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Revision hints and tips for Part 1 of the GPhC Mock Assessment

Suppository sizes - adults 4g child 2g and infant 1g

Suppositories with glycogelatin base need to be multiplied by a factor of 1.2 as it is more dense

than theobroma oil (standard oil based base) https://pharmafactz.com/pharmaceutical-

calculations-density-and-displacement-values/

20 drops per ml for oral, nose, eye drops

Nasal sprays – dosage is each nostril unless specified otherwise

Rounding of numbers should be done at the end (unless it’s a two part calculation which

requires fixed quantities e.g. tablets / bottles of solution)

You must know the dosages for paracetamol and ibuprofen for children

Molecular weight of a drug compound = 1 MOL (1000mmol)

Sense check your answer at the end of your calculations…. Think about your answer and if this is

usable in a practice setting….are you able to administer 6/8th of a tablet???

Useful resources:

http://www.resourcepharm.com/pre-reg-pharmacist/prereg-pharmacy-calculations.html

Main topics to guide revision for Part 2 of the GPhC Mock Assessment

Common Drug/food interactions

BNF: Appendix 1

Amiodarone

Grapefruit juice should be avoided

Theophylline and smoking

BNF: theophylline monograph: CAUTIONS: dose adjustments may be necessary if smoking started

or stopped during treatment or treatment suboptimal despite recommended dosing.

Warfarin – Coumarins

Broccoli and other green leafy vegetables contain a large amount of vitamin K. Significant

changes in consumption will affect the INR

Major changes in consumption of alcohol

Cranberry juice possibly enhances anticoagulant effect

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Common Drug/drug interactions

Amlodipine – can cause myopathy if taken with Simvastatin (at doses higher than 20 mg)

Diclofenac – reduces the elimination of methotrexate but is not contra-indicated

Digoxin – Furosemide can increase risk of cardiac toxicity if hypokalaemia occurs

Domperidone – interacts with erythromycin

Levothyroxine – Calcium salts reduce absorption of levothyroxine

Methotrexate: NSAIDs

Phenytoin – reduces the effectiveness of EHC with levonorgestrel, and possibly ulipristal acetate

Ramipril – Spironolactone; due to increased potassium levels (avoid concurrent use or use lowest

possible doses of both medicines)

Tetracycline’s – Antacids containing aluminium, bismuth calcium or magnesium markedly reduce

or even abolish the therapeutic effects of tetracycline’s. Sodium Bicarbonate may reduce the

bioavailability of some tetracycline’s

Warfarin – For complete list see BNF Appendix 1 Coumarins

St John’s Wort - a hepatic enzyme inducer (reduced anticoagulant effect, lower INR)

Glucosamine – raises INR

Aspirin and NSAIDs should be avoided (due to antiplatelet effect) – No effect on INR

Prolonged regular use of paracetamol of 2g or more daily (can raise INR)

Amiodarone – an enzyme inhibitor (enhanced anticoagulant effect, raised INR)

Fluconazole or Miconazole - enhance the anticoagulant effects and can lead to haemorrhage

Public Health

Definition

Public health relates to the promotion and protection of health and wellbeing in the community

setting. Community pharmacies are asked to collect this type of data for many reasons including

understanding the needs of the local community and to demonstrate how pharmacy services are

helping to improve outcomes for patients. This information is not collected for the purpose of

assessing prescribers

Reference: RPS. Professional Standards for Public Health Practice for Pharmacy. March 2014.

Standard 1.0.

Health promotion including alcohol and dietary advice, smoking cessation, exercise

Pharmacy technician GPhC registration requirements

The qualifying period is “A minimum of two years relevant work‐based experience in the UK

under the supervision, direction or guidance of a pharmacist to whom the applicant was directly

accountable for not less than 14 hours per week”

http://www.pharmacyregulation.org

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Secondary prevention of Cardiovascular disease

If there is no evidence of familial hyperlipidaemia: treat with a high intensity statin: initially

atorvastatin 80mg daily unless contraindicated. Rosuvastatin 10mg also suitable but this is more

expensive as this is only available as a branded product.

Baseline lipid levels are used to rule out familial hyperlipidaemia.

Levels of total cholesterol above 7.5mmol should be referred for specialist management

Reference: http://cks.nice.org.uk/lipid-modification-cvd-prevention#!scenario:1

Medicines use in the elderly

Read this section in the BNF

Long-acting antidiabetic drugs such as glibenclamide should be avoided altogether.

Counselling points

Amiodarone

Travel is allowed just requires a high factor sun protection

Patients do not need to remain in an upright position when taking

Dosing will reduce over time to a maintenance dose

Ivabradine

Visual disturbances- transient luminous phenomena which may affect ability to drive at night

or using machinery

Finasteride

For women of child-bearing age: Avoid handling crushed or broken tablets

Sodium Valproate

The tablets should be swallowed whole and not crushed, halved, dissolved or chewed

Although there is no specific evidence of sudden recurrence of underlying symptoms

following withdrawal of valproate, discontinuation should normally only be done under the

supervision of a specialist in a gradual manner. This is due to the possibility of sudden

alterations in plasma concentrations giving rise to a recurrence of symptoms

MHRA warning pregnancy prevention

Suitability of use in a monitored dosage system?

Methotrexate

Good practice to only supply one strength of methotrexate and label with number of tablets

as well as strength, not good practice to dispense tablets to half when there is a suitable

alternative – methotrexate MHRA warning

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First Aid

Acute asthma attack: If someone has an asthma attack: First, reassure them and ask them to

breathe slowly and deeply which will help them control their breathing. Then help them use their

reliever inhaler straight away. This should relieve the attack. Next, sit them down in a

comfortable position. If it doesn’t get better within a few minutes, it may be a severe attack. Get

them to take one or two puffs of their inhaler every two minutes, until they’ve had 10 puffs. If

the attack is severe and they are getting worse or becoming exhausted, or if this is their first

attack, then call 999 for an ambulance. Help them to keep using their inhaler if they need to.

