Adult Internal Medicine: Pharmacology, Toxicology and Addiction Medicine

Presentations

• Coma
• Delirium (agitated or hypoactive)
• Seizures
• Associated with adverse drug interactions:
  • acid-base and electrolyte disorders
  • anaphylaxis
  • arrhythmias
  • constipation
  • cutaneous reactions
  • diarrhoea
  • gastrointestinal bleeding
  • hypo- and hyperglycaemia
  • hypotension
  • mental state changes
  • movement disorders
  • nausea
  • renal impairment
  • rhabdomyolysis
  • vomiting

Conditions

• Acute and chronic effects, including overdose, from the use of:
  • alcohol
  • amphetamines
  • benzodiazepines and Z-drugs
  • cannabis
  • cocaine
  • ecstasy
  • opioids
• Adverse drug reactions from:
  • antiarrhythmics
  • antibiotics
  • anticonvulsants
  • anticoagulants
  • antidepressants
  • chemotherapy
  • non-steroidal anti-inflammatories
• Poisoning from:
  • antidepressants
  • antidiabetic medicines
  • antihypertensives
  • antipsychotics
  • digoxin
  • paracetamol
  • sedatives
• Substance use disorder, including relapse prevention and acute withdrawal from:
  • alcohol
  • benzodiazepines and Z-drugs
  • nicotine
  • opioids
• Toxidromes:
  • anticholinergic
  • cholinergic
  • hallucinogenic
  • opioid
  • sedative-hypnotic
  • serotonin syndrome
  • sympathomimetic
  • withdrawal

For each presentation and condition, Basic Trainees will know how to:

Synthesise

• recognise the clinical presentation
• identify relevant epidemiology, pathophysiology, and clinical science
• take a relevant clinical history
• conduct an appropriate examination
• establish a differential diagnosis
• plan and arrange appropriate investigations
• consider the impact of illness and disease on patients¹ and their quality of life

Manage

• provide evidence-based management
  For less common or more complex presentations and conditions the trainee must also seek expert opinions
• prescribe therapies tailored to patients’ needs and conditions
• recognise potential complications of disease and its management, and initiate preventative strategies
• involve multidisciplinary teams

Consider other factors

• identify individual and social factors and the impact of these on diagnosis and management

Presentations

• Unusual (idiosyncratic, Type B) adverse drug reactions, e.g. Stevens-Johnson Syndrome
• Poisonings:
  • carbon monoxide
  • insect stings
  • pesticides
  • salicylates
  • snake bites
  • spider bites

Conditions

• Life-threatening adverse drug reactions causing:
  • cardiac arrhythmias, such as, tachy and brady arrhythmias or cardiac conduction blocks
  • cardiac failure
  • neutropaenia
  • QT prolongation
  • respiratory depression
  • seizures

For each presentation and condition, Basic Trainees will know how to:

Synthesise

• recognise the clinical presentation
• identify relevant epidemiology, pathophysiology, and clinical science
• take a relevant clinical history
• conduct an appropriate examination
• establish a differential diagnosis
• plan and arrange appropriate investigations
• consider the impact of illness and disease on patients¹ and their quality of life

Manage

• provide evidence-based management
  For less common or more complex presentations and conditions the trainee must also seek expert opinions
• prescribe therapies tailored to patients’ needs and conditions
• recognise potential complications of disease and its management, and initiate preventative strategies
• involve multidisciplinary teams

Consider other factors

• identify individual and social factors and the impact of these on diagnosis and management

• Accepted healthy alcohol intake according to sex, age, and pregnancy and lactation status
• Categories of drug safety in pregnancy and their impact on prescribing
• Common drug-drug interactions between prescription medications, non-prescription medications, and complementary therapies
• Interpretation of the results of clinical trials involving medicines
• Key neurotransmitters and their actions
• Mechanism of action at the receptor and intracellular level, adverse effects, interactions, and pharmacokinetics of common types of:
  • analgesics
  • antiarrhythmics
  • antiasthmatics
  • anticoagulants
  • antidepressants
  • antidiabetics
  • antihypertensives
  • antimicrobials
  • antipsychotics
  • benzodiazepines
  • chemotherapeutics
  • diuretics
  • immunosuppressants
• Effect of liver failure, renal failure, critical illness, ageing and pregnancy on pharmacokinetics, and the need for dose adjustment in these circumstances
• Empiric antimicrobial therapy with appropriate agent (considering antimicrobial spectrum) and dose, taking patient factors into consideration, such as age, history of adverse drug reactions, comorbid conditions and medications, and local or national guidelines
• Medication adherence:
  • factors affecting adherence
  • strategies to improve adherence
• Non-pharmacological alternatives to psychotropic medication
• Pharmacotherapy in pain management and the safe prescribing of opioids
• Principles of pharmacology and pharmacokinetics:
  • absorption
  • bioavailability
  • delivery techniques, such as oral, intravenous, transdermal
  • excretion
  • mechanisms of action
  • dose-response relationship
  • metabolism, including genetic factors and drug–drug interactions of cytochrome P450 enzymes
• Substance use disorders:
  • definitions and epidemiology of substance use disorders, including prevalence and age of onset
  • principles of the neurobiology of addiction and tolerance
  • principles of addiction treatment including withdrawal management and relapse prevention
  • principles of harm reduction

Investigations

• Liver function and impact on drug clearance
• Renal function and impact on drug clearance
• Specific electrocardiogram changes in drug toxicity

Clinical assessment tools

• Mental state examination
• Pain scoring tools
• Screening for substance misuse and conducting brief interventions to reduce harm from drug, alcohol, or cigarette use
  • Therapeutic drug monitoring, including:
    • indications for monitoring plasma concentrations, the importance of understanding the therapeutic range, and how to respond to concentrations outside that range
    • identification of adverse reactions
    • monitoring for common adverse drug reactions
    • monitoring of renal or hepatic function
    • specific drug concentrations and their interpretation, including digoxin, lithium, antibiotics, and anticonvulsants
  • Withdrawal scales for:
    • alcohol
    • opioids

• Best practice for self-monitoring the effect of medicines prescribed for treating chronic disease, such as diabetes, hypertension, and respiratory disease
• Ethics and consent processes associated with using therapies ‘off label’
• Indications and methods for use and interpretation of withdrawal scales for alcohol and opioids relevant to settings
• Legislation regarding prescribing of controlled and restricted drugs
• Medication safety:
  • antimicrobial stewardship
  • assessment of likelihood of an adverse drug reaction (including allergy), for example using of the Naranjo Scale
  • factors predisposing to polypharmacy including the ‘therapeutic cascade’ and the process for deprescribing
  • factors increasing risk of error:
    • dispensing
    • dose selection
    • medicine selection
    • transcription
  • prescribing in special populations, relating to age, pregnancy, renal impairment, liver failure, or critical illness
  • risk-benefit analysis for prescribing anticoagulants
• Obtaining accurate medication history, including drug allergies and complementary and alternative medicines
• Patient factors impacting on prescribing, such as adverse drug reactions, age, and pregnancy
• Phases of drug development
• Recognition that an adverse drug reaction may contribute to the differential diagnosis
• Regulatory and funding frameworks in which medicines are made available