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OSPAP Programme
Commonly prescribed
medications
Summary and prescribing advice
Part 1

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Aciclovir
• What is it?
– Anti-viral
– Others in class – Famciclovir, Valaciclovir
• Indication
– Herpes simplex infections (eye, mouth, lips, genitals)
– In individuals with good immune function, mild infection of the eye and lips (cold sores)
can be treated topically
– Primary or recurrent genital herpes simplex is treated orally
– Varicella-zoster infections (chicken pox) – treat orally in immunocompromised patients
or those with severe infection – start within 24 hours of onset of rash may reduce
duration and severity of symptoms
– Herpes-zoster infections (shingles) – systemic antiviral treatment can reduce the severity
and duration of pain and complications – should be started within 72 hours and
continued for 7-10 days
• Interactions – see BNF
• Side effects – GI, CNS, rash
• Dose – herpes simplex treatment – 200mg 5 times daily for 5 days
• Varicella and herpes zoster treatment – 800mg 5 times daily for 7 days

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Alendronic acid
• Bisphosphonate – adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of
growth and dissolution, and therefore reducing the rate of bone turnover.
• Other drugs in class
– Disodium etidronate
– Risedronate
– Others see BNF
• Indication
– Prophylaxis (long term or repeated steroid use) and treatment of osteoporosis (confirmed by DEXA
scanning)
• Interactions
– Chelation – food/other drugs
– Treatment should be accompanied with calcium/vitamin D supplementation
• Side effects
– Osteonecrosis of the jaw (rare but severe) – Dentists should be aware of treatment
– Oesophageal reactions
• Oesophagitis, oesophageal ulcers, oesophageal stricture etc
• Dose
– Daily vs Weekly
• Counselling
– important

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Alendronic acid – case studies

• A 85 year old women prescribed alendronic acid

70mg once per week for prophylaxis of osteoporosis
as is on long term steroid treatment (prednisolone
7.5mg daily)
• Admitted to hospital as general deterioration of
heath/ability to cope at home
• Some dysphasia, develops severe mouth ulcers
• ? Cause

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Alendronic acid – case studies

• A 35 year old man on alendronic acid for

prophylaxis of osteoporosis as requires long
term treatment with steroids, requires dental
treatment.
• Develops osteonecrosis of jaw, some of which
has to be removed as a result

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Alfacalcidol
• Vitamin D deficiency can be caused by intestinal
malabsorption or chronic liver disease
• Patients may develop hypercalceamia
• CKD stage 4 and 5 should be prescribed alfacalcidol rather
than colecalciferol. This is because vitamin D requires
hydroxylation by the kidney to its active form, therefore the
hydroxylated derivatives such as alfacalcidol should be
prescribed
• Vitamin D deficiency due to lack of exposure to sunlight or
lack in diet in people with normal renal function or stage
1,2,3 CKD is treated with colecalciferol

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Alfuzosin
• Alpha-blocker (others in this class: doxazosin,
indoramin, prazosin, tamsulosin, terazosin)
• Urinary retention
• Relax smooth muscle in benign prostatic hyperplasia
producing an increase in urinary flow and an
improvement in obstructive symptoms
• Since selective alpha-blockers reduce blood pressure
patients receiving antihypertensive treatment may
require a dosage reduction

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Allopurinol
• Long term control of gout
• The formation of uric acid from purines may be reduced with
the xanthine-oxidase inhibitor allopurinol
• Treatment should be continued indefinitely to prevent further
attacks by correcting the hyperuriceamia
• Should NEVER be started during an attack, usually started 2-3
weeks after the attack has settled
• Interactions – See BNF
• Dose – maintenance (100mg-300mg daily)
• Side effects
– Rashes – withdraw therapy, if rash mild re-introduce cautiously but
discontinue immediately if re-occurs

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Amiodarone
• Amiodarone is used in the treatment of arrhythmias
• Should only be initiated under hospital or specialist supervision
• Very long half-life (extending to several weeks)
• Many weeks or months are required to achieve steady state plasma-
amiodarone concentration
• This is important when considering drug interactions
• Most patients develop corneal microdeposits (reversible on withdrawal of
treatment)
• Phototoxic reactions, patients should be advised to shield the skin from
light during treatment and for several months afterwards
• Amiodarone contains iodine and can cause disorders of thyroid function
(TFT tests during treatment) –hepatotoxic response –raised transaminases
• Pneumonitis should be suspected if SOB develops
• Hepatoxicity (LFTs during treatment)

