Safe Prescribing in Special Populations

How to estimate renal function for drug dosing, which drugs to avoid or adjust in chronic kidney disease, how to recognise nephrotoxic combinations and apply sick-day rules, and how to prescribe when the liver is impaired. Uses British National Formulary dosing and UK guidance; practice varies by region and formulary.

1. Estimating Renal Function and Applying It to Drug DosingPreview

   This lesson explains how creatinine clearance and estimated glomerular filtration rate are calculated, why UK drug dosing usually relies on Cockcroft-Gault creatinine clearance or a product-specific estimate, and where creatinine misleads in frail, cachectic or acutely ill patients. It then shows how to turn an estimate into a practical dose decision for renally cleared drugs, covering loading and maintenance doses, monitoring, and how to document which estimate was used.

   10 min
2. Drugs to Avoid or Adjust in Chronic Kidney Disease, Nephrotoxic Combinations and Sick-Day Rules

   This lesson builds on estimating renal function and shows how to apply it when prescribing for adults with chronic kidney disease. It covers the main drug classes that commonly need dose reduction or avoidance, including anticoagulants, opioids, antidiabetics and antivirals. It also examines common nephrotoxic combinations and the sick-day rules used to hold selected medicines during acute illness such as vomiting, diarrhoea or dehydration. The emphasis is on UK practice, using British National Formulary dosing and NICE-style guidance, while noting where practice varies by region or formulary.

   10 min
3. Prescribing in Liver Disease: Hepatic Impairment, Child-Pugh Scoring and Drugs to Avoid in Cirrhosis

   Liver disease alters drug handling in several ways at once: reduced hepatic blood flow and enzyme capacity, changed plasma protein binding, and portosystemic shunting that bypasses first-pass metabolism. This lesson explains how those changes translate into prescribing decisions for a patient with cirrhosis or acute liver injury. It covers the Child-Pugh and MELD scores, why they are prognostic tools rather than validated dose-adjustment guides, drugs that should be avoided or used cautiously, paracetamol dosing in chronic liver disease, the risk of precipitating hepatic encephalopathy with sedatives and other central nervous system drugs, and the monitoring that should accompany treatment. Doses quoted in the lesson are teaching examples only; the platform's rules, the current formulary and local protocols decide whether a prescription is safe.

   10 min
4. Case: Acute Kidney Injury in an Older Patient with Diarrhoea
   20 min
5. Prescribing: Acute Gout in Chronic Kidney Disease: Choosing a Safe Anti-Inflammatory
   15 min
6. Prescribing: Recurrent hypoglycaemia in an older patient with renal impairment
   15 min
7. Prescribing: Pulmonary embolism in renal impairment
   15 min
8. Quiz: Renal and Hepatic Impairment: Prescribing Safely in Special Populations
   8 min

This module covers prescribing before, during and after pregnancy. It examines teratogenic risk and safer drug alternatives, the treatment of hypertension, infection and epilepsy in pregnancy, acute obstetric emergencies including severe pre-eclampsia and ruptured ectopic pregnancy, contraception counselling, and drug transfer into breast milk. Teaching reflects UK practice, British National Formulary dosing and NICE-style guidance, and notes where practice varies by region or formulary.

1. Teratogenic Drugs and Safer Alternatives: Principles of Prescribing in Pregnancy

   This lesson explains how teratogenic risk arises, why the first trimester is the most vulnerable period, and how to balance maternal benefit against fetal harm. It covers high-risk drugs including valproate, isotretinoin, methotrexate, warfarin, ACE inhibitors and ARBs, with safer alternatives and folic acid supplementation. It introduces the valproate pregnancy prevention programme, drug choice for epilepsy in pregnancy, and reliable information sources such as the BNF and UKTIS. The focus is on clinical reasoning for finals, the Prescribing Safety Assessment and foundation prescribing.

