFRCA
SpecialistRegistrarinAnaesthesiaandIntensiveCare,King’sCollege Hospital,London
PeteMaskellMBBSFRCPMSc
ConsultantStrokePhysicianandElderlyCareLead,Maidstoneand TunbridgeWellsNHSTrust
AllisonCMortonBMedSciMBChBMRCPPhD
ConsultantCardiologist,SheffieldTeachingHospitalsNHSFoundation Trust;andClinicalResearchManager,NIHRCardiovascularBiomedical ResearchUnit,NorthernGeneralHospital,Sheffield
VictorPaceFRCP
ConsultantinPalliativeMedicine,StChristopher’sHospice,Sydenham, London
JamesJHRuckerMBBSBScMRCPsych
ClinicalResearchFellow,Social,GeneticandDevelopmentalPsychiatry Centre,InstituteofPsychiatry,King’sCollegeLondonandHonorary SpecialistRegistrarinGeneralAdultPsychiatry,TheSouthLondonand MaudsleyNHSFoundationTrust,London
StephenDerekQuinnMBBSBScMRCOG
ClinicalResearchFellow,StMary’sHospital,London
BibaStantonBMedSciMBBSMRCPPhD
SpecialistRegistrar,NationalHospitalforNeurologyandNeurosurgery, QueenSquare,London
AlexTullochPhDMRCPMRCPsych
BRCPreparatoryClinicianScientistFellow
EstherUnittBMedSciMBBSMRCPDM
ConsultantGastroenterologistandHepatologistattheUniversity Hospital,CoventryandWarwickshireHospitalsNHSTrust
WStephenWaringBMedSciMBPhDFRCP(Edin)
ConsultantinAcuteMedicine,YorkTeachingHospitalNHSFoundation Trust,andHonorarySeniorLecturer,HullYorkMedicalSchool
FOREWORD
Contemporarymedicalpracticenecessitatesabroadknowledgeof drugtreatments,whichareconstantlybeingupdatedandmodified. Iamdelightedtowritetheforewordforthisvolumewhich,inthe principleoftheverybesttravelguides,issmallbutpackedwith essentialandeasilyaccessibleinformation.Ofallthesubjectsthatare inthemedicalcurriculum,pharmacologycansometimesseem especiallyabstractandtheoretical.Aquickflickthroughthepagesof thisbookthatarerelevanttoone’sownspecialityisanimmediate reminderoftheimportanceofunderstandingthewaysinwhichthe drugsthatweroutinelyprescribearehandled.Theclearidentification ofhazardoussideeffectsandpotentialinteractionsisespecially welcome.Finally,thesectionprovidingcurrentinformationand managementguidelinesforcommonlyencounteredmedicalemergenciesisbothclearandcomprehensive.
Safeuseofthemoderntherapeuticarmamentariumisadaunting taskforjuniordoctorsandmedicalstudents.Althoughtherehasbeen alargegrowthinelectronicresourcesandsomeexcellentonline textbookshavebeenproduced,thereremainsacriticalneedforsmall referencetextsthatcanbecarriedatalltimesandusedtocheckdrug dosesorpotentialinteractionsatthepointofprescription.The simpleprecautionofcheckingfactsinanyunfamiliarprescribing situationislikelytopreventmistakes,andexemplifiescurrent emphasisonsafe-practiceandclinicalriskmanagement.
Ibelievethateventhemostseniorspecialistcouldlearnsomething fromthisbook’spagesandthatacomprehensiveup-to-datevolume suchasthisisanessentialpartofanyjuniordoctor’stoolkit,andwill proveusefulfarbeyonditstargetaudience.
ProfessorDameCarolM.BlackDBE FormerpresidentoftheRoyalCollegeofPhysicians
ACKNOWLEDGEMENTS
Thisbookisdedicatedtomyfamilyandfriendsaswellasallthe inspirationalteachersIhavebeenluckyenoughtolearnfromoverthe years,inparticularJohnYoule,KatieBlackman,JerryKirk,Carol Black,HuwBeynon,MartinRossor,MichaelTrimble,MariaRon, MatthewHotopfandTonyDavid.
ParticularthanksfortheirhelpandtimetoAnandandSubbu,Usman Ali,CharlieArcher,HoumanAshrafian,SelmaAybek,Prithwish Bannerjee,AmlanBasu,NickBateman,SimoneBrackenborough, HarrisBirthright,GurpreetChana,ReenaChauhan,RogerCross, JonnyCrowston,ChrisDenton,SamanthaDickinson,PaulDilworth, MichaelDuick,PhilDyer,NickEynon-Lewis,FahadFarooqi, CatherineFarrow,RogerFernandes,AroshaFernando,DeniseForth, JackGalliford,ThomasGalliford,HamidGhodse,NatashaGilani, CarolineGoh,NikeshGudka,AshanGunarathne,NadyaHamedi, JaneHenderson,PeterHargreaves,NicholasHirsch,RickHolliman, EmilyHorwill,SaadhiyaHussain,NickJackson,SudheshKumar, SimonLittle,Ruey-LengLoo,GrahamMacGregor,MelMahadevan, OmarMalik,JanadaMamza,ChungManWan,JoelaMatthews, NarbehMelikian,HinaMistry,NeilMuchatuta,DevMukerjee,Tejal Patel,RahulPatel,RakitaPatel,GideonPaul,AnnabelPrice,Deirdre Prinsloo,GemmaRobinson,RicardoSainz,SaileshSankar,Muriel Shannon,AmarSharif,JenniferSharp,RamsaySinger,Bran Sivakumar,SianStanley,RichardStratton,HenrySquire,Becky Szekely,SheenaThomas,MikeTravis,RudolfUher,AaronVallance, PayalVasani,JimWade,MandyWan,JayneYeungandAbbasZaidi. SpecialthankstoHelenGalley.