Keep checking their breathing, pulse and level of response.

Source: St John’s Ambulance

http://www.sja.org.uk/sja/first-aid-advice/illnesses-and-conditions/asthma-attack.aspx

Reference: WebMD. First aid & emergencies.

Injury

As soon as possible after an injury such as a sprain, pain and swelling can be relieved and healing

and flexibility promoted using PRICE: Protection, Rest, Ice, Comfortable support, Elevation.

Ibuprofen is preferable to paracetamol and it is anti-inflammatory as well as an analgesic but

should not be used in first 48 hours due to interference with healing process.

Epilepsy:

Recommended: Protect the person from injury (remove harmful objects from nearby), cushion

their head, look for an epilepsy identity card or identity jewellery, aid breathing by gently placing

them in the recovery position once the seizure has finished, stay with the person until recovery is

complete and be calmly reassuring.

Not recommended: Restraining the person’s movements, putting anything in the person’s

mouth, trying to move them unless they are in danger, giving them anything to eat or drink until

they are fully recovered and attempting to bring them round.

Call an ambulance if: You know it is the person’s first seizure, or the seizure continues for more

than five minutes, or one tonic-clonic seizure follows another without the person regaining

consciousness between seizures, or the person is injured during the seizure, or you believe the

person needs urgent medical attention.

Source: Epilepsy Action https://www.epilepsy.org.uk/info/firstaid

Choking

If you can see the object, try to remove it. Don’t poke blindly or repeatedly with your fingers. You

could make things worse by pushing the object further in and making it harder to remove. If the

child is coughing loudly, there’s no need to do anything. Encourage them to carry on coughing

and don’t leave them. If the child is still conscious, but they’re either not coughing or their

coughing is not effective, use back blows. If back blows don't relieve the choking and the baby or

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child is still conscious, give chest thrusts to infants under one year or abdominal thrusts to

children over one year.

Source: NHS Choices

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/helping-choking-baby.aspx

Burns and scalds

Reference: NICE Clinical Knowledge Summaries. Burns and scalds. July 2015.

http://cks.nice.org.uk/burns-and-scalds

Superficial dermal burns can be managed with appropriate first aid. The area should be cooled

(but not frozen), cleaned and dressed and appropriate simple analgesia (paracetamol or

ibuprofen) recommended whilst the area heals. Blisters should be left alone or the risk of

infection increases. Creams or ointments should not be used on the skin.

Serious reactions to bee stings

In adults, 500mcg of adrenaline should be administered into the anterolateral aspect of the

middle third of the thigh (even if through clothing). Doses may be repeated several times if

necessary at 5 minute intervals according to blood pressure, pulse, and respiratory function

Reference: BNF

P medicines with limitations on their sale:

Chloramphenicol eye drops

Codeine containing preparations

Pseudoephedrine and ephedrine

Revise - Indications, Referral criteria, warnings, dosage, storage

Other P medicines to revise include:

Clotrimazole pessaries; Amorolfine, Orlistat, Anti-malarials, dovonex, Azithromycin;

Sumatriptan; PPI; Orlistat; Tamsulosin ; Tranexamic acid; sildenafil and Oral EHC

See www.RPharms.com/support-resources/reclassification.asp – Reclassification guidance

Adverse effects to memorise

ACE inhibitors: angioedema associated with ankle swelling, dyspnoea and muscle cramps;

hyperkalaemia (through reduced aldosterone production that reduces potassium excretion by

the kidneys)

Amlodipine: can cause dyspepsia by lowering the tone of the lower oesophageal sphincter

(Chocolate and smoking can worsen symptoms) ; can also cause ankle oedema

Calcium channel blockers can cause gingival enlargement and overgrowth.

Lithium: thyroid disorders and mild cognitive and memory impairment

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Carbimazole: Blood disorders (require immediate referral to GP) - sore throat is the first sign of

an infection that could be the result of carbimazole-induced bone marrow suppression and

agranulocytosis. A full blood count is essential

Loop diuretics: Cause hyponatraemia and hypokalaemia due to increased renal excretion of

sodium and potassium

Mefloquine: can cause potentially serious neuropsychiatric disorders

Mesalazine: Blood disorders (require referral to GP)

Methotrexate: Sore throat, fever, chills, mouth ulcers, diarrhoea and rash are symptoms

indicating methotrexate toxicity

Nicorandil: can cause gastrointestinal ulcerations, skin and mucosal ulceration which are

refractory to treatment and necessitate withdrawal of nicorandil

Omeprazole: causes hyponatraemia (see side effects of PPIs)

Pantoprazole: causes hypomagnesaemia

Pioglitazone: heart failure associated with weight gain, ankle swelling, dizziness and blurred

vision. Incidence is increased if pioglitazone is combined with insulin.

Pramipexole: has been associated with somnolence and episodes of sudden sleep onset

Quinolones: tendon damage has been reported (rarely) in patients receiving quinolones.

Healthcare professionals are reminded that:

Quinolones are contra-indicated in patients with a history of tendon disorders related to

quinolone use;

Patients over 60 years of age are more prone to tendon damage;

The risk of tendon damage is increased by the concomitant use of corticosteroids;

If tendonitis is suspected, the quinolone should be discontinued immediately.