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Amiodarone

• Very toxic in overdose (fatalities)

• Needs loading dose due to long half life
• 200mg tds for 1 week, reduced to 200mg bd
for a further week, maintenance 200mg daily
• Side effects are dose and duration of
treatment related – reduce dose reduce
incidence of side effects

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Amitriptylline
• Tricyclic antidepressant

• Those with sedative properties include amitriptyline, clomipramine,

dosulepin, doxepin, trazodone

• Less sedative – imipramine, lofepramine and nortriptyline

• Side-effects
– cardiovascular (arrhythmias and heart block)
– anti-muscarinic (drowsiness, dry mouth, blurred vision (very rarely
precipitation of angle-closure glaucoma), constipation, urinary
retention)

• Overdosage – limited quantities of tricyclic antidepressants should be

prescribed at any one time because their cardiovascular effects are
dangerous in overdosage – dosulepin and amitriptyline is associated with
high rate of fatality

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Amitriptyline

• Amitriptyline is now rarely used an an

antidepressant, now more likely to be used for
neuropathic pain at lower dosages 10mg -
50mg daily

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Amlodipine
• Calcium-channel blockers interfere with inward displacement of calcium
ions
• They influence the myocardial cells, the cells within the specialised
conducting system of the heart, and the cells of vascular smooth muscle
• Myocardial contractility nay be reduced, the formation and propagation of
electrical impulses within the heart may be depressed, and coronary or
systemic vascular tone may be diminished
• Verapamil and Diltiazem vs dihydropyridine calcium channel blockers
(amlodipine, felodipine, isradipine, lercanidipine, nicardipine, nifedipine)
• Verapamil (negative inotropic effect) and diltiazem should be avoided in
heart failure because they may further depress cardiac function and cause
clinically significant deterioration. Verapamil should NOT be used with
beta-blockers and diltiazem used with care

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Amlodipine
• Dihydropyridine calcium channel blockers (ie amlodipine)
relax smooth muscle and dilate coronary and peripheral
arteries.
• More influence on the vessels and less on the myocardium
• Don’t have anti-arrhythmic activity
• Different durations of action
• Licensed for hypertension and or prophylaxis of angina
• Grapefruit juice increases plasma concentations of felodipine,
isradipine, lacidipine, lercanidipine, nicardipine, nifedipine,
nimodipine, nisoldipine and verapamil
• Ankle swelling common with amlodipine 10mg

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Amoxicillin

• Broad spectrum antibiotic

• Always check allergy
• Macropapular rashes commonly occur with
amoxicillin but are not usually related to true
penicillin allergy

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Aspirin

• Not now used as an analgesic

• Prophylaxis of cerebrovascular disease or
myocardial infarction (secondary prevention)
• 75mg daily
• ? Control BP before initiation
• If patient is at high risk of gastro-intestinal
bleed, a proton pump inhibitor can be added

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Atenolol
• Beta-adrenoceptor blocking drugs, act in the heart, peripheral
vasculature, bronchi, pancreas and liver
• Beta-blockers should be avoided in patients with a history of
asthma or bronchospasm
• Some are cardioselective but not cardiospecific, have less
effect on airways resistance but are not free of this side effect
• Assoicated with fatigue, coldness of the extremities and sleep
disturbances with nightmares
• Can be used for a variety of indications
– Hypertension Arrhythmias
– Angina Heart failure
– Post MI

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Azathioprine

• Immunosuppressant
• DMARD
• Used in transplant recipients and in a number of
auto-immune conditions
• Blood tests and monitoring for sings of
myelosuppression are essential (FBC)
• The enzyme TPMT metabolises azathioprine
• Risk of myelosuppression increased in people with
low activity

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Beclomethasone

• Inhaled corticosteroid
• Now changed to CFC – note not equipotent
• Prescribed as per BTS guidelines for asthmatic
patients, some use in COPD (unlicensed)
• Can induce adrenal suppression at high doses –
steroid card (doses above 2mg)
• Bone mineral density can be reduced
• Growth retardation in children
• Oral thrush