Theinformationinthisbookhasbeencollatedfrommanysources, includingmanufacturer’sinformationsheets(‘SPCs’ Summaryof ProductCharacteristicssheets),the BritishNationalFormulary (BNF), nationalandinternationalguidelines,aswellasnumerouspharmacology andgeneralmedicalbooks,journalsandpapers.Whereinformationis notconsistentbetweenthesesources,thatfromtheSPCshasgenerally beentakenasdefinitive.
HOWTOUSETHISBOOK
STANDARDLAYOUTOFDRUGS
DRUG/TRADENAME
Class/action: Moreinformationisgivenforgenericforms,especially fortheoriginalandmostcommonlyuseddrug(s)ofeachclass.
Use: use x (correlatingtodoseasbelow).
CI: contraindications; L (liverfailure), R (renalfailure), H (heart failure), P (pregnancy), B (breastfeeding). Allergytoactivedrug,or anyexcipients(othersubstancesinthepreparation)assumedtoo obvioustomention.
Caution: L (liverfailure), R (renalfailure), H (heartfailure), P (pregnancy), B (breastfeeding), E (elderlypatients).Ifacontraindicationisgivenforadrugitisassumedtooobvioustomentionthata cautionisalsoinherentlyimplied.
SE: sideeffects;listedinorderoffrequencyencountered.Common/ importantsideeffectssetin bold.
Warn: informationtogivetopatientsbeforestartingdrug.
Monitor: parametersthatneedtobemonitoredduringtreatment.
Interactions: includedonlyifverycommonorpotentiallyserious; / ¡P450 (induces/inhibitscytochromeP450metabolism), W (increaseseffectofwarfarin), W (decreaseseffectofwarfarin).
Dose: dosex (forUsex asabove). NBDosesareforadultsonly. Importantpointshighlightedatendofdrugentry.
Use/doseNICE: NationalInstituteofHealthandClinicalExcellence guidelinesexistforthedrug(basicsofteninBNF see www.nice.org.ukforfulldetails).
DoseBNF/SPC: doseregimencomplicated;pleaserefertoBNFand/or SPC(SummaryofProductCharacteristicssheet;themanufacturer’s informationsheetenclosedwithdrugpackaging canalsobe viewedatordownloadedfromwww.emc.medicines.org.uk).
Asterisks(*) and daggers($) denotelinksbetweeninformation withinlocaltext.
x HOWTOUSETHISBOOK
Onlyrelevantsectionsareincluded foreachdrug. Tradenames (in OUTLINE font)aregivenonlyiffoundregularlyondrugcharts orifnon-proprietary(generic,non-trade-name)drugdoesnot existyet.
KEY
Potentialdangershighlightedwithskullandcross-bones
% Newdrugornewindicationunderintensesurveillanceby CommitteeonSafetyofMedicines(CSM): importanttoreport allsuspecteddrugreactionsviaYellowCardscheme (accurateas goingtopress:fromDecember2011CSMlist)
J Goodfor:reasonstogiveacertaindrugwhenchoiceexists
L Badfor:reasonstonotgiveacertaindrugwhenchoiceexists
[ Causes/goesto Therefore
D Change/disturbance
C Psychiatric Increase/high
¡ Decrease/low
/ ¡ electrolytesreferstoserumlevels,unlessstatedotherwise.
DOSES
odoncedaily nocteatnight bdtwicedailymaneinthemorning tdsthreetimesdailyprnasrequired qdsfourtimesdailystatatonce
ROUTES
imintramuscularpooral inhinhaledprrectal ivintravenousscsubcutaneous iviintravenousinfusiontoptopical nebvianebuliserslsublingual
Routesarepresumedpo,unlessstatedotherwise.