Rifampicin: can change urine colour to orange-red (counselling point for patients)

Sodium valproate: Blood disorders (require referral to GP)

Thiazide diuretics: can cause an attack of gout

Vitamin D analogues e.g. colecalciferol can cause hypercalcaemia

Diagnostic signs and symptoms

A rash that does not fade under pressure is a sign of meningococcal septicaemia

https://www.meningitisnow.org/meningitis-explained/signs-and-symptoms/glass-test/

Psoriasis is a skin condition that causes red, flaky, crusty patches of skin covered with silvery

scales. These patches normally appear on your elbows, knees, scalp and lower back, but can

appear anywhere on your body. Most people are only affected with small patches. In some cases,

the patches can be itchy or sore.

.http://www.nhs.uk/Conditions/Psoriasis/Pages/Introduction.aspx

Signs of digoxin toxicity: Dizziness, nausea and irregular pulse

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Difference between sensitivity (allergic response not initiated but immune response can be

involved e.g. coeliacs) intolerance (usually food related – lacking enzymes for metabolism e.g.

lactose intolerance)) and allergy (allergic response from mast cells activated e.g. peanut allergy)

Malaria

Read the BNF section on malaria prophylaxis

Occurrence after returning to UK

The BNF states: “It is important to be aware that any illness that occurs within 1 year and

especially within 3 months of return from a country where malaria exists, might be “malaria”

even if all recommended precautions against “malaria” were taken. Travelers should be warned

of this and told that if they develop any illness particularly within 3 months of their return they

should go immediately to a doctor and specifically mention their exposure to “malaria”.

Medicines and Healthcare products Regulatory Agency (MHRA) collate information regarding

defective medicines and issue drug alerts

https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-

agency

Therapeutic Drug Monitoring

TDM requirements for Gentamicin and other narrow therapeutic drugs

The BNF recommends that all patients receiving pharmacological doses of vitamin D

should have their plasma-calcium concentration checked at regular intervals.

Treatment of overdoses

Read the emergency treatment of poisoning section in the BNF

Paracetamol overdose - Acetylcysteine Opiate overdose - Naloxone

Alcohol consumption – Units and recommendations

The maximum weekly recommended limit for both men and women is 14 units = 6 standard

(175ml) glasses of wine.

8 pints of beer = 20 units i.e. exceeds the limit

The recommendations also advise to have several alcohol free nights per week and not to binge

drink. https://www.gov.uk/government/news

http://www.nhs.uk/change4life https://www.drinkaware.co.uk

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Veterinary medicines

MEP states where appropriate, a statement highlighting that the medicine is prescribed under

the veterinary cascade (e.g. ‘prescribed under the cascade’ or other wording to the same effect).

The veterinary medicines regulations state that regarding the receipt or supply of veterinary

medicines “the documentation and records must be kept for at least five years.”

http://www.rpharms.com/support-resources-a-z/veterinary-medicines-quick-reference-

guide.asp

Vitamins and Minerals

High alcohol consumption can lead to low thiamine levels which can cause Wernicke’s

encephalopathy

Low calcium can lead to osteoporosis which can cause low impact fracture

Phenytoin can lead to low folate levels which can be a cause of spina bifida

Reference: BNF

Vitamin intake during pregnancy

Vitamin A should be avoided due to the risk of teratogenicity

Vitamin D should be taken throughout pregnancy

Folic acid 400mcg should be taken until 12 weeks

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/vitamins-minerals-supplements-

pregnant.aspx

Emergency Hormonal Contraception

Revise all aspects – P products and POM products on PGD

Responding to symptoms

Vaginal thrush

Product licence restrictions for topical imidazole’s such as clotrimazole and fluconazole:

If the patient has had more than two episodes in 6 months and has not consulted a GP about the

condition for more than a year

Athlete’s Foot

Treatment with clotrimazole 2%

Nail fungal infections

Treatment with Curanail is for mild cases of fungal infection and is limited up to 2 nails. Due to

the lack of clinical experience available, Loceryl Curanail 5% nail lacquer is not recommended for

patients below the age of 18 years.

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Community Pharmacy Services

GPhC - Guidance on the provision of pharmacy services affected by religious and moral beliefs

Clinical governance requirements for community pharmacy. (1.3 Patient satisfaction Survey)

All pharmacies should undertake a patient satisfaction survey annually as it is part of the patient

and public involvement programme which also includes displaying practice leaflets and

publicising NHS services. The satisfaction surveys are a valuable opportunity to assess how well a

pharmacy is performing from a patient’s perspective and to improve its services. The minimum

number of returns for over 8001 items is 150. All pharmacies should complete their own survey

and a mix of patients should be surveyed. It is unacceptable to survey all patients who have

received an MUR as it should reflect the business as a whole.

Action should be taken to address issues raised by respondents where this is practical and

proportionate to the issue raised. There may not be a solution to an issue raised that is within

the control of the contractor.

Results should be published in one of three ways: in the pharmacy as a leaflet or poster, on the

pharmacy’s website or on the pharmacy’s NHS Choices profile (where available).

Reference: PSNC website

GPhC Standards for pharmacy premises

There are 5 principles which underpin the standards a registered pharmacy premises must meet:

Principle 1 – governance arrangements

Principle 2 – empowered and competent staff

Principle 3 – managing pharmacy premises

Principle 4 – delivering pharmacy services

Principle 5 – equipment and facilities

Reference https://www.pharmacyregulation.org/pharmacystandardsguide/introductionGPhC

Pharmacy Law and Ethics

Medicines returned by patients

Patient returned medication does not need to be entered into the Controlled Drugs register, but

patient-returned Schedule 2 Controlled Drugs should be recorded in a separate register for this

purpose.

Patient returned medication does not need to be destroyed in the presence of an authorised

witness, but ideally should be witnessed by another member of staff.

Finally, as the pharmacy is busy, it wouldn’t be convenient to start denaturing the tablets

immediately, so they can be segregated and destroyed at a convenient time. MEP

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Typographical errors in prescriptions for Schedule 2 or Schedule 3 drugs

Where a prescription for a Schedule 2 or 3 Controlled Drug contains a minor typographical error

or spelling mistake, or where either the words or figures (but not both) of the total quantity has

been omitted, a pharmacist can amend the prescription indelibly so that it becomes compliant

with legislation.