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Bendroflumethiazide
• Thiazide diuretic
• Inhibit sodium re-absorption in the distal convoluted
tubule
• A low dose i.e. 2.5mg produces a maximal blood pressure
lowering effect with little biochemical disturbance
• Higher doses cause more marked disturbance in plasma
potassium, sodium, uric acid, glucose and lipids with little
advantage for blood pressure control
• Now removed from hypertension guidelines as no good
evidence for outcomes (evidence that does exist is for
trials which used 10mg)

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Bupropion

• Smoking cessation aid

• Contra-indicated in patients with history of
seizure, alcoholism and in patients at high risk
of seizures or on other medications that can
lower the seizure threshold

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Candesartan

• Angiotensin II inhibitor

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Candesartan

• Others in class – eprosartan, irbesartan,

losartan, olmesartan, telmesartan, valsartan
• Used second line to ACE inhibitors
• Unlike ACE they do not inhibit the breakdown
of bradykinin and therefore are unlikely to
cause a dry cough
• All licensed to treat hypertension – some have
other indications

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Citalopram

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Citalopram
• Selective serotonin reuptake inhibitor
• Others in the class – escitalopram, fluoxetine,
fluvoxamine, paroxetine, sertraline
• SSRIs are less sedative and have fewer antimuscarinic
and cardiovascular effects than TCAs
• GI side effects
• Some reports of suicidal behaviour – particularly in
young people
• Not ‘addictive’ but there are withdrawal effects

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Citalopram and QT interval
• Citalopram and escitalopram are associated with dose-
dependent QT interval prolongation and should not be used in
those with: congenital long QT syndrome; known pre-existing
QT interval prolongation; or in combination with other
medicines that prolong the QT interval. ECG measurements
should be considered for patients with cardiac disease, and
electrolyte disturbances should be corrected before starting
treatment. For citalopram, new restrictions on the maximum
daily doses now apply: 40 mg for adults; 20 mg for patients
older than 65 years; and 20 mg for those with hepatic
impairment.

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Clopidogrel

• Anti-platelet
• Licensed for secondary prevention IHD
• Second line (except remember stroke secondary
prevention)
• Aspirin and clopidogrel after stent, non-STEMI (1
year)
• Interacts with omeprazole/esomeprazole

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Codeine phosphate

• Weak opiate
• Opiate side effects, drowsiness, constipation
• Tolerance
• Pro-drug
• 8/500 co-codamol sub-therapeutic dose

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Diazepam

• Benzodiazepine
• Licensed for short term use in anxiety or
insomnia
• Highly additive
• Used in alcohol withdrawal
• Status epilepticus

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Diclofenac

• Non-steroidal anti inflammatory drug

• Main side effects are GI and CVS
• Risks and benefits must be carefully balanced
• Precautions can be put in place ie PPI cover

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Diclofenac
• MHRA guidance
• Available data indicate that the cardiovascular risk with
diclofenac is similar to that of the selective COX-2
inhibitors. Consistent with COX-2 inhibitors, diclofenac is
now contraindicated in those with: ischaemic heart
disease; peripheral arterial disease; cerebrovascular
disease; or established congestive heart failure (New York
Heart Association [NYHA] classification II–IV). The
treatment advice applies to systemic formulations (ie,
tablets, capsules, suppositories, and injection available
both on prescription and via a pharmacy, P); it does not
apply to topical (ie, gel or cream) formulations of diclofenac

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Digoxin
• Cardiac glycoside
• Used in heart failure and arrhythmias
• Long half life
• Side effects are usually associated with excessive dosage –
anorexia, nausea, vomiting, diarrhoea, abdominal pain,
headache, confusion etc
• Narrow therapeutic index
• Regular monitoring of plasma concentration not needed
unless toxicity suspected
• Care with dosages
• Hypokalaemia predisposes to toxicity

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Digoxin

• Dosage dependant on age/lean body weight

and renal function
• Sampling for serum levels should be taken at
least 6 hours after the last dose
• Therapeutic range 0.5-1microgram/L
• Other monitoring: heart rate, BP, ECG, K+

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