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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