Insomnia

• First line is CBT-I
• Benzodiazepine Receptor Agonists:
  • Temazepam 10-20mg nocte
  • Zolpidem 5-10mg noct
• Melatonin:
  • Melatonin (Circadin) 2mg nocte
• Orexin A/B Antagonist:
  • Suvorexant (Belsomra) 20mg nocte
  • Lemborexant (Dayvigo) 5-10mg nocte
• Antidepressants: Especially when insomnia is comorbid with depression
  • Endep 10mg nocte
  • Mirtazapine 15mg nocte
• Over-the-Counter (OTC): Sedating antihistamines, doxylamine
  • These are not recommended for long-term use due to side effects

COVID-19

• Nirmatrelvir/Ritonavir 150/100 (Paxlovid)
  • 2+1 tablets oral BD 5/7
• Budesonide
  • Budesonide 400ug inhaled BD

Urology

Cystitis

• Acute simple cystitis
  • Trimethoprim 300mg oral OD for 3/7 or
  • Cephalexin 500mg oral BD for 5/7
  • Amoxicillin+Clavulanate 500+125 oral BD for 5/7
• Acute complicated cystitis
  • Non severe: Amoxicillin+Clavulanate 875+125 oral BD for 14/7
  • Severe: Hospital – IV gentamicin + amoxicillin

Incontinence

• Urge
  • Anticholinergics ie Oyxbutynin 2.5-5mg oral BD-TDS
  • NB: Oxybutynin patch 3.9mg/24 hour topical twice weekly has less cholinergic side effects.
  • Solafenacin 5mg oral OD targets the M3 receptor and has less anticholinergic side effects (not PBS but only $16/month)
  • Mirabegron 25-50mg oral OD is a Beta-3 agonist (not PBS and $70/month)
• Stress
  • Pelvic floor exercises
  • Oestriol cream PV

Renal Colic

• NSAID
  • Ketorolac 30mg IM
  • Indomethacin 50mg oral TDS
• Narcotic
  • Oxycodone 5mg oral QID PRN
• α₁-blocker
  • Tamsulosin 400ug oral OD until stone passed

Prostatitis

• Same as UTI + Ciprofloxacin
• Acute
  • Trimethoprim 300mg oral OD 14/7
  • 2nd Keflex 500mg oral QID 14/7
  • Ciprofloxacin 500mg oral BD 14/7 (if resistance)
  • If severe -> Hospital for IV ABX
• Chronic
  • Ciprofloxacin 500mg oral BD 28/7 (cover Chlamydia)

Epididymo-orchitis

• If suspected to be non-STD as for prostatitis
  • Trimethoprim 300mg oral OD 14/7
  • 2nd Keflex 500mg oral QID 14/7
  • Ciprofloxacin 500mg oral BD 14/7 (if resistance)
• If suspected to be STD
  • Ceftriaxone 500mg IM/IV +
  • Doxycycline 100mg oral BD 14/7 or
  • Azithromycin 1g oral stat, repeat in 1/52

BPH

• alpha-1 adrenergic antagonist
  • Tamsulosin 400ug oral OD
  • s/e orthostatic hypotension, ejaculatory dysfunction
  • precautions Phosphodiesterase-5 inhibitors
    • Sildenafil appears ok with Tamsulosin @400ug dose
• Phosphodiesterase-5 inhibitors
  • Sildenafil 50mg oral nocte
• 5-alpha reductase inhibitors
  • Finasteride 5mg oral OD
  • Dutasteride 500ug oral OD
  • s/e sexual dysfunction
  • precaution: these drugs decrease PSA by ~ 50% so need to 2x values of PSA
• Combination therapy
  • Duodart = Tamsulosin+Dutasteride

Erectile Dysfunction

• Sildenafil 50mg oral 1/24 before sex
• c/i Nitrates, alpha blockers
• Caverject Impulse (Alprostadil)

Premature Ejaculation

• Lignocaine 2.5% + Prilocaine 2.5% cream 10-20 minutes before
• Sertraline 50mg oral OD (or 3-5 hours before)

Rheumatology

Polymyalgia Rheumatica (15% association temporal arteritis)

• Prednisolone 15mg oral OD with very slow taper over >= 1 year
  • 15mg 1/12
  • 12.5mg 1/12
  • 10mg 1/12
  • Then -1mg every 4-8 weeks (needs > 1 year treatment)
• Giant Cell Arteritis requires high dose prednisolone (40-60mg) and aspirin 100mg oral OD

Pagets Disease

• Zoledronic acid 5mg IV over 15/60
  • As for bisphosphonates check Ca, Vit D and eGFR > 30

Gout

• Acute
  • NSAID ie Voltaren 50mg oral TDS
  • Prednisolone 25mg oral OD 3-5/7 (note mid size dose)
  • Colcicine 1mg oral then 0.5mg 1/24 later as full course
• Prevention (target urate <0.30 if tophi or <0.36 otherwise)
  • Allopurinol – starting at 50mg oral OD and titrating up based on urate level
    • Reason AHS – Allopurinol Hypersensitivity Syndrome
  • RACGP like the concomittent use of Colchicine 0.5mg daily for flare prophylaxis

RA

• Fish Oil
• NSAID
• Prednisolone 5-15mg oral OD
• csDMARD (conventional synthetic Disease Modifying Anti-Rheumatic Drugs)
  • Methotrexate 10->25mg oral weekly
    • Folic acid rescue 5-10mg oral the following day
    • s/e GIT, liver toxicity, bone marrow suppression, mouth ulcers, pneumonitis, fatigue
    • Alternates leflunomide, sulfasalazine, hydroxychloroquine
• bDMADS (biological Disease Modifying Anti-Rheumatic Drugs)
  • Adalimumab – Humira
  • Etanercept – Enbrel
  • Infliximab – Remicade
  • Rituximab – Rituxan
  • Tocilizumab – Actemra
  • Abatacept – Orencia
  • Golimumab – Simponi
  • Certolizumab – Cimzia

OA

1. Topical
   1. NSAID eg Voltaren gel topical QID
   2. Capsiacin cream (Zostrix HP 0.075%) topical QID
2. NSAID
   1. COX-2 ie Celecoxib 100-200mg oral OD-BD (max 400mg)
   2. Non selective ie Voltaren 25-50mg oral BD-TDS (max 200mg)
3. Paracetamol 1g oral QID or 1.33g oral TDS
4. Duloxetine 30mg oral OD for 1/52, then 60mg (max 120mg)
5. Intraarticular steroid, i.e. Methylprednisolone acetate (Depo-Medrol) 40mg/ml 1-2ml for knee, less for smaller joints.
6. Opiods

Ankylosing Spondylitis

• NSAID (helps with both pain and to slow progression)
• DMARDs – methotrexate, sulfasalazine (minimal effect spinal disease)
• TNF inhibitors (66% response rate)
  • Adalimumab (Humira)
  • Etanercept (Enbrel)
  • Infliximab (Remicade)

Osteoporosis

• Ensure adequate vitamin D and Ca intake and eGFR > 30
  • ie prove adequate serum levels before treatment
  • do a dental check (osteonecrosis of the jaw)
• Bisphosphonates ie Alendronate 70mg oral weekly on an empty stomach
  • S/E include GIT upset/oesophagitis
  • Consider stopping after 5 years (10 if minimal trauma fracture)
• Denosumab 60mg s/c every 6/12
  • Stopping (or late dose) is associated with increased # risk

Psychiatry

GP Psychiatry Support Line 1800 16 17 18 (7 am-7 pm Mon-Fri)

Neuroleptic Malignant Syndrome

• Caused by starting dopamine antagonists (ie antipsychotics) or stopping dopamine agonists (ie Parkinson’s meds)
• Hyperthermia and muscle rigidity
• Rx fluids and diazepam/midazolam IV
• Bromocriptine 2.5mg oral 8/24