MEP 39, page 103:

Emergency Supply legislation

Emergency supplies of Schedule 2 and 3 drugs are not permitted.

Tramadol is a Schedule 3 drug and may not be supplied. Zopiclone is in Schedule 4 part 1.

MEP 39 July 2015.

Emergency supply at the request of a Doctor

One of the conditions that apply is that they inform you of the nature of the emergency. You

need to be satisfied that the prescriber is unable to provide a prescription immediately due to an

emergency (i.e. Patient cannot collect prescription from the prescriber, the prescriber is unable

to drop off the prescription at the pharmacy and the patient urgently needs the medicine(s).

Following an emergency supply at the request of a Doctor the prescriber should provide you with

a prescription within 72 hours.

Dispensing process:

How to minimise the risk of making a dispensing error:

• Produce dispensing labels before any product is selected from the shelf.

• Do not select stock using dispensing labels or patient medication records (PMR). Refer to the

prescription when selecting stock for dispensing.

MEP 39 Appendix 2

Data Protection principles

Patient data held in a pharmacy, including address/contact details of patients should be

“Accurate and up to date”. Reference: http://www.legislation.gov.uk/ukpga/1998/29/schedule/1

Consent for any consultation service in community pharmacy Reference: GPhC Guidance on

Consent

Drugs, Medicines and Other Substances that may be ordered only in certain circumstances

Clobazam: Not prescribable under the NHS except for epilepsy and endorsed ‘SLS’

Controlled Drug registers

Registers should be kept for two years from the date of the last entry - MEP

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Expiry dates

“Use by” means it expires by that date.

Reference: MEP Edition 39 July 2015 Section 3.5 p69 also see UKMI Q and A on expiry dates

http://www.medicinesresources.nhs.uk/upload/documents/Evidence/Medicines%20Q%20&%20

A/QA213_2Expirydates.doc

Private prescriptions for a POM

The prescriptions must be retained for two years from the date of the sale or supply or for

repeatable prescriptions from the date of the last sale or supply. Records must be made in the

POM register (written or electronically), which should be retained for two years from the date of

the last entry in the register. The record must include:

Supply Date – the date on which the medicine was sold or supplied

Prescription Date – the date on the prescription

Medicine Details – the name, quantity, formulation and strength of medicine supplied

(where not apparent from the name)

Prescriber Details – the name and address of the practitioner

Patient Details – the name and address of the patient

MEP

Borderline Substances

Prescribers should endorse prescriptions with the endorsement ‘ACBS’ if they are issuing the

prescription in accordance with the Committee’s advice.

If the ACBS endorsement is missing for a product on the borderline substances list, pharmacy

contractors can still dispense the prescription and it will be passed for payment by NHS

Prescription Services – the ‘ACBS’ endorsement is not a compulsory requirement. However the

prescriber may be asked by their CCG/LHB to justify why the product has been dispensed at NHS

expense. Pharmacy staff should not add the ACBS endorsement.

Reference: Pharmaceutical Services Negotiating Committee PSNC – The Borderline Substances

List

Preparation and storage of medicines

Beta lactam antibiotics are subject to hydrolysis which is why they are formulated as dry

powders and reconstituted prior to dispensing

For information on drug stability and degradation read:

http://www.pharmaceutical-journal.com/opinion/comment/understanding-the-chemical-basis-

of-drug-stability-and-degradation/11029512.article

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Fridge temperature should be between 2-8°C Reference:

https://www.pharmacyregulation.org/pharmacystandardsguide/principle-4-delivery-pharmacy-

services

Insulin should be stored below 25 degrees C when in use.

https://www.diabetes.org.uk/Guide-to-diabetes/Teens/Me-and-my-diabetes/Getting-my-

glucose-right/Insulin/Storage/

Preparation of unlicensed medicines

GPhC Guidance for registered pharmacies preparing unlicensed medicines. May 2014.

As a rule, the law requires that only licensed medicines should be supplied to patients. However,

there are exemptions that allow a pharmacist to prepare and supply medicines in a registered

pharmacy without the need for the product to be licensed. Pharmacists and pharmacy

technicians involved in preparing unlicensed medicines have a responsibility to provide medicines

safely to patients therefore there are specific standards to be met for their preparation. Detailed

records should be kept which cover the process, formula and ingredients however it is not

necessary to include the registration number of the supervising pharmacist and/or the

pharmacist that provides the final check, their name is sufficient.

Immunisations

Flu vaccine

Immunisation is recommended for persons at high risk, and to reduce transmission of infection.

Annual immunisation is strongly recommended for individuals aged over 6 months with the

following conditions:

chronic respiratory disease (includes asthma treated with continuous or repeated use of

inhaled or systemic corticosteroids or asthma with previous exacerbations requiring hospital

admission)

chronic heart disease

chronic liver disease

chronic renal disease

chronic neurological disease

complement disorders

diabetes mellitus

immunosuppression because of disease (including asplenia or splenic dysfunction) or

treatment (including prolonged systemic corticosteroid treatment [for over 1 month at dose

equivalents of prednisolone: adult and child over 20 kg, 20 mg or more daily; child under 20

kg, 1 mg/kg or more daily] and chemotherapy);

HIV infection (regardless of immune status).

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Seasonal influenza vaccine is also recommended for all pregnant women, for all persons aged over

65 years, for residents of nursing or residential homes for the elderly and other long-stay facilities,

and for carers of persons whose welfare may be at risk if the carer falls ill. Influenza immunisation

should also be considered for household contacts of immunocompromised individuals.