LISTOFABBREVIATIONS
5-ASA5-aminosalicylicacid
5HT5-hydroxytryptamine( serotonin)
A&Eaccidentandemergency
AACantibiotic-associatedcolitis
Abantibody
ABPMambulatorybloodpressuremonitoring
ACCAmericanCollegeofCardiology
ACCPAmericanCollegeofChestPhysicians
ACE-iACEinhibitor
AChacetylcholine
ACSacutecoronarysyndrome
ADPadenosinephosphate
AFatrialfibrillation
Agantigen
AHAAmericanHeartAssociation
AKIacutekidneyinjury
ALLacutelymphoblasticleukaemia
ALPalkalinephosphatase
ALSadultlifesupport(algorithmsofEuropean ResuscitationCouncil)
ALTalanine(-amino)transferase
AMIacutemyocardialinfarction
AMTSabbreviatedmentaltestscore(sameasMTS)
ANAanti-nuclearantigens
APTTactivatepartialthromboplastintime
ARB(s)angiotensinreceptorblocker(s)
ARDSadultrespiratorydistresssyndrome
ASaorticstenosis
ASAPassoonaspossible assocassociated
ASTaspartatetransaminase
AVarteriovenous
AVMarteriovenousmalformation
AVNatrioventricularnode
AZTzidovudine
BBBbundlebranchblock
BCSHBritishCommitteeforStandardsinHaematology
BCTbroadcomplextachycardia
BFbloodflow
BGserumbloodglucoseinmmol/l; seealsoCBG
BHSBritishHypertensionSociety
BIHbenignintracranialhypertension
BIPAPbilevel/biphasicpositiveairwaypressure
BMbonemarrow(NB:BMisoftenused,confusingly,to signifyfinger-prickglucose;CBG(capillaryblood glucose)isusedforthispurposeinthisbook)
BMIbodymassindex weight(kg)/height(m)2
BP bloodpressure
BPHbenignprostatichypertrophy
BTSBritishThoracicSociety
Bx biopsy
C constipation
Ca cancer(NB:calciumisabbreviatedtoCa2 )
CAHcongenitaladrenalhyperplasia
CBFcerebralbloodflow
CBGcapillarybloodglucoseinmmol/l(finger-pricktesting) (NB:BMisoftenusedtodenotethis,butthisis confusingandlessaccurateandthusnotusedinthis book)
CCFcongestivecardiacfailure
cfcomparedwith
CIcontraindicated
CKcreatinekinase
CKDchronickidneydisease
CLLchroniclymphocyticleukaemia
CMLchronicmyelogenousleukaemia
CMVcytomegalovirus
LISTOFABBREVIATIONS
CNScentralnervoussystem
COcardiacoutput
COPDchronicobstructivepulmonarydisease
COXcyclo-oxygenase
CPRcardiopulmonaryresuscitation
CRFchronicrenalfailure
CRPCreactiveprotein
CSFcerebrospinalfluid
CSMCommitteeonSafetyofMedicines
CTcomputerisedtomography
CVAcerebrovascularaccident
CVPcentralvenouspressure
CXRchestX-ray
Ddiarrhoea
D&Vdiarrhoeaandvomiting
D1/2/3 ... dopaminereceptorsubtype1/2/3 ...
DAdopamine
DCTdistalconvolutedtubule
dfxdefects
DIdiabetesinsipidus
DICdisseminatedintravascularcoagulation
DIGAMIglucose,insulinandpotassiumintravenousinfusion usedinacutemyocardialinfarction
DKAdiabeticketoacidosis
DMdiabetesmellitus
DMARDdisease-modifyinganti-rheumatoidarthritisdrug
dtdueto
DWIdiffusionweighted(imaging);specialistMRImostly usedforstroke/TIA
Dxdiagnosis
EØ eosinophils
e’lyteelectrolyte
EBVEpstein Barrvirus
ECGelectrocardiogram
ECTelectroconvulsivetherapy
EF ejectionfraction
ENTear,noseandthroat
EPSEextrapyramidalsideeffects
ERCEuropeanResuscitationCouncil
ESCEuropeanSocietyofCardiology
ESRerythrocytesedimentationrate
exacexacerbates
FBCfullbloodcount
Fe iron
FFPfreshfrozenplasma
FHxfamilyhistory
FiO2 inspiredO2 concentration
FMFfamilialMediterraneanfever
fxeffects
G6PDglucose-6-phosphatedehydrogenase
GABAgammaaminobutyricacid
GBSGuillain Barre ´ syndrome
GCSGlasgowComaScale
GFRglomerularfiltrationrate
GIgastrointestinal
GIKglucose,insulinandK infusion
GMCGeneralMedicalCouncil(ofUK)
GTNglyceryltrinitrate
GUgenitourinary
hhour(s)
H(O)CMhypertrophic(obstructive)cardiomyopathy
Hbhaemoglobin
HBheartblock
HBPMhomebloodpressuremonitoring
Hcthaematocrit
HDLhighdensitylipoprotein
HFheartfailure
HIVhumanimmunodeficiencyvirus
HLAhumanleucocyteantigen
HMG-CoA3-hydroxy-3-methyl-glutarylcoenzymeA
HONKhyperosmolarnon-ketoticstate hrlyhourly
HSVherpessimplexvirus
HTNhypertension
HUShaemolyticuraemicsyndrome
Hxhistory
IBDinflammatoryboweldisease
IBSirritablebowelsyndrome
ICPintracranialpressure
ICUintensivecareunit
IHDischaemicheartdisease
IL-2interleukin2
imintramuscular
incincluding inhinhaled
INRinternationalnormalisedratio(prothrombinratio)
IOPintraocularpressure
ITPimmune/idiopathicthrombocytopenicpurpura
ITUintensivetherapyunit
ivintravenous
IVDUintravenousdruguser
iviintravenousinfusion
Ixinvestigation
K potassium(serumlevelsunlessstatedotherwise)
LØ lymphocytes
LAlong-acting
LBBBleftbundlebranchblock
LDLlowdensitylipoprotein
LFliverfailure
LFTsliverfunctiontests
LMWHlow-molecular-weightheparin
LPlumbarpuncture
LVFleftventricularfailure
MØ macrophages
maneinmorning
MAOImonoamineoxidaseinhibitor
MAPmeanarterialpressure
MCAmiddlecerebralartery