Serotonin Syndrome

• Caused by excess serotonin from SSRI, SNRI, MAOI, triptans, tramadol, cocaine, MDMA, dextromethorphan, St John’s Wort
• aggitation, hyperreflexia/clonus, hyperthermia
• Rx fluids and diazepam/midazolam
• Cyproheptadine (Periactin) 12 mg stat then 2mg every 2/24 with maintenance 4-8mg 6/24

Schizophrenia

• Olanzipine 5-10mg oral nocte (max 30)
• Clozapine for treatment-resistant but requires weekly monitoring FBC for the first 18/52
  • ECG, Echo, Clozapine level, CRP, Troponin, FBC, UEC, LFT, BSL, Lipids at start

PTSD

• Trauma focussed CBT or EMDR (Eye Movement Desensitisation and Reprocessing)
• Sertraline 50mg oral mane (max 200)
• Mirtazipine 15mg oral nocte (max 60)
• Prazosin 1-15mg oral nocte (Nightmares)

Depression

• Social Prescribing
  • Men’s shed
  • Walking groups
  • Gardening groups
  • Cooking lessons
• Psychotherapy
  • Online CBT ie This Way Up
  • CBT
  • IPT
• First line
  • SSRI ie Sertraline 50-200mg oral OD (titrate up every 2-4 weeks)
  • Tetracyclic ie Mirtazapine 15-45mg oral nocte
• Second line
  • SNRI ie Venlefaxine 75-300mg oral OD
  • Agomelatine (Valdoxan) 25-50mg oral nocte (low side effects)
    • Note non-PBS and $75/month cost is a barrier
• Third line
  • TCA
  • MAOI – Moclobemide
• Side effects
  • Weight gain
  • Sexual dysfunction
  • Sleep disturbance
  • CNS agitation, sedation, fatigue
  • Anticholinergic ie dry mouth, tremor
  • GIT
  • Low sodium (SSRI)
  • Serotonin syndrome (SSRI, SNRI, MAOI)
• Despite common use, no evidence mirtazapine + SSRI/SNRI improves the response
• Non-response questions
  • Is the diagnosis correct?
  • Have possible medical causes of symptoms been identified and treated?
  • Have alcohol or other substance use problems been addressed?
  • Have relevant psychosocial factors been addressed?
  • Has the patient been treated with an adequate dose of the antidepressant for an adequate duration?
  • Is an interacting drug reducing the response?
  • Is the patient adherent to therapy?
    • Have they been taking their antidepressants regularly?
    • Is the patient experiencing an adverse effect?

Bipolar I & II

• Bipolar I has mania +/- depression
• Bipolar II has hypomania +/- depression
• Treatment for each is the same and the first line options are:
  • SSRI + mandatory mood stabiliser ie
    • Sertraline 50->100mg oral OD (max 200mg)
      • Lithium Carbonate SR 450->675mg oral nocte or
      • Quetiapine
  • Quetiapine 50->300mg oral BD
• Acute Mania
  • Olanzapine 10-15mg oral stat (max 30mg daily)

Smoking Cessation

1. NRT
   1. Patches 21->14mg/24 hours
   2. Gum/Lozenge 4->2mg PRN
   3. Spray 1mg/spray i-ii PRN
   4. Can combine patches and other NRT and is more effective
   5. Pre-cessation patch increases quit rates
2. Verenacline (Champix) 1mg BD (after initial titrate up; nausea 30% s/e; neuropsych s/e)
   1. 0.5mg OD for 3/7
   2. 0.5 mg BD for 4/7
3. Buproprion (Zyban) 150mg BD (s/e seizures so c/i seizures)
   
   1. 150mg OD for 3/7 to start
4. Nortriptyline 25->75mg oral OD

Opiod Overdose

• ABCDEFG
• Naloxone 0.4-2mg IM/IV/Nasal

Alcohol Detox

• Thiamine 300mg IM/IV/Oral once daily
• Diazepam 20mg 2/24 oral with expectation 60mg is usually sufficient
• Post detox
  1. Naltrexone 50mg oral OD (c/i opiods, cirrhosis)
  2. Acamposate 666mg oral TDS (c/i CKD)
  3. Disulfiram 100-300mg oral OD

ADHD

• Methylphenidate
• Dexamphetamine
• Atomoxetine (Noradrenaline reuptake inhibitor)
• Clonidine

Anxiety

• Psychological interventions – CBT – are first line but benzos can be used short term.
• Adjustment disorder with anxious mood
  • Diazepam 2-5mg oral BD for up to 2/52
• GAD – Generalised Anxiety Disorder
  • Escitalopram 10-20mg oral OD (increase by 5mg every 2/52)
  • Sertraline not TGA approved and Escitalopram has the best evidence
  • Duloxetine 30-120mg OD (good for anxious thoughts)
  • Buspirone 5-20mg oral TDS
• Panic
  • Sertraline 25mg oral OD (start with low dose due to activating effect risk)
• OCD Obsessions (thoughts) and Compulsions (rituals)
  • Respond best to combined CBT + Pharmacotherapy
  • Sertraline 50-200mg oral OD
  • Clomipramine 50-300mg oral nocte (may be uniquely effective)

Sedation in nursing home

• Non pharmacological interventions first
• Beware antipsychotics in Parkinsons and Lewy Body Dementia
• Delerium
  • Treat underlying cause (Organic ie infection, CVA; Medication related; Psychiatric ie depression)
• For hallucinations
  • Risperidone 0.5mg oral but… (orthostatic hypotension)
• BPSD (Behaviours and Psychological Symptoms associated with Dementia)
  • Risperidone 0.5mg oral but… (orthostatic hypotension)
  • Parkinsons and Lewy Body – Quetiapine (at a pinch)
  • RACGP – Oxazepam 7.5mg oral
  • eTG – Lorazepam (Ativan)  0.5-1mg every 30/60 (max 3mg)

Palliative Care

• Narcotic:
  • Morphine 2.5-5mg s/c 1/24 PRN
  • CKD: Hydromorphone (5x potency morphine, minimal renal clearance)
• Anti-emetic:
  • Metoclopramide 10mg s/c 4/24 PRN
  • Domperidone – oral only, contraindicated in CKD, long QT
  • Ondansetron – can cause constipation
• Sedative:
  • Haloperidol 0.5mg s/c 4/24 PRN
  • Clonazepam 2-6 drops (0.2-0.6mg) s/l 1/24 PRN
• Secretions: Hyoscine butylbromide 20mg s/c 4/24 PRN
• Apperients: Docusate+Senna 50+8mg i-ii oral BD
• Steroids: Dexamethasone 4-8mg oral daily
• Cease: Any medication that does not have an immediate effect on the patient ie ACE, ARB, Statin, Aspirin, Vitamin D, Calcium….

Pain

Start with non pharmacological interventions (if appropriate) then select from stepped care:

1. Paracetamol 1g oral 4-6/24 (max 4g) (15mg/kg)
2. Ibuprofen 200-400mg oral 8/24 (max 1.2g) (10mg/kg)
   1. Caution with CVD, Peptic Ulcer, CKD
3. Codeine 30-60mg oral 6/24
   1. Tramadol 50-100mg oral 6/24 is an alternative
   2. Start low, go slow
   3. Apperients
   4. Note that PRN dose of narcotic should be 1/6 total daily dose

Neuropathic Pain

• Gabapentin 100-300mg oral nocte (increase to BD)
• Amitriptyline 5-12.5mg oral nocte (increase to 150mg)
• Duloxetine 30mg oral mane (increase to 120mg)

Paediatrics

UTI and pyelonephrtitis

• Trimethoprim (eTG) or
• Cefalexin (RCH and UpToDate)
  • 33mg/kg BD for UTI
  • 45mg/kg TDS for pyelonephritis
• IV Gentamicin + Benzylpenicillin for severe illness
  • Duration: 7 days or 10 days with fever

