GPhC Clinical Therapeutics — Questions and Answers
Question 1: A 62-year-old patient with type 2 diabetes and an eGFR of 25 mL/min/1.73m² is currently taking metformin 1g twice daily. According to NICE guidelines, what action should be recommended?
- Continue metformin at the current dose as it remains effective
- Discontinue metformin as eGFR is below 30 mL/min/1.73m² (Correct answer)
- Increase the dose to improve glycaemic control
- Switch to gliclazide only if HbA1c is above 58 mmol/mol
Correct answer: Discontinue metformin as eGFR is below 30 mL/min/1.73m²
NICE guidelines and the BNF recommend that metformin should be reviewed when eGFR falls below 45 mL/min/1.73m², the dose reduced if eGFR is 30-45, and discontinued when eGFR falls below 30 mL/min/1.73m² due to the risk of lactic acidosis from impaired renal clearance.
Question 2: A patient is started on ramipril for hypertension. After two weeks, blood tests show a rise in serum creatinine of 35% from baseline. What is the most appropriate action?
- This is expected; continue ramipril and recheck in 3 months
- Stop ramipril immediately and investigate for renal artery stenosis (Correct answer)
- Reduce the dose by half and recheck in 2 weeks
- Add a calcium channel blocker to protect the kidneys
Correct answer: Stop ramipril immediately and investigate for renal artery stenosis
A rise in serum creatinine of more than 30% from baseline after starting an ACE inhibitor suggests possible renal artery stenosis and the drug should be stopped. A rise of up to 30% is considered acceptable and the drug can be continued with monitoring. This patient's 35% rise exceeds the acceptable threshold.
Question 3: Which antibiotic is recommended as first-line treatment for an uncomplicated lower urinary tract infection in a non-pregnant adult woman, according to NICE guidelines?
- Amoxicillin 500mg three times daily for 7 days
- Nitrofurantoin 100mg modified-release twice daily for 3 days (Correct answer)
- Ciprofloxacin 500mg twice daily for 3 days
- Co-amoxiclav 625mg three times daily for 5 days
Correct answer: Nitrofurantoin 100mg modified-release twice daily for 3 days
NICE recommends nitrofurantoin 100mg MR twice daily for 3 days (or trimethoprim 200mg twice daily for 3 days if low risk of resistance) as first-line for uncomplicated lower UTI in non-pregnant women. Fluoroquinolones should be reserved for more serious infections due to resistance concerns and side effects.
Question 4: A patient on long-term oral corticosteroids (prednisolone 15mg daily for 6 months) wants to stop the medication. What is the recommended approach?
- Stop immediately as corticosteroids can be discontinued at any time
- Gradually taper the dose to avoid adrenal crisis (Correct answer)
- Switch to inhaled corticosteroids before stopping
- Halve the dose for one week then stop completely
Correct answer: Gradually taper the dose to avoid adrenal crisis
Long-term corticosteroid use suppresses the hypothalamic-pituitary-adrenal (HPA) axis. Abrupt withdrawal can cause adrenal crisis, which can be life-threatening. Gradual dose reduction allows the adrenal glands to recover their ability to produce cortisol naturally.
Question 5: A 70-year-old patient with atrial fibrillation has a CHA₂DS₂-VASc score of 4. Which of the following is the most appropriate anticoagulation strategy according to NICE?
- Aspirin 75mg daily
- No anticoagulation needed at this score
- A direct oral anticoagulant (DOAC) such as apixaban or edoxaban (Correct answer)
- Clopidogrel 75mg daily
Correct answer: A direct oral anticoagulant (DOAC) such as apixaban or edoxaban
NICE recommends offering anticoagulation to patients with a CHA₂DS₂-VASc score of 2 or above. DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) are recommended as options. Aspirin monotherapy is no longer recommended for stroke prevention in atrial fibrillation.
Question 6: A patient taking simvastatin reports new-onset muscle pain and weakness. Their creatine kinase (CK) level is found to be 12 times the upper limit of normal. What is the most appropriate action?
- Reassure the patient that mild myalgia is common with statins
- Reduce the simvastatin dose and monitor symptoms
- Stop simvastatin immediately due to risk of rhabdomyolysis (Correct answer)
- Add coenzyme Q10 to manage the side effects
Correct answer: Stop simvastatin immediately due to risk of rhabdomyolysis
A CK level greater than 10 times the upper limit of normal with muscle symptoms indicates likely rhabdomyolysis, a serious and potentially life-threatening condition. The statin must be stopped immediately. Rhabdomyolysis can cause acute kidney injury from myoglobin release.
GPhC Clinical Therapeutics
A 62-year-old patient with type 2 diabetes and an eGFR of 25 mL/min/1.73m² is currently taking metformin 1g twice daily.
According to NICE guidelines, what action should be recommended?