MCVmeancorpuscularvolume
metabmetabolised
MGmyastheniagravis
MHRAMedicinesandHealthcareProductsRegulatory Authority(UK)
MImyocardialinfarction
MMFmycophenolatemofetil
MMSEMini-MentalStateExamination(scoredoutof30*)
MRmodified-release(drugpreparation)$
MRImagneticresonanceimaging
MRSAmethicillin-resistant Staphylococcusaureus
MSmultiplesclerosis
MTS(abbreviated)MentalTestScore(scoredoutof10*)
MUSTmalnutritionuniversalscreeningtool
Mxmanagement
Nnausea
N&Vnauseaandvomiting
NØ neutrophils
NAnoradrenaline(norepinephrine)
NSAIDnonsteroidalanti-inflammatorydrug xvi LISTOFABBREVIATIONS
Na1 sodium(serumlevelsunlessstatedotherwise)
NBMnilbymouth
NCTnarrowcomplextachycardia
NDRInoradrenalineanddopaminereuptakeinhibitor
nebvianebuliser
NGTnasogastrictube
NHnon-Hodgkin’s(lymphoma)
NIHSSNational(US)InstituteofHealthStrokeScale
NIVnon-invasiveventilation
NMJneuromuscularjunction
NMSneurolepticmalignantsyndrome
NPISNationalPoisonsInformationService
LISTOFABBREVIATIONS
NSTEMInon-STelevationmyocardialinfarction
NYHANewYorkHeartAssociation
OCDobsessivecompulsivedisorder
OCPoralcontraceptivepill
ODoverdose (NB:od oncedaily!)
OGDoesophagogastroduodenoscopy
p’way(s)pathway(s)
PANpolyarteritisnodosa
PBCprimarybiliarycirrhosis
PCIpercutaneouscoronaryintervention(nowpreferred termforpercutaneoustransluminalcoronary angioplasty(PTCA),whichisasubtypeofPCI)
PCOSpolycysticovarysyndrome
PCP Pneumocystiscarinii pneumonia
PCVpackedcellvolume
PDApatentductusarteriosus
PEpulmonaryembolism
PEApulselesselectricalactivity
PEGpercutaneousendoscopicgastrostomy
PG(x)prostaglandin(receptorsubtype x)
phaeophaeochromocytoma
PHxpasthistory(of)
PIDpelvicinflammatorydisease
PMLprogressivemultifocalleukoencephalopathy
PMRpolymyalgiarheumatica
pobymouth
PO4 phosphate(serumlevels,unlessstatedotherwise)
PPIprotonpumpinhibitor
prrectal
prep(s)preparation(s)
prnasrequired
PSAprostatespecificantigen
Ptplatelet(s)
PTprothrombintime
PTHparathyroidhormone
xviii LISTOFABBREVIATIONS
PTSDpost-traumaticstressdisorder
PUpepticulcer
PUOpyrexiaofunknownorigin
PVDperipheralvasculardisease
Pxprophylaxis
QT(c)QTinterval(correctedforrate)
RArheumatoidarthritis
RASrenalarterystenosis
RBFrenalbloodflow
RFrenalfailure
RLSrestlesslegssyndrome
ROSIERrecognitionofstrokeinemergencyroomscalefor diagnosisofstroke/TIA
RRrespiratoryrate
RRTrenalreplacementtherapy
RSVrespiratorysyncytialvirus
RTIrespiratorytractinfection
RVrightventricle
RVFrightventricularfailure
Rxtreatment
SAHsubarachnoidhaemorrhage
SANsinoatrialnode
SBEsubacutebacterialendocarditis
scsubcutaneous
SE(s)sideeffect(s)
secsecond(s)
SIGNScottishIntercollegiateGuidelinesNetwork
SIADHsyndromeofinappropriateantidiuretichormone
SJSStevens Johnsonsyndrome
slsublingual
SLEsystemiclupuserythematosus
SOAswellingofankles
SOB(OE)shortnessofbreath(onexertion)
SPCsummaryofproductcharacteristicsheet(seepageviii)
sppspecies
SR slow/sustainedrelease(drugpreparation)
SSRIselectiveserotoninreuptakeinhibitor
SSSsicksinussyndrome
STEMISTelevationmyocardialinfarction suppsuppository
SVTsupraventriculartachycardia
t1/2 half-life
T3 triiodothyronine/liothyronine
T4 thyroxine( / ¡T4 hyper/hypothyroid)
TCAtricyclicantidepressant
TEthromboembolism
TEDSthromboembolismdeterrentstockings
TENtoxicepidermalnecrolysis
TFTsthyroidfunctiontests
TGtriglyceride
TIBCtotalironbindingcapacity
TIMIscoreriskscoreforUA/NSTEMInamedafterTIMI (thrombolysisinMI)trial
TNFtumournecrosisfactor
toptopical
TPMTthiopurinemethyltransferase
TPRtotalperipheralresistance
TTA(s)(drugs)totakeaway,i.e.prescriptionsforinpatientson discharge/leave(akaTTO)
TTO(s)seeTTA
TTPthromboticthrombocytopenicpurpura
U&Esureaandelectrolytes
UA(P)unstableangina(pectoris)
UCulcerativecolitis
URTIupperrespiratorytractinfection
UTIurinarytractinfection
UVultraviolet
Vvomiting
VE(s)ventricularectopic(s)
VFventricularfibrillation
vit vitamin
VLDLverylowdensitylipoprotein
VT ventriculartachycardia
VTEvenousthromboembolism
VZVvaricellazostervirus(chickenpox/shingles)
w with
w/inwithin
w/owithout
WCCwhitecellcount
WEWernicke’sencephalopathy
wk week
ZE Zollinger Ellisonsyndrome xx LISTOFABBREVIATIONS
WPWWolff Parkinson Whitesyndrome
Wt weight
xs excess
HOWTOPRESCRIBESAFELY
Taketime/careto ¡risktopatients(andprotectyourself). Alwayscheckthefollowingarecorrectforallprescriptions: patient, indicationanddrug, legible format(genericname,clarity,handwriting, identifiablesignature,yourcontactnumber),dosage,frequency,time(s) ofday,date,durationoftreatment,routeofadministration.