Meningitis

• Ceftriaxone 50mg/kg up to 2g IV stat
• Dexamethasone 0.15mg/kg (max 10mg) IV 6/24 for 4/7
• Contact chemoprophylaxis:
  • Rifampicin 10mg/kg (max 600mg) oral BD for 2/7

Impetigo

• Mupirocin (Bactroban) 2% topical TDS 5/7
• Flucloxacillin 12.5mg/kg (max 500mg) oral QID for 7/7
  • Cefalexin 12.5mg/kg (max 500mg) oral QID for 7/7
    • Trimethoprim/Sulfamethoxazole 4+20mg/kg oral BD for 3/7
    • Use this if no allergy or no response to flucloxacillin or cephalexin
• Decolonisation with nasal bactroban, chlorhexidine, bleach baths
• ATSI – consider benzathine benzylpenicillin IM as stat dose

Gastroenteritis

• Oral rehydration solution 10ml/kg/hr (0.5ml/kg/5 every minutes)
• 1:4 dilution of lemonade or apple juice if ORS refused
• NGT
• IVT 10-20ml/kg stat bolus
• Ondansetron oral wafer 2mg < 15kg; 4mg < 30kg; 8mg > 30kg
• Antidiarrhoeal NOT recommended
• Probiotics NOT effective
• Antibiotics NOT used for uncomplicated diarrhoea
  • Reserved for specific indications
  • Carry risk of HUS if bloody diarrhoea without sepsis is casued by enterohaemorrhagic E.coli O157

Nocturnal Enuresis

• Star Charts
• Enuresis alarms
• Desmopressin (DDAVP, Minirin)

Constipation

• Iso-osmotic laxative: Macrogol 3350 (Movicol) 1-4 sachets per day oral
• Osmotic laxative: Lactulose 1-3ml/kg up to 60ml/day oral
• Stimulant laxative: Senna oral nocte

Mastitis

• Express and drain breast, but if systemic or not resolving in 24-48 hours
• Flucloxacillin 500mg oral QID 5/7
  • Keflex 500mg oral QID 5/7
    • Clinamycin 450mg oral TDS 5/7
• For all ABX treatment may require extension to 10/7

Low milk supply

• Domperidone 10-20mg oral TDS

Stop lactation

• Bromocriptine 2.5mg BD

Thickener for GOR

• Cornflour
• Karicare Food Thickener

Obstetrics

All

• Folate 400ug
  • 5mg in high risk ie DM, antipsychotic, PHx/FHx NTD
• Iodine 150ug

Hypertension drugs in pregnancy

• First line:
  • Labetolol 100-400mg oral TDS
  • Methyldopa 250-750mg oral TDS
• Second line:
  • Hydralazine 25-50mg oral TDS
  • Nifedipine SR 20-60mg oral BD

Delivery

• Oxytocin (Syntocinon)
• Oxytocin/Ergometrine (Syntometrine)
• Tranexamic acid

Postnatal Depression

• Bio-psycho-social approach
• Temazepam for 3 nights to initiate sleep
• Sertraline 50-200mg oral OD

Nephrology

CKD

• Antihypertensives: BP target 130/80 – ACE inhibitors and ARBs.
• SGLT2: Particularly in T2DM
• Diuretics: To help remove excess fluid and manage blood pressure.
• Statins: To manage high cholesterol levels, which are common in CKD.
• Vitamin D Supplements: To prevent bone disease associated with CKD.
• Erythropoiesis-Stimulating Agents: To treat anaemia associated with CKD.
• Phosphate Binders: To control high phosphate levels in blood.
• Potassium Binders: For hyperkalaemia.
• Sodium Bicarbonate: For metabolic acidosis.

UTI (Cystitis)

• Trimethoprim 300mg oral 3/7
  • Keflex 500mg oral BD 5/7 (pregnancy)

Neurology

Tension HA

• Acute: Ibuprofen 400mg or Paracetamol 1g (particularly if pregnant)
• Preventer: Amitriptyline 10->75mg nocte (increase by 10mg weekly)
• Preventer (2nd line): Mirtazapine, Venlefaxine

Migraine (Acute)

• First line: NSAID (Ibuprofen 400-600mg) or Aspirin 900mg (4-6 hours between doses)
  • Avoid in 1st trimester and after 30 weeks
  • Use paracetamol 1g oral 4-6 hours between doses
• Metoclopramide 10mg oral TDS PRN (Domperidone, Ondansetron and Prochlorperazine are 2nd line)
• Sumatriptan (Imigran) 50-100mg stat (2 hours between, max 300mg in a day)
• Naratriptan 1.25-2.5mg oral BD for menstrual migraine
• Ketorolac 30mg IM

Migraine (Prophylaxis)

• Pizotofen (Sandomigran) daily
• Beta-Blockers: Such as propranolol bd
• Calcium Channel Blockers: Such as verapamil SR daily
• ARB: Candesartan daily
• TCA: Like amitriptyline and nortriptyline daily
• Anticonvulsants: Including topiramate daily and valproate in divided doses

Epilepsy

• Focal: Carbemazepine 200-600 oral BD
• Generalised: Sodium Valproate 400-1000mg oral BD (teratogenic)
• Pregnancy: Lamotrigine (needs up titration over 8 weeks due to SJS risk)
• Status: Midazolam 10mg IV/IM
• IUD or Depot for contraception if on enzyme inducing AED

Alzheimers

• Cognition
  • Donezipil (Aricept) 5mg oral nocte (4 weeks) ->10mg (if tolerated)
  • Rivastigmine (Exelon) 4.6mg patch daily (4 weeks) ->9.5mg (if tolerated)
• Depression:
  • Sertraline 50-200mg or
  • Citalopram 20-40mg oral OD
• Sedation
  • Antipsychotics
    • Risperidone 0.25-1mg oral BD
    • Olanzipine  2.5-10mg oral daily in 1-2 doses
    • Warn relatives increased risk of death
    • Monitor: anticholinergic, extrapyramidal, postural hypotension, sedation
  • Oxazepam 7.5mg 1-3 times a day (max 2 weeks)

Lewy Body Dementia

• Parkinsonism tends to be non responsive
• Quetiapine (minimal dopamine blockade) is sedation agent of choice (12.5-100mg)

Trigeminal Nueralgia

• Carbamazepine 100-400mg oral BD

Bell’s Palsy

• Prednisolone 75mg oral OD 5/7 (<72 hours)
• Famciclovir 500mg oral TDS 7/7 (if HSV or VZV aka Ramsay Hunt)
• Eye protection

Musculoskeletal

Frozen Shoulder

• Freezing Phase
  • Paracetamol and/or NSAID
  • Intrarticular steroid (variable results so oral preferred)
  • Prednisolone 30mg oral OD for 3/52 then taper over 2/52 (not with NSAID)
• Frozen Phase
  • Physiotherapy
  • Hydrodilation
  • EUA
  • Arthroscopy
• Thawing Phase
  • Physiotherapy

Osteoporosis and minimal trauma fracture

• Measure Ca++ and Vitamin D prior to starting
• Alendronate 70mg oral weekly on empty stomach
• 5mg Zoledronic acid IV over 15/60 once a year
  • Must have Vit D > 50; Ca++ normal range; eGFR > 35
• Denosumab 60mg s/c 6/12
• Stop after:
  • Low risk 3 years (IV) 5 years (oral)
  • High risk 6 years (IV) 10 years (oral)

Pagets Disease

• 5mg Zoledronic acid IV over 15/60
• Re-evaluate after 6/12

Infectious Disease

Pertussis

• Azithromycin 10mg/kg oral up to 500mg on day 1, then 5mg/kg up to 250mg on days 2-5.
  • Same regimen is use for prophylaxis in contacts
• Can return to school after 5/7 Rx
• No point after 21 days cough because non infectious at this stage and can return to day care/school

Malaria

• Propylaxis doxycycline 100mg oral OD for 2 days before, during and 4 weeks after travel.
  • Not approved for kids < 8 where Malarone is used (Atovaquone/Proguanil)

Leptospirosis

• Doxycycline 100mg oral BD for 7/7

Influenza (Rx within 48 hours)

• Oseltamavir 75mg BD oral for 5/7
• The following groups of individuals are at higher risk of poor outcomes from influenza (eg complications, severe influenza, hospitalisation, death):
  • adults aged 65 years or older
  • pregnant women
  • people with the following conditions:
    • heart disease
    • Down syndrome
    • obesity (body mass index [BMI] 30 kg/m² or more)
    • chronic respiratory conditions
    • severe neurological conditions
    • immune compromise
    • other chronic illnesses
  • Aboriginal and Torres Strait Islander people of any age
  • children aged 5 years or younger
  • residents of aged-care facilities or long-term residential facilities
  • homeless people.