   10 min
2. Hypertension and Infection in Pregnancy: Choosing and Monitoring Treatment

   This lesson covers drug treatment for hypertension and common infections in pregnancy. It begins with chronic and gestational hypertension: when to start treatment and the target blood pressure ranges used in UK practice. Labetalol, nifedipine and methyldopa are compared for efficacy, adverse effects and monitoring, alongside drugs to avoid such as ACE inhibitors, angiotensin receptor blockers and atenolol. Low-dose aspirin for pre-eclampsia prevention is covered, including who to offer it to and when to start. The second half deals with urinary tract infection, distinguishing asymptomatic bacteriuria from symptomatic infection, and how antibiotic choice varies by trimester, particularly nitrofurantoin and trimethoprim. Safe options for common chest, skin and vulvovaginal infections are summarised.

   10 min
3. Emergencies and After Birth: Severe Pre-eclampsia, Ectopic Pregnancy, Contraception and Breastfeeding

   Severe pre-eclampsia, eclampsia and ruptured ectopic pregnancy are obstetric emergencies in which prescribing must be fast, accurate and safe. This lesson covers recognition of severe pre-eclampsia, the use of magnesium sulphate, and the choice of urgent antihypertensives with their maternal and fetal considerations. It then examines resuscitation and drug prescribing in a ruptured ectopic pregnancy with haemorrhagic shock. The second half moves to care after birth: contraception counselling, the combined oral contraceptive pill, preventing pregnancy when a teratogenic medicine is essential, and prescribing during breastfeeding. Doses given are teaching examples based on British National Formulary and NICE-style practice; local protocols and formularies vary. Content is for education and training, not a substitute for professional clinical judgment.

   10 min
4. Case: Severe Pre-eclampsia: A Case of Headache and Hypertension in Pregnancy
   20 min
5. Case: Ruptured Ectopic Pregnancy: A Case of Shock and Shoulder-Tip Pain
   20 min
6. Prescribing: Hypertension in pregnancy
   15 min
7. Prescribing: Symptomatic UTI in a 30-Week Pregnancy
   15 min
8. OSCE station: Counselling a 22-year-old woman starting the combined oral contraceptive pill
   11 min
9. Quiz: Pregnancy and Breastfeeding: Safe Prescribing in Special Populations
   9 min

This module covers prescribing for children, from calculating weight-based doses and selecting suitable formulations through to managing fever and pain, choosing antibiotics for common childhood infections, and recognising the child who is seriously unwell with sepsis, meningitis or dehydration. It prepares learners for the paediatric cases and prescribing activities that follow, in UK practice using BNF for Children dosing and NICE-style guidance.

1. Weight-Based Dosing and Paediatric Formulations: Getting the Dose and the Medicine Right

   Children are not small adults. Doses are usually calculated from body weight using the BNF for Children, sometimes from age bands or body surface area, and the formulation chosen matters as much as the number. This lesson covers how to read and apply weight-based dosing, when age or surface area applies instead, and how to choose between oral suspensions, dispersible tablets and other paediatric preparations. It examines concentration, excipients and palatability, dose-volume accuracy, tenfold and decimal-point errors, and the practical administration of oral medicines to infants and young children, including refusal of medicine and feeding tubes. It closes with the cross-checks that catch a wrong dose before it reaches the child.

   10 min
2. Fever, Pain and Common Childhood Infections: Analgesia and Antibiotic Choice

   This lesson covers the assessment and management of fever, pain and common infections in children. It begins with the NICE traffic light system for the febrile child and the age thresholds that change how urgently a child should be referred. It then examines paracetamol and ibuprofen in detail: weight-based dosing, dosing intervals, maximum daily doses, and the clinical situations in which ibuprofen is best avoided. The second half addresses antibiotic decision-making for acute otitis media, sore throat and tonsillitis, urinary tract infection and community-acquired pneumonia, including watchful waiting, delayed prescriptions, penicillin allergy, and the influence of local resistance patterns. Teaching doses given here are examples only; always check the current BNF for Children and your local formulary.