DO
• Makeaclear,accuraterecordinthenotesofallmedicines prescribed,writtenatthetimeofprescription
• Completeallergyboxandalertlabels,whererelevant
• IncludeonalldrugchartsandTTAsthepatient’ssurnameand givenname,dateofbirth,dateofadmissionandconsultant(if possibleuseaprintedlabelforpatientdetails)
• PRINT (i.e.useuppercase)alldrugsasapproved(generic)names, e.g.‘IBUPROFEN’ not ‘nurofen’
• Statedose,routeandfrequency,givingstrengthofsolutions/creams
• Writethewordmicrograminfull;avoidabbreviationssuchasmcg or m
• Abbreviatethewordgramto‘g’(ratherthan‘gm’whichiseasily confusedwithmg)
• Writetheword‘units’infull,precededbyaspace;abbreviatingto ‘U’canbemisreadaszero(a10-folderror)
• Documentweightwheredosingisweight-dependent
• Writequantities B1ginmg(e.g.400mg not 0.4g)
• Writequantities B1mginmicrograms(e.g.200micrograms not 0.2mg).
• Notusetrailingzeroes(10mg not 10.0mg)
• Precededecimalpointswithanotherfigure(e.g0.8ml not .8ml) andonlyusedecimalswhereunavoidable
• Checkandrecheckcalculations
• Provideclearadditionalinstructions,e.g.formonitoring,reviewof antibioticrouteandduration,maximumdaily/24hdoseforPRN drugs
• Specifysolutiontobeusedanddurationofanyivinfusions/ injections
• Avoidusingabbreviated/non-standarddrugnames
• Avoidwriting‘T’(tabletsign)fornon-tabletformulations, e.g.sprays
• Amendaprescribeddrugbydrawingalinethroughit,dateand initialthis,thenrewriteasnewprescription
• Checkandcountnumberofdrugswhenrewritingadrugchart
• Checkwhenprescribingunfamiliardrug(s)/dosesordrugsyouwere familiarwithbuthaven’tprescribedrecently.
IMPORTANTFURTHERADVICE
1 Makesurechoiceofdruganddoseisrightforthepatient,their conditionandsignificantcomorbidity,withparticularattentionto age*,gender,ethnicity,renalorliverdysfunction,riskofdrug drug anddrug diseaseinteractions,andrisksinpregnancy(andthoseof child-bearingagewhomaybecomepregnant)andduring breastfeeding.Anticipatepossibleeffectsofover-the-counterand herbalmedicinesandlifestyle(e.g.dietarysaltandalcoholintake).
*Althougharbitraryageof 65denotes‘elderly’,fxofagecan occurearlier/laterandarecontinuous.
2 Commonsettingswheredrugproblemsoccurareoften predictableifyouunderstandrelevantpathology,routesofdrug metabolism(liver,P450,renal,etc)anddrugmechanismsof action.Takeparticularcarewith:
• Renalorliverdisease
• Pregnancy/breastfeeding:usesafestoptions(intheUKconsider consultingtheNationalTeratologyInformationService; tel:01912321525)
• NSAIDs/bisphosphonatesandpepticulcerdisease
• Asthmaand b-blockers
• Conditionsworsenedbyantimuscarinicdrugs(seep.233): urinaryretention/BPH,glaucoma,paralyticileus
• Rareconditionswheredrugscommonlyposerisk,e.g.porphyria, myasthenia,G6PDdeficiency,phaeo.
