High risk drug is exceptionally important in your revision for your preregistration exam. High-risk drugs are those that have a potential high risk of causing substantial harm or even death if used inappropriately. Hence special safeguards are in place to minimize the occurrence of errors. High-risk drugs can be classified by a Menominic to help you remember.  A PINCH list:


Potassium and concentrated electrolytes


Narcotics and sedatives

Chemotherapy agents

Heparin and other anticoagulants

These drugs fall under the category of either narrow therapeutic drugs or drugs with serious adverse effects. Pharmacists have a role to assure medications are administered safely and effectively, this is carried out by informing patients of signs of toxicity and providing advice on how to avoid this occurring. A list of few drugs that are encountered on a day-to-day basis are listed below, with the appropriate counselling that could be provided.


Toxicity Monitoring Counseling

Narrow Therapeutic range

  • Nausea and vomiting
  • Abdominal pain
  • Bradycardia
  • Delirium
  • Visual disturbance
  • Digoxin plasma levels 6 hours after loading dose and when stable every 4 to 6 months
  • U&E’s especially K
  • ECG
  • Kidney Function test
  • Do not stop abruptly
  • Take it the same time each day
  • Maintain adequate Potassium intake (as hyperkalaemia predisposes to toxicity)
Lithium (0.4 -1mmol/L)
  • Loss of appetite
  • Ataxia
  • Rolling of the eyes
  • Drowsy
  • Lithium serum levels every week until steady, then in every 3 months
  • Kidney function tests
  • WBC
  • Thyroid test
  • U&E’s especially Na+
  • Drink adequate amount of fluids, avoid any dietary changes which increase or decrease Na+  (pasta, bread, cheese and sandwiches)
  • In hot weather drink more fluids
  • Report polyuria, polydipsia, vomiting and nausea

Serious adverse effects 

  • Amiodarone levels
  • LFT
  • Thyroid tests
  • BP/Pulse
  • ECG
  • Chest scans
  • Avoid Grapefruit juice
  • If you develop photosensitivity, you should cover arms and legs, wear suitable hats and apply a total sun block to exposed areas of the skin
  • Do not stop abruptly


  • Bleeding and bruising
  • Rash
  • Alopecia
  • Diarrhea and vomiting
  • INR every day for the first week, then once a week until stable, and then very three months
  • Warfarin should be taken once a day usually at around 6pm
  • Warfarin takes 3-5 days to have an effect
  • Do not make changes to diet especially green vegetables.
  • Avoid cranberry juice and drink alcohol in moderation
  • Before taking OTC medication please consult with the pharmacist.
  • Bruising
  • Nausea
  • Rash
  • MXT levels
  • Hb, MCV, WBC, Platelets- Neutrophils, lymphocytes
  • ALT/AST, creatinine, CRP, ESR/PV
  •  PIIINP* (MXT specific)
  • Once a week, same day same time afterfood
  • Take folic acid once a week but on a different day to Methrotrexate
  • Avoid NSAIDS, Co-trimazole and trimethoprim
  • Take with caution: unpasterizured milk and soft cheese
  • Can not have live vaccines
  • GO TO THE DOCTOR IF: sore throat, other infections, fevers, chills, mouth ulcers, easy bleeding, bruising, dirrhoea, vomiting, rash and breathlessness
  • Hypoglycaemia
  • Glucose plasma levels
  • Blood pressure
  • Cholesterol levels
  • Foot checks
  • Eye checks
  • Take the injection at the same time every day
  • Change the site of injection
  • Signs of hypoglyceamia; shaking, sweating, shivering, thirst, hunger and confusion: take rapid acting carbohydrate, immediately followed by slow release carbohydrate




1. http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+topics/medicines+and+drugs/high+risk+medicines

  1.  http://www.ismp.org/tools/institutionalhighAlert.asp

  2.  http://www.pharmacymag.co.uk/ezines/PM_Sep10_HighRisk.pdf

  3.  http://medimoon.com/2013/04/counseling-parameters-for-theophylline/

  4.  http://www.nhs.uk/medicine-guides/pages/MedicineOverview.aspx?condition=Heart%20rhythm%20disorders&medicine=Amiodarone&preparationAmiodarone%20100mg%20tablets

  5.  http://diabetes.niddk.nih.gov/dm/pubs/hypoglycemia/

  6.  BNF 66

10. http://www.bad.org.uk/site/1121/default.aspx