Reference: BNF

Vaccine safety and management of adverse events after immunisation

Commons symptoms include skin itchiness, cough/wheeze, tachycardia with a weak or absent

pulse, loss of consciousness. A strong pulse would not be usual and would more likely be a

symptom of fainting.

Reference:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/147868/Green

-Book-Chapter-8-v4_0.pdf

Childhood vaccinations

BCG: only given to ‘at risk’ groups and is not routine. Leaves a fluid-filled spot at the injection site

which then crusts over leaving a scar behind

Flu vaccine for children: given as a single dose of nasal spray squirted up each nostril.

Routine vaccinations for babies

The first MMR vaccination is given within a month of the first birthday, with a booster at 3yrs

4mths (up to school age). Symptoms of rubella are generally mild but it is a serious concern is if a

pregnant woman catches the infection during the first 20 weeks of her pregnancy. This may lead

to congenital rubella syndrome (CRS).

Reference: NHS choices, accessed at: www.nhs.uk/Conditions/vaccinations/Pages/vaccination-

schedule-age-checklist.aspx

The use of medication prior to a vaccination is not advised unless necessary – cool clothing

and/or a cool flannel will usually suffice. Paracetamol or ibuprofen suspension may be supplied

for new-borns OTC but only for post-vaccination pyrexia)

Reference: NHS Choices

http://www.nhs.uk/Conditions/vaccinations/Pages/vaccination-schedule-age-checklist.aspx

Inhalers

Conversion of inhaled corticosteroid doses – see BNF section

Fluticasone is twice as potent as beclometasone dipropionate

Accuhalers are dry powder inhalers. They cannot be used with spacer devices. Inhalation from

such a device should be ‘forceful’

Ventolin Accuhaler is licensed from the age of 4 years

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Spacers

Don't scrub the inside of the spacer as this affects the way it works. Leave it to air-dry as this

helps to prevent the medicine sticking to the sides of the chamber and reduces the static. Wipe

the mouthpiece clean of detergent before you use it again. Don't worry if your spacer looks

cloudy - that doesn't mean it's dirty. Your spacer should be replaced at least every year,

especially if you use it daily, but some may need to be replaced sooner.

https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-

spacers/spacers/

Raising concerns

For any issues/concerns relating to inappropriate prescribing patterns, contact the local NHS

primary care Service

Reference: http://www.bma.org.uk/working-for-change/patient-information/raising-concerns

If you have concerns about a colleague not signing in as the responsible pharmacist regularly you

must speak to them in the first instance and explain that signing in is a legal requirement for the

running of a pharmacy and they have to start doing it

If a colleague keeps making dispensing or checking errors and have been made aware of it

already, this has to be reported to the line manager first who can subsequently report it to the

superintendent or the GPhC

Responding to complaints and concerns – GPhC booklet

http://www.pharmacyregulation.org/sites/default/files/Responding%20to%20complaints%20an

d%20concerns%20g.pdf

Audit cycle - Useful references:

http://patient.info/doctor/audit-and-audit-cycle

http://www.hqip.org.uk/public/cms/253/625/19/44/Clinical%20audit%20for%20Boards%20guid

e-2015-1-1.pdf?realName=qMsXN1.pdf

Paracetamol dosing

Neonates

Paracetamol suspension: 120mg/5mL

• Do not give to babies less than 2 months of age

• Do not give more than two doses

• Leave at least 4 hours between doses

• If further doses are needed, talk to your doctor or pharmacist

For post-vaccination fever: 2.5mL once but if necessary a second 2.5mL dose can be given after

4-6 hours

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For all other causes of pain and fever: same dosing but give only to babies weighing over 4Kg and

born after 37 weeks

Children

7.5ml of Paracetamol suspension 250mg/5ml up to four times a day

Reference: MHRA UK public assessment report – Liquid paracetamol for children: revised UK

dosing instructions

Prescribing of NSAIDs in ischaemic heart disease

Naproxen 500 mg twice daily is the safest NSAID to prescribe. Other NSAIDs e.g. Diclofenac,

etoricoxib, ibuprofen and indomethacin are contra-indicated.

Reference: Drug Safety Update 24/6/2013: Diclofenac: new contraindications and warnings.

Prescribing of morphine in palliative care

Read BNF section on Prescribing in palliative care

Prescribing in Diabetes

Metformin is first line oral antidiabetic drug in overweight patients.

Prescribing of strontium ranelate

Contra-indicated in patients with temporary or permanent immobilisation – see BNF

Antidepressants

Fluoxetine is the only antidepressant where the balance of risks and benefits is considered

favourable. It is the only antidepressant that has been shown in clinical trials to be effective in

depressive illness in children and adolescents

MAOIs inhibit monoamine oxidase, thereby causing an accumulation of amine

neurotransmitters. The metabolism of some amine drugs such as indirect-acting

sympathomimetics (present in many cough and decongestant preparations,) is also inhibited and

their pressor action may be potentiated; the pressor effect of tyramine (in some foods, such as

mature cheese, pickled herring, broad bean pods, and Bovril®, Oxo®, Marmite® or any similar

meat or yeast extract or fermented soya bean extract) may also be dangerously potentiated.

These interactions may cause a dangerous rise in blood pressure

Citalopram

MHRA Dose recommendations for citalopram due to risk of a dose-dependent QT prolongation

(2011):

Maximum dose 40mg/day in adults – Mr X’s dose exceeds the maximum and requires

gradual reduction

Contraindicated with known QT prolongation, congenital long QT

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syndrome or taking other QT-prolonging medicines – Mr O’s symptoms suggest possibility

of QT prolongation

Caution with higher risk of developing Torsades de Pointes

Abrupt withdrawal of antidepressants is not recommended

Increased plasma levels with omeprazole but not lansoprazole

Prescribing of antidepressants in teenagers - BNF for Children:

Antidepressant drugs should not be used routinely in mild depression, and psychological therapy

should be considered initially; however, a trial of antidepressant therapy may be considered in

cases refractory to psychological treatments or in those associated with psychosocial or medical

problems. Drug treatment of mild depression may also be considered in children with a history of

moderate or severe depression.