3 Alwaysensureinformedconsent;agreeproposedprescriptions withthepatient(orcarerifpatienthasauthorisedtheirinvolvementintheircareorhaslostcapacity),explainingproposed benefits,natureanddurationoftreatment,clarifyingconcerns, warningofpossible,especiallysevere,adverseeffects,highlightingrecommendedmonitoringandreviewarrangementsand statingwhatthepatientshoulddointheeventofasuspected adversereaction.Onlyinextremeemergenciescanitbejustified tohavenotdonethis.Fordrugswithcommonpotentiallyfatal/ severesideeffectsdocumentthattheseriskshavebeenexplained to,andacceptedby,thepatient.
4 Seelegaladviceoneligibilitytoprescribeanduseofunlicensed medicinesontheGMCwebsite(www.gmc-uk.org).
5 Makesurethatyouarebeingobjective.Prescribingshouldbefor thebenefitofthepatientnottheprescriber.
6 Keepuptodateaboutmedicinesyouareprescribingandthe relatedconditionsyouaretreating.
7 FollowCSMguidanceonreportingsuspectedadversereactionsto medicines(seetoprightlinkatwww.mhra.gov.ukforlinksto detailsoftheYellowCardreportingschemeanddownloadsof reportedadversedrugreactionsforspecificmedicines).
8 Ensurecontinuityofcarebykeepingthepatient’sGP(orother preferredmedicaladviser)informedaboutprescribing,monitoringandfollow-uparrangementsandresponsibilities.
9 Checkthatappropriatepreviousmedicinesarecontinuedand over-the-counterandherbalmedicineuseisrecorded.
10 PatientGroupDirections:theGMCadvisestheseshouldbe limitedtosituationswherethereisa‘distinctadvantagefor patientcare ... consistentwithappropriateprofessional relationshipsandaccountability’.
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Common/usefuldrugs
ABCIXIMAB/REOPRO
Antiplateletagent monoclonalAbagainstplateletglycoproteinIIb/ IIIareceptor(involvedinPtaggregation).
Use: PxofischaemiccomplicationsofPCIandPxofMIinunstable anginaunresponsivetoconventionalRxawaitingPCINICE (seep.240).
CI: activeinternalbleeding,CVAw/in2years,intracranialneoplasm, aneurysmorAVM.Majorsurgery,intracranial/intraspinalsurgeryor traumaw/in2months.Hypertensiveretinopathy,vasculitis, ¡Pt, haemorrhagicdiathesis,severe BP. L (ifsevere)/R (ifrequiring haemodialysis)/B.
Caution: drugsthat bleedingrisk, L/R/P/E.
SE: bleeding* / ¡Pt*, N&V, ¡BP, ¡HR,pain(chest,backorpleuritic), headache,fever.Rarely,hypersensitivity,tamponade,ARDS.
Monitor: FBC*(baselineplus2 4h,12hand24haftergiving)and clotting(baselineatleast).
Dose: 250microgram/kgivover1min,then0.125microgram/kg/min (max10microgram/min)ivi;seeBNF/productliteraturefordose timing. NB:useivnon-pyrogenic,lowproteinbindingfilter.Needs concurrentheparin.Specialistuseonly:getsenioradviceorcontact on-callcardiology.
ACAMPROSATE/CAMPRALEC
ModifiesGABAtransmission [¡pleasurablefxofalcohol ¡s cravingandrelapserate.
Use: maintainingalcoholabstinence.
CI: L (onlyifsevere), R/P/B.
SE: GIupset,pruritus,rash, D libido.
Dose: 666mgtdspoifage18 65years(avoidoutsidethisagerange) and 60kg(if B60kggive666mgmanethen333mgnoonand nocte). StartASAPafteralcoholstopped.Usuallygivefor1year.
ACARBOSE
Oralhypoglycaemic: a-glucosidaseinhibitor.Delaysdigestionand ¡s absorptionofstarchandsucrose.
Use: DMnotcontrolledbyconventionaloralhypoglycaemics.
CI: IBD,hernia,Hxofabdominalsurgeryorobstruction R (ifsevere) L/P/B.
SE: flatulence,GIupset,rarelyhepatitisandileus.
Monitor: LFTs.
Interactions: may hypoglycaemicfxofsulphonylureasandinsulin.
Dose: initially50mgodpo, upto200mgtdspo.
ACIDEX
Alginateraft-formingoralsuspensionforacidreflux.
Dose: 10 20mlaftermealsandatbedtime(NB:3mmol Na /5ml)
ACETAZOLAMIDE/DIAMOX
Carbonicanhydraseinhibitor(sulphonamide).
Use: glaucoma(acute-angleclosure,primaryopen-angleunresponsive tomaximaltopicalRx,orsecondary), ICP.Rarelyforepilepsyor diuresis.
CI: ¡K , ¡Na , Cl acidosis,sulphonamideallergy,adrenocortical insufficiency. L (ifsevere)/R.
Caution: acidosis,pulmonaryobstruction R/P/E.
SE: nausea/GIupset,paraesthesia,drowsiness,mood D,headache, D LFTs.Ifprolongeduseacidosis(metabolic)ande’lyte Ds.Rarely blooddisordersandskinreactions(incSJS/TENS).
Monitor: FBC,U&Eifprolongeduse.
Interactions: slevelsofcarbamazepine.Can cardiactoxicity(via ¡K )ofdisopyramide,flecainide,lidocaineandcardiacglycosides. ¡s fxofmethenamineand fxofquinidine.