Oral Mucocutaneous Herpes (Rx within 72 hours)

• Initial – Famciclovir 500mg oral BD for 7/7 (also Rx for Herpetic Whitlow)
• Recurrent – Famciclovir 1500mg oral stat
• Suppression – Famciclovir 250mg oral BD for 6/12

Genital Herpes (Rx within 72 hours)

• Initial – Famciclovir 250mg oral TDS for 10/7 (stop at 5/7 if response rapid)
• Recurrent – Famciclovir 1000mg BD for 1/7
• Suppression – Famciclovir 250mg oral BD
• Failure – Valaciclovir 500mg oral BD

Herpes Zoster (including Herpes Zoster Opthalmicus) (Rx within 72 hours)

• Famciclovir 500mg oral TDS for for 10/7

Haematology

Iron Deficiency

• Ferrous Sulfate / Ascorbic acid (Ferograd C) i-ii oral OD for 3 months
• Ferric Carboxymaltose  (Ferrinject) 1000mg IV in 100-250ml 0.9% Saline over 15 minutes (may need repeat)

Cardiovascular

AF Drugs

• Rhythm Control
  • Acute
    • Flecanide or Amiodarone IV
  • Chronic
    • Sotalol 40-160mg oral BD
    • Flecanide or Amiodarone oral
• Rate Control
  • Acute
    • Metoprolol 2.5-5mg IV, repeat every 5 minutes up to 3 doses
    • Digoxin and Amiodarone as additional
  • Chronic
    • Atenolol 25-100mg oral OD
    • Metoprolol 25-100mg oral BD
    • Diltiazem MR 180-360 oral OD if BB contraindicated

Hypertension Drugs

• Non-drug
  • DASH diet
  • Exercise
  • Weight Reduction
  • Alcohol Reduction
  • Moderate salt
• First Line
  • ACE
    • Ramipril 2.5-10mg oral OD
  • ARB (Preferred in black people)
    • Irbesartan 75-300mg oral OD
  • Dihydropyridine Calcium Channel Blockers
    • Amlodipine 5-10mg oral OD
  • Thiazide and Thiazide Like Diuretics
    • Hydrochlorothiazide 12.5-50mg oral OD
• Second Line
  • Potassium Sparing Diuretics
    • Spironolactone 12.5-50mg oral OD
  • Beta Blockers
    • Metoprolol 25-100mg oral BD
  • Alpha Blockers
    • Prazosin 0.5-10mg oral BD
  • Nondihydropyridine Calcium Channel Blockers
    • Diltiazem SR 180-360mg oral OD
  • Centrally Acting
    • Methyldopa 125-500ug oral BD-TDS (ok in pregnancy)
  • Direct Acting (last resort)
    • Minoxidil 5-30mg oral BD

Hypertension – Pregnancy

• First Line
  • Methyldopa 125-500mg oral BD-TDS
  • Labetalol 200-400mg BD (IV dose is 1/10 ie same a metoprolol)
• Second Line
  • Nifedipine SR 30-60mg
  • Hydralazine 40-200mg daily in divided doses

Heart Failure Drugs

• ACE: Ramipril 2.5 mg oral OD
• ARB: Irbesartan 75mg oral OD
• ARNI: (ARB+Neprilysin Inhibitor)  Sacubitril+Valsartan 24/26mg oral BD
• Beta Blocker: Carvedilol 3.125-25mg oral BD
• MRA: Spironolactone 25-50mg oral OD
• SGLT2: Dapagliflozin 10mg oral OD
• Other Drugs
  • Loop Diuretics – Furosemide 20-40mg oral OD-BD
  • Ivabradine 2.5-5mg oral BD
  • Digoxin 62.5-250ug oral OD

Angina Drugs

• Acute
  • GTN spray 400ug/dose i-ii, repeat every 5 minutes
• Prophylactic
  • Beta Blockers: Metoprolol 25-50mg oral BD
  • Non-dihydropyridine: Diltiazem SR 180-360mg oral OD (do not use with a Beta blocker) or Verapamil
  • Dihydropyridine: Amlodipine 2.5-10mg oral OD (can be added to Beta blocker) or Nifedipine
  • Nitrates: Isosorbide Mononitrate MR 30-120mg oral OD or GTN patch
  • Other: Nicorandil 5-20mg oral BD
  • Titrate up as required

Antiplatelet

• Low dose aspirin 100mg oral daily
• Clopidogrel 75mg oral daily (for dual antiplatelet Rx post PCI)

Antithrombotic (DVT)

• Apixaban 10mg oral BD for 7 days then 5mg oral BD (eGFR >25, non-pregnant)
• Enoxaparin 1.5mg/kg s/c daily (all patients eGFR >30; eGFR <30 1mg/kg)
• Warfarin is 1st choice for antiphospholipid syndrome (with enoxaparin cover)

Dyslipidaemia

• Cholesterol
  • Atorvastatin (Lipitor) 10-80mg oral daily (high dose is 40-80)
  • Ezetimbe (Ezetrol) 10mg oral daily
  • PCSK9: Evolocumab 420mg s/c 4/52
• Triglycerides
  • Fish oil 4g omega-3 equivalent daily
  • Fenofibrate (Lipidil) 145mg oral daily

Rheumatic Fever

• Benzathine penicillin IM 1.2 million units stat (10-20kg 0.6 million units) – every 21-28 days
• Naproxen 500mg oral BD (10mg/kg for kids) until joint symptoms settled for 1-2 weeks

Endocarditis (Empirical)

• Benzyl Penicillin 1.8 g IV 4/24 +  Flucloxacillin 2 g IV 4/24 + Gentamicin IV
• Cefazolin 2g IV  8/24 + Vancomycin IV + Gentamicin IV (penicillin allergy)

Gynaecology

PMS/PMDD

• Lifestyle
• CBT
• Ethinyloestradiol/Drospirenone 20/3000ug (Yaz) – proven in RCT
• SSRI ie Sertraline 50mg oral daily or for the 14 days prior to menstruation

PCOS

• Lifestyle (1st line)
  • Diet and Exercise
  • Hair removal – shaving, bleaching, depilatory, laser
• Hormonal options (1st line)
  • COCP with low androgenic activity ie Yaz
  • Levonorgestrel 52mg IUD
  • Cyclical Norethisterone 2.5-5mg OD for 14 days on, 14 days off.
• Anti-androgen
  • COCP ie Ethinyloestradiol/Cyproterone 35/2000ug (Dianne) Ethinyloestradiol/Drospirenone 20/3000ug (low dose – Yaz) or 30/3000ug (standard dose – Yasmin) oral OD
  • Spironolactone 50mg oral BD (teratanogenic so needs OCP)
• Metformin 500mg oral BD or TDS (2nd line)
• Mental health Rx for issues relating to hirsutism, weight and sub-fertility
• IVF