   10 min
3. Recognising the Seriously Unwell Child: Sepsis, Meningitis and Dehydration

   This lesson covers how to recognise a febrile child who is seriously unwell and what to do first. It reviews red flags including non-blanching rash, altered consciousness, poor perfusion, and abnormal respiratory rate, heart rate, temperature and capillary refill. Learners work through the immediate priorities for suspected sepsis and bacterial meningitis, including when time-critical intravenous antibiotics must be given and how to choose and dose them by weight. The lesson also covers assessing and correcting dehydration in gastroenteritis using clinical signs and fluid deficit calculations, and the criteria for escalating to senior or critical care. Teaching examples follow UK practice with British National Formulary for Children dosing and NICE-style guidance; local protocols and formularies vary, and the platform's prescribing rules, not the learner's memory, decide whether a prescription is safe.

   10 min
4. Case: A 6-week-old with fever and bulging fontanelle: a case of bacterial meningitis
   20 min
5. Case: Fever and Seizure in an 18-Month-Old
   20 min
6. Case: Dehydration in a 2-year-old with vomiting and diarrhoea
   20 min
7. Case: Jaundice in a 3-Day-Old Term Breastfed Baby: Assessment and Management
   20 min
8. Prescribing: Prescribing for a 2-Year-Old with Fever and Pain
   15 min
9. Prescribing: Acute Otitis Media in a 4-Year-Old: Antibiotic and Analgesic Prescribing
   15 min
10. Quiz: Paediatric Prescribing: Weight-Based Dosing, Fever, Infection and the Seriously Unwell Child
    8 min

This module covers the prescribing challenges that become common in older patients: polypharmacy, falls, anticholinergic burden, deprescribing, dangerous drug interactions, and the recognition, reporting and disclosure of adverse drug reactions and medication errors. It prepares learners for the Prescribing Safety Assessment and for safe practice in UK hospitals and community settings.

1. Polypharmacy, Falls and Anticholinergic Burden in Older People

   Older people hold a large share of all prescriptions, yet they are least able to tolerate the drugs they receive. This lesson explains how ageing alters pharmacokinetics and pharmacodynamics, why taking five or more medicines multiplies the risk of harm through interactions, prescribing cascades and adverse effects, and how cumulative anticholinergic load contributes to confusion, constipation, urinary retention and falls. It examines three drug groups that repeatedly cause falls in later life: antihypertensives, sedative-hypnotics and hypoglycaemics. You will work through structured medication review using tools such as STOPP/START, and practise shared decision making about stopping medicines, including how to withdraw safely, monitor and document. Practice varies by region: STOPP/START is widely used in Europe and the Beers criteria in North America, and local formularies and protocols always take precedence.

   10 min
2. Drug Interactions That Cause Serious Harm: Lithium, Digoxin and Azathioprine

   This lesson covers three high-risk drug interactions that can cause serious harm. It explains how ACE inhibitors, angiotensin receptor blockers, diuretics and NSAIDs raise lithium concentrations and can precipitate toxicity. It describes how bisoprolol, verapamil and amiodarone increase digoxin exposure and the risk of bradycardia and toxicity. It explains why allopurinol with azathioprine can cause severe myelosuppression. Using British National Formulary advice, it sets out monitoring, dose adjustment and when to avoid the combination, with a focus on older people with polypharmacy.

   10 min
3. Adverse Drug Reactions and Medication Errors: Recognition, Reporting and Open Disclosure

   Final lesson in the module. Teaches final-year medical and pharmacy students and foundation doctors how to separate an adverse drug reaction from a medication error, assess causality using structured questions, and report suspected reactions through the UK Yellow Card scheme. It then covers the professional duty of candour after a medication error, using a double insulin dose in an older inpatient as the worked example: recognise harm or near miss, apologise, explain, document, escalate and learn. Practice varies by region and employer policy; local incident reporting and safeguarding systems still apply.

   10 min
4. Case: Lithium Toxicity and ACE Inhibitor Interaction
   20 min
5. Case: Complete Heart Block in an 80-Year-Old on Digoxin and Bisoprolol
   20 min
6. Prescribing: Recurrent Falls in an 86-Year-Old Woman Taking Multiple Antihypertensives
   15 min
7. Prescribing: Urate-lowering therapy after a second gout flare in a patient on azathioprine
   15 min
8. OSCE station: Disclosure of a medication error: double insulin dose to a 70-year-old inpatient
   11 min
9. Quiz: Older People, Interactions and Adverse Reactions: Prescribing Safely in Later Life
   9 min