Choice of antidepressant drug should be based on the individual child’s requirements, including

the presence of concomitant disease, existing therapy, suicide risk, and previous response to

antidepressant therapy.

When drug treatment of depression is considered necessary in children, the SSRIs should be

considered first-line treatment; following a safety and efficacy review, fluoxetine is licensed to

treat depression in children.

Tricyclic antidepressant drugs should be avoided for the treatment of depression in children.

St John’s Wort (Hypericum perforatum) is a popular herbal remedy on sale to the public for

treating mild depression in adults. It should not be used for the treatment of depression in

children because St John’s Wort can induce drug metabolising enzymes and a number of

important interactions with conventional drugs, including conventional antidepressants, have

been identified. Furthermore, the amount of active ingredient varies between different

preparations of St John’s Wort and switching from one to another can change the degree of

enzyme induction. If a child stops taking St John’s Wort, the concentration of interacting drugs

may increase, leading to toxicity.

Prescribing of antibiotics

Treatment of UTIs:

If the patient has had an anaphylactic reaction to a penicillin, all penicillin’s and cephalosporin’s

and meropenem should be avoided.

If a patient has had an allergic reaction to clotrimazole they should not be prescribed

trimethoprim. Nitrofurantoin can be used instead

Treatment of mild Clostridium difficile: Metronidazole should be used

For cellulitis in adults: Flucloxacillin (high dose) is first line

For impetigo in children: Flucloxacillin (Empirical treatment is aimed at Staph aureus).

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Although impetigo usually gets better with no treatment within 2 – 3 weeks, treatment is

recommended to reduce the length to 7 – 10 days by treatment with an antibiotic cream or oral

antibiotics.

For bilateral otitis media in children under 2 years old: Amoxicillin is first line

Self-management of acute bacterial conjunctivitis

Use lubricant eye drops to reduce discomfort in the eye.

It can take 48 hours before a significant improvement is seen with treatment and the

drops should be used for the full 5-day course.

Tepid water should be used to bath the eye not cold.

When both chloramphenicol eye drops and ointment are being used, the drops should be used

during the day and the ointment just once at night

Prescribing of antiemetic’s

For patients with Parkinson’s disease: Domperidone is first line – most other common

antiemetic’s cause extrapyramidal side effects and can worsen Parkinson’s disease

For cancer patients receiving radiotherapy: Dexamethasone is first line when patient has no

appetite

For animal bites: Co-amoxiclav is first line (if patient is not allergic to penicillin’s)

For migraine: Domperidone or metoclopramide are first line

Prescribing for respiratory conditions

For children diagnosed with asthma using their reliever inhaler more than twice a day:

Adding an inhaled corticosteroid would be the next step at a very low to low dose e.g.

beclomethasone 100mcg bd

For children under 5 years old on inhaled corticosteroids who need to use the salbutamol

inhaler at least four times a week:

The BTS/SIGN recommendation is to add a leukotriene receptor antagonist e.g. montelukast 5mg

at night

For adults newly diagnosed with COPD, presenting with breathlessness and inability to

exercise: Ipratropium or salbutamol are the drugs of first choice

For patients on salbutamol prn, long-acting beta2 agonist and medium dose inhaled

corticosteroids who still need to use their reliever at least 5 days a week:

The BTS/SIGN recommendation is to try one of the following:

● Leukotriene receptor antagonist e.g. montelukast 10mg daily

● Modified release oral theophylline

● Long acting muscarinic antagonist e.g. tiotropium

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Prescribing in Hypertension

Read the NICE guidance on treatment of hypertension: www.nice.org.uk/cg127

First line treatments:

For patients under the age of 55: An ACE inhibitor or low-cost ARB

For patients over the age of 55 or black and of African or Caribbean family origin: a calcium

channel blocker is indicated first-line.

Prescribing in hypothyroidism

Patients over 50 should be started on 25mcg levothyroxine daily for 2 -3 months. Dose should

be taken before breakfast. Calcium can affect absorption.

Patients under 50 can be started at higher doses of 50 – 100 mcg daily.

Liothyronine is used for severe hypothyroidism when a rapid response is needed.

Thyotropin is not indicated in hypothyroidism

Reference: Primary hypothyroidism CKS.

http://cks.nice.org.uk/hypothyroidism#!prescribinginfosub:3

Prescribing in hyperthyroidism

Carbimazole and propylthiouracil are used for overactive thyroid conditions.

Prescribing in Epilepsy

Children with absence seizures – BNF for Children

Ethosuximide and sodium valproate are the drugs of choice for absence seizures and syndromes

in male children; lamotrigine can be used if these are unsuitable, ineffective or not tolerated.

Sodium valproate should be used as the first choice if there is a high risk of generalised tonic-

clonic seizures. A combination of any two of these drugs may be used if monotherapy is

ineffective. Second-line therapy includes clobazam, clonazepam, levetiracetam, topiramate or

zonisamide which may be considered by a tertiary specialist if adjunctive treatment fails.

Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine, and vigabatrin are

not recommended in absence seizures or syndromes.

Management of epilepsy patients on phenytoin

Phenytoin is a category 1 medicine and patients on phenytoin cannot be switched to a different

brand/formulation

Reference: MHRA/CHM advice: Antiepileptic drugs: new advice on switching between different

manufacturers’ products for a particular drug (November 2013). (

Phenytoin is also a strong enzyme inducer. It reduces the effectiveness of Emergency Hormonal

Contraception with levonorgestrel, and possibly ulipristal acetate. A copper intra-uterine device

has to be used instead. If the copper intra-uterine device is undesirable or inappropriate, the

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dose of levonorgestrel should be increased to a total of 3 mg taken as a single dose [unlicensed

dose—advise women accordingly].