HRT

1. Hormonal (CI > 60 and all the COCP MEC 4)
   1. With no uterus, continuous oestrogen
      1. Oestradiol 25-100ug/day patch topically (Estradot twice a week)
   2. Perimenopausal – continuous oestrogen + cyclical progesterone for 14 days
      1. Oestradiol 25-100ug/day patch topically (Estradot twice a week)
      2. Norethisterone (Primolut) 2.5-5mg oral OD for the same 14 days of cycle
   3. Postmenopausal – continuous oestrogen + progesterone
      1. Oestradiol+Norethisterone patch topically 50/140 (or 50/250)  (Estalis twice a week)
2. Local Topical Hormonal
   1. Oestradiol pessary (Vagifem) 10ug PV daily at bedtime for 2 weeks then twice a week
   2. Oestriol pessary (Ovestin) 0.5mg PV daily at bedtime for 2 weeks then twice a week
3. Non Hormonal
   1. Sylk vaginal lubricant
   2. Venlafaxine 37.5-75mg oral daily (for vasomotor symptoms)
   3. Stellate ganglion block
   4. CBT, mindfulness, hypnosis, weight loss, acupuncture

Bleeding

• Tranexamic acid 1-1.5g oral TDS
• NSAID – ibuprofen 400mg oral TDS
• Norethisterone 5mg oral BD days 5-26 (note must cover 21 days)
• COCP
• IUD – levonorgestrel-releasing IUD 52 mg (replace every 5 years)

Hyperemesis Gravidarum

• Diet and lifestyle advice to maintain hydration
• Metoclopramide (Maxolon) 10mg oral TDS (Cat A)
• Ondansetron (Zofran) 4-8mg oral TDS (Cat B1)
• Complementary:
  • Vitamin B6 + Doxylamine
  • Ginger
  • Acupressure on the wrist at the PC6 point
• Thiamine supplementation if prolonged vomiting to prevent Wernicke’s

Anti-D

• Women who are Rh -ve require anti-D with any sensitizing event ie miscarriage, termination + at 28/40 and birth.
  • 250 IU IM/IV < 12/40
  • 625 IU IM/IV > 12/40

Contraception

• COCP
  • Ethinyloestradiol/Levonorgestrel oral OD 20/100ug (low dose) 30/150ug (standard dose)
  • Ethinyloestradiol/Drospirenone oral OD  20/3000ug (low dose – Yaz) 30/3000ug (standard dose – Yasmin)
• Mini Pill (Progesterone only)
  • Levonorgestrel 30ug oral OD (must be taken within 3/24 of same time or 2/7 condoms) (Microlut)
  • Drospirenone 4mg oral OD (Slinda)
• Progesterone Depot
  • Medroxyprogesterone acetate 150mg/ml 1ml IM 3/12 +/- 14/7
• Implanon
  • Etonogestrel implant replaced every 3 years
• Mirena IUD
  • Levonorgestrel 52mg IUCD replaced every 5 years
• Morning After 
  • Morning after pills
    • Ulipristal acetate (Ellaone) 30mg oral stat (prescription) (5 day limit)
      • RU486 like SPRM (Selective progesterone receptor modulator) that is more effective than levonorgestral
    • Levonorgestral 1.5mg (Postinor) oral stat (3 day limit)
    • Repeat if vomit < 3 hours
  • Copper IUD
• Non-pharmacological considerations
  • Confidentiality
  • Sexually transmitted infections
  • Future contraception plans
  • Safeguarding, rape and abuse

STDs

LetThemKnow.org.au

• Anonymous text based contact

Syphilis

• Early – Benzathine benzylpenicillin 2.4 million units intramuscularly stat
  • Doxycycline 100mg BD 14/7 (non pregnant)
• For late latent syphilis Benzathine benzylpenicillin weekly for 3 weeks
  • Doxycycline for 28/7

HIV

• eTG: Tenofovir alafenamide/Emtricitabine/Bictegravir (Biktarvy) 25 mg+200 mg+50 mg orally
• WHO: Tenofovir(TDF)/Lamivudine(3TC)/Dolutegravir(DTG)
• PEP: TDF/Emtricitabine +/- Dolutegravir oral 4/52
• PREP Tenofovir/Emtricitabine 300/200mg oral OD (Truvada)
  • Check HIV status and eFGR (+/- ACR) before starting

Herpes simplex 1 & 2

• Initial: Aciclovir 400mg oral TDS for 10/7
• Episodic: Aciclovir 800mg oral TDS for 2/7
• Suppressive: Aciclovir 400mg oral BD

Pelvic Inflammatory Disease (PID)

• Ceftriaxone 500g IM or IV stat plus
• Metronidazole 400mg oral BD for 14/7 plus
• Doxycycline 100mg oral BD for 14/7 or if pregnant
  • Azithromycin 1g oral stat + 1g @ 7/7

Neisseria gonorrhoeae

• Ceftriaxone 500g IM or IV stat plus
• Azithromycin 1g oral stat (2g for pharangeal infection)

Chlamydia trachomatis

• Doxycycline 100mg oral BD for 7/7
  • 21/7 if rectal
•  Azithromycin 1g oral stat (pregnant women)

Mycoplasma genitalium

• Doxycycline 100mg oral BD for 7/7 followed by
• Azithromycin 1g oral day 1, then 500mg on days 2 and 3
  • Moxifloxacin 400mg oral OD for 7/7 if resistance to macrolides

Gardnerella vaginalis (Bacterial Vaginosis)

• Metronidazole or Tinidazole 2g oral stat
• Can use topical metronidazole

Trichamonas vaginalis

• Metronidazole or Tinidazole 2g oral stat

Donovanosis (Klebsiella granulomatis)

• Azithromycin 500mg oral OD for 7/7

Candida albicans (Candidiasis/Thrush)

• Clotrimazole 500mg pessary PV stat at bedtime
• Fluconazole 150mg oral stat  (not for pregnant women)
• For non responding/severe use both the above for 4 days

Gastroenterology

IBS

• Abdominal Pain
  • Peppermint oil (Mintec) 0.2ml/cap 1-2 caps oral TDS
  • Hyoscine butylbromide (Buscopan) 20mg oral QID PRN
• IBS-D
  • Amytryiptyline 10-50mg oral nocte
• SIBO
  • Rifaximin 550mg oral TDS for 10-14/7
  • Neomycin 500mg oral BD for 10-14/7
  • Metronidazole 400mg oral TDS for 10-14/7

Ulcerative Colitis

• 5-aminosalicilates ie Mesalazine and Sulfasalazine
• Corticosteroids
• Immunosuppressives
  • Thiopurines
    • Azothioprine
    • 6-Mercaptopurine
  • Ciclosporin (short term)
• Biologics
  • TNFα inhibitors
    • Infliximab (Remicade)
    • Adalimumab (Humira)
• Avoid anti-diarrhoeal and anticholinergics -> toxic megacolon
• Smoking protective (unlike Crohn’s)

Induction 

• Mesalazine (Salofalk) 1-4g rectal (divided or single daily)
• +
• Mesalazine (Salofalk, Mezovant) 2-4.8g oral (divided or single daily)

Acute

• Hydrocortisone 100mg IV 6/24

Salvage

• Infliximab (Remicade)
• Ciclosporin

Crohn’s Disease

Treatment is similar to UC with the following variations:

• 5-aminosalicilate enemas are rarely indicated (oral is used)
• Steroids are first line for induction
• Methotrexate maintenance 10-25mg s/c or IM weekly
  • +/- Folic acid rescue 5-10mg oral the day after (eTG)
• Smoking makes Crohn’s worse (cf UC)

GORD

• Trial magnesium hydroxide + aluminium hydroxide 10-20ml oral PRN then, if that fails
• Esomeprazole 20mg oral OD 1/2 hour before a meal PRN
• Look to stop by 8 weeks
• If not settled Esomeprazole 20mg BD is more effective than 40mg OD
• Laproscopic fundoplication can be considered

Helicobacter

• Triple therapy with Nexium HP7 for 7-14 days:
  • Esomeprazole 20mg oral BD 7/7
  • Amoxicillin 1g oral BD 7/7
    • Metronidazole 400mg oral BD 7/7 if penicillin allergic
  • Clarithromycin 500mg oral BD 7/7
• NB: Check for cure in 4+ weeks with urea breath test of faecal antigen