Dose: 0.25 1g/daypoorivSPC.Alsoavailableas250mgMR preparation(as DiamoxSR;max2capsules/day).
Extravasationatinjectionsitecan [ necrosis .
ACETYLCYSTEINE/PARVOLEX
Precursorofglutathione,whichdetoxifiesmetabolitesofparacetamol.
Use: paracetamolOD.
Caution: asthma*.
SE: allergy:rash,bronchospasm*,anaphylactoidreactions(espifivi tooquick**).
Dose: initially150mg/kgin200ml5%glucoseasiviover15min, then50mg/kgin500mlover4h,then100mg/kgin1litreover16h.
NB:usemaxweightof110kgfordosecalculation,evenifpatient weighsmore.Ensurenotgiventooquickly**.Seep.266forMxof paracetamolODandtreatmentlinegraph.
ACICLOVIR (previously ACYCLOVIR)
Antiviral.InhibitsDNApolymerase onlyininfectedcells:needs activationbyviralthymidinekinase(producedbyherpesspp).
Use: iv: severeHSVorVZVinfections,e.g.meningitis,encephalitis andinimmunocompromisedpatients(espHIV alsousedforPx); po/top: mucousmembrane,genital,eyeinfections.
Caution: dehydration*, R/P/B.
SE: at doses: AKI, encephalopathy (espifdehydrated*).Also hypersensitivity,seizures,GIupset,blooddisorders,skinreactions (includingphotosensitivity),headache,manynon-specificneurological symptoms, ¡Pt, ¡WBC.Rarely C reactionsandhepatotoxicity.
Interactions: levels dbyprobenecid.
Dose: 5mg/kgtdsiviover1h(10mg/kgifHSVencephalitisor VZVinimmunocompromisedpatients);po/topSPC/BNF.
ivileaks [ severelocalinflammation/ulceration .
ACTIVATEDCHARCOAL seeCharcoal.
ACTRAPID Short-actingsolubleinsulin;seep.202foruse.
ADENOSINE
Purinenucleoside.SlowsAVNconductiontime,dilatescoronary arteries;actsonitsownspecificreceptors.
Use: RxofparoxysmalSVT(espifaccessoryp’wayse.g.WPW)and DxofSVT(NCTorBCT; ¡sratetorevealunderlyingrhythm).
CI: asthma*(considerverapamilinstead). 2nd-/3rd-degreeAV blockorsicksinussyndrome(ifeitherw/opacemaker).
Caution: hearttransplant( ¡dose),AF/atrialflutter( saccessory pathwayconduction), QTc,COPD*.
SE: bronchospasm*, ¡BP.Rarely ¡HR/asystole/arrhythmias(mostly transient),angina(discontinueifoccurs)&flushing.
Warn: can [ transientunpleasantfeelings:facialflushing,dyspnoea, chokingfeeling,nausea,chestpainandlight-headedness.
Interactions: fx by dipyridamole: ¡initialadenosinedoseto
0.5 1mgandwatchfor bleeding(anti-Ptfxofdipyridamolealso d byadenosine).fx ¡dby theophyllines andcaffeine.Usewithdigoxin may riskofVF.
Dose: 3 6mgivover2sec;doubledoseandrepeatevery1 2min untilresponseorsignificantAVblock(max12mg/dose). NB:attach cardiacmonitorandgiveviacentral(orlargeperipheral)vein, thenflush.t1/2 B10sec:oftenneedsreadministration(espifgivenfor RxcfDx).
ADRENALINE(im/iv)
Sympathomimetic:powerfulstimulationof a (vasoconstriction), b1( HR, contractility)and b2 (vasodilation,bronchodilation,uterine relaxation).Also ¡simmediatemastcellcytokinerelease.
Use: CPRandanaphylaxis(seealgorithmsoninsideandoutsidefront cover,respectively).Rarelyforothercausesofbronchospasmorshock (e.g.28 tospinal/epiduralanaesthesia).
Caution: cerebrovascular*andheartdisease(esparrhythmiasand HTN),DM, T4,glaucoma(angleclosure),labour(esp2ndstage), phaeo. H/E.
SE: HR, BP,anxiety,sweats,tremor,headache,peripheral vasoconstriction,arrhythmias,pulmonaryoedema(at doses), N&V,weakness,dizziness, C disturbance,hyperglycaemia,urinary retention(espif prostate),localreactions.RarelyCVA*(28 to HTN:monitorBP).
Interactions: fx dbydopexamine,TCAs,ergotamineand oxytocin.Riskof:1. BPand ¡HRwithnon-cardioselective b-blockers(canalso [¡HR),TCAs,MAOIsandmoclobemide. 2.arrhythmiaswithdigoxin,quinidineandvolatileliquid
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the Dauphinois had marched off, sir John returned with his army to his castle of Beaurevoir, where he dismissed his captains, and the others who had followed him.
Shortly after, sir James de Harcourt made an inroad as far as Auxi on the river Authie, and to other towns and villages, whence he returned to Crotoy with many prisoners and much plunder.
CHAP. LXXV.
KING HENRY REDUCES MEAUX TO HIS OBEDIENCE. THE EXECUTIONS THAT TAKE PLACE IN CONSEQUENCE OF ORDERS FROM HIM.
THE king of England was indefatigable at the siege of Meaux, and having destroyed many parts of the walls of the market place, he summoned the garrison to surrender themselves to the king of France and himself, or he would storm the place. To this summons they replied, that it was not yet time to surrender,—on which the king ordered the place to be stormed. The assault continued for seven or eight hours in a most bloody manner: nevertheless, the besieged made an obstinate defence, in spite of the great numbers that were attacking them.
Their lances had been almost all broken; but in their stead they made use of spits, and fought with such courage, that the English were driven from the ditches, which encouraged them much. Among the besieged who behaved gallantly must be noticed Guichart de Sisay; and his courage and ability were remarked by king Henry, who, after the reduction of the place, offered him a large sum if he would take the oaths and serve him; but he would never listen to the proposal, and remained firm to the dauphin.
Many new knights were made by the English at this attack, such as John Guigny, a Savoyard, and the bastard de Thiam, who had formerly been a great captain in the free companies under duke John of Burgundy. There were also at this siege, under the king of England, the lords de Châtillon and de Genlis, with many others of the french nobility.
From the commencement of this siege until the last moment, when they had no longer any hopes of relief from the dauphin, the
besieged poured torrents of abuse upon the English. Among other insults which they offered, they had an ass led on the walls of the town, and, by beating it, made it bray, and then cried out to the English, that it was their king calling out for assistance, and told them to go to him. This conduct raised the king's indignation against them.
During the siege, a young knight, son to sir John Cornwall, and cousin german to king Henry, was killed by a cannon shot, to the great sorrow of the king and the other princes; for, although he was but a youth, he was very well behaved and prudent.
Toward the end of April, the besieged, having lost all hopes of succour, and finding they could not hold out longer, offered to enter into terms of capitulation. King Henry appointed his uncle the duke of Exeter, the earl of Warwick, the count de Conversan and sir Walter Hungerford, his commissioners for this purpose. On the part of the besieged were nominated sir Phillip Mallet, Pierron de Luppel, John d'Aunay, Sinader de Gerames, le borgne de Caucun, John d'Espinach and Guillaume de Fossé. They had several conferences, and at length agreed to the following terms:
First, on the 11th day of May, the market-place, and all Meaux, was to be surrendered into the hands of the kings of France and England.
Item, sir Louis de Gast, the bastard de Vaurus, Jean de Rouvieres, Tromagon, Bernard de Meureville, and a person called Oraches, who had sounded the trumpet during the siege, were to be delivered up to justice,—and such punishment was to be inflicted on them as they might deserve.
Item, Guichart de Sisay, Pierron de Luppel, master Robert de Gerames, Philip de Gamaches and John d'Aunay, were to remain in the power of the two kings until all the forts held by them, or their allies, in the realm should be given up; and when that was done, they were to have their liberty.
Item, all the English, Welsh, Scots and Irish, subjects to the king of England who had assisted in the defence of the place, were to be delivered up to the two kings.
Item, all other persons, as well men at arms as burghers, were to have their lives spared, but to remain prisoners to the two kings.
Item, the count de Conversan was to be acquitted of all his engagements to Pierron de Luppel respecting his ransom; and the latter was to promise that he would hold him acquitted of the above, without fraud or malice.
Item, the besieged, within eight days preceding the surrender of the town, were to carry all their effects to an appointed place, without any way injuring them, and to deliver inventories thereof to commissaries named by the said kings. They were to carry all relics, ornaments, or church-furniture, to a separate place.
Item, they were to deliver up all prisoners, whether confined in the market-place or in other forts, and acquit them of their pledges.
Item, they were not to suffer any person to quit the place before the surrender of the town, and, in like manner, were not to permit any one to enter it, unless so ordered by the kings.
Item, for the due observance of these articles, the besieged were to give assurances signed with the hand and seal of one hundred of the principal townsmen, four-and-twenty of whom were to remain as hostages so long as the two kings might please.
Item, on the signing this treaty, all hostilities were to cease on each side.
Matters now remained in this state until the 10th day of May, when the substance of the above articles was put into execution by commissaries appointed by the two kings, who sent off the prisoners under a strong guard. Some of the principal were carried to Rouen, and thence to England, and others to Paris, where they were confined. The whole of the prisoners of war might be about eight hundred; and their commander in chief, the bastard de Vaurus, was,
by king Henry's command, beheaded, and his body hung on a tree, without the walls of Meaux, called thenceforth Vaurus's Tree. This Vaurus had, in his time, hung many a Burgundian and Englishman: his head was fixed to a lance, and fastened on the tree over his body.
Sir Louis Gast, Denis de Vaurus, master John de Rouvieres, and he who had sounded the trumpet, were beheaded at Paris,—their heads fixed on lances over the market-place, and their bodies hung by the arms to a gibbet. All the wealth found in Meaux, and which was very great, was distributed according to the pleasure of king Henry. He was very proud of his victory, and entered the place in great pomp, and remained there some days with his princes to repose and solace himself, having given orders for the complete reparation of the walls that had been so much damaged by artillery at the siege.