Reference: https://www.medicinescomplete.com/mc/bnf/current/PHP78143-contraceptives-

interactions.htm

Benzodiazepine withdrawal

The BNF recommendation is to switch to diazepam first as it has a long half-life and therefore

avoids sharp fluctuations in plasma levels. It is possible to initiate withdrawal on Nitrazepam but

this would be done very slowly (1.25mg every 2 weeks)

Reference: http://cks.nice.org.uk/benzodiazepine-and-z-drug-withdrawal April 2015

Prescribing Over the Counter Topical Preparations

For ringworm (fungal infection) - Clotrimazole 1%.

For eczema - Diprobase and hydrocortisone. However, hydrocortisone is only licensed for children

over 10 years.

Worm infections

Treat with anti-helminthic e.g. mebendazole

Mebendazole is a type of anthelmintic i.e. a medicine that kills worms that infect the body.

Children must take the medicine for the number of days recommended by the doctor. If the

medicine is stopped too soon the worm infection may come back.

Doctors normally recommend that all members of the family should be treated on the same day,

whether or not they have any symptoms of infection.

To prevent reinfection, it is important that for at least 6 weeks after a child’s infection, all

members of the family take extra care to wash their hands, including under the fingernails,

before preparing or eating a meal and when using the toilet.

Other advice includes:

• Wear underwear while in bed and wash the bedding regularly

• Take a shower or a bath immediately after waking up in the morning

• Do not share towels

Mebendazole should not be used for children under the age of 2 years.

Mebendazole may harm an unborn baby. If a female thinks they may be pregnant she must talk

to her doctor before taking mebendazole.

From Vermox PIL:

You do not need to use a laxative or change your diet.

For threadworms (pinworms): one tablet A single Vermox tablet will kill threadworms. Your

doctor may tell you to take a second tablet after two weeks in case of re-infection.

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For other common worm infections: one tablet two times a day

Reference: http://www.medicinesforchildren.org.uk/mebendazole-worm-infections

Sign and symptoms in cardiovascular disease

Loss of feeling in extremities: Transient ischaemic attack

Weakness around the mouth and inability to swallow: Stroke

Radiating chest pain, shortness of breath and rapid pulse: Myocardial infarction

Swollen ankles: water retention/heart failure

Diseases

Erythema infectiosum (also known as fifth disease or slapped-cheek syndrome) is usually a

benign childhood condition characterised by a slapped-cheek appearance. Reassuring the

parents of children with the condition often is the only intervention necessary, but symptomatic

relief may be provided using NSAIDs or paracetamol.

Ref: NHS choices, accessed at:

www.nhs.uk/Conditions/Slapped-cheek-syndrome/Pages/Introduction.aspx

Glandular fever is a common cause of severe pharyngitis in teenagers. Treatment with certain

antibiotics (notably amoxicillin or ampicillin) is associated with severe, generalised rashes, which

are not of true allergic origin.

Ref: BNF online (March 2016), accessed at: www.evidence.nhs.uk/formulary/bnf/current/5-

infections/51-antibacterial-drugs/511-penicillins/5113-broad-spectrum-penicillins

Test results and ranges

Blood pressure: A BP reading of over 140/90 mmHg would be considered raised and require

investigation.

Reference: NICE quick reference guide. Hypertension: management of hypertension in adults in

primary care. https://www.nice.org.uk/guidance/cg127

Diabetes: NICE do not provide target blood glucose level ranges in their guidance. A non-diabetic

patient would be expected to have a pre-prandial blood glucose level of 4.0 – 5.9 mmol/l and a

post prandial level of below 7.8mmol/l. Anything above this would indicate the presence of

diabetes.

Reference: Diabetes.co.uk (using International Diabetes Federation target ranges)

UK Government. UK Chief Medical Officers Alcohol Guidelines Review.

http://www.diabetes.co.uk/diabetes_care/blood-sugar-level-ranges.html

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Biochemical tests to support treatment

Hypothyroidism: Thyroid function tests

http://www.thyroiduk.org.uk/tuk/about_the_thyroid/hypothyroidism_signs_symptoms.html

Pulmonary embolism treated with unfractionated heparin: Activated partial thromboplastin

time (APTT)

Blood tests

Patients on clozapine: Full blood count due to risk of neutropaenia and potentially fatal

agranulocytosis

Patients starting treatment with statins: Serum Alanine Transaminase - Statins must be used in

caution in patients with liver disease, if active liver disease or raised tranaminases to three times

upper normal limit then they contraindicated

Laxatives

Glycerin suppositories normally act within 30-60mins and are the fastest acting laxative available.

Stimulant laxatives, such as Senna, take 8-12hours. (Bisacodyl, glycerin, picosulfate also

stimulants

Bulk forming laxatives, such as Fybogel, take 24-36 hours.

Osmotic laxatives, such as lactulose, take 1-3 days.

Softener – docusate capsules act within 1-2 days – used for chronic constipation also

Read BNF Section on Laxatives; http://www.pharmaceutical-journal.com/learning/cpd-

article/constipation-managing-the-condition-in-adults/20068188.cpdarticle

Anaesthesia

Dantrolene: used to treat malignant hyperthermia

BNF section on malignant hyperthermia

Sugammadex: used to reverse neuromuscular blockade

BNF section on neuromuscular blockade reversal page 1106

COSHH Regulations

Identification of hazard symbols:

http://www.hse.gov.uk/chemical-classification

http://www.hse.gov.uk/chemical-classification/labelling-packaging/hazard-symbols-hazard-

pictograms.htm

e.g. A flame over a circle indicates the substance is oxidising.