Constipation

1. Psyllium husk (Metamucil) up to 3 times a day
2. Macrogol 3350 (Movicol, Osmolax) up to 3 sachets per day
   1. Kids –  lactulose 1-3ml/kg up to max of 60ml
3. Docusate+Senna (Coloxyl and Senna) up to 4 tablets per day
   1. Kids – Bisacodyl 5-10mg nocte
4. Glycerine suppositories
5. Microlax enema
6. Fleet enema
7. NB With opioids need apperients

Pseudomembanous Colitis (C.diff)

• Metronidazole 400mg oral TDS for 10/7

Gastroenteritis

• Children
  • Weight based Ondansetron 2/4/8mg to facilitate fluids
  • 10ml/kg/hr oral rehyration fluid in small aliquots
• Adults
  • For severe disease – Azithromycin 500mg oral OD for 3/7 (alternatives are Ciprofloxacin and Norfloxacin)

Diarrhoea (Functional)

• Loperamide (Imodium, Gastro-Stop) 2mg oral up to 4 times a day

Diarrhoea (Bile Salt ie post cholecystectomy)

• Cholestyramine 4-8g oral BD

Diarrhoea (Travellers)

• Loperamide (Imodium, Gastro-Stop) 2mg oral 2 stat then 1 after each loose motion (max 8/day)
  • Not if bloody stools
• Azithromycin 1g oral stat (treat daily for 3/7 if severe)
• Alt – Norfloxacin 800mg oral stat (400mg BD for 3/7 if severe)

Giardia

• Tinidazole 2g oral stat
• Alt Metronidazole 2g oral OD 3/7

Diverticulitis (Uncomplicted)

• If patient is immunocompromised, right sided pain, or failed to improve after 72 hours conservative Rx (clear fluids)
• Amoxicillin+Clavulanate 875/125mg one oral BD for 5/7
  • Penicillin allergy
    • Trimethoprim/Sulfamethoxazole 160/800mg oral BD for 5/7
    • +
    • Metronidazole 400mg oral BD for 5/7

Alcohol

Non-drug

• FLAGS or FRAMES
• Motivational interviewing
• CBT
• Alcoholics Anonymyous (AA) or SMART Recovery

Acute

• Diazepam 10-20mg every 1-2 hours
• Thiamine 100-300mg oral daily

Chronic

• Naltrexone 50mg oral daily
• Acamprosate 333mg ii oral TDS
• Disulfiram 250mg oral daily
• Baclofen 5-20mg oral TDS (TGA warning not to use)

Eye

Periorbital (pre-septal) cellulitis

• Usual S.aureus Rx – Flucoxacillin, Cefalexin, Clindamycin
  • Augmentin if H.influenzae vax not UTD
  • Bactrim or Clindamycin if MRSA suspected
• Flucloxicillin 500mg oral QID for 7/7
  • Cefalexin 500mg QID and Clindamycin 450mg TDS for 7/7 are alternatives for allergy
  • Hib risk – Amoxicillin/Clavulanate 875/125mg BD or Cefuroxime 500mg BD for 7/7
  • MRSA – Trimethoprim/Sulfamethoxazole 160/800mg oral BD for 7/7
• IV for serious
  • Flucloxicillin 2g QID
  • Cefazolin 2g TDS  or Clindamycin 600mg TDS for 7/7
  • Hib risk – Ceftriaxone 1g OD 7/7
  • MRSA – Vancomycin

Orbital cellulitis

• Need inpatient IV Rx and total Rx for 10-14/7
• Ceftriaxone 2g OD + Flucloxicillin 2g QID initially
• Change to oral Augmentin/Keflex/Clindamycin/Bactrim for discharge

Conjuctivitis

• Allergic
  • Topical antihistamine and mast cell stabilisers (1 drop BE BD)
    • Azalastine (Eyezep),
    • Ketotifen (Zaditen)
    • Olopatadine (Patanol),
  • Topical antihistamine Levocabastine (Zyrtec, Livostin)
  • Topical vasoconstrictor Naphazoline
  • Oral Loratidine
• Viral
  • No role for chloramphenicol drops
• Bacterial
  • General – Chloramphenicol 0.5% eye drops BE QID for up to 7/7
  • Chlamydia (including Trachoma) – Azithromycin 1g stat (neonates 20mg/kg for 3/7)
  • Gonnococcal – Ceftiaxone 1g IM stat (or 50mg/kg for < 20kg)
    • + Chlamydia coinfection common so always (eTG) add Azithromycin

Corneal FB/Abrasion

• Chloramphenicol 0.5% 1 drop to affected eye QID

Keratitis

• Bacterial (Psudomonas, Staph, Strep) – Ciprofloxacin 0.3% 1 drop to affected eye every 1/24 and urgent referral
• Note: Pseudomonas is NOT sensitive to chloramphenicol and is associated with contact lens wear and can lead to perforation within 3 days so urgent referral must be considered if corneal defect present.
• Herpes Simplex – Aciclovir 3% to affected eye 5 times a day 14/7 or 3/7 after healing (whichever shorter)
• Herpes Zoster – Valaciclovir 1g oral TDS (or Aciclovir 800mg oral 5 times a day) for 7/7
  • Note that topical aciclovir has no role treating herpes zoster opthalmicus
  • Use IV aciclovir for immunocompromised

Blepharitis

• Anterior Blepharitis
  • Warm compresses and cleaning
  • Chloramphenicol ointment BE BD 1-2/52
• Posterior Blepharitis (associated with rosacea)
  • Doxycycline 100mg OD -> 50 mg OD for 8/52 minimum
    • Pregnant or breastfeeding – Erythromycin 500mg oral OD for 8/52
  • Mild topical steroid (opthamology guidance)

Dacryocystitis

• Keflex 500mg oral QID
• Crigler massages

Open Angle Glaucoma

• Latanaprost (Xalatan) 1 drop BE nocte
• Timolol 1 drop BE BD
• Latanaprost+Timolol (Xalacom) 1 drop BE OD

Closed Angle Glaucoma

• Pilocarpine + Timolol + Acetazolamide
• Laser peripheral iridotomy

Macular Degeneration

• Vitamins A C E Zn and beta carotene (dry)
• VEGF modulator – Ranibizumab (wet)

Endocrine

SIADH

• Fluid restriction 1L/day

Diabetes Insipidus

• Desmopressin 100ug oral BD to TDS

Phaeochromocytoma

• Prazosin 0.5-5mg oral BD (must be established before beta blockers)
• Metoprolol 50mg oral BD

Primary Hyperaldersteronism

• Spironolactone 25mg oral od (or) 
• Amiloride 5mg oral bd (to avoid anti-androgenic effects or spironolactone causing ED and gynaecomastia)

Adrenal Insufficiency

Primary adrenal insufficiency (damage to adrenals) = Addison’s disease

Acute

• 2L Normal saline stat
• 100mg IV Hydrocortisone

Chronic

• Hydrocortisone 10mg mane, 5mg midi, 2.5mg nocte
• Fludrocortisone 0.1mg mane

Acute Illness

• Double or triple hydrocortisone (not fludrocortisone)

Type 2 Diabetes

Biguanides

• Metformin Immediate Release 500-1000mg oral BD (2g max if eGFR > 60, or 1g max if eGFR 30-60)
  • increases insulin sensitivity and decreases glucose production by the liver. 
  • does not cause weight gain (and may cause some weight loss).
  • does not cause hypoglycaemia.
• Notable side effects of metformin:
  • Gastrointestinal symptoms, including pain, nausea and diarrhoea
  • Lactic acidosis (e.g., secondary to acute kidney injury, trauma, surgery)
  • Can lower B12 so check pre-treatment and annually
• Contraindications
  • eGFR < 30
  • liver failure, heart failure, excess alcohol

SGLT-2 Inhibitors

• Dapagliflozin (Forxiga) 10mg
  • The sodium-glucose co-transporter 2 protein is found in the proximal tubules of the kidneys. It acts to reabsorb glucose from the urine back into the blood.
  • SGLT-2 inhibitors block the action of this protein, causing more glucose to be excreted in the urine.
  • Loss of glucose in the urine lowers the HbA1c, reduces the blood pressure, leads to weight loss and improves heart failure
  • Can cause hypoglycaemia when used with insulin or sulfonylureas.
  • Also licensed for heart failure and chronic kidney disease.
• Notable side effects of SGLT-2 inhibitors include:
  • Glycosuria (glucose in the urine)
  • Increased urine output and frequency
  • Genital and urinary tract infections (e.g., thrush)
  • Weight loss
  • Diabetic ketoacidosis, notably with only moderately raised glucose
  • Lower-limb amputation
  • Fournier’s gangrene

Thiazolidinedione

• Pioglitazone (Actos)
  • increases insulin sensitivity and decreases liver production of glucose.
  • It does not typically cause hypoglycaemia.
• Notable side effects of pioglitazone include:
  • Weight gain
  • Heart failure
  • Increased risk of bone fractures
  • A small increase in the risk of bladder cancer

Sulfonylureas

• Gliclazide (Diamicron) MR oral 30-120mg OD
  • Sulfonylureas stimulate insulin release from the pancreas.
• Notable side effects of sulfonylureas:
  • Weight gain
  • Hypoglycaemia

DPP-4 Inhibitors and GLP-1 Mimetics

Incretins are hormones produced by the gastrointestinal tract. They are secreted in response to large meals and act to reduce blood sugar by:

• Increasing insulin secretion
• Inhibiting glucagon production
• Slowing absorption by the gastrointestinal tract 

The main incretin is glucagon-like peptide-1 (GLP-1). Incretins are inhibited by an enzyme called dipeptidyl peptidase-4 (DPP-4).

DPP-4 inhibitors

• Sitagliptin (Januvia) 100mg oral od (eGFR > 50), 50mg (eGFR 30-50), 25mg (eGFR < 30)
  • blocks the action of DPP-4, allowing increased incretin activity.
  • does not cause hypoglycaemia.
• Notable side effects of DPP-4 inhibitors:
  • Headaches
  • Low risk of acute pancreatitis

 GLP-1 mimetics

• Dulaglutide (Trulicity) 0.75mg s/c weekly increasing to 1.5mg
  • imitate the action of GLP-1.
• Notable side effects of GLP-1 mimetics:
  • Reduced appetite
  • Weight loss
  • Gastrointestinal symptoms, including discomfort, nausea and diarrhoea

Insulin

• Rapid-acting insulins – insulin aspart – (e.g., NovoRapid) start working after around 10 minutes and last about 4 hours.
• Short-acting insulins – regular (e.g., Actrapid) start working in around 30 minutes and last about 8 hours.
• Intermediate-acting insulins – insulin protamine – (e.g., Humulin N) start working in around 1 hour and last about 16 hours.
• Long-acting insulins – insulin glargine (e.g., Optisulin, Toujeo, Lantus) start working in around 1 hour and last about 24 hours or longer.
• Combinations insulins contain a rapid-acting and intermediate-acting insulin (Rapid:Intermediate).
  • Ryzodeg (30:70) insulin aspart : insulin degludec
  • Novomix 30 (30:70) insulin aspart : insulin protamine

Pregnancy

• Metformin and/or (no other orals can be used except glibenclamide)
• Insulin (usually needed if fasting BGL > 5.8)

Hypoglycaemia

• BSL < 4 – 15g glucose wait 15 minutes and review (more glucose or long acting carbohydrate)
• Glucagon 1mg s/c or IM (0.5mg < 25kg)

Diabetic Retinopathy

• Fenofibrate (Lipidil) 145mg oral daily (added to statin)
• Laser
• Macula oedema – Anti-VEGF injections and Intralesional steroids

Thyroid

Hyperthyroidism

• Propranolol 10-40mg oral BD
• Carbimazole 10-20mg oral BD
  • Risks agranulocytosis, liver injury

Hypothyroidism

• Thyroxine 1.6ug/kg oral daily (full replacement)
• 25-50ug oral daily adjusted every 4-8 weeks (care in elderly)

Subacute thyroiditis

• NSAID – Ibuprofen 200-400mg oral TDS
• Prednisolone 40mg oral OD taper over 2-4 weeks

ENT

Otitia Externa

Bacteria – S.aureus, Psudomonas

• Bacterial – Dexamethasone/Framycetin/Gramicidin (Sofradex) 3 drops BE TDS for 7 days
• Fungal – Flumetasone/Clioquinol (Locacorten) 3 drops BE BD for 7 days
• Both – Triamcinolone/neomycin/gramicidin/nystatin (Otacomb Otic) 3 drops BE TDS for 7 days

Oral

• Flucloxacillin 500mg oral QID + Ciprofloxacin 750mg oral BD for 7-10 days
• Penicillin allergy – Keflex 500mg oral QID or Clindamycin 450mg oral TDS for 7-10 days

Prevention

• Acetic acid/Isopropyl alcohol (Aqua ear)

Otitis media

Persistent Otitis Media with Effusion (Glue Ear)

• If present for > 3 months Amoxicillin TDS for 2-4 weeks
• Referral for grommets +/- adenoidectomy

Chronic Suppurative Otitis Media (CSOM)

• Weekly review
• Ciprofloxacin drops 0.3% 5 drops 3 times a day after mopping
  • Continue until ear dry for 3/7
• In AKT 2023.2 Prescription of Azithromycin 30mg/kg stat to a 3yo ATSI child was the answer desired (however this also noted Amoxicillin is first line and Azithromycin was because of a lack of refrigeration)
  • Azithromycin is repeated after a week
• Not settling after 4 months -> Trimethoprim/Sulfamethoxazole BD
• Hearing loss > 30dB -> Hearing aids

Acute rhinitis

• Nasal saline (Fess)
• Loratidine 10mg oral OD
• Azelastine 1mg/ml 1 spray BN BD
• Intranasal Steroids
  • Fluticasone furoate (Avamys) i-ii BN OD (> 2 years)
  • Mometasone (Nasonex) i-ii BN OD (> 3 years)
  • Beclomethasone (Beconase) 1-ii BN BD (> 6 years)
  • Budesonide (Rhinocort) i-ii BN BD (> 6 years)
• Azelastine + Fluticasone 1 spray BN BD (Dymista)
• Montelukast 5-10mg oral OD
• Ipratropium 44ug 2 sprays BN TDS
• Decongestants
  • Oxymetalazine
  • Pseudoephedrine
  • Use for > 3 days associated with Rhinitis Medicamentosa
• Immunotherapy

Acute rhinosinusitis

• Usually viral so supportive Rx
• Bacteria – S. pneumoniae, H. influenzae, M. catarrhalis
  • Amoxicillin, Cefuroxime, Doxycycline, Augmentin

Chronic rhinosinusitis (>12 weeks)

• Loratidine oral OD (not nasal antihistamine)
• Fluticasone nasal OD
• Montelucast oral OD
• Saline nasal irrigation
• Prednisolone (Medical polypectomy)

Tonsilitis

• Phenoxymethyl Penicillin 500mg oral BD for 10 days
  • Penicillin allergy – Azithromycin 500mg oral OD for 5/7
• NSAID/Paracetamol
• Prednisolone 50mg oral OD for 2/7

Meniere’s Disease

• Salt restriction 3g daily
• Hydrochlorothiazide 25-50mg oral OD

Vestibular Suppressant

• Prochlorperazine 12.5mg IM, followed by 5-10 QID
• Diazepam (preferred) 5-10mg IM, followed by 5mg TDS

Respiratory

Pneumonia

Mild CAP

• Amoxicillin 1g oral TDS (if typical pneumonia suspected)
  • Cefuroxime 500mg oral BD (for penicillin allergy)
• Doxycycline 100mg oral BD (if atypical pneumonia suspected)
• Start with monotherapy and review in 48 hours (amoxicillin is drug of choice due to increasing resistance of S.pneumoniae to doxycycline)
• If not improving Amoxicillin + Doxycycline
• May give both if follow up potentially problematic
• Duration 5-7 days

Moderate CAP

• Benzylpenicillin 1.2g IV QID plus
  • Ceftriaxone 1g IV OD (for penicillin allergy)
• Doxycycline 100mg oral BD
• + Oseltamivir 75mg BD  (when admitted during influenza season) for 5/7

Severe CAP

• Ceftriaxone 2g IV OD plus
• Azithromycin 500mg IV OD

• Children:
  • Mild: Amoxicillin oral TDS
  • Moderate: Amoxicillin oral TDS
  • Severe: Ceftriaxone IV
  • Can use Doxycycline BD as alternative if allergy
• Adults
  • Mild: Amoxicillin oral TDS (can be + Doxycycline if follow up @ 48 hours uncertain)
  • Moderate: Benzylpenicillin IV 6/24 + Doxycycline 100mg oral BD
  • Severe: Ceftriaxone IV + Azithromycin IV

Legionnaires

• Azithromycin 500mg oral/IV OD preferred to Doxycycline but for exam Doxycycline 100mg BD works.

Croup (6 months – 6 years)

Mild/Moderate

• Prednisolone 1mg/kg oral stat (max 50mg)

Severe

• Adrenaline neb 5ml 1:1000, repeat after 30 minutes
• Prednisolone 2mg/kg oral stat (max 50mg) with 1-2mg/kg 24 hours later
• Urgent transfer to hospital
• At least 4 hours observation, stridor free for discharge

COPD

1. First line
   1. SABA – Salbutamol 100ug pMDI 1-2 PRN
2. Second line
   1. LAMA – Tiotropium, aclidinium, gyycopyronium, umeclidinium 62.5 OD (Incruse Elipta)
   2. LABA – Salmeterol, Indaceterol, Formoterol 6-12 mg OD-BD (Oxis)
3. Combined LAMA/LABA
   1. Umeclidinium/Vilanterol 62.5/25mcg OD (Anoro Ellipta)
4. Triple therapy ICS/LAMA/LABA
   1. Fluticasone furoate/ umeclidinium/vilanterol 100/62.5/25 (Trelegy Ellipta)
5. Oxygen
   1. PaO2 <55 mmHg or
   2. PaO2 <59 mmHg + polycythaemia, pulmonary H/T or RHF

COPD (Acute Exacerbation)

1. SABA + SAMA ie Salbutamol + Ipratropium
   1. Salbutamol 100ug pMDI – 8; Ipratropium 21ug pMDI – 4 (as effective as nebs when delivered by spacer)
   2. Salbutamol/Ipratropium 5mg/500ug nebs
2. Prednisolone 30-50mg daily for 5 days
3. Amoxicillin 500mg oral TDS or Doxycyline 100mg oral daily for 5 days (if sputum change, fever)
4. Oxygen to get Sa02 88-92%
5. Non invasive ventilatory support (PaCO2 > 45, pH < 7.35)
6. Post event -> pulmonary rehabilitation referral ASAP

Asthma Chronic

Child 1-5

1. Step 1
   1. Salbutamol 100ug 2-6 inhalations pMDI via spacer
2. Step 2
   1. Fluticasone propionate 50-100ug pMDI via spacer BD (only steroid for 1-5 year olds)
3. Step 3
   1. 125ug fluticasone propionate BD (high dose is > 200 daily, max 500)
4. Step 4
   1. add Montelukast to 50-100ug fluticsone BD and/or
   2. Refer for specialist advice

Child 6-11

1. Step 1
   1. Salbutamol 100ug 2-12 inhalations pMDI via spacer
2. Step 2
   1. Fluticasone propionate 50-100ug pMDI via spacer BD OR
   2. Budesonide 100-200ug via DPI BD OR
   3. Montelucast 5mg oral OD
3. Step 3
   1. Moderate dose ICS 125-250ug fluticasone propionate BD OR Budesonide 300-400ug via DPI BD OR
   2. Low dose ICS + Montelukast (from step 2) OR
   3. Fluticasone+Salmeterol (Seretide) 100/50 pMDI via spacer of DPI BD
4. Step 4
   1. Add montelucast 5mg to step 3

Child over 12

• Essentially treat as an adult
• Budesonide+Fometerol (Symbicort) 100/3 or 200/6 BD + as reliever (rather than SABA) * not PBS approved for < 12

Asthma exacerbation (plan)

• Double/Quadruple up on Preventer
• Prednisolone 1mg/kg oral daily for 3-5 days
• Hospital if not improving

Pregnancy

• Budesonide and Salbutamol are Category A.
• Fluticasone and LABAs are B3 but can be used if required.

Asthma – Acute (Primary)

Mild (SaO2 > 94% speaking in sentences)

• Salbutamol 100ug pMDI via spacer (+ mask for infants)
  • 1-5 years 2-6 puffs
  • 6+ years 4-12 puffs

Severe (SaO2 90-94, not full sentences)

• Salbutamol 100ug/actuation pMDI via spacer (+ mask for infants)
  • 1-5 years 6 puffs
  • 6+ years 12 puffs
• Ipratropium 21ug/actuation pMDI via spacer (+mask for infants)
  • 1-5 years 4 puffs
  • 6+ years 8 puffs
• Nebulised salbutamol+ipratropium
  • 1-5 years 2.5mg/250ug
  • 6+ years 5mg/500ug
• Oxygen (intranasal) titrated to SaO2 95%+ in kids (<12) or 93-95% in adults

Life Threatening (SaO2 < 90, drowsy, exhausted)

• Nebulised salbutamol+ipratropium
  • 1-5 years 5mg/250ug
  • 6+ years 10mg/500ug
• Oxygen (intranasal) titrated to SaO2 95%+ in kids (<12) or 93-95% in adults
• NPPV or Intubate and Ventilate (if required)
• Consider adrenaline
• Urgent transfer

Asthma – Acute (Secondary Assessment)

In the first 1 hour

Mild and Moderate – repeat above Rx every 20 minutes

Severe – continuous nebs

IV or Oral Corticosteroid (ASAP)

• Oral Prednisolone 50mg (1mg/kg) for 3-5 days (kids) and 5-10 days (adults)
• IV Hydrocortisone 100mg (4mg/kg) 6 hourly on day 1, then BD on day 2 and OD on day 3 (no taper for adults)

IV MgSO4 – 10mmol over 20/60 (0.1-0.2mg/kg)

Consider IV adrenaline, salbutamol, aminophylline

NB Salbutamol is relatively safe but can cause metabolic acidosis, low K, low Mg, long QT, arrhythmias, AMI

After the first 1 hour

• Post Acute Care (includes education, pMDI training, asthma plan, follow up, 4x4x4 method, and 3 days prednisolone)
• Discuss/Transfer

Dermatology

Head Lice

• Permethrin 1% topical – leave on for 10 minutes. Repeat in 1 week (? still available)
• Ivermectin

• Mild:
  • Hydrocortisone 1% cream
• Moderate:
  • Triamcinolone 0.02% (Aristocort) – cream and ointment
  • Betamethasone valerate 0.02% (Betnovate 1/5) – cream only
  • Betamethasone valerate 0.05% (Betnovate 1/2) – cream and ointment
• Potent:
  • Methylprednisolone 0.1% (Advantan) – cream and ointment
  • Mometosone 0.1% (Elocon, Novasone) – cream and ointment
  • Betamethasone valerate 0.1% (Betnovate) – cream and ointment
  • Betamethasone diproprionate 0.05% (Diprosone) – cream and ointment
• Ultrapotent:
  • Betamethasone diproprionate 0.05% (Diprosone OV)