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Trainee Feedback from June 2017 GPhC assessment (August 2017)

Topics Part 2

Ibuprofen dosing – e.g. for a 3-year old (no questions on paracetamol)

Vincristine – how to administer it? IV, IM or oral?

Dog bite: finger went red and swollen, which antibiotic would you recommend?

Cellulitis: which antibiotic would you give to a patient who is allergic to penicillin?

Drug interactions: Co-amoxiclav with simvastatin?? Metronidazole and simvastatin?

What’s the cautionary label for lansoprazole?

What should be on a label legally? Extract was provided with date of dispensing missing

Patient comes in asking for EHC. She is on paroxetine. Anything wrong with that? What would

you recommend?

Which EHC is suitable in breast feeding?

Check which meds are licensed for post-operative analgesia

Tranexamic acid- look at age licensing and when you would refer

Lots of questions on asthma and COPD guidelines

Sources of information e.g. Martindale

Where you would look for info on IV administration? Is Green book the right answer?

SPC for Levemir – find out how to change dose in renal impairment and when you are adding a

glp1 to the insulin. How do you change dose

Practise how to use SPCs – lots of questions!

COC plus trimethoprim

Electrolyte imbalances- recognising symptoms

Lots of questions on MEP

Dispensing label resource asked what was missing that is a legal requirement.

Lots of case studies where you had to decide why it was necessary to contact the prescriber

Lots of OTC medicines case studies with patients on multiple drug treatments e.g. warfarin, anti-

hypertensives

How many days’ supply of CDs in humans?

Patient wants to buy miconazole – contra-indicated – Why is it?

|Patient on multiple medicines wants to buy tranexamic acid. OTC. Patient on COC

Mouth ulcer not responding to HC

Patient with 25% hand burns (not deep). Do you refer due to age (6 years old) or due to the

amount burned or the depth of the burns?

Smoking cessation – scenario of customer who stopped smoking but was worried that he

would start again due to stress. What stage was he at? Contemplation? Preparation?

Diazepam unopened bottle – do you denature?

Hospital discharge note

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Why is glucose suitable for use as a diluent in IV therapy

Osmolarity/Isotonic?

Extract question with a methadone discrepancy. Figuring out what the discrepancy was. 3

patients taking 3 different quantities at different times of the week

SPC of insulin and how you would change doses for different patients

Question on insulin- a patient needed basal insulin to inject before breakfast once a day. Which

insulin would you give? The MCQ listed two short acting, two biphasic and one long-acting

(glargine)

Know how insulin should be written on a prescription i.e. does it have to say units in full rather

than IU or U?

Which drug causes falls in the elderly? – Risperidone

Drugs for respiratory depression in palliative care

3 pictures with skin rashes and MCQs asked what you would do. E.g. refer, give paracetamol for

fever and reassure patient

o One picture with a girl’s tongue fungal infection like thrush?

o Ringworm

o some kind of warts not very clear child with spots on the skin and fever

Look up molluscum contagiosum for third picture.

Tip: Look at NHS choices info for skin conditions in addition to the Minor Ailments book

Man overdosed with heroin. How would you treat opioid overdose? Naloxone was one of the

options

Clinical was heavily scenario-based- multiple drugs for multiple conditions

Rivaroxaban dose IM PX?

Laxative for patient travelling abroad waiting for dietary changes to take effect.

Sub-conjuctividal haemorrhage – what to do?

Chickenpox- Initial management paracetamol or ibuprofen?

Patient on allopurinol, age 70 and now added NSAID.

Patient on lymecycline, an acne cream and dermol added – what’s wrong?

Dermol is not indicated

Benzoyl peroxide counselling

Lansoprazole advice – don’t crush or chew tablets

Warfarin and miconazole interaction – alternative antifungal or extra monitoring?

Doxycycline and Phenytoin? – drug metabolism inducer but the interaction is not clinically

significant

Roaccutane -do not dispense if treatment is for more than 7 days

What to do when quantity is missing in words

Make a technical amendment?

Paclitaxel – What group of cytotoxics is it in?

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How long does it take for myelosuppression to occur?

What can you do in absence of a responsible pharmacist?

Part 1 Calculations

Pharmaco-economics-question on drug costs oral versus IV. For oral the calculation was per Kg

and for IV based on square meters so easy to miss!

There was a round up dose but give the MINIMUM number of tablets that make up the

quantity. Each dose was bd for 14 days

Learn how to calculate: IBW, Half-life, Css, CrCl

Pregabalin calculation based on SPC for GAD

Summary Guidance for Revision

Review the GPhC Registration Assessment Framework (for sittings in 2018)

Focus on high and medium weighting chapters of BNF for revision:

High: Cardiovascular, Endocrine system, Infection, Nervous System

Medium: Blood and nutrition, Gastro-intestinal system, Genito-urinary tract system, Immune

system and malignant disease, Respiratory system

Specific topics

Signs and symptoms of toxicity of drugs with a narrow therapeutic range:

o Digoxin, Lithium, Phenytoin, Theophylline, Gentamicin, Warfarin

Drugs commonly causing electrolyte abnormalities such as hypo/hyperkalaemia.

Ethnic groups that may metabolise medicines differently e.g. Codeine

Use of (common) drugs in pregnancy and breastfeeding such as analgesics, vitamins.

First aid basics, especially anaphylaxis

Law & Ethics especially regarding script requirements for CDs and Tramadol /Temazepam.

Potencies of topical corticosteroids (in BNF).

Roles of different agencies such as MHRA, JPAG, NRLS.

Counselling points for different types of inhaler devices.

Veterinary Prescription requirements

Useful resources for revision:

http://www.resourcepharm.com/pre-reg-pharmacist/prereg-essential-